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 11, 2010 · 2:00 AM

Longevity Components of the Mediterranean Diet

According to Greek researchers, the components of the Mediterranean diet that contribute to longer lifespan are:

  • moderate alcohol consumption
  • low consumption of meat
  • high consumption of vegetables, fruits, nuts, olive oil, and legumes

The following didn’t seem to contribute much, if any:

  • cereals (the grain of a grass such as wheat, corn, oats)
  • dairy products
  • fish and seafood

Investigators at the University of Athens examined the Greek portion of the European Prospective Investigation into Cancer (EPIC) and Nutrition, which included 23,349 men and women free of diabetes, cancer, and coronary heart disease at the outset.  Food habits were documented by questionnaire. 

The focus of this particular study was death rates over an average follow-up of 8.5 years.  Adherence to the traditional Mediterranean diet ranged from minimal to high, as would be expected. 

As with numerous other studies of the Mediterranean diet, higher adherence to the Mediterranean diet was associated with lower chance of death. 

My Comments

The lack of benefit from fish is unexpected.  I have no explanation.  A preponderance of evidence elsewhere suggests fish consumption helps prolong life via lowered rates of heart disease.

Alcohol can be dangerous, of course.  Some people should not partake, ever.     

For people with diabetes who wish to avoid the carbohydrate load in cereals and dairy products, you don’t need to worry much about cutting those out of an otherwise Mediterranean-style diet.

Steve Parker, M.D. 

Reference:  Trichopoulou, Antonia, et al.  Anatomy of health effects of the Mediterranean diet: Greek EPIC prospective cohort study.  British Medical Journal, 338 (2009): b2337.  DOI: 10.1136/bmj.b2337.

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April 10, 2010 · 2:00 AM

Fruits and Vegetables DON’T Prevent Heart Disease

Fruit and vegetable consumption does not seem to reduce the risk of heart attacks (coronary heart disease), according to a recent literature review by French epidemiologists.

I recently wrote about a study that found no overall reduced risk of cancer via consumption of fruits and vegetables.

Heart attacks and cancer are the first and second leading causes of death in the developed world.

So just why, again, are we supposed to be eating our fruits and vegetables?

Here’s most of the abstract written by the epidemiologists:

This Review summarizes the evidence for a relationship between fruit and vegetable consumption and the occurrence of coronary heart disease…Most of the evidence supporting a cardioprotective effect comes from observational epidemiological studies; these studies have reported either weak or nonsignificant associations.  Controlled nutritional prevention trials are scarce and the existing data do not show any clear protective effects of fruit and vegetables on coronary heart disease.  Under rigorously controlled experimental conditions, fruit and vegetable consumption is associated with a decrease in blood pressure, which is an important cardiovascular risk factor.  However, the effects of fruit and vegetable consumption on plasma lipid levels, diabetes, and body weight have not yet been thoroughly explored.  Finally, the hypothesis that nutrients in fruit and vegetables have a protective role in reducing the formation of atherosclerotic plaques and preventing complications of atherosclerosis has not been tested in prevention trials.  Evidence that fruit and vegetable consumption reduces the risk of cardiovascular disease remains scarce thus far.

What do they mean by controlled prevention trials?  Here’s an example.  Find 20,000 people with similar characteristics.  Randomly assign half of them to eat significantly more fruits and vegetables, and make sure they do it.  The other half eats their usual way, and make sure they do it.  Analyze the entire group’s health and food consumption after 10 years and see which half has more or less heart disease.   

Such a study is very difficult and costly.  Even if the fruit and veggie group had less heart disease, someone would argue that the heart benefit was gained because of what they cut out of their eating to make way for the fruits and veggies!  “They quit eating Cheetos; that’s why they had fewer heart attacks.”

Bottom Line

Fruits and vegetables don’t prevent heart disease, according to these researchers.

Fruits and vegetables are components of overall healthy diet patterns such as the Mediterranean diet, the DASH diet, and the “prudent diet.”  Is it possible they reduce the risk of stroke, the second leading cause of death?  I’ll leave that for another day.

I’m starting to think if I read enough nutritional literature, I won’t know anything with certainty.

Steve Parker, M.D. 

Dauchet L., Amouyel, P., and Dallongeville, J. (via MedScape).  Fruits, vegetables and coronary heart disease.  Nature Reviews Cardiology, 6 (2009): 599-608.  doi: 1011038/nrcardio.2009.131

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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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April 7, 2010 · 2:00 AM

Quote of the Day

Of all the behavioral aspects of diabetes management, none is more important than nutrition.  However, nutritional control is usually not well done by patients and is largely ignored by physicians.

—David K. McCulloch, M.D., Clinical Professor of Medicine, University of Washington

—in “Insulin therapy in type 1 diabetes mellitus,” UpToDate.com, version 17.3, September, 2009

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April 4, 2010 · 2:00 AM

New Page Here: Drugs for Diabetes

This is the best time in history to have diabetes.  Thanks to the advancement of science, supported by the profit motive and a degree of free market economics, we now have 10 classes of drugs to help us conquer the disease. 

I recently finished a series of brief reviews on each drug class.  Click on the Drugs for Diabetes page for links to all the reviews. 

Steve Parker, M.D.

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April 2, 2010 · 2:00 AM

Association of American Physicians and Surgeons Challenges New Healthcare Reform Law

Equal Justice Under Law

AAPS is the first national physician group to sue the federal government over the the Democrat’s new healthcare reform law, according to an article at MedPageToday.  The challenge is based on violations of both the Fifth and Tenth Amendments to the U.S. Constitution, which the polititians had taken an oath to uphold. 

The new law will interfere greatly with the patient-physician relationship, inserting polititians and bureaucrats into the middle.  Patients will suffer. 

Steve Parker, M.D. 

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March 31, 2010 · 3:07 PM

Drug Review: Meglitinides (repaglinide and nateglinide)

Meglitinides—also called glinides—increase the output of insulin by the pancreas beta cells into the bloodstream.  In that respect they are similar to sulfonylurea drugs, so the two classes are sometimes lumped together as insulin secretagogues.  If the pancreas produces no insulin at all—as in most cases of type 1 diabetes—these drugs won’t work. 

Two meglitinides are available in the U.S.: repaglinide is sold as Prandin, and nateglinide is Starlix. 

Meglitinides have about the same effectiveness as sulfonylureas, but are considerably more expensive.  Repaglinide and nateglinide  increase the pancreas’ output of insulin, working faster than sulfonylureas.  They don’t last as long as sulfonylureas, which may help avoid hypoglycemia.  Glinides work mostly to reduce sugar levels after meals.   

We don’t know if these drugs affect death rates. 

Uses

May be used alone or in combination with certain other diabetic drugs.  Since they have the same mechanism of action, sulfonylureas and meglitinides would not normally be used together.  In combination therapy, you want to use drug classes that work by different mechanisms. 

Dosing

Starting dose for repaglinide is 0.5 mg by mouth before each meal.  Maximum dose is 4 mg before each meal.

Nateglinide: 120 mg by mouth immediately before each meal.

Side Effects

Hypoglycemia is the most common and potentially serious adverse effect of the meglitinides, but may be less common than with sulfonylureas.   

Weight gain is common. 

Precautions . . .

Nateglinide:  Use with great caution, if at all, in the setting of severe kidney disease and moderate to severe liver disease.

Repaglinide:  Use cautiously in severe kidney and liver disease.

Steve Parker, M.D.

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March 31, 2010 · 2:00 AM

Ronald McDonald Retiring

Tom Naughton at his Fat Head blog has a hilarious interview with Ronald McDonald.

Steve Parker, M.D.

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March 30, 2010 · 11:59 AM

What’s Passover?

This is the first day of Passover, a major Jewish holiday.  My Lord and Savior, Jesus Christ, was a Jewish carpenter while he was walking the Earth.  I figure he must have observed Hebrew traditions.  In preparation for teaching my children about Passover, I reviewed it at Wikipedia.  Here’s a brief summary:

Passover is the Jewish celebration of the Hebrews’ release from enslavement by Pharaoh in Egypt.  Before release, the Lord brought ten plagues to Egypt.  The tenth plague was the killing of the firstborn – all in the area: humans (including Pharaoh’s firstborn), even cattle.

The Hebrews were instructed to mark their doorposts with the blood of a spring lamb.  The spirit of the Lord would pass over those homes, sparing the firstborn therein.

The Wikipedia article is a quick read full of interesting details on Passover customs.

Steve Parker, M.D.

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