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 16, 2010 · 2:00 AM

Eat the Right Carbs to Alleviate Diabetes and Heart Disease

Harvard’s Dr. Frank Hu in 2007 called for a paradigm shift in dietary prevention of heart disease, de-emphasizing the original diet-heart hypothesis and noting instead that “. . . reducing dietary GL [glycemic load] should be made a top public health priority.”  Jim Mann at the University of Otago (Dunedin, New Zealand) authored a 2007 review of carbohydrates and effects on heart disease and diabetes.  Here are highlights from the article summary in the European Journal of Clinical Nutrition:

The nature of carbohydrate is of considerable importance when recommending diets intended to reduce the risk of type II diabetes and cardiovascular disease and in the treatment of patients who already have established diseases. Intact fruits, vegetables, legumes and whole grains are the most appropriate sources of carbohydrate. Most are rich in [fiber] and other potentially cardioprotective components.  Many of these foods, especially those that are high in dietary fibre, will reduce total and low-density lipoprotein cholesterol and help to improve glycaemic control in those with diabetes.

Frequent consumption of low glycaemic index foods has been reported to confer similar benefits, but it is not clear whether such benefits are independent of the dietary fibre content of these foods or the fact that low glycaemic index foods tend to have intact plant cell walls.

A wide range of carbohydrate intake is acceptable, provided the nature of carbohydrate is appropriate. Failure to emphasize the need for carbohydrate to be derived principally from whole grain cereals, fruits, vegetables and legumes may result in increased lipoprotein-mediated risk of cardiovascular disease, especially in overweight and obese individuals who are insulin resistant.

Why does this matter to me and readers of this blog?  Dietary carbohydrates are a major determinant of blood sugar levels, tending to elevate them.  Chronically high blood sugar levels are associated with increased complication rates from diabetes.  People with diabetes are prone to develop heart disease, namely coronary artery disease, which causes heart attacks, weakness of the heart muscle, and premature death. 

Steve Parker, M.D.

References: 

Mann, J.  Dietary carbohydrate: relationship to cardiovascular disease and disorders of carbohydrate metabolism.  European Journal of Clinical Nutrition, 61 (2007): Supplement 1: S100-11.

Hu, Frank.  Diet and cardiovascular disease prevention: The need for a paradigm shift.  Journal of the American College of Cardiology, 50 (2007): 22-24.

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January 14, 2010 · 2:00 AM

Low-Glycemic Index Eating Improves Control of Diabetes

Lowering glycemic index (GI) led to improved contol of blood sugar, better insulin sensitivity, and weight loss in people with type 2 diabetes given group education sessions, according to researchers at Pennsylvania State University.

As background, the scientists note that:

GI may play a role in preventing or treating type 2 diabetes by decreasing the risk for obesity or by altering metabolic endpoints.  Improvements in glycaemic control were observed in people with diabetes in a recent meta-analysis.  A lower-GI diet was shown to decrease postprandial glucose [blood sugar after meals] and insulin responses and improve serum lipid concentrations.  Lower-GL [glycemic load] diets were associated with decreased risk for type 2 diabetes, decreased levels of C-reactive protein and inflammation, and weight loss.

Ninety-nine test subjects completed the study that enrolled adults 40 to 70  years old who had diabetes at least one year but were not taking insulin shots.  Average body mass index was 33, so they were obese.  Average weights were 84.5 kg (186 lb) for women and 108.7 kg (239 lb) for men.  Average baseline hemoglobin A1c was estimated at 7%, so these folks were under good glucose control.  Baseline carbohydrate intake was 45% of total energy, a bit lower than the general population. 

The 9-week intervention involved nine weekly group education sessions—lasting 1.5 to 2 hours—focusing on selection of lower-GI (vs higher-GI) foods instead of restricting carbohydrates.  Also covered were monitoring of portion sizes to control carb consumption, carb counting to control carb distribution and intake, and self-monitoring of food intake. 

Results

Although weight loss was not a goal, weights fell by 1-2 kg (2-4 pounds).  Men lost more than women.  Overall diet glycemic index fell by 2-3 points (a modest amount).  Comparing values before and after intervention, fasting glucose and postprandial glucose fell significantly, and insulin sensitivity improved.  Although not measured, the authors estimate hemoglobin A1c levels would have fallen an absolute 0.3%, based on measured glucose levels.  Percentage of calories from carbohydrate did not change. 

Comments

This is one of the few studies to try low-glycemic index behavioral intervention in adults with type 2 diabetes.  Results are encouraging. 

The researchers and I wonder if results would have been even more dramatic if the test subjects hadn’t been so well controlled before intervention or if they had dropped their glycemic index even lower.  Probably so.  Many people with type 2 diabetes have hemoglobin A1c’s well over 7%.

The researchers attribute the weight loss to portion control and simple self-monitoring of consumption. 

For people with diabetes, this study supports selection of lower-glycemic index instead of higher-GI.  In fact, we’d see less diabetes, heart disease, breast cancer, and gallbladder disease if all women—diabetic or not—ate lower-GI. 

Steve Parker, M.D.

Reference:  Gutschall, Melissa, et al.  A randomized behavioural trial targeting glycaemic index improves dietary, weight and metabolic outcomes in patients with type 2 diabetes.  Public Health and Nutrition, 12(2009): 1,846-1,854.

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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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January 10, 2010 · 2:00 AM

Diabetes + Overweight and Obesity = Diabesity

Mark Hyman, M.D., blogged about diabesity at the Huffington Post December 24, 2009.  He defines diabesity as a problem with glucose regulation associated with overweight and obesity.  The glucose physiology problem ranges from metabolic syndrome to prediabetes to full-blown type 2 diabetes.

“Diabesity” has been in circulation for a few years, but hasn’t caught on yet. 

What interested me about his blog post was that he advocates the Mediterranean diet as both therapeutic and prophylactic.  To quote Dr. Hyman:

The optimal diet to prevent and treat diabesity includes:

  • Fruits
  • Vegetables
  • Nuts
  • Seeds
  • Beans
  • Whole grains
  • Healthy fats such as olive oil, nuts, avocados, and omega-3 fats
  • Modest amounts of lean animal protein including small wild fish such as salmon or sardines

This is commonly known as a Mediterranean diet.  It is a diet of whole, real, fresh food. It is a diet of food you have to prepare and cook from the raw materials of nature.  And it has broad-ranging benefits for your health.

Food for thought, no doubt. 

Steve Parker, M.D.

Reference:  Hyman, Mark.  The diabesity epidemic part III:  Treating the real causes instead of the symptoms.  The Huffington Post, December 24, 2009

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January 9, 2010 · 2:00 AM

Recipe: Low-Carb Chili

I made this chili last night for the family.  It’s spicy, but not hot spicy.  Sliced and peeled cold cucumbers are a nice side dish.  The kids are not eating low-carb; they enjoyed the chili mixed 50:50 with cheese macaroni, and buttered cornbread on the side.      

Ingredients

20 oz  Ground beef, 80% lean meat/20% fat, raw

20 oz  Sausage, Italian, pork, raw

1  Onion, large, raw 

14.5 oz  Tomatoes, canned, diced

4 oz  Tomato paste 

1 tbsp  Cocoa powder, dry, unsweetened

5  Garlic cloves, raw

1/2 tsp  Salt

1/4 tsp  Allspice, ground

2 tbsp  Chili powder

1/4 tsp Cinnamon, ground

0.5 tbsp Cumin, ground 

1/4 tsp Cayenne pepper, ground

2 packets  Splenda sweeteners (packet is 1 g)

 1 cup  Water

Preparation

Cut the Italian suasage into small pieces.  Fry the sauage, ground beef, onions, and garlic in a large pot.  Don’t just brown the meat: cook it thoroughly.  When done, drain off the fat if desired.  Add the remainder of ingredients, bring to a boil, then simmer for about an hour.  Add additional water if the chili looks too thick.  Makes eight cups.  Serving size is one cup. 

Nutrient Analysis (compliments of NutritionData.com)

One cup serving:  492 calories.  10% of calories from carbohydrate, 69% from fat, 21% from protein.  Total fat 38 g.  Total protein 24 g.  Total carbohydrate 14 g.  Fiber 3 g.  Digestible carbohydrate 11 g.  Percent Daily Values: 23% of vitamin A, 28% of vitamin C, 21% of iron. 

Notes: Analysis is based on fat not being drained from the cooked meat.  Calorie count and calories from fat would be a bit lower if you drained off fat.

Steve Parker, M.D.

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January 8, 2010 · 2:00 AM

What Are Phytonutrients and What Have They Done For Me Lately?

Nutrition scientists think that plants have small amounts of numerous “bioactive compounds,” sometimes referred to as phytonutrients, that protect us against disease.

Many scientific studies have looked at groups of people over time, noting the various foods they eat as well as the diseases they develop.  These are called epidemiologic, ecological, or observational studies.  One finding is that lower rates of heart disease, vascular disease, and cancer are seen in people consuming plant-based diets.  “Plant-based” isn’t necessarily vegetarian or vegan.  The traditional Mediterranean diet, for example, is considered by many to be plant-based because meat, fish, and poultry are not prominent compared to plants. 

In contemplating what source of carbohydrates a person with diabetes should eat, I’ve been reviewing the scientific literature to see which sources of carbs might provide the biggest bang for the buck in terms of health and longevity benefits.

Here are some quotes from a 2002 review article in the American Journal of Medicine:

Phenolic compounds, including their subcategory, flavonoids, are present in all plants and have been studied extensively in cereals, legumes, nuts, olive oil, vegetables, fruits, tea, and red wine. Many phenolic compounds have antioxidant properties, and some studies have demonstrated favorable effects on [blood clotting] and [growth of tumors]. Although some epidemiologic studies have reported protective associations between flavonoids or other phenolics and cardiovascular disease and cancer, other studies have not found these associations.

Hydroxytyrosol, one of many phenolics in olives and olive oil, is a potent antioxidant.

Resveratrol, found in nuts and red wine, has antioxidant, [anti-blood-clotting], and anti-inflammatory properties, and inhibits [malignant tumor onset and growth].

Lycopene, a potent antioxidant carotenoid in tomatoes and other fruits, is thought to protect against prostate and other cancers, and inhibits tumor cell growth in animals.

Organosulfur compounds in garlic and onions, isothiocyanates in cruciferous vegetables, and monoterpenes in citrus fruits, cherries, and herbs have [anti-cancer] actions in experimental models, as well as [heart-healthy effects].

In summary, numerous bioactive compounds appear to have beneficial health effects. Much scientific research needs to be conducted before we can begin to make science-based dietary recommendations. Despite this, there is sufficient evidence to recommend consuming food sources rich in bioactive compounds. From a practical perspective, this translates to recommending a diet rich in a variety of fruits, vegetables, whole grains, legumes, oils, and nuts.

The article discusses phytoestrogens—plant chemicals that act in us like the female hormone estrogen—but effects are complex and I suspect we know much more now than we did in 2002 .  Soy products are the most well-known source of phytoestrogens.

The traditional Mediterranean diet is rich in all of the foods mentioned above, except for tea.  Even the Ketogenic Mediterranean Diet includes the aforementioned foods except for tea (I need to add tea and coffee), cereals, and cherries.

Steve Parker, M.D.

Reference:  Kris-Etherton, P.M., et al.  Bioactive compounds in foods: their role in the prevention of cardiovascular disease and cancer.  American Journal of Medicine, 113 (2002. Supplement 9B): 71S-88S.

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January 7, 2010 · 2:00 AM

Book Review: Cheating Destiny – Living With Diabetes, America’s Biggest Epidemic

I read James Hirsch’s book in 2006 but never got around to reviewing it.  Better late than never?  I give it four stars per Amazon.com’s rating system: “I like it.”

♦   ♦   ♦

Cheating Destiny: Living With Diabetes, America's Biggest EpidemicIf you have diabetes or love someone who is afflicted by diabetes, you’ll benefit from this book. It’s an insider’s view into the world of diabetes, with a predominant focus on type 1 rather than type 2.  Both are covered well.

Look elsewhere for a “how-to” book on managing diabetes.  Cheating Destiny is about emotions, coping strategies, public policy, and history.  Although I’ve been treating diabetes for over two decades, Mr. Hirsch taught me a thing or two.  For instance, did you know . . . that some people with diabetes are offended if you call them diabetics? (They prefer “people with diabetes.”)  That diabetes was considered shameful years ago?  That even the preeminent Joslin Diabetes Clinic loses money and has to be supported by private donations?  That the founder of d-Life TV was a patient of the iconoclastic Dr. Richard Bernstein?  About the exciting story of the discovery of insulin by Fred Banting and Charles Best in 1922?   

The author himself has type 1 diabetes.  The heart-wrenching story of his son’s diagnosis at age 3 showcases Mr. Hirsch’s considerable writing skills. 

To counter the sad and frustrating aspects of diabetes, the book is peppered with  funny anecdotes.  Did you ever duck in to a private booth at a girlie peep show to inject insulin?  Mr. Hirsch has!  [It’s not what you think.]

One undercurrent of the book I take issue with is the implication that the medical profession somehow perpetuates diabetes or purposefully provides inadequate care, because that’s where the money is.  Why work hard to cure diabetes or prevent complications when the profession makes money off the disease and it’s complications?  I don’t see it that way at all.  It is true, however, that preventive care and cognitive medical services (as opposed to invasive procedures) are poorly funded by insurance.  That’s an economic and political problem, not an ethical one in physicians and researchers.
 
Full disclosure:  My defunct outpatient medical practice is mentioned in chapter five.  The author outlines my efforts to provide conscientious care to people with diabetes – mostly type 2 – despite poor funding from insurers (primarily Medicare in my practice at the time).  Poor pay for cognitive services forced me to close my office.  I found Mr. Hirsch to be a thorough and accurate researcher.

[I’m a hospitalist and health blogger now.]

Other highlights of the book are discussions of Dr. Elliott Joslin, an overweight Southern black woman (the Diabetes Queen), intimate details about the type 1 diabetes experience from the patient and family perspective, Dr. Richard Bernstein, insulin pumps, islet cell transplants, origins of the Juvenile Diabetes Research Foundation, Douglas Melton and stem cell research, research rivalries and funding, and inspirational survivor tales.

Mr. Hirsch rightfully criticizes many aspects of the health and medical fields with regards to diabetes.  Thankfully, he never suggests a sweeping government take-over of the healthcare industry.  He urges diabetics – people with diabetes – to take care of their own disease and demand improvements in the current system.

The U.S. already has 24 million people with diabetes and another 54 million with prediabetes.  Approximately one of every three persons born in the U.S. in 2000 will develop diabetes in his or her lifetime, according to the Centers for Disease Control and Prevention.

I agree with Mr. Hirsch that diabetes is “the country’s leading public health crisis,” driven by obesity and the aging of the population.”  This book will help alleviate the damages. 

Steve Parker, M.D.

Disclosure:  I bought this book at Amazon.com.  I was not paid to review it.

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January 6, 2010 · 2:00 AM

Legumes and Whole Grains: Any Role in Diabetes?

Expert nutrition panels consistently recommend whole grains and legumes for people with diabetes.  Why?  And do these foods affect development of diabetes?  I found a pertinent scientific review article on the subject from 2004 in the European Journal of Clinical Nutrition.  Here are some pertinent quotes from the summary:

Epidemiological studies strongly support the suggestion that high intakes of whole grain foods protect against the development of type II diabetes mellitus (T2DM). People who consume approximately 3 servings per day of whole grain foods are less likely to develop T2DM than low consumers (<3 servings per week) with a risk reduction in the order of 20-30%.

The role of legumes in the prevention of diabetes is less clear, possibly because of the relatively low intake of leguminous foods in the populations studied. However, legumes share several qualities with whole grains of potential benefit to glycaemic control including slow release carbohydrate and a high fibre content. A substantial increase in dietary intake of legumes as replacement food for more rapidly digested carbohydrate might therefore be expected to improve glycaemic control and thus reduce incident diabetes. This is consistent with the results of dietary intervention studies that have found improvements in glycaemic control after increasing the dietary intake of whole grain foods, legumes, vegetables and fruit.

. . . it is cereal fibre that is largely insoluble [rather than soluble fiber] that is associated with a reduced risk of developing T2DM.

Thus, there is strong evidence to suggest that eating a variety of whole grain foods and legumes is beneficial in the prevention and management of diabetes. This is compatible with advice from around the world that recommends consumption of a wide range of carbohydrate foods from cereals, vegetables, legumes and fruits both for the general population and for people with diabetes.

Gluten Intolerance

A major protein in wheat is gluten.  The last few years have seen the popular emergence of gluten-free this and gluten-free that.  The idea is that gluten causes a variety of gastrointestinal, immunologic, and other problems, so wheat products should be avoided.  Certainly they should be avoided in people with celiac disease, a well-established medical condition.  I follow a few paleo blogs and know that grains and legumes are not part of that way of eating: the paleos say we are not evolved optimally to process them.    

If legumes or wheat or other grains cause problems for you, don’t eat them.  They have no essential nutrients that you can’t get elsewhere. 

Glycemic Index

In my quest to develop a healthy Diabetic Mediterranean Diet, I’m finding that grains—compared to nearly all other carbohydrate-containing food groups—tend to have a higher glycemic index (GI).   A low GI is 55 or less.  High GI is 70 or greater.  Grains in general raise blood sugar levels higher than many other sources of carbohydrates.  But this is highly variable and depends partially on preparation of the grain.  Whole grain products have a lower GI than highly processed counterparts.  For instance, white bread has a GI of 70; whole wheat bread 67.  Regular spaghetti is 38.  Table sugar’s GI must be sky high, right?  No, its just 61.  A baked potato is a whopping 85.   

Beans have a GI around 30 or 40.  And they pack a lot more fiber per serving.  For a diabetic struggling to keep blood sugars under control, which is a better choice: grains or legumes?  I’m leaning towards legumes and other components of a low-glycemic-index diet.   

Steve Parker, M.D.

PS:  [Before you correct my GI numbers, please note I’m  aware that various GI lists don’t agree with each other.]

Reference:  Venn, B.J. and Mann, J.I. Cereal grains, legumes and diabetes.  European Journal of Clinical Nutrition, 58 (2004): 1,443-1,461.

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January 5, 2010 · 2:00 AM

One of Every Three Born in 2000 Will Develop Diabetes

"No diabetes in my future!"

The U.S. already has 24 million people with diabetes and another 54 million with prediabetes.  Approximately one of every three persons born in the U.S. in 2000 will develop diabetes in his or her lifetime, according to the Centers for Disease Control and Prevention.

Incredible.

And largely preventable if we have the will.

Steve Parker, M.D.

Reference: Prediabetes FAQs at the CDC website.

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