Category Archives: Stroke

September 30, 2010 · 8:10 AM

Diabetes and Shortened Lifespan: “How Bad Is It, Doc?”

Diabetes mellitus for years has been linked with cardiovascular disease such as heart failure and coronary heart disease (blocked arteries in the heart, and the leading cause of death in the Western world).  How scared should diabetics be?

An article  in the Archives of Internal Medicine gives us one answer.

Researchers from the Netherlands and Harvard examined medical records of 5,209 people (mostly white, 64% men) enrolled in the Framingham (Massachusetts, USA) Heart Study.  This cohort has been examined every other year for more than 46 years. 

Study subjects who had diabetes at age 50 were identified; health outcomes going forward were then analyzed, with particular attention to lifespan and cardiovascular disease.  “Cardiovascular disease” in this context means coronary heart disease, stroke, congestive heart failure, intermittent claudication (leg pain during exertion caused by blocked arteries), and transient ischemic attack (stroke-like symptoms that resolve within 24 hours).

Results

Compared to those in the cohort free of diabetes, having diabetes at age 50 more than doubled the risk of developing cardiovascular disease for both women and men. 

Compared to those without diabetes, having both cardiovascular disease and diabetes approximately doubled the risk of dying, regardless of sex.

Compared to those without diabetes, women and men with diabetes at age 50 died 7 or 8 years earlier, on average.

[Specific causes of death were not reported.]

Take-Home Points

We’d likely see longer lifespans and less cardiovascular disease if we could prevent diabetes in the first place.  How do we do that?  Strategies include regular physical activity, avoidance or reversal of overweight and obesity, and low-glycemic-index diets.

The Mediterranean diet it linked to reduced heart attacks and strokes, and longer lifespan.  That’s why I’ve been working for the last year and a half to adapt it for diabetics.

ResearchBlogging.orgWe have better treatments for cardiovascular disease and diabetes and these days, so the death rates and illness numbers shouldn’t  be quite so alarming.  Up-to-date management of diabetes and cardiovascular disease will prevent some acute disease events—such as heart attacks and strokes—and prolong life.   

Steve Parker, M.D.

References: 

Franco, O., Steyerberg, E., Hu, F., Mackenbach, J., & Nusselder, W. (2007). Associations of Diabetes Mellitus With Total Life Expectancy and Life Expectancy With and Without Cardiovascular Disease Archives of Internal Medicine, 167 (11), 1145-1151 DOI: 10.1001/archinte.167.11.1145

Knowler, W.C., et al.  Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin.  New England Journal of Medicine, 346 (2002): 393-403.

Tuomilehto, J., et al.  Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance.  New England Journal of Medicine, 344 (2001): 1,343-1,350.

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September 19, 2010 · 1:34 AM

Do We Really Need to Cut Salt?

Dr. Paul Maher just finished a two-part series on dietary salt that is well worth a read, especially if you are convinced we need to cut our consumption.

Part 1

Part 2

Polititians and public health mandarins have been on the low-salt bandwagon again for the last couple years.  Some researchers question whether it’s even possible to reduce salt consumption as low as they would have us.

I’ll consider the polititians’ opinions on my salt intake as soon as they produce reasonable wait times at the post office, reasonable service times at the Department of Motor Vehicles, improve public school student achievement scores to a respectable level, balance state and federal budgets, and drastically reduce corruption in their hallowed halls. 

Steve Parker, M.D.

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April 24, 2010 · 8:21 AM

Whole Grains Reduce Heart Attacks and Strokes

Whole grain consumption is associated with a 21% reduction in cardiovascular disease when compared to minimal whole grain intake, according to a 2008 review article in Nutrition, Metabolism, and Cardiovascular Disease.   

Coronary heart disease is the No. 1 killer in the developed world.  Stroke is No. 3.  The term “cardiovascular disease” lumps together heart attacks, strokes, high blood pressure,  and generalized atherosclerosis (hardening of the arteries). 

Investigators at Wake Forest University reviewed seven pertinent studies looking at whole grains and cardiovascular disease.  The studies looked at groups of people, determining their baseline food consumption via questionnaire, and noted disease development over time.  These are called “prospective cohort studies.” 

None of these cohorts was composed purely of diabetics.

The people eating greater amounts of whole grain (average of 2.5 servings a day) had 21% lower risk of cardiovascular disease events compared to those who ate an average of 0.2 servings a day.  Disease events included heart disease, strokes, and fatal cardiovascular disease.  The lower risk was similar in degree whether the focus was on heart disease, stroke, or cardiovascular death.

Note that refined grain consumption was not associated with cardiovascular disease events. 

Why does this matter?

The traditional Mediterranean diet is rich in whole grains, which may help explain why the diet is associated with lower rates of cardiovascular disease.  If we look simply at longevity, however, a recent study found no benefit to the cereal grain component of the Mediterranean diet.  Go figure . . . doesn’t add up. 

Readers here know that over the last four months I’ve been reviewing the nutritional science literature that supports the disease-suppression claims for consumption of fruits, vegetables, and legumes.  I’ve been disappointed.  Fruit and vegetable consumption does not lower risk of cancer overall, nor does it prevent heart disease.  I haven’t found any strong evidence that legumes prevent or treat any disease, or have an effect on longevity.  Why all the literature review?  I’ve been deciding which healthy carbohydrates diabetics and prediabetics should add back into their diets after 8–12 weeks of the Ketogenic Mediterranean Diet.

The study at hand is fairly persuasive that whole grain consumption suppresses heart attacks and strokes and cardiovascular death.  [The paleo diet advocates and anti-gluten folks must be disappointed.]  I nominate whole grains as additional healthy carbs, perhaps the healthiest.

But . . .

. . .  for diabetics, there’s a fly in the ointment: the high carbohydrate content of grains often lead to high spikes in blood sugar.  It’s a pity, since diabetics are prone to develop cardiovascular disease and whole grains could counteract that.  We need a prospective cohort study of whole grain consumption in diabetics.  It’ll be done eventually, but I’m not holding my breath.

[Update June 12, 2010: The aforementioned study has been done in white women with type 2 diabetes.  Whole grain and bran consumption do seem to protect them against overall death and cardiovascular death.  The effect is not strong.]

What’s a guy or gal to do with this information now?

Non-diabetics:  Aim to incorporate two or three servings of whole grain daily into your diet if you want to lower your risk of heart disease and stroke. 

Diabetics:  Several options come to mind:

  1. Eat whatever you want and forget about it [not recommended].
  2. Does coronary heart disease runs in your family?  If so, try to incorporate one or two servings of whole grains daily, noting and addressing effects on your blood sugar one and two hours after consumption.  Eating whole grains alone will generally spike blood sugars higher than if you eat them with fats and protein.  Review acceptable blood sugar levels here.
  3. Regardless of family history, try to eat one or two servings of whole grains a day, noting and addressing effects on your blood sugar.  Then decide if it’s worth it.  Do you have to increase your diabetic drug dosages or add a new drug?  Are you tolerating the drugs?  Can you afford them?    
  4. Assess all your risk factors for developing heart disease: smoking, sedentary lifestyle, high blood pressure, age, high LDL cholesterol, family history, etc.  If you have multiple risk factors, see Option #3.  And modify the risk factors under your control.   
  5. Get your personal physician’s advice.    

Steve Parker, M.D.

Extra Credit:  The study authors suggest a number of reasons—and cite pertinent scientific references—how whole grains might reduce heart disease:

  • improved glucose homeostasis (protection against insulin resistance, less rise in blood sugar after ingestion [compared to refined grains], improved insulin sensitivity or beta-cell function)
  • advantageous blood lipid effects (soluble fiber from whole grains [especially oats] reduces LDL cholesterol, lower amounts of the small LDL particles thought to be particularly damaging to arteries, tendency to raise HDL cholesterol and trigylcerides [seen with insulin resistance in the metabolic syndrome])
  • improved function of the endothelial cells lining the arteries (improved vascular reactivity)

Disclaimer:  All matters regarding your health require supervision by a personal physician or other appropriate health professional familiar with your current health status.  Always consult your personal physician before making any dietary or exercise changes.

Reference: Mellen, P.B, Walsh, T.F., and Herrington, D.M.  Whole grain intake and cardiovascular disease: a meta-analysis.  Nutrition, Metabolism and Cardiovascular Disease, 18 (2008): 283-290.

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April 19, 2010 · 2:00 AM

More Chocolate, Less Strokes

Chocolate seems to protect against stroke, according to Canadian researchers as reported by TheHeart.Org. 

Investigators reviewed the best available studies and found:

  1. 22% lower risk of stroke in those who ate about one serving of chocolate per week, and
  2. 46% reduction in death from stroke in those who ate 50 g of chocolate per week

[These figures are comparisons to those who never ate chocolate.]  At least one study found no association between chocolate consumption and stroke and death rates.

Researchers cite the flavonoids and procyanidins in chocolate as the potentially healthy components, along with other antioxidants.  Dark chocolate has much more than milk or white chocolate.  The underlying studies typically do not inquire as to the type of chocolate eaten.

It’s possible that chocolate consumption is simply a marker for healthy or health-conscious people who have other characteristics that would reduce stroke risk, such as keeping blood pressure under control, exercising, and not smoking.

The evidence for chocolate’s health benefits is not super-strong.  People who love chocolate don’t need science to support their habits.  The “healthy dose” of dark chocolate—if there is one—is probably no more than 20 g every three days.  That’s not much.

Interested in dark chocolate and don’t know how to get started?  I reviewed seven brands of dark chocolate at one of my other blogs.

Steve Parker, M.D.

Reference:  Jeffery, Susan.  Chocolate linked to lower stroke and stroke mortality risk.  HeartWire by TheHeart.Org, February 12, 2010.

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April 9, 2010 · 2:00 AM

Prediabetes Ignored Way Too Often

Only half of Americans with prediabetes take steps to avoid progression to diabetes, according to a recent report in the American Journal of Preventive Medicine.

Prediabetes is defined as:

  1. fasting blood sugar between 100 and 125 mg/dl (5.56–6.94 mmol/l) or
  2. blood sugar level 140–199 mg/dl (7.78–11.06 mmol/l) two hours after drinking 75 grams of glucose

Prediabetes is a strong risk factor for development of full-blown diabetes.  It’s also associated with increased risk for cardiovascular disease such as heart attack and stroke.  One of every four adults with prediabetes develops diabetes over the next 3 to 5 years.  The progression can often be prevented by lifestyle modifications such as dietary changes, moderate-intensity exercise, and modest weight loss.  

Investigators looked at 1,402 adult participants in the 2005-2006 National Health and Nutrition Examination Survey (NHANES) who had fasting blood sugar tests and oral glucose tolerance tests diagnostic of  prediabetes.  

The researchers estimate that 30% (almost one out of every three) of the adult U.S. population had prediabetes in 2005-2006, but only 7% of them (less than one in 10) were aware they had it.

Only half of the prediabetics in this survey reported attempts at preventative lifestyle changes in the prior year.  Only one of every three prediabetics reported hearing about risk reduction advice from their healthcare provider.

People, we’ve got to do better! 

My fellow physicians, we’ve got to do better!

The U.S. Centers for Disease Control and Prevention predicts that one of every three Americans born in 2000 will develop diabetes.  The great majority of this will be type 2 diabetes.  You understand now why James Hirsch, author of Cheating Destiny, calls diabetes America’s leading public health crisis.  I agree.

Steve Parker, M.D.

Reference:  Geiss, Linda S., et al.  Diabetes risk reduction behaviors among U.S. adults with prediabetes.  American Journal of Preventive Medicine, 38 (2010): 403-409.

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February 27, 2010 · 4:05 AM

Alcohol Habit (Especially Wine) Started in Middle-Age Reduces Heart Attack and Stroke

Jesus turned water into wine at a wedding.  His mother asked him to do it.  Of all the miracles he performed and could have performed, I wonder why this is the first one recorded in the Holy Bible.

We have known for years that low or moderate alcohol consumption tends to lower the risk of cardiovascular disease such as heart attack and stroke, and prolongs life span.  Physicians have been hesitant to suggest that nondrinkers take up the habit.  We don’t want to be responsible for, or even accused of, turning someone into an alcoholic.  We don’t want to be held accountable for someone else’s drunken acts.  Every well-trained physician is quite aware of the ravages of alcohol use and abuse.  We see them up close and personal in our patients.

A scientific study published in 2008, however, lends support to a middle-aged individual’s decision to start consuming moderate amounts of alcohol on a regular basis.  It even provides a positive defense if a doctor recommends it to carefully selected patients.

This research, by the way, was supported by a grant from the National Heart, Lung, and Blood Institute, not the wine/alcohol industry.

Methodology

Researchers at the Medical University of South Carolina examined data on 15,637 participants in the Atherosclerosis Risk in Communities (ARIC) study over a 10-year period.  These men and women were 45 to 64 years old at the time of enrollment, living in four communities across the U.S.  Of the participants, 27% were black, 73% nonblack, 28% were smokers, and 80% of them had high blood pressure, high cholesterol, or diabetes.

Out of 15,637 participants at the time of enrollment, 7,359 indicated that they didn’t drink alcohol.  At baseline, these 7,359 had no cardiovascular disease except for some with high blood pressure.    Subsequent interviews with them found that six percent of the nondrinkers – 442 people – decided independently to become moderate alcohol drinkers.  Or at least they identified themselves as such.

“Moderate” intake was defined as 1-14 drinks per week for men, and 1-7 drinks a week for women.  Incidentally, 0.4% of the initial non-drinking cohort – 21 people – became self-identified heavy drinkers.

93.6% of the 7,359 non-drinkers said that they continued to be non-drinkers.  These 6,917 people are the “persistent nondrinkers.”

Type of alcohol consumed was also surveyed and broken down into 1) wine-only drinkers, or 2) mixed drinkers: beer, liquor, wine.

Researchers then monitored health outcomes for an average of 4 years, comparing the “new moderate drinkers” with the “persistent nondrinkers.”

Results

  •  Over 4 years, 6.9% of the new moderate drinkers suffered a cardiovascular event, defined as a heart attack, stroke, a coronary heart disease procedure (e.g, angioplasty), or death from cardiovascular disease.
  • Over 4 years, 10% of the persistent nondrinkers suffered a cardiovascular event.
  • The new moderate drinkers were 38% less likely than persistent nondrinkers to suffer a new cardiovascular event (P = 0.008, which is a very strong association).  The difference persisted even after adjustment for demographic and cardiovascular risk factors.
  • There was no difference in all-cause mortality (death rate) between the new moderate drinkers and the persistent nondrinkers.
  • New  drinkers had modest but statistically significant improvements in HDL and LDL cholesterol and mean blood pressure compared with persistent nondrinkers.
  • 133 new moderate drinkers consumed only wine
  • 234 new moderate drinkers consumed mixed types of alcohol
  • Wine-only drinkers were 68% less likely than nondrinkers to suffer a cardiovascular event.
  • “Consumers of moderate amounts of beer/liquor/mixed (which includes some wine) tended to also be less likely to have had a subsequent cardiovascular event than nondrinkers…but the difference was not significant.”

A Few Study Limitations

  • Four years is a relatively brief follow-up, especially for cancer outcomes.  Alcohol consumption is associated with certain types of cancer.
  • If moderate alcohol consumption indeed lowers death rates as suggested by several other studies, this study may not have lasted long enough to see it.
  • The alcohol data depended on self-reports.

Take-Home Points

The study authors cite four other studies that support a slight advantage to wine over other alcohol types.  It’s a mystery to me why they fail to stress the apparent superiority of wine in the current study.  Several other studies that found improved longevity or cardiovascular outcomes in low-to-moderate drinkers suggest that the type of alcohol does not matter.  Perhaps “the jury is still out.”  In the study at hand, however, it is clear that the reduced cardiovascular disease rate in new moderate drinkers is associated with wine.

In all fairness, other studies show no beneficial health or longevity benefit to alcohol consumption.  But at this point, the majority of published studies support a beneficial effect.

Wine is a component of the traditional healthy Mediterranean diet.  The Mediterranean diet is associated with prolonged life span and reduced cardiovascular disease.  This study strongly suggests that wine is one of the health-promoting components of the Mediterranean diet.

Starting a judicious wine habit in middle age is relatively safe for selected people and may, in fact, improve cardiovascular health, if not longevity.

Now the question is, red or white.  Or grape juice?

Steve Parker, M.D.

Reference:  King, Dana E., et al.  Adopting Moderate Alchohol Consumption in Middle Age: Subsequent Cardiovascular Events.  American Journal of Medicine, 121 (2008): 201-206.

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January 18, 2010 · 2:00 AM

Grains and Legumes: Any Effect on Heart Disease and Stroke?

Several scientific studies published in the first five years of this century suggest that whole grain consumption protects agains coronary heart disease and possibly other types of cardiovascular disease, such as stroke. 

Note that researchers in this field, especially outside the U.S., use the term “cereal” to mean “a grass such as wheat, oats, or corn, the starchy grains of which are used as food.”  They also refer frequently to glycemic index and glycemic load, spelled “glycaemic” outside the U.S.  Most of the pertinent studies are observational (aka epidmiologic): groups of people were surveyed on food consumption, then rates of diseases were associated with various food types and amounts.  “Association” is not proof of causation. 

Here are highlights from a 2006 review article in the European Journal of Clinical Nutrition: 

The researchers concluded that a relationship between whole grain intake and coronary heart disease is seen with at least a 20% and perhaps a 40% reduction in risk for those who eat whole grain food habitually vs those who eat them rarely.

Whole grain products have strong antioxidant activity and contain phytoestrogens, but there is insufficient evidence to determine whether this is beneficial in coronary heart disease prevention.

Countering the positive evidence for whole grain and legume intake has been the Nurses Health Study in 2000 that showed women who were overweight or obese consuming a high glycaemic load (GL) diet doubled their relative risk of coronary heart disease compared with those consuming a low GL diet.

The intake of high GI carbohydrates (from both grain and non-grain sources) in large amounts is associatied with an increased risk of heart disease in overweight and obese women even when fiber intake is high but this requires further confirmation in normal-weight women.

Promotion of carbohydrate foods should befocused on whole grain cereals because these have proven to be associatied with health benefits.

Whether adding bran to refined carbohydrate foods can improve the situation is also not clear, and it was found that added bran lowered heart disease risk in men by 30%.

Recommendation:  Carbohydrate-rich foods should be whole grain and if theyare not, then the lowest GI product available should be consumed.

My Comments

This journal article focuses on whole grains rather than legumes, and promotes whole grains more than legumes.  For people with diabetes, this may be a bit of a problem since grains—whole or not—generally have a higher glycemic index than legumes, which may have adverse effects on blood sugar control.  Keep in mind that highly refined grain products, like white bread, have a higher glycemic index than whole grain versions.

Did you notice that the abstract doesn’t recommend a specific amount of whole grains for the general population?  My educated guess would be one or two servings a day. 

Grains are high in carbohydrate, so anyone on a low-carb diet may have to cut carbs elsewhere. 

Diabetes predisoses to development of coronary heart disease.  Whole grains seem to help prevent heart disease, yet may adversely affect glucose control, contributing to diabetic complications.  It’s a quandary.  “Caught between the horns of a dilemma,” you might say.  So, what should a diabetic do with this information in 2010, while we await additional research results?

Several options come to mind:

  1. Eat whatever you want and forget about it.
  2. Note whether coronary heart disease runs in your family.  If so, try to incorporate one or two servings of whole grains daily, noting and addressing effects on your blood sugar.
  3. Try to eat one or two servings of whole grains a day, noting and addressing effects on your blood sugar.  Then decide if it’s worth it.  Is there any effect?  Do you have to increase your diabetic drug dosages or add a new drug?  Are you tolerating the drugs?    
  4. Assess all your risk factors for developing heart disease: smoking, sedentary lifestyle, high blood pressure, age, high LDL cholesterol, family history, etc.  If you have multiple risk factors, see Option #3.  And modify the risk factors under your control.   
  5. Get your personal physician’s advice.    

Before you stress out over this, be aware that we don’t really know whether a diabetic who doesn’t eat grains will have a longer healthier life by starting a daily whole grain habit.  Maybe . . . maybe not.  The study hasn’t been done.    

Steve Parker, M.D.

References:

Flight, I. and Clifton, P.  Cereal grains and legumes in the prevention of coronary heart disease and stroke: a review of the literature.  European Journal of Clinical Nutrition, 60 (2006): 1,145-1,159.

Malik, V. and Hu, Frank.  Dietary prevention of atherosclerosis: go with whole grains.  American Journal of Clinical Nutrition, 85 (2007): 1,444-1,445.

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January 12, 2010 · 2:00 AM

Does Diet Influence Risk of Stroke?

Harvard researchers suggest that our food consumption does indeed influence our risk of suffering a stroke.  This matters since stroke is the third leading cause of death in the U.S.

Scientists looked carefully at 121 different studies—published between 1979 and 2004—on the relationship between dietary factors and stroke.  High blood pressure is a major modifiable risk factor for stroke, so it also was considered.  Dietary factors included fats, minerals, animal protein, cholesterol, fish, whole grains, fiber, carbohydrate quality, fruits and vegetables, antioxidants, B vitamins, and dietary patterns.

I quote their conclusions:

Diets low in sodium and high in potassium lower blood pressure which will likely reduce stroke risk.

Consumption of fruits and vegetables, whole grains, folate, and fatty fish are each likely to reduce stroke risk.

A prudent or traditional Mediterranean dietary pattern, which incorporates these individual dietary components as well as intake of legumes and olive oil, may also prevent stroke.

Evidence is limited or inconsistent regarding optimal levels of dietary magnesium, calcium, antioxidants, total fat, other fat subtypes, cholesterol, carbohydrate quality, or animal protein for stroke prevention.

A diet low in sodium, high in potassium, and rich in fruits, vegetables, whole grains, cereal fiber, and fatty fish will likely reduce the incidence of stroke.

Take Home Points

The article abstract does not address the optimal intake amount of these various foods, vitamins, and minerals.  That’s probably not known with any certainty.

The traditional Mediterranean diet incorporates many of these stroke-preventing foods.  The Advanced Mediterranean Diet helps people lose weight while teaching how to eat Mediterranean-style.

The very low-carb Ketogenic Mediterranean Diet includes these stroke-preventing foods and minerals, except for whole grains and a tendency to be low in potassium.  The KMD is high in total fat and animal protien, and potentially high in cholesterol; this study indicates those issues are nothing to worry about in terms of future strokes.

I’ll use articles such as this to recommend long-term food consumption for followers of any future Diabetic Mediterranean Diet.

Steve Parker, M.D.

Reference:  Ding, E.L, and Mozaffarian, D.  Optimal dietary habits for the prevention of stroke. Seminars in Neurology, 26 (2006): 11-23.

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