Picking your protein.

Excessive carbohydrate calories, especially from the simple sugars glucose and fructose, increase the risk for obesity, high blood pressure, heart disease, and even cancer. Cutting back on your daily carbs will mean increasing the fat and protein calories in your diet. But what kind of fat? And what kind of protein?

Cholesterol and saturated fats have been tagged as major risk factors for blood vessel disease (atherosclerosis) for decades. But recent work suggests they are not the most important factor in all those heart attacks.  Merely a late stage contributor to damage already well under way.

The results of numerous studies and investigations points to Trimethylamine N-Oxide (TMAO) as the real culprit.


There is proof of cause and effect. In an experimental mouse model, raising blood TMAO levels by dietary manipulation increased blood vessel disease in the absence of any changes in the cholesterol or fat content.


Numerous clinical studies of heart disease (chest pain in the ER, progression of known atherosclerotic heart disease) show a direct correlation between increasing blood levels of TMAO and cardiovascular disease.


Carnitine, a protein found in red meat and to a much lesser degree in chicken and fish, is the source of TMAO. Any dietary carnitine not digested and absorbed in the small bowel  passes into the colon where bacteria (our microbiome) metabolize it to an intermediate molecule, TMA.  TMA is in then absorbed and modified further in the liver to TMAO.


There is a similar pathway for the production of TMAO from lecithin, a protein found in egg yolks.
Solid evidence supports diet as the major determinant of blood TMAO levels. A recent study documented that a diet low in red meat and eggs lowered TMAO levels independent of the amount of cholesterol or saturated fats in those diets.


TMAO production can be reduced with oral antibiotics (which alter the makeup of the microbiome) or by decreasing the dietary intake of carnitine. Vegans as a group have the lowest blood TMAO levels (and the lowest rate of cardiovascular diseases) while those on a regular red meat diet the highest.  Just replacing red meat with chicken will lower the amount of TMAO excreted in the urine by two thirds.
What does this suggest for your diet?


Carbohydrates should be limited, and this means daily caloric requirements will be replaced by increasing total protein and fat.


Saturated fats, found in butter, cheese, red meat and other animal-based foods, do play a role in the development of cardiovascular disease, but there risk has been overstated.

Your decision on the source of the third component of the daily diet, protein, has considerable impact on your health. We know that vegetarians have the lowest levels of blood vessel disease, and your goal should be a move toward a meat free diet.


But that does not mean you have to become a vegan. You can add one or two meat free dinners a week. Or decrease red meat portion sizes. And now we know that your choice of protein, substituting chicken or fish for red meat, adds a third option.


http://www.drmirkin.com/nutrition/latest-research-on-tmao.html

https://www.drmirkin.com/nutrition/new-research-on-tmao.html

Carbohydrates and the glycemic index

Diets high in carbohydrate calories increase the risks for obesity, high blood pressure, heart disease, and even cancer.

Many of the health risks are related to the ease with which a carbohydrate is digested and absorbed. This is reflected in a food’s glycemic index - the higher the glycemic index, the more rapid the rise in the blood sugar after eating.

All carbohydrates are built up from single sugar molecules. Simple carbohydrates (table sugar for example) is composed of just two single sugar molecules (one glucose and one fructose). Complex carbohydrates are made from longer chains of multiple sugar molecules.

To be absorbed from the small intestine, all carbohydrates must first be broken down (digested) into single sugar molecules. Some complex carbohydrates are easily digested (wheat flour for instance) while others are not (fruit and vegetable fiber).

A food’s glycemic index is higher if it contains processed carbohydrates. In processed grains the outer bran and inner germ layer (which tend to bind its sugar molecules and retard their absorption) are removed from the original kernel of grain. The result?  A more rapid spike in blood sugar levels than after eating a less-processed grain.

Table sugar is easily digested, readily absorbed into the bloodstream has a high glycemic index. As a result, these carbohydrate molecules are often absorbed faster than they can be used in normal metabolism.  The excess are converted into fat (triglycerides) and stored for future needs. This fat is the most likely culprit behind the health risks of high carbohydrate diets.

Another negative aspect to high glycemic foods is their potential to cause “reactive hypoglycemia” (low blood sugar). The rapid spike in blood sugar levels immediately after eating stimulates the release of insulin from the pancreas. Insulin is needed to move blood sugar into many tissues. But the sugar from these foods is so quickly and efficiently absorbed that the insulin is often still working when there is no more sugar being absorbed. This leads to an equally sudden drop in blood glucose levels and symptoms of fatigue and hunger.

Complex carbohydrates or starches are more slowly broken down by digestive enzymes and in turn more slowly absorbed. The rate of rise of the blood sugar after eating starches is less (their glycemic index is lower) and is spread over a longer period of time. The blood sugar spike is less severe, less insulin is released, sugar calories are absorbed over a longer period of time, and the body now has more time to use them as part of normal metabolism.  As a result hypoglycemia is less of a problem.

Fiber is also a complex carbohydrate, but the sugar molecules are linked in a way that resists digestion. As a result they pass relatively unchanged into the colon.  Fiber has a glycemic index of zero.

This poor absorption explains fiber’s health benefits. Once it reaches the colon, resident bacteria (the microbiome) which have the enzymes necessary to digest it, produce numerous small molecules in the process which can be absorbed and have proven health benefits.

The following are a few ideas and conclusions to improve your (and your family’s) daily diet.

First, limit your daily carbohydrate calories to no more than 50% of the daily total daily. The only exception is for those on a regular exercise program. As active muscles use glucose directly as fuel, any carbohydrate drinks and snacks that replace these exercise calories can be added to your daily total.

Second, minimize simple sugars. Get rid of the sugar bowl on the table, take pre sweetened cereals and sugar-ed drinks out of the cupboard, and limit processed food which are often high in added sugars.

Finally, take advantage of the health benefits of more slowly absorbed complex carbohydrates. Have an extra serving of vegetables instead of a piece of bread or a double serving of potatoes.

And for an added health bonus, add a tablespoon of minimally digested flax fiber to your morning routine to keep the microbiome healthy.

----

Notes:

• The physical form of a carbohydrate affects glycemic index - wheat in Spaghetti vs wheat in bread. https://nutritionfacts.org/video/which-is-a-better-breakfast-cereal-or-oatmeal/

Artificial sweeteners might be worse than sugar.

Too much sugar is bad for you. It has been linked to obesity, heart disease, diabetes, depression, acne, and even cancer.  But switching to artificial sweeteners to lower your total sugar use may present even more health risks.

The current theory is that along with too many calories from a high sugar diet, the blood sugar surge after a high sugar snack is the reason for many of the negative health impacts. This surge releases insulin which in turn forces the extra sugar calories directly into fat cells in our body and also increases damage to the lining of our blood vessels.

If too much sugar leads to obesity, diabetes, and heart disease, it would make sense that decreasing both total calories and the blood sugar spikes should be a plus for our health. And artificially sweetened drinks sound ideal. They satisfy that craving for something sweet without the harmful potential of sugar.

However a 2015 study of 100,000 women followed for 8 years revealed a 30% increase in the death rate (mainly from heart disease) in those drinking two or more diet sodas a day.

And last month another study confirmed the health risks when it highlighted a 25% increase in strokes in that same group drinking more than two diet sodas a day.

The common factor in heart attacks and strokes is small blood vessel disease.  It doesn’t make a lot of sense. Less sugar should translate to less blood vessel damage not more.

Further investigation suggests it is the colon bacteria, our microbiome, that holds the missing piece to the puzzle. The food we eat is never completely absorbed by our upper digestive tract and the “leftovers”  make their way to the colon where they provide a food source for the many types of bacteria.

Artificial sweeteners impact the microbiome in two ways. First they change the balance of the colon’s bacterial community, directly suppressing the “good” bacteria which digest dietary fiber providing us with health promoting short chain fatty acids. And at the same time they directly stimulate the growth of “bad” bacteria, the source of blood vessel harming toxic molecules.

It is a deadly combination. Decrease the production of fatty acids which lower cholesterol and moderate high blood pressure, protecting our blood vessels, and increase the level of toxic molecules that directly harm the blood vessels as they rev up the immune system and body wide inflammation.

And beyond strokes,  there is the increased risk of dementia, another small blood vessel disease, also more common as the intake of artificially sweetened sodas increases.

Can you do anything to blunt the risk of these artificially sweetened drinks?

No, nothing lessens the effect of artificial sweeteners on the microbiome. Although it is boring, water is your only real alternative.  Between meals, when you are thirsty, make yourself a cup of tea or grab a glass of water instead of that soda (sweetened or diet). For variety, perhaps a carbonated water drink such as LaCroix (carbonated water, flavorings) - no sugar or artificial sweeteners to worry about.

The only logical role for diet drinks is in weaning yourself off  sugar based drinks of all types, in the transition to water and other healthier beverages. That is as a crutch in that process (analogous to using nicorette gum to help stop cigarettes)

Real sugar sweetened drinks can be healthier than those artificially sweetened if used as part of a meal which blunts the speed of absorption.  Otherwise they are just as harmful, the only difference being their effects are via a direct impact on insulin and fat metabolism, not indirectly via the colon bacteria.

Another option for a sugar-ed soda is as an energy drink when you are exercising (when they are rapidly metabolized by your exercising muscles without needing insulin).

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4371001/

https://www.ahajournals.org/doi/10.1161/STROKEAHA.118.023100

https://www.healthline.com/nutrition/too-much-sugar#section3

https://adoctorsrx.blogspot.com/2017/06/the-microbome-and-your-health.html

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6222326/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6353871/

http://www.drmirkin.com/morehealth/dementia-risk-increased-by-harmful-bacteria-in-your-colon.html

https://www.ncbi.nlm.nih.gov/pubmed/28428346

http://www.drmirkin.com/nutrition/artificial-sweeteners-weight-gain-and-diabetes.html

Additional references after article published.

Artificial sugars make you want more sugar!! https://nutritionfacts.org/2020/01/14/why-drinking-diet-soda-makes-you-crave-sugar/

Effect of sucralose on the microbiome. https://nutritionfacts.org/video/flashback-friday-effect-of-sucralose-splenda-on-the-microbiome/

Where's the harm in a frozen pizza?

Most of us have heard or read about the health risks of processed foods.


Strictly speaking, a processed food is any grocery item that has been modified from its original form.  Even steel cut oats, a grain everyone would consider a “healthy” food (low in fat, rich in fiber), is a processed food.


But the “processing” of foods covers much more than mechanical alteration.
It includes the full spectrum from foods only mechanically modified (steel cut oats, shredded lettuce) to the nutritional fortification of the most  popular convenience foods. And the longer the list of additives, the more a food moves towards the ultra-processed end of the spectrum.


How risky are these ultra-processed foods? A recent paper from France linked increased consumption of ultra-processed food to an increased risk of breast, colon, and prostate cancer. And prior investigations have associated diets high in ultra-processed foods with an increased risk of heart disease, type 2 diabetes, and obesity.


Why are processed food so harmful?


First, ultra-processed foods often contain additional fats (cheap, refined seed- and vegetable oils which are hydrogenated into unhealthy trans fats) as well as sugar and salt. The extra calories lead to a slow slide into obesity over time, the sugar has been implicated  in pre-diabetes, and the fats (along with the obesity) are a major risk factor for heart disease.


Then we have chemical additives such as sodium nitrite (in processed meat) or titanium dioxide (white food pigment) are cancer risk factors in animal and cellular models. And chemical compounds such as acrylamide, heterocyclic amines, and polycyclic aromatic hydrocarbons formed during the high temperature preparation of these foods,  all suspects as cancer promoters.


Here is a group of additive compounds you may never have read about - emulsifiers. Emulsifiers are added to foods such as ice cream, salad dressing, pastas, bread and cookies, to prolong shelf life and keep ingredients from separating.  In mice they disrupt intestinal bacteria (the microbiome) resulting in inflammation and weight gain. If these results are documented in humans, emulsifiers may be part of the explanation for the increases we are seeing in obesity, insulin insensitivity, and diabetes.


Finally, there are the risks from what has been lost in processing - fiber and vitamins. Many vitamins and micronutrients are lost with cooking, and fiber, the nutrient most important to our microbiome, is often purposefully removed.


What can you do to lower your family’s health risks from ultra processed foods?  The only reasonable strategy is avoidance, minimizing impulse buying and replacing these products with foods you (unfortunately) prepare yourself.


If you think it is time to make a move in that direction (remember, any change will be a health positive, you don’t have to go 100% “fresh” all at once), I have three suggestions that might help.


First,  shop from a list.  Or if not a list, then some clear ideas of a few main meal menus for the next few days.


Second, avoid food shopping when you are hungry (go soon after breakfast or lunch). This will blunt the tendency to impulse shop for those temptingly packaged and marketed convenience foods.


And finally, change your route through the store. Supermarkets are all built with a similar floor plan - fresh foods (fruits, vegetables, dairy, meat, and fish) around the perimeter with the ultra - processed foods lurking in the center aisles .  So walk the perimeter first and try to avoid the aisles unless you have a specific item in mind.

http://www.drmirkin.com/nutrition/emulsifiers-may-disrupt-gut-bacteria.html

https://www.timesnownews.com/health/article/ultra-processed-foods-linked-to-early-death-these-foods-can-also-increase-your-risk-of-cancer-diabetes-heart-disease-obesity/365106

https://www.bmj.com/content/360/bmj.k322

https://www.bmj.com/content/365/bmj.l1949

-- added after article published --

https://www.drmirkin.com/nutrition/why-whole-grains-are-healthful.html

Achy joints? It may be your diet.

One in four adults experience regular joint pain, and for those over 65, more than 50% have had their physician make a diagnosis of arthritis.  


Arthritis is the common vernacular for joint pain, a symptom found in hundreds of diseases.  But there are really two main groupings.


Traumatic arthritis results from a direct injury to the joint ligaments and cartilage. Healing of this injury then alters normal joint biomechanics leading to chronic discomfort.


Inflammatory arthritis is often just one aspect of a body-wide inflammatory process, rheumatoid arthritis and lupus, an autoimmune disease being two examples. Inflammation begins in the joint lining, or synovium, which then slowly destroys the joint cartilage.


Osteoarthritis, the “arthritis of aging”, has been assumed to be in the traumatic arthritis group, the result of years of  “wear and tear” on the joint cartilage. This presumption was supported by the observation that osteoarthritis was seven times more frequent in obese than in normal weight individuals. And was found more commonly in those who participated in soccer, competitive weight lifting, and elite level running, activities that increase joint stress .


However recent studies have identified low level synovial inflammation in what otherwise appeared to be classic osteoarthritis, suggesting a new possibility - our diet.


Studies of diseases as varied as cancer, diabetes, and heart disease had previously identified higher than expected blood levels of C-reactive protein, a specific finding in low level, chronic inflammation.  Many researchers have speculated that this inflammation is one of the factors involved in the development of these diseases. And now we have the same finding in many patients with osteoarthritis.


It turns out that diet can affect the level of C-reactive protein, and adopting a diet low in animal products and high in fruits and vegetables can lower this blood marker of inflammation.  Which suggests another addition to treating this common ailment.


We already know that a regular exercise routine decreases joint symptoms. A study following 6500 women for 12 years found that those who exercised regularly had far fewer complaints of joint pain than those who did not. Although it seems counter intuitive that a treatment for joint pain might be using them more, all the signs are pointing in that direction.


Adding a dedicated period of exercise into your daily routine is an easy first step. A non impact sport such as cycling, swimming, or water aerobics is preferable, but if that is more than you have the time for, a brisk daily walk will do.


You might consider losing weight. Even of you don’t think of yourself as obese, any weight you lose will lessen the stress on your hips and knees.


And now you have a third option. It makes sense to consider adopting a more anti inflammatory diet.  This would include eliminating all sugar. Substituting fish, whole grains, and vegetables for the red meat main course several times a week. And using healthy oils such as olive oil, avocado oil, canola oil in your food prep. You can find additional ideas in one of the many articles or books on the  Mediterranean diet.


It is possible your joint aches are just the tip of the iceberg, a symptom warning of a body wide inflammatory process, in which case this lifestyle change will continue to deliver additional health benefits as the years roll by.

https://www.arthritis.org/Documents/Sections/About-Arthritis/arthritis-facts-stats-figures.pdf

http://www.drmirkin.com/joints/inactivity-linked-to-arthritis.html

https://www.ncbi.nlm.nih.gov/pubmed/27103057

https://www.ncbi.nlm.nih.gov/pubmed/25574790

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3372675/

https://adoctorsrx.blogspot.com/2017/07/anti-inflammatory-diets.html

The Fountain of Youth

Exercise regularly and you will maintain a stronger immune system, lower your risk of a heart attack, and have less chance of developing diabetes. And over time maintain a better memory and lower your odds of developing dementia.


But even with those positives, the aging process moves inexorably onward. It has been estimated that after our peak at age 30, we lose between 5 and 10% of our physical stamina every decade, and as the years pass, that is reflected in the fatigue we feel at the end of the day.


Loss of stamina is a combination of less muscle bulk (strength) combined with a decrease in the effectiveness of our cardiovascular system (aerobic capacity) in providing the oxygen our muscles need to function.


Regularly pushing the cardiovascular system (High Intensity Interval training - HIIT) and stressing the musculoskeletal system (weight or resistance training) can blunt the rate of decline. Just 30 minutes a day of either HIIT or working out at the gym can have a significant impact on your energy levels.


There is little question as to the mental lift you experience from taking charge of your health. But how much physiologic return do you get for that 30 minutes a day? And could you do better?


Investigators in Indiana (Ball State) located 28 men and women who had exercised regularly for 50 years. Most took up running in the health conscious 1970’s and then just stuck with it. They enjoyed it and made it part of their life. Most were recreational athletes (running, biking, swimming) and only a few actually exercised to be able to compete. On average, group members exercised 5 days (or 7 hours) a week.


Investigators also identified a healthy peer group (also average age of 70 years) who were not regular exercisers, and a 3rd group of active, but not athletic, 30 year olds. They then tested all subjects to determine their aerobic (cardiovascular) capacity as well as taking a small sample of leg muscle tissue (a minor procedure).


The findings were even more impressive than had been expected.


First, the analysis of number of capillaries (need to deliver oxygen to the muscle fibers) and concentration of muscle cell enzymes (needed to process oxygen and glucose to provide energy for physical activity) in the muscles of the athletic seniors were identical to those of the 30 year old comparison group.


Even more astounding was the finding that the aerobic capacity (the measure of how much work a subject could do per minute), although slightly less than that of the 30 year old comparison group, was 40% better than their sedentary peers.  And using information in the medical literature, equivalent to the aerobic capacity of active adults 30 years their junior.


This study shows how effective regular aerobic exercise can be as a tool to blunting the effects of aging.  Instead of the inexorable 5 to 10% decrease per decade described in many articles on aging and human physiology, this group of regular exercisers slowed the rate of decline significantly. If you believe the data, to perhaps 3 or 4% per decade.


It may not be as easy as drinking the water of the fountain of youth, and not all of us have the inclination or time to take on this level of exercise commitment, but  if you did, it would appear that for an average of an hour of aerobic exercise a day (17,500 hours over 50 years) you gain an additional 30 years of robust exercise capacity. Or about 1 day for each hour invested. In my book, that’s a pretty good ROI (return on Investment).


References:

https://www.nytimes.com/2018/11/21/well/move/regular-exercise-may-keep-your-body-30-years-younger.html


https://www.physiology.org/doi/abs/10.1152/japplphysiol.00174.2018

New Year's Resolutions - Aging well

It’s the holiday season. Which means confronting that annual task of making your New Year’s resolutions.

We are all another year older, so it’s not unusual for aging to work its way into our deliberations.  How are we feeling? Are we doing all that we can to stay healthy and be ready for those trips and projects that we put off?

This year’s columns focused on strategies to decrease our odds of falling victim to the four major diseases of modern life  - heart disease, cancer, diabetes, and dementia. It seemed the ideal time for a summary in case you needed help jump starting the resolution planning.

And just like your IRA, making changes early, investing some energy in your 30s and 40s, leverages the benefits with greater rewards than you’ll get putting things off until that AARP invitation arrives in the mail. So for your first resolution - “No more procrastination”.

Smoking remains the number one cause of morbidity (illness) and mortality (death) in the US. If you are still taking an occasional puff, stopping smoking is an easy number two for the list.

Recent work suggests there is no completely risk free level of alcohol intake, and previous suggestions of a small health benefit from a drink a day were most likely wishful thinking. Health risks go up more quickly after that first drink, so moderation should be the goal.

Loss of your muscles accelerates with aging, but resistance exercise (lifting heavy objects) decreases the rate of loss.  

Stress your heart and you will not only decrease the risks of developing coronary artery disease, but you will be able to do more with those disappearing muscles.

Diet is a much more complex issue. Here are several common components in all healthy eating plans.

   - Get rid of sugar. More and more evidence indicates sugar is more harmful to your health than either salt or fats.

   - Replace red meat with fish, whole grains, and vegetable side dishes. Your microbiome will love the extra  fiber.

   -  Don’t skimp on protein. As we get older we need more, not less, protein. The inadequate daily protein intake of the elderly on limited incomes is a significant factor in their muscle loss.

   - Use more healthy oils -  olive oil, avocado oil, canola oil, walnut oil, flaxseed oil, or chia seed oil. Oily fish such as Salmon provide the especially healthy omega-3 fatty acids.

Social interaction is the final piece. Keep in touch with close friends. Go to church. Volunteer. Play bridge. These connections are important to keep your mind healthy and your spirits up.

So there you have it,  the secrets to not only living longer, but living better - aging well.  A healthy diet, regular exercise, no smoking, and alcohol in moderation.

Need a few more specific resolutions?   

Eliminate sugar from your diet. I’d make this number three on your must do list. It will be a challenge.  Sugar is addicting and the first 2 weeks will be hard. But the health rewards are huge.

Cut your red meat portions in half, or better yet consider two meatless meals a week (fish can count as “meatless”)

Fifteen or twenty minutes of dedicated exercise a day. For the week, three days of resistance exercise and four days of vigorous walking or biking to the point you feel short of breath.

Happy New Year.

References (more references in topic specific blog posts - right column):

https://www.ahajournals.org/doi/abs/10.1161/CIRCULATIONAHA.117.032047

https://www.nytimes.com/2018/09/03/well/live/preventing-muscle-loss-among-the-elderly.html

https://well.blogs.nytimes.com/2015/04/15/the-right-dose-of-exercise-for-a-longer-life/