Fork U with Dr. Terry Simpson

The term vitamin was coined by the chemist Casimir Funk as he revealed the Thiamine structure to the world. So while you may think – isn’t vitamin A (it is the alphabet) the first vitamin – we take our poetic license here to point out that the first compound to be called a vitamin was Thiamine, now known as vitamin B1. But the story of that vitamin was made possible by two individuals – but the most noteworthy was Takaki Kanehiro.Our podcast today discusses the education of Kanehiro and how that influenced his view. But let’s work backward a bit.Vitamin B1 and BeriberiBeriberi is caused by a lack of vitamin B1 (thiamin) in the diet. This vitamin is essential in the biochemical process of utilizing fats, carbohydrates, and proteins for energy. The nerves are particularly affected because of their metabolic pathways – hence, a wide range of symptoms from difficulty with walking (motor function) then sensory function of the legs, and finally, it affects the conduction in the heart, which leads to death.White Rice and BeriberiWhite polished rice was the fad food not only in the cities of Japan but also in China. To polish the rice, the husk and germ are removed, but this is also where the vitamins are. When people eat just one food item, they are likely to develop a deficiency disease, and this was the case with sailors and white polished rice.The officers would not only eat rice but were given a variety of foods and thus avoided beriberi. But the crew typically only ate white rice.Beriberi in Mid-1800’s JapanIn Japan in the mid-1800s, especially in the city, polished white rice was the calorie source of choice. White rice is easy to store, looks clean, is faster to cook, and eating it is less chewy. White rice was considered what the wealthy people ate – it was beautifully displayed, and unlike brown rice, did not go rancid. What they didn’t know was the processing of the rice led to stripping the rice of the vitamin-rich portion. In the rural areas of Japan, there was little beriberi as they mostly ate brown rice (barley rice). This led to a major problem in their Navy, where beriberi was endemic. White polished rice was the caloric source for the Navy, and often one third of the crew would develop beriberi and be unable to carry out their duties.There were many thoughts as to the cause of beriberi, but none of them had panned out well.Eastern Traditional Cures for BeriberiOn occasion, Eastern healers would recommend various teas and herbs. But, some would recommend barley rice. Some of these cures are retrospective, meaning once the traditional Japanese medical folks learned that barley rice was a cure for beriberi, they stated that they had prescribed it for years. Barley rice does have vitamin B1 (1 cup contains a day’s supply). But during the time, the cures from these village doctors were rare and not enough for the Japanese Navy, in spite of losing more people to beriberi than to war – would adopt. Also, note that barley rice is not as transportable as white polished rice and has a shorter shelf life. During this time, Japan was becoming westernized, and they were working on importing medical ideas from Germany, although they had a fair bit of influence from the British method. Kanehiro’s trainingWhen Kanehiro was being trained, his initial training was from the Eastern Medicine part of his province. This training was apprentice-like, and he heard someone say that “There are no good doctors in Sustama.” When William Wills opened a medical school in his province, he jumped at the chance – but Wills encouraged him to go to London for further training.In order to do this, Kanehiro joined the Navy in 1872. He remained in the Japanese Navy for the rest of his life.In 1875 Kanehiro went to London and began to study at St Thomas Hospital. To this day, St Thomas hospital sits across the Thames River from Westminster, Big Ben, and parliament.Epidemiology – cholera to beriberiJust a 30-minute walk from the St Thomas hospital is the Broad Street Pumping station, where 22 years before, John Snow had meticulously shown how cholera had been transmitted through the water. The theory of cholera was not widely accepted at the time, in spite of the guardians removing the pump handle in 1859 and the outbreak stopping. By the time Kanehiro arrived, the methodology of Snow and the field of epidemiology was the most heralded new science of the day.Besides learning modern surgical methods of the day, Kanehiro also learned epidemiology and the scientific method.Return to Japan and the Study of Diet as a cause of BeriberiWhen Kanehiro returned to Japan, he dedicated himself to finding the cure for beriberi – the disease that killed more Japanese sailors than battle. Using the methods of epidemiology, he developed an experiment to prove that beriberi was secondary to the food they ate and not the other conditions of the ship.For the rest of the story – please liste

The Green Mediterranean DietImagine being able to improve the Mediterranean Diet with a few changes. Is the new "Green" Mediterranean Diet the ultimate hack? The Green Mediterranean Diet  (Green-Med) has become the hottest version of the MED diet yet.Advantages of the Green Mediterranean DietThere are three advantages to Green-MedLess Fatty LiverDecreased risk of heart diseaseLess Visceral FatFatty LiverNon-alcoholic fatty liver disease is the number one cause of liver failure in the United States. It surpassed alcoholic liver disease as the number one reason for liver transplants. But how do you get fatty liver?Is fatty liver caused by sugar or fat or both?Low-Carb enthusiasts blame fructose, or almost any sugar, as the cause of fatty liver disease. Although the latest boogyman is "seed oils." On the other hand, vegans will blame saturated fats.But sugars in mice are not the same as sugars in men.Fatty liver appears to be a byproduct of obesity, excess calories, and genetics.Reducing fatty liverAfter weight loss surgery, people rapidly lose weight, including in their liver.But people on the Green Mediterranean Diet lost more weight in their liver than those with the standard Mediterranean diet.Visceral FatBelly fat is one of the hardest fats to get rid of. As people age, belly fat increases. So when women go through menopause, they increase belly fat.  And lowering belly fat is best done through weight loss with a high-fiber diet and cardiovascular exercise. But Green-Med appears to lower it even more.Cardiovascular Risk FactorsAlthough MED is known for reducing the risk of heart disease, Green-Med seems superior.Implementing the green Mediterranean DietThe difference between the green and standard Mediterranean diet28 grams of walnuts a day - about one ounce3-4 cups of green tea per day100 grams per day of frozen MankaiReduction in red meatGreen Tea is EasyThere are more polyphenols in it than in black tea - so it's easier to drink.Adding walnuts is easy; they are also a great source of omega-3 fatty acids.Decreasing red meat isn't difficult.Finding Mankai or duckweed - well, you can't in the United StatesNo one has reproduced the data about the Green Mediterranean Diet - perhaps because they can't find those frozen cubes of duckweed.

LiverKing Falls From GraceNot that anyone was surprised the so-called Liverking was using steroids. But he fooled many people that his diet and intense training led to this frame. The diet he recommended was some form of an "ancestral" diet. We have covered the carnivore-type diet before. So how did this all happen?The Rise of LiverKingLiverKing's rise was meteoric. He began posting on Instagram in 2021 and now has almost 2 million followers.His trademark was showing off his abdominal muscles on his five-foot-five-inch frame. All the time advocating eating raw liver.Isn't that a hook? Eat raw liver, get abdominal muscles, and look like him.But his rise was anything but an accident.Powering up the MediaIn his emails, he whines about how he wants to build his following but was concerned that the steroids he had were not enough. So he was begging for help from someone in the UK. He was taking thousands of dollars of steroids a month.His plan? Getting over a million followers and selling supplements.He had a "live-in" video recorder to follow his antics.Guess who his partner was in supplements?The Supplement IndustryHow do most scam artists in the medical field make money? Selling supplements. Be that Joseph Mercola, or Mark Hyman, or Ken Berry. All people who make millions a year selling supplements.So what to do if you are trained in psychiatry but don't want to see people? You sell supplements. So the business partner is one Dr. Paul Saldino - aka Carnivore MD.Since the revelation about Brian Johnson's (LiverKing) steroid use Saldino said he would have to distance himself from him. Good friend, eh? That is a business decision. If you are a friend of mine and have a fall from grace, I will be at your door to help, not distance.This was pure theater and pure business - well, not so pure.Supplements can kill.But so can their diet.The Diet They Don't EatMake a following eating raw liver. Yell at the dinner table about how raw liver is good for you. Makes great content for your videos. Eating raw liver can kill you.Carnivores and extreme keto types always like pointing to hunter-gatherer societies for optimal "primal health." But my cousins in Alaska don't eat liver.There is enough vitamin A in polar bear's liver to kill 52 people. But the biggest outbreak of trichinellosis in the United States came from eating grizzly bear liver.Wait, can I get sick from too much Vitamin A?Vitamin A toxicity symptoms include drowsiness, irritability, abdominal pain, nausea, and vomiting. Then you lose your hair; then your skin starts to peel. Not to mention it can damage your liver - ironic, eh?The tolerable limit of vitamin A is 10,000 units a day. Beef liver has 15,000 units in 3 ounces.But LiverKing didn't eat liver in real life. What did he eat?The Maple Syrup and Hormone DietLiverKing ate 120 grams of maple syrup, 50 grams of dextrose, and ONLY 2 ounces of red meat a day.Why - he was taking insulin and needed to take a lot of sugar.He said he was super strict, working out - and his emails had his diet. Almost none of it was organ meat. He was specific and precise.-----Produced by Simpler Media

Leaky Gut: Facts and FadsThe latest fad of supplement makers is to talk about "gut health." The latest boogyman for the gut is the "leaky gut." The other name for leaky gut is intestinal permeability.A Surgeon's ViewAs a surgeon, a "leaky gut" is a devastating surgical emergency. Surgeons emergently operate to remove the gut that no longer has a barrier function.The dark gut is dead and needs to be surgically removed. This gut has no barrier function and will allow bacteria from the inside of the small bowel to easily enter the patient's bloodstream. Leading to septic shock and death.The Non-Surgical Emergency or Chronic Leaky GutBut a leaky gut doesn't have to be so dramatic.  Not leading to septic shock or needing to be removed. In this model, the intestinal barrier is "leaky," not to the point of causing sepsis. But the leaky gut enables small molecules to leak out of the gut into the bloodstream. Thus producing chronic inflammation.Chronic inflammation may cause obesity. Emphasis on "may."Emulsifiers and ObesityRodent studies have provided fascinating insights. Certain emulsifiers, when added to the diet of mice or rats, lead to obesity.  In one experiment, rodents were fed identical amounts of kibble. But one group, emulsifiers, was added to their water.  These emulsifiers, like polysorbate 80, not only produced obesity but also disrupted the microbiome of the gut (ref). But mice are not men.When dietary emulsifiers are examined in humans, high levels cause disruption of the gut. However, there is little evidence that small amounts found in the food supply cause issues. (ref 4)Non-Humans and Leaky GutWhile animal models are interesting, human studies provide useful information. That a rat or mouse has a leaky gut based on some intervention is not an equivalence in humans.Functional Medicine and Leaky GutIf you searched "leaky gut," you will find a host of "functional medicine" doctors providing supplements, bone broth, probiotics, and other scams.  On the shelves of drug stores and "health food stores," you will find abundant supplements to "support gut health."Disease States and Leaky GutFunctional medicine physicians associate many disease states with leaky gut. The following have little or no good evidence to be caused by a leaky gut:Alcoholic cirrhosisAsthmaAutismChronic fatigue syndromeDepressionEczemaEnvironmental enteropathyEosinophilic esophagitisFibromyalgiaKwashiorkorMetabolic syndromeMultiple sclerosisNon-alcoholic fatty liver disease (NAFLD)ObesityPancreatitisParkinson's diseasePsoriasisRheumatoid arthritisNon-Controversial Causes of Leaky GutThere is no doubt celiac disease, Crohn's disease, radiation, and ulcers from non-steroidal anti-inflammatory drugs; certain bacteria can cause a change in intestinal permeability (another name for leaky gut). Celiac disease and Crohn's disease have been studied for years (ref 2, ref 3). While we know gluten exacerbates the auto-immune function of those with Celiac disease, we do not yet have a mechanism for Crohn's disease.Gut Barrier Anatomy and FunctionThe small bowel's purpose is primarily for the absorption of nutrients. Some nutrients are actively transported from the gut to the bloodstream, and some are passively absorbed. The gut must also serve as a barrier to prevent bacteria, toxins, and other materials from entering the body.The first line of defense is the mucus layer of the gut. Secreted by Goblet cells, mucus prevents bacteria, toxins, and potential antigens from contact with the epithelial cells. There are multiple mucus proteins secreted. Gut immune cells secrete IgA antibodies into the mucus as a further defense against invaders.Most research focuses on the tight junctions between intestinal epithelial cells.Correlation or CausationWhat if altered permeability is an association and not causation? While stress, antigens, and intense physical activity alter barrier function, there is no evidence it causes a clinical consequence. Finally, there is no evidence that barrier function leads to any disease. Nor is there any evidence that intervention to improve barrier function alters the natural history of disease (ref 4).Mediterranean Diet and Barrier FunctionIn a recent clinical study, 260 women with the BRCA gene were assigned to the Mediterranean Diet or a control group (ref 5). These women were part of a study examining the effect of the Mediterranean diet and physical activity, who were at high risk for breast and ovarian cancer.In the Mediterranean Diet group, there was an increase in short-chain fatty acids and fiber found in the stools.  There was no statistically significant change in the plasma LBP or fecal zonulin. But in multiple-level regression, the change in short-change fatty acids did lead to a decrease in the permeability makers. When looking at the food groups, they found that vegetables, fruit, legumes, nuts, olives, wine, and total fiber were correlated with the shift in short-chain fatty acids

The Beer and Sausage DietThere are a lot of crazy diets out there. All of them you can lose weight with. Weight loss has many advantages. But the beer and sausage diet was fun. Here is what we learned:A calorie is just a calorieBeing in calorie deficit is difficultMeticulous journaling is importantYour lab values will improve with weight lossA beer is a good unit measureWeighing your food is importantEpisode Sponsor: Modifyhealth.com I'm The DoctorIf you hear Evo Terra on national television talking about the beer diet, you will hear my name. I'm the doctor.Late one September, I get a call from my friend, Evo Terra. He said, "October is coming; I want to lose some weight and want to do a beer fast. "So we devise a diet, not just beer - but let's add sausages. After all, what is beer without sausages?Careful SupervisionThis was a medically supervised diet. It ran for the month of October every year for four years. Every week he would come into my clinic.  Every week he would have blood draws. cholesterol levels liver enzymesWeekly weightWe would check muscle mass vs. fat mass inflammatory markersWe were prepared to stop the experiment and return him to a normal diet. For Evo, a normal diet is maybe not your diet.  Since Evo likes the food I make, I assume he has a great diet.  For many years, one of my great joys in Phoenix was when Evo and his wife would come over for dinner Sunday nights. Damn, I miss those days.There are advantages to beer and sausagesA beer is a single unit. There is little variation in terms of caloric intake.Sausage can easily be weighed, and Evo was strict regarding the weight of his sausages.We added vitamins and fiber to his regimen.He had six beers a day, and a designated driver at all times.Science WinsFor those who say grains are evil and you can never lose weight or you would have horrible inflammation, well, Evo didn't fit with that. Because no one does. The idea that grains are evil is a myth of the low-carb community.Vegans didn't like the idea of Evo eating sausages: "Pure processed meat will lead to inflammation and all the evils associated with eating meat."It didn't happen.Calorie deficit led to weight loss, despite drinking beer and eating sausages.His inflammatory markers didn't rise; they went down.His cholesterol went down.His liver enzymes decreased - not that they were high to begin with.Every year he kept his weight off - we are now over ten years past the last experiment.Conclusions:I don't recommend this as a weight loss method. I do recommend weight loss by the simple principles of calorie restriction, a well-rounded diet, and vigorous exercise. Which diet, you ask? Either the Mediterranean or the DASH diet.Evo wrote a book, and you can buy it here.

Losing Weight With AppsCan a phone app help you lose weight? How about with your cholesterol, blood pressure, or waist size?Perhaps you've heard the latest Noom ads, where they boast forty publications showing that their app will help you lose weight.Apple is coming out with more ways to have their new watch track your heart rate and steps, with apps even looking at your yoga workout and eventually telling your blood glucose.Episode Sponsor: Modifyhealth.com What the Studies ShowA recent meta-analysis of randomized controlled trials showed that the average weight loss in the first three months was slightly below five pounds (2.18 kg).Unfortunately, the weight loss didn't last.  Nine months later, they had regained a pound and a half for a total loss of 3.5 pounds (1.63 kg).Blood Pressure, Cholesterol, and CaloriesThere was a slight improvement in blood pressure at three months. But cholesterol and total energy intake, as well as waist circumference and blood glucose, remained the same.The Proliferation of AppsThere are over 500,000 applications on Android and Apple phones to track various health data points. In addition, there are other devices just measuring fitness. The theory of measuring fitness behaviors with calorie tracking to provide feedback to improve health is appealing.Many Apps With Poor QualityMany apps had a lack of behavioral coaching and poor quality of scientific information. Tracking over a three-day period found that the accuracy of energy intake among apps was only fair in terms of total calories and amounts of macro- and micronutrients.What About NoomNoom is one of the more popular paid apps. They boast over 40 peer-reviewed articles. A quick glance at the articles showed some surprising flaws:One article compared Noom in pancreatic cancer patients to a control group who received no coaching.Another article used Noom data for their references.Article after article that Noom sites are little more than using Noom's data without dropout rates. References:Chen J, Cade JE, Allman-Farinelli M. The Most Popular Smartphone Apps for Weight Loss: A Quality Assessment. JMIR Mhealth Uhealth. 2015 Dec 16;3(4):e104. doi: 10.2196/mhealth.4334. PMID: 26678569; PMCID: PMC4704947.Chew HSJ, Koh WL, Ng JSHY, Tan KK. Sustainability of Weight Loss Through Smartphone Apps: Systematic Review and Meta-analysis on Anthropometric, Metabolic, and Dietary Outcomes. J Med Internet Res. 2022 Sep 21;24(9):e40141. doi: 10.2196/40141. PMID: 36129739; PMCID: PMC9536524.Keum J, Chung M, Kim Y, Ko H, Sung M, Jo J, Park J, Bang S, Park S, Song S, Lee HUsefulness of Smartphone Apps for Improving Nutritional Status of Pancreatic Cancer Patients: Randomized Controlled Trial JMIR Mhealth Uhealth 2021;9(8):e21088 URL: https://mhealth.jmir.org/2021/8/e21088 DOI: 10.2196/21088Pohl, M. "325,000 mobile health apps available in 2017—Android now the leading mHealth platform. Research 2 Guidance." (2017).

Decreasing cholesterol: drugs and dietThere is a persistent belief that lifestyle can take care of all cholesterol problems. Lifestyle can make things worse, but once things are worse, it cannot make things better.Once you have disease, or cholesterol is higher, you need treatment often beyond lifestyle management.This distresses many people, who wish to have control over their fate.High cholesterol is one of the main causes of heart attacks, strokes, and peripheral vascular disease. You can lower cholesterol through diet and exercise by as much as 15 percent. Lifestyle changes are the first choice to decrease cholesterol. Modern drugs, however, will lower cholesterol levels far more than diet or exercise.The progressive changes of a vesselThe normal artery, as shown below, is a free-flowing blood vessel. When a person is in their late teens, there is already fatty formation on the inside of the vessel wall.As more fat is deposited in the vessel wall, blood flow decreases, leading to ischemia in the end organ.Angina, or heart pain, occurs when there is insufficient blood flow to the heart secondary to an artery narrowed by plaque.Factors contributing to atherosclerotic plaque formationDamage to the blood vessel begins the process ofSmokingHypertensionHigh blood sugarsDiets rich in saturated fats and refined grainsHowever, the lower the level of LDL, the less risk those factors become, as you shall see.Anatomy of the Blood VesselIf you examine the autopsy specimen of the coronary artery above, the blood flows through that lumen. The inner wall, the wall the blood comes into contact with, is called the endothelium. There are three layers to the wall of an artery:Tunica intimaTunica MediaTunica AdventiciaAtherosclerosis begins when the cholesterol transport protein enters the wall of the tunica media, whose first layer is the endothelium.Discovery of LDLIn 1954, Dr. John Gofman reported the discovery of LDL and HDL. These were the particles found when he separated plasma cholesterol-carrying lipoproteins with an ultracentrifuge. Gofman was the first to note that heart attack patients had high LDL levels. The correlation of high LDL and heart attacks has been called “one of the most profound epidemiologic correlations in all of medicine.”High LDL levels have been shown to correlate with atherosclerosis in all species studied.High LDL and AtherosclerosisThe higher the LDL level, the faster atherosclerosis develops. Factors that increase atherosclerosis are those which injure blood vessels: smoking, hypertension, hyperglycemia, and genetic factors that predispose endothelium to early injury.High LDL levels can lead to heart attacks in children as young as 6 years old. This rare form of homozygous familial hypercholesterolemia inspired Brown and Goldstein to elucidate the genetic defect in the receptor for LDL.Discovery of the LDL receptor defect Brown and Goldstein discovered that when LDL receptors are defective, it leads to the following:LDL particles circulate for a long timeThis leads to an increase in plasma levels of LDLAs a result, more deposits are made into the arteriesCreating atherosclerotic plaquesLowering LDL by feedbackTo keep blood LDL constant, your body uses a feedback mechanism. As your LDL levels increase, the target tissues produce more receptors to take up the LDL. If the LDL receptor is defective, the liver continues to increase production of LDL.Brown and Goldstein speculated that an HMG CoA reductase inhibitor would deprive liver cells of endogenous synthesis as a source of cholesterol. This deprivation would relieve the feedback repression of LDL receptors, and the resultant increase in LDL receptors would lower plasma LDL.Developing the first statinsThe FDA approved the first statin 1987, Mevacor, which reduced plasma levels of LDL and was well tolerated. It was only theory that lowering LDL would reduce heart attacks.Statins Reduce Heart Attacks and Prolong LifeStatins block cholesterol synthesis, which causes the cell to increase LDL receptors, which further decrease cholesterol in blood plasma.The first study showing that statins not only reduce LDL, decrease heart attacks, and prolong life was reported in 1994. These studies have been repeated:1996 Sachs reported use of Pravastatin on heart attacks with normal cholesterol levels1998, LIPID showed prevention of heart attacks with a wide range of cholesterol levels2002, Heart protection by cholesterol lowering in over 20,000 high-risk people in a randomized placebo control trialThe 2002 study was large enough to show a reduction in relative risk even when subjects had risk factors such as diabetes, hypertension, and smoking.For each reduction of LDL cholesterol by 40 mg /dl, cardiovascular events are reduced by 20%. This even applies to people considered low-risk (ref).Better GeneticsIn addition to people who have high cholesterol, there are those who

Alcohol and the Mediterranean DietAlcohol consumption is controversial.  No one disputes that excess alcohol consumption leads to dire consequences. But what about moderate alcohol consumption? Can we define moderate alcohol consumption? Is there a safe and therapeutic level of alcohol consumption?Alcohol is a component of the Mediterranean Diet. However, the consumption is limited to 10 ounces of red wine for men, which translates to 14 grams of alcohol. Half that amount for women. In a number of articles, this amount of alcohol is beneficial.Bias from AuthorsConfirmation bias is ingrained in all humans.  Treatment programs for alcohol addiction teach that there is no safe level of alcohol consumption.  Fundamentalist Christians, Muslims, and other organized religions have taboos regarding alcohol consumption. Finally, consumers of alcohol will be biased against abstinence.Components of WineIn their article, Wine, Polypenols and Mediterranean Diet, the authors note that one can get polyphenols from other sources in the diet, and thus the alcohol may be unnecessary.  They conclude that moderate consumption is likely an important component of a mechanistic as well as social norm.Dose Dependent Effects of Polyphenols on the BodyDecreased risk of cardiovascular diseaseDose-dependent reduction of LDL-CIncrease HDL-C and decrease triglycerides in patients with diabetesReduction of Blood PressureIncrease production of nitric oxide (NO), which increases blood flow and reduces blood pressureImprove LDL/HDL ratioResveratrol inhibition of pro-inflammatory agentslower risk of type 2 diabetesResveratrol improves glucose homeostasisModulate gut microbiotaImprovement in blood vessel wall function (endothelial function)Reduction of drugs in diabetic patientsMechanistic vs HolisticThe issue with the Mediterranean Diet is always those who approach from a mechanistic view versus those who approach nutrition and lifestyle from a holistic view. The original data from the Mediterranean Diet came from the Seven Countries Study. This was a holistic examination, not only of their diet but also their lifestyle.Alcohol Toxicity is in the DoseA bit of wine is good, a lot of wine is not.If you look at every improvement in human physiology with alcohol listed above, the opposite effect happens when the dose is beyond about 50 grams of alcohol.-----Produced by Simpler Media

Mediterranean Diet after weight loss surgerySuccess after weight loss surgery doesn't end with an operation. It just gets started.The most recalcitrant people to diets are those who undergo weight loss surgery. Weight loss surgery patients were on multiple diets prior to surgical intervention.  The Mediterranean Diet is the best post-operative diet one can have.Weight Loss and the Mediterranean DietThe Med Diet is favorable for health. Multiple studies have shown decreased risk of cardiovascular disease, cancer, and autoimmune disease. What about weight loss? Systematic reviews have shown the Med Diet is equal or superior to other diets for weight loss. However, we found no post-operative program to adopt the Med Diet after weight loss surgery.Preoperative Med DietWe began coaching patients with the Med Diet before surgery. Many insurance companies require a preoperative, physician-supervised diet. In 2010, we began to use the Mediterranean Diet as a template for our patients using the 9-point scale.  Contrary to weight loss plans, our emphasis was learning the Med Diet.Weight Loss Surgery Protocol Liquid PhaseThe immediate post-operative diet emphasized soups and smoothies rich in legumes, vegetables, and fruits. Modular, unflavored protein supplements (whey or pea-based) were used to augment the protein content during this time, as were standard chewable vitamins.  Thus, the beginning of the post-operative plan was already a rich Mediterranean-style diet.Early Solid Food PhaseLegumes and fish were emphasized during the early solid food phase, which were universally easy to digest. One of the favorite Mediterranean-style foods were tacos.  Contrary to popular belief, the Med Diet is not foods commonly eaten in the Mediterranean. Instead, it consists of foods rich in whole grains (corn tacos), fruits (homemade salsa), legumes (lentils), some dairy products (cheese), and fish.We noted lettuce was problematic for some in the early phase, but spinach was easy to digest. Thus salads were based upon spinach rather than lettuce.Later Solid Food PhaseAs the stomach continued to heal, we stressed the increase in food with multiple fiber types.  We de-emphasized red meats, cautioned against excess alcohol, and worked on olive oil as the primary source for fats.Follow upCooking classes were a constant feature of our support group, often bringing in guest chefs from the area and the Food Network. We emphasized the importance of patients learning to cook.  Many of our patients believed that cooking was the most important aspect of their postoperative care. We found that those who learned to cook their meals had better weight loss than those who did not.Validated Food Frequency Questionnaires (FFQ) were used to follow a group of patients. The FFQ were validated using dietary logs during follow-up with patients.Getting in that quantity of foodStomach capacity after weight loss surgery is limited. How, then, does one get in the required amount of food? It is not difficult.All food is measured pre-cooked. Take broccoli. If you take nine ounces of broccoli and bake it, you end up with a small amount of volume but still have the one Mediterranean Diet point.The increase of vegetables in the diet is one way to reduce inflammation.Food increases over timeFood volume increases over time with both the Gastric Sleeve, Lap-Band, and RNY gastric bypass. The answer is not to eat less or take more protein shakes. The answer is to eat better. To have a balanced diet.Putting someone on yet another low-carb plan does not provide a healthy long-term solution. Protein DeficiencySince meat is not emphasized in the Mediterranean Diet, some patients were concerned about protein intake. Lab tests did not show any patient with protein deficiency.The StudyOver 220 patients agreed to long-term follow-up with FFQ, but we obtained consistent data on 134 patients after surgery, with a minimum seven-year follow-up.The FFQ were converted to the nine-point Med Diet, and the results were analyzed.Of the 134 patients, there were 65 which had scores of 5-9 Mediterranean Diet points. They showed an absolute reduction of weight of 54% total weight loss. Those patients who scored 0-3 points had a total weight loss of 32%.What About Poor Adherence to Med DietOf the patients studied, 74 had the Lap-Band, 50 had the Vertical Sleeve Gastrectomy, and ten had the RNY gastric bypass. There was no weight loss difference regarding the type of weight loss surgery.AlcoholThose patients who did not do well with weight loss all had >50 grams of alcohol per day. In contrast, those who did well reported less than 50 grams of alcohol per day.

Implementing the Med Diet - Part OneDo you think you eat enough plants in your diet? How many plants do you eat in a week? Not refined grains, but plants. You can cook them, boil, bake, microwave, roast them or even eat them raw. How many? Further, it's not just eating more volume of plants, it's diversity.Mediterranean Diet and PlantsAdherence to the Mediterranean diet depends more on plants.VegetablesFruits, Tree Nuts, SeedsLegumesWhole GrainsOlive oilWhen it comes to plants, more is better. But not just in quantity of plants, but also diversity.Think about this: there is no one plant that can provide all the micronutrients and macronutrients a person needs. We tell vegetarians to use several plant sources for complete proteins, the same is true for any nutrient.Gut Bugs and PlantsYour gut contains a trillion bugs. There are more of them than of us. But what do they eat? It turns out, most of what they eat are the things we don't. Gut bugs eat plant parts. Without them eating those plant parts, we would be far worse off. Thus, the gut microbiome is an exciting research field.Guts break down fiber to chemicals shown to:Decrease the risk of colon cancerLower cholesterolDecrease blood sugar spikesDecrease depressionAllow absorption of polyphenolsFiber is an Essential NutrientPlants provide vitamins, minerals, macro and micronutrients. A single source of plants cannot provide the nutrients a person requires, which has been the main reason we recommend a diversified diet. Fiber is also a nutrient, an essential nutrient, one that humans cannot make, but without it there is clearly an increase in disease. While those on the extreme of low-carb diets will disagree, the literature is unambiguous.MythFiber supplements are not a substitute. Some are expensive, one selling for over $150 a month. But no supplement gives you the diversity of nutrients that you can get from your diet. Mother Nature gives you a better deal. So, eat your fiber, don't buy a supplement.Now begin to chart your diversityToday's assignment is simple: begin to chart the diversity in your diet, so that you increase the sources of your plants. One of my favorite dieticians, Dr. Megan Rossie, suggests a person has 30 plant-based foods per week. Sound impossible? Let's try it using the Meditereanean Diet.Why 30?It isn't that difficult to implement, but consider that you want to consume the vitamins, minerals, antioxidants, and other nutrients, and there is no one plant that does this. But many will.Vegetables:One Mediterranean diet point is achieved by consuming 9 ounces of vegetables per day.  Run through the list of vegetables that you can add to your diet in any given week.AsparagusBeetsBok ChoiBroccoliBrussels SproutsCabbageCauliflowerCarrotsCeleryCucumbersEggplantJicamaKaleLeeksLettuceOnionsParsnipsPeppersSpinachSquashTomatillosZucchiniFruits:ApplesApricotsAvocadoBananasBlueberriesCherriesCoconutsDatesGrapesGrapefruitJackfruitKiwiLemonLimeMangosMelonsNectarinesPeachesPearsPineapplePomegranatesPlumbsPrunesOrangesTomatoWatermelonLegumes:Black beansButter beansChickpeasGreen beansKidney beansNavy beansPinto beansNavy beansLentilsPeanutsWhole Grains:BarleyBrown RiceBuckwheatBulgurCornMilletOatmealWhole wheatRed riceNuts:AcornsAlmondsBrazil nutsCashewsChesnutsHazelnutsMacadamiasPecansPine nutsPistachiosWalnutsSeeds:ChiaFlax seedsHempPomegranatePoppy seedsPumpkinSesame seedsSquash seedsSunflowerThese provide a diversity of micronutrients, macronutrients and fiber.All of which provide a healthy diet.But let's not forget one of the most important plants: Perhaps the most important part of the Mediterranean Diet is this plant.  Breakfast ideas:Overnight oats, which in my recipe has oats, chia seeds, and in the morning I add blueberries and peanut butter. There are four different plants. Lunch ideas:A whole grain sandwich to which I add: tomatoes, cucumbers, lettuceAdd an appleThe whole grain can have multiple grains in it.Snack:A handful of almondsDinner:Want some pasta - how about the sauce? Start the sauce with onions, mushrooms, carrots, garlic, all in olive oil.You haven't even had a salad yet.On this day, we have 15. Tips:Salads are a great way to add seeds, nuts, and even some legumes.Buy the mixed vegetables not just the broccoli.Terry's TacosThe standard fast-food taco is a lot of ground beef, a lot of cheese, and a smear of sauce.My taco is: lots of cabbage which I have for a slaw and other great crunchMy salsa has some amazing fresh ingredients in it like my mango salsaAnd cheese and meat are more of a condiment. But you can reduce the meat by using lentils and mushrooms.Soups:Vegetable soups in the winter! Lots of additions here for vegetables. Diversity is not only healthy, but it is delicious.

Mediterranean Diet - FatsPerhaps the most important part of the Mediterranean Diet is this plant.Olive oil is the single ingredient most associated with the Mediterranean Diet. It is the one single food substitution you can do that will improve your health immediately and have great consequences. But not all olive oil is the same.Olive oil and your heartThere are many types of fat that you can find in your diet. Saturated fat will raise your LDL level, increasing your risk of heart disease and stroke. Olive oil, which is unsaturated, decreases the risk of heart disease.Types of FatFats are confusing. You will hear saturated, poly unsaturated, monounsaturated, and trans fats. First, we won't look at the chemical structure of fats. Second, we will look at the evidence that the food is associated with fat and how it influences our bodies. Finally, we will dismantle some bad arguments against certain fats.Saturated Fats - it's the source, not the ingredientSources: butter, red meat, dairy.What the Mediterranean Diet showed us what that the total diet mattered more than the individual ingredient. In spite of the revolutionary approach to using cohort studies with complete diets, many have insisted on pulling that apart to find out if one ingredient is "bad." For years, saturated fat was considered the "bad" part of what we ate. The American Heart Association recommended limiting saturated fat to just ten percent of what you eat.  The AHA recommended changing from saturated fat to polyunsaturated fat or monounsaturated fat. There has never been a question about olive oil, but a few concerns have been raised about some polyunsaturated fat.But it isn't as simple as the saturated fat molecule. We don't eat pure saturated fat, it turns out we eat food containing that fat. Depending on the food, it depends on how saturated fat affects you.Dairy and Fish vs Red MeatAdding more fish and dairy to your diet decreases the risk of heart disease. Adding more red meat to your diet increases your risk of heart disease. This study, from the EPIC group, was impressive in its size, and its ability to factor out other issues that might increase heart disease. Once again, cohort studies show it isn't as important.CheeseBesides heart disease, cheese decreased the risk of dementia among a cohort of Finnish men followed for 22 years.Perhaps the greatest snack of all time (my opinion - not science).Another cohort study found that cheese was associated with a lower risk of pre-diabetes. Other forms of dairy products did not have this same benefit. This flies in the face of some vegans, who insist diabetes comes from saturated fat.Finally, non-dairy cheese is not a great source of nutrients. I know my fellow vegans want to find a good alternative for cheese, but there simply isn't one.Proving again that the whole food is greater than its parts, fish.Fatty fish have been shown to decrease not only cardiovascular mortality, but all causes of mortality. But not fish oil.Who doesn't love a good salmon?Fish consumption has been associated with a lower risk of heart disease. Further, fatty fish decreases the risk of all-cause mortality.Fatty fish contain high quantities of omega-3 fatty acids.  Our body cannot make these fats, we must get them from our diet. Here are the fish that are high in omega-3 fatty acids:salmonsardinesmackerelherringlake troutcanned light tunaEven tilapia has some omega-3 fatty acids, in fact, it has about four times as much omega-3 fatty acids as grass-fed beef. However, tilapia has ten times less omega-3 fatty acid as salmon. Some have discouraged the consumption of tilapia, but it remains an inexpensive, sustainable type of fish. Just for reference, tilapia has the same amount of omega-3 fatty acid as cod, scallops, shrimp, and wild lobster.Different types of Omega-3 fatty acidsThere are two kinds of omega-3 fatty acids in fish — eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA).  One of the few supplements that all physicians recommend are DHA for pregnant women. This is essential to the brain of the child. Yes, he is a smart kid - was it genetics or the DHA his mother took during pregnancy?Polyunsaturated Fatty AcidsThey are anti-inflammatoryThey are extracted with hexaneThey are healthyThere is less hexane if you consumed from your diet for a year than one whiff of the gas you put into your automobile Olive OilYou can cook with it, this is the only oil used in cooking in most homes in Italy and GreeceExtra Virgin Olive oil standards are the highest from those produced in the United StatesOver 80% of the Extra Virgin Olive oil imported is contaminated with other oilsThe smoke point is around 400, but up to 475 F when you used "refined" olive oilMy favorite olive oil is from the US, but the tastiest is from Liguria in Italy (my opinion)Olive oil, balsamic vinegar, sardines all provide elements of taste - the sour, salty, and savory, combine with bread - the sweet and you have a per

Inflammation and the Mediterranean DietThe Mediterranean Diet is the most anti-inflammatory diet studied.The inflammatory response is the body's mechanism to fight infection, repair itself and rid itself of cancer.  Inflammation is a coordinated response to trauma, infection, and cancer. Without inflammation, we would be dead within twenty-four hours.Too little or too muchToo much inflammation results in wanton destruction of tissues, pain, fevers, and misery. It is associated with heart disease, cancer, aging. It is that delicate balance of inflammation we need.Does diet play a role with inflammation? The answer is "sort of."Short Course about InflammationInflammation is involved in:Wound healing, removing dead cells - breaking them down into components so they can be recycledRemoving and destroying bacteriaInactivating and eliminating virusesDestroying cells that have changed into cancer cellsRepairing injury from infectionDestroying parasitesRemoves toxic chemicalsThe immune system is one branch of the inflammatory response.Five Signs of InflammationThe five signs of acute inflammation and their Latin names:Redness - in Latin this is called rubor.Swelling - in Latin this is called tumor.Fever - in Latin this is called calorPain - in Latin this is called dolorSecretion - in Latin this is called fluorMedical school teaches inflammation as one of the first series of lectures.Simple InflammationYour finger was hit with a hammer. You have an injury to your finger. Some cells are injured. The cells send a distress signal, and immediately white blood cells begin to swarm into the area to help the injured cells.  All that extra blood flowing to the area will lead to redness (rubor) and swelling (tumor). Soon, the finger will feel a bit hot (calor) and will have pain (dolor).Some cells are so badly injured that they are no longer viable. Your inflammatory reaction breaks down these cells, removes the debris, and recycles the parts to create new tissue in the area.Unwanted InflammationI love nature walks but like to avoid Poison Ivy.Sometimes, we want to decrease the immune response. Inflammation is the response of our skin to poison ivy.  We reduce the immune response by reducing hives and itching.Rheumatoid arthritis is another example of unwanted inflammation.  Rheumatoid arthritis is an auto-immune disease.  The resulting inflammation leads to pain, fever, and joint destruction. The aim of the treatment is to reduce the inflammatory response that saves joints and improves well-being.The inflammatory response of COVID, influenza, or the common cold is reduced by the use of non-steroidal anti-inflammatory drugs, such as aspirin or Motrin.Acute Disease and InflammationHeart disease is partially the result of inflammation. When you have a heart attack, the coronary arteries are blocked. As a result, a part of your heart muscle is without oxygen. The cells send out inflammatory signals, and you begin to feel pain (dolor). If the blood flow is restored, your cells can heal, but if it takes too long, some of those cells will die. Then your body will get rid of those dead cells and replace them with scar tissue. The result is that your heart becomes less effective.Cardiovascular disease and inflammationPlaque formation in the arteries is the result of genetics, diet, and inflammation. The increased cholesterol, either from the genetics or from a diet high in saturated fat, is deposited in the arteries.  When cholesterol enters the artery wall, the body's inflammatory response tries to get rid of it, causing inflammation in the arteries. Did you know that 18-year-olds already have signs of early plaque formation in their arteries?Chronic InflammationChronic inflammation is when your body continues to send inflammatory signals, even when there is no acute injury or danger. This is what happens in rheumatoid arthritis, lupus, long Covid, and is involved in diabetes, obesity, dementia, and premature aging.Western Diet and InflammationIt is easy to obtain calories in western societies. In human history, we have gone from people on the verge of starvation to being overfed. We have also increased lifespan because of sanitation, vaccination, clean water, availability of food, and modern medicine. Living longer means seeing more chronic diseases. The role of diet in those diseases has never been in doubt since Hippocrates said, "Let thy food be thy medicine." The result has been an increase in inflammatory diseasesHow Diet Has Changed in the USContrary to the Mediterranean diet, the typical US diet has changed to a diet rich in fats. Fat consumption has risen by 11% at the expense of healthy carbohydrates.Refined sugars have increased from 18 pounds a year in 1800 to over 180 pounds per year in 1999. Since 1999 sugar consumption has been decreasing in the United States.The typical western diet has decreased in the amounts of fruits, nuts, seeds, vegetables, legumes, and fish. All while increasing

Adherence to the Mediterranean Diet decreases the risk of cardiovascular disease. The Seven Country Cohort Study clearly showed this.But what about cancer? Does the Mediterranean Diet impact cancer or cancer prevention? To study this, another cohort study began called the EPIC study. Uniquely, the EPIC showed not only a decreased risk of cancer but also mortality from cancer.All vegetables, even the green ones, have nitrates. It turns out that the components of The Mediterranean Diet decreases the risk of cancer, decreases the risk of cancer recurrence, improves survival from cancer, and decreases overall mortality.EPIC StudyThe European Prospective Investigation into Cancer and Nutrition (EPIC) is a large cohort study involving over 521,000 individuals from 23 centers from ten countries.Adherence to the Mediterranean Diet and LongevityThe EPIC researchers developed a simple scoring system to determine adherence to the Mediterranean Diet.  Greater adherence to the Mediterranean Diet was associated with longevity.The Scoring SystemThe Mediterranean Diet is scored on a scale of one to nine. Nine being a perfect Mediterranean Diet Score, and zero being poor. Great adherence to the Mediterranean Diet is a score of seven points or more.Eating more of these foods gives you pointsThe Mediterranean diet is rich with vegetables, legumes, fruits and nuts, whole grains, and fish.You get a point for consuming 9 ounces or more of vegetables a day. If you consume less than nine ounces, you get a score of zero.Legumes will net you a point if you consume two ounces or more per day.Fruits and nuts are one point for nine ounces or more.Likewise, whole grains are worth a point for nine ounces or more.Fish is an average of an ounce a day, or two main meals per week. Thus,  by consuming a diet rich in these five components can score five points.The weight is based on pre-cooked food.Lentils are a legume, and if you consume more than 2 ounces per day, you will score one Mediterranean Diet point. They are high in protein and fiber and low in saturated fat.Eat Less for MorePeople from the Mediterranean didn't eat much meat or dairy.  By consuming less of these, you can achieve Mediterranean Diet points.Eating less than  4 ounces of meat a day  is worth one pointConsuming 1.5 ounces of hard cheese a day or LESS is worth one pointConsuming less than 8 ounces of dairy is worth one point (mostly consume yogurt).Thus by eating less dairy and meat, or none, you can score two additional points.You might think that 6-ounce burger is small, but if you eat less than four ounces of meat a day, you get one Mediterranean Diet point. Eat more than four ounces, and you get zero points.AlcoholAlcohol is a component of the Mediterranean Diet but in moderation.For ethanol, a value of 1 was assigned to men who consumed between 10 and 50 g per day and to women who consumed between 5 and 25 g per day. This corresponds to 5 ounces of wine for women or 10 ounces for men.Olive OilOlive oil is an important component of the Mediterranean Diet. The type of fat in olive oil is mainly monounsaturated. The ideal ratio of olive oil or monounsaturated fats to saturated fats should be at least 60%.The best olive oils come from the US.Interventions in the Mediterranean DietIncreasing the score in the Mediterranean Diet by two points in the Mediterranean diet led to an 8% reduction in mortality.Imagine a simple dietary intervention leading to a decrease in mortality.Colorectal Cancer and the Mediterranean Diet ComponentsIn a recent update of the Mediterranean Diet they found a higher consumption of fruits and vegetables combined led to a decrease in colorectal cancers. But just eating fruits alone or just vegetables alone didn't do it.  Proving again, the entire dietary pattern is important.A Mediterranean Diet score of 6-9 led to an 11% decrease risk of colorectal cancer!If you eat a lot of red meat but eat a lot of vegetables, your risk of colon cancer decreases.Breast Cancer and the Mediterranean DietThe  Mediterranean Diet was found to protect against breast cancer. In addition, it improved overall survival of those who developed breast cancer.Alcohol consumption increases the risk of breast cancer. While the Mediterranean Diet is a low in alcohol consumption, it is still a factor.  Thankfully, coffee consumption is protective against breast cancer. Of interest, sugar-sweetened and artificially sweetened beverages were not associated with an increase in breast cancer.Lung Cancer and the Mediterranean DietWhole grains, fruits, and vegetables were associated with less risk of lung cancer.  Smokers decreased their risk of breast cancer with increasing vegetable consumption. Lung cancer even decreased with higher consumption of apples and pears.There was no association with meat or fish consumption and lung cancer.  Alcohol was also not associated with an increased risk of lung cancer.Other CancersAdherence to the M

Was Ancel Keys responsible for the modern epidemic of obesity?If you have read any low carb blog lately, you would think so.Their revisionist history is broken down to this:Ancel Keys was an influential scientist who thought fat was to blame for heart diseaseHe did a study of diet and correlated fat and heart disease in those people of the seven countriesBut Dr. Keys left out countries that would have proven his hypothesis wrongThe influence of Dr. Keys work turned the US away from saturated fat and to sugarSugar causes obesity and all the lifestyle illness of the worldDr. Keys brought us snackwells instead of pork rinds and we are all obese with diabetesYou will find versions of this in blogs, books, and videos.  Low-carb bloggers plagiarize one another. Nor have they never the primary source material.The Mediterranean Diet Founder and the StudyKeys is the founder of the Mediterranean Diet. He was a pioneer physiologist, one of the first to show that diet was an important component of heart disease.In the 1950's few considered diet an important component of heart disease.Rich People and Diets"In 1952 when Margaret and I were making surveys in Naples and then Madrid. It seemed quite clear that there was some relationship between diet and the incidence of coronary heart disease. Rich people had different diets and different blood cholesterols, and they had the only heart attacks in town. When those findings were written up and presented at a meeting in Amsterdam, some people were impressed and some didn't believe anything about it. " - Ancel KeysThis early observation by Keys  was the impetus for  the Seven Country Study.That diet was responsible for heart disease was contrary to the prevailing theory: in the 1950's heart disease was hypothesized to be phenomenon of aging.  Dr. Keys meticulous research revealed the strong correlation between heart disease and a diet rich in saturated fat.The First GraphThe graph below is a result of looking at macro dietary statistics of a country compared with death rates from heart disease. Keys presented this data at a WHO meeting in the early 1950's. The conclusion about fat and heart disease,  was met with a great deal of skepticism. Diet was not considered a factor in heart disease.While this data points to a potential cause, to examine this hypothesis one must perform a cohort study.Some assume that Keys collected country wide data about diet and heart disease, but he did not. Bloggers probably assume this based on this graph, as well as the name, Seven Countries Study. But the Seven Country Study was far more precise. The Study was a Cohort type study.Cohort StudiesA cohort study follows subjects for a long period of time. The Seven Countries Study followed over 12,000 men for nearly 50 years.Following these men involved yearly physical examinations, blood work, hospital and death records, as well as very specific dietary follow up.Of all the factors examined, saturated fat and blood cholesterol were most correlated with  heart disease.One of the more common myths about the Seven Country Study was that sugar was not examined. In fact, sugar was examined as an independent dietary factor. Sugar was not an primary variable for heart disease, unless combined with saturated fat.Testing both low and high fat countriesThe low-carb bloggers assume that Keys only tested those countries whose diet was rich in carbs, and low in fat. Keys chose his cohorts based on different diets, from those who were low fat, to high fat. Total fat, as it turns out, was not a factor for heart disease. Greeks had 40% of their dietary calories from fat but a low heart disease rate.Most of their fat came from monounsaturated fat,  olive oil.The Finish CohortThe Finland cohort was chosen precisely because of their high fat diet:"Loggers’ lunches, even today, are things of wonder, unsurpassed in caloric density: Large hunks of meat are suspended in congealed fat, enveloped in a dark bread loaf fully permeated by fat. The whole – at 250 grams of fat and well over 2,000 calories – is packaged in aluminum foil and tied with a ribbon. This hefty fare is preceded by a breakfast of fish soup, containing fifty percent butter fat calories and several grams of salt. The evening meal provides the rest of the 6,000 calories the logger needs to work outdoors all day." - Henry BlackburnFinland had a high level of coronary heart disease. The Fins also have a very active lifestyle, which didn't prevent them from the ravages of atherosclerosis.Reversing the Diets - Fins to Italians"Though the picture in Finland confirms the major causal hypothesis about the role of dietary saturated fatty acids, a basic issue remains, as exposed in a practical dietary experiment completed some years ago. Can the picture be changed? East Finns were placed on an Italian diet and Italian farmers on a Finnish diet. As in the black and white prisoners that Keys and John Brock of Capetown studied in Sou

Scientists and dieticians consistently  rank The Modern Mediterranean Diet (MED diet) as the diet most recommended.  But often people don't know what the MED diet is. This post will  define the Med diet.Critics of the Med DietCritics  argue that there is no uniform MED diet. They make these assertions based on one of these three arguments:That there is no uniform diet of the Mediterranean Region. There are over 20 countries on the 26,000 miles of coastline of the Mediterranean Sea. Each country with their own unique diets. Many of which have adopted a more modern American style diet.The diet is simply made up and therefore should be ignored.Finally some point out that there are many Med Diets as the literature.Heart disease and DietAncel Keys is the scientist most responsible for not only the Med diet but the relationship of heart disease to diet. In the 1950's, heart disease was thought to be a disease of aging, and smoking but not diet or lifestyle.In the 1950's, much like today, heart disease was the number one cause of death among of middle aged executives. While there was a clear association between smoking and heart disease, there were far more deaths than could be explained from smoking.  Then an Italian scientist told Dr. Keys about the low incidence of cardiovascular deaths of men in Naples.Heart Disease and Diet in EuropeKeys confirmed this claim when he took a sabbatical in Oxford in 1952.  Keys found there was a difference of heart disease between the poor and the executives of Italy. He developed the hypothesis that diet might explain difference  between the two groups.  To confirm this Keys, and his wife, then traveled throughout Europe catalog different diets and rates of heart disease.In 1955 Keys presented his data to the World Health Organization, concluding  that diet played a significant role in heart disease.  Many members of the WHO mocked his  "diet-heart theory."  Keys then organized the seven countries study (click here).Seven Countries StudyThe seven countries study was an observational study looking at biomarkers, lifestyles and their relationship to heart disease.  Those countries were Greece, Italy, former Yugoslavia, Finland, The Netherlands, Japan, and the United States. The cohorts were chosen because of diverse diets, lifestyle, and risk factors. Dietary and lifestyle influence on cardiovascular disease was unknown at the time. The seven country study was to answer the question about dietary influence and heart disease.The French ParadoxLow-carb bloggers accuse the seven country study of leaving out France. They cite the French Paradox, that the French eat a diet high in saturated fat but have a low incidence of heart disease.However, France was not left out of the study.  French investigators were present at the original pilot study in Nicotera Italy, but ultimately decided not to participate in the study.  France was recovering from World War 2 and simply didn't have the resources to commit to such a study.In fact, The French Paradox was "coined" in the 1980s, over twenty years after the  start of the seven country study. The investigators didn't have access to that data, or the term. Low-carb bloggers  didn't read the seven country study or the French paradox.French Paradox ExplainedTwo factors explain the French Paradox.The high fat diet was not widely adopted by the French prior to the mid 1970's. It  takes time for a  habit to have an effect on cardiovascular disease. For example, one doesn't develop heart disease after the first cigarette. The primary French diet in the 1950's through 70's was a Mediterranean Diet.  Thus, the effect of the high fat diet would not be evident for twenty plus years after it was adopted.The second explanation is that French physicians consistently underreported heart disease. Of note, Wine consumption has been the most studied aspect of the French Paradox. Red wine sales increased dramatically after the airing of the "French Paradox" on Sixty Minutes.  Wine is an important component of the Med diet.Seven Country Study and The Med DietFrom 1958 to 1970  over 12,000 men were tracked for diet, weight, smoking, physical activity, vital signs, cholesterol, and lung capacity. During that time there were about 2300 deaths, 27% from heart disease. Different countries had different rates of deaths from heart disease: USA 50%, Northern Europe 40%, Southern Europe 17%, Japan 5%.  The dietary pattern that was identified in this study became the basis of what Keys would call The Mediterranean Diet. Key's book became a bestseller, describing not only the first version of the Mediterranean Diet, but providing healthy recipes for a country trying to fight the number one killer. Keys even wrote a best selling cookbook with his wife touting the benefit of the diet.Adopting the Mediterranean Diet Keys died shortly before his 101'st birthda

If you don’t have diabetes, should you even consider a blood glucose monitor? Well, here is the science behind this new tiktok trend and why these Continuous Blood Glucose Monitors (CGM) are here to stay and what we know about them.The deviceFirst, the device – a continuous blood glucose monitor is a device that you place on your body and it measures the blood glucose level and reports that data typically to an application on your phone. The first blood glucose monitors were used to help patients with type 1 diabetes regulate their blood sugar. They were revolutionary, but expensive, not covered by many insurance companies, and cumbersome. As the technology has improved, the price has decreased, the comfort level has improved, and the accuracy of the monitoring has improved. As with most technology, blood glucose monitors are now less expensive, better, and widely available.You can read more about the history of the blood glucose monitor here.Most diabetics use a fingerstick to see what their blood glucose is, and use that information to determine the medicine they need to help regulate their blood glucose. The CGM allows real-time data which can be checked against food logs to allow a person to see impact of their diet on their regulation of food. As the epidemic of diabetes grows, about 55 million predicted with diabetes by 2030, we know that the less variability in glucose, the better long-term outcome (reference here) and here.Variability in blood glucose with non-diabeticsIt turns out that even people who are not diabetic, have wide variations of blood glucose (reference here). Further, the variations in blood glucose have real time effects and we should care about those effects.  For example, high glucose spikes lead to inflammation of the arteries, even in non-diabetics, which lead to atherosclerosis, heart disease, strokes and peripheral vascular disease (click here). A study published in Journal of the American Medical Association (here) concluded “Providing individuals with tools to manage their glycemic responses to food based on personalized predictions of their PPGRs may allow them to maintain their blood glucose levels within limits associated with good health.”What is best?Avoiding the large variability in blood glucose is clearly important to health whether one has diabetes or not. Trying to predict what variability will be based on fasting blood glucose or hemoglobin A1C cannot be done. Using a healthy diet like the Mediterranean or DASH diet – this has been found in studies with CGM on young people with type 1 diabetes (reference ) Even variations of the Mediterranean Diet and CGM have found improvement in glucose variability.Economies of ScaleContinuous Glucose monitors are getting less expensive, more accurate, and more comfortable to wear. This is good news for patients who have diabetes, and as demand raises among all to use these tools the price will drop further. The economies of scale work with medical devices. Consider the pulse oximeter that you can purchase from a local pharmacy for $25 – they used to cost over $900 and were used to manage patients with lung disease. Now, for less than a copay, you can have one of these devices and they not only help manage patients with lung disease, but also keep people with COVID out of the hospital when they are doing well, or provide a warning to get patients into the hospital.The original pulse oximeters were large, expensive and cumbersome. The modern pulse oximeter is available at any pharmacy for $25.These are another tool in our toolbox.Disclosure: I received a continuous glucose monitor from Nutrisense. They do not manufacture the device but provide the device as a part of the service with registered dietitians to help people navigate what the data means. They have a subscription model which may, or may not be good for you.

About 15 years ago physician came to me telling me that she was opening a new venture, distributing plant-based bioidentical hormones, and surgically implanting those hormones as pellets. She wanted me to send her all of my patients who presented in menopause because "with bioidentical hormones they won't need weight loss surgery." She went on to say how every woman would be tested for their hormones and then a compounding pharmacy would make up the exact hormones to replace the ones the person was not producing enough of. This would, "almost reverse aging and cause weight loss." In fact, those bioidentical hormones cause weight gain.Bioidentical hormones, from whatever source, cause weight gain, not weight loss (reference) . In spite of a number of "advertisement" from providers who wish to provide you with "compounded" bioidentical hormones that propose they will cause weight loss - they don't.  This physician was not an Ob-Gyn, nor was she a board certified endocrinologist, in fact her specialty was about as far from treatment of complex menopausal hormone replacement or obesity as one could imagine.The red flags for this clinic were (a) proposing weight loss (b) associating with a compound pharmacy (c) offering anti aging treatments (d) a provider that is not an expert in the field of endocrinology or gynecology.Bioidentical hormones made by any compounding pharmacies do not meet rigorous FDA standards. In fact, compounded forms of bio-identical hormones are similar to supplements, and have the same issues that supplement industries have had that we have outlined previously.Menopausal Hormone Replacement is Medicine, Compounded bioidentical hormones are ?With every scam there is a separation of the chaff from the wheat. Here is the current evidence about hormones and changes that occur as women enter menopause. Accepted sources for this information include The Menopause Society as well as The American College of Obstetrics and Gynecology.Women undergoing menopause they decrease their production of certain hormones. This can lead to severe symptoms of menopause that hormone replacement therapy can alleviate. Symptoms of menopause such as hot flashes, sleep disturbances, joint aches and pains, mood changes, vaginal dryness. That is undisputed and the improvement in quality of life is why many seek hormone replacement therapy. There is also potential benefit to decreasing risk of cardiovascular disease, if started within ten years of symptoms and before the age of 60 years.The major concern of hormone replacement therapy came from the study published in 2002, the Women’s Health Initiative, showing that hormone replacement, with the most commonly prescribed medicine, Prempro, led to an increase in heart attacks, strokes, deep venous thrombosis and pulmonary embolism as well as breast cancer.The concern among gynecologists led to a rapid decrease in the prescription of Prempro by nearly 70%. This also led to a decrease in the quality of life by women going through menopause. Some gynecologists and endocrinologists continued to prescribe hormone replacement therapy.Compound Pharmacies Filling the GapBioidentical hormones made by any compounding pharmacies do not meet rigorous FDA standards. In fact, compounded forms of bio-identical hormones are similar to supplements, and have the same issues that supplement industries have had that we have outlined previously.To quote from the FDA "Compounded drugs are not FDA-approved. This means that FDA does not verify the safety or effectiveness of compounded drugs. Consumers and health professionals rely on the drug approval process for verification of safety, effectiveness, and quality. Compounded drugs also lack an FDA finding of manufacturing quality before such drugs are marketed." - from June 29, 2022 (reference here)Throughout this blog I will be speaking of compound bioidentical hormone therapies (cBHT). There are hormone replacement pharmaceuticals that have undergone testing for toxicity, safety, efficacy and have follow up programs with the FDA to look for long-term issues, those are not cBHT. Some of those pharmaceuticals   call their products bioidentical – those are different. Unless otherwise stated, please assume that the drugs made by the compounding pharmacies do not meet quality and purity of the FDA nor do they carry the warnings. In addition, they are provided often by clinics whose physicians are not board certified in gynecology or endocrinology.In 2013, after a major breach in sterilization led to meningitis from spinal injections made from a compounded pharmacy, new guidelines were established for better manufacturing processes and control. This is the 503B of the Food and Drug and Cosmetic Act. Some compounding pharmacies have attempted to state these were an equivalent of FDA approved drugs, but as you can see from June of 2022 reference above, this is not the case.There is more than safety standards (as addressed in 503A and 50

 The US Preventative Task Force updated their recent recommendations about vitamins and supplements in The Journal of the American Medical Association - reference here.Their conclusion was: "Conclusions and Relevance Vitamin and mineral supplementation was associated with little or no benefit in preventing cancer, cardiovascular disease, and death, with the exception of a small benefit for cancer incidence with multivitamin use. Beta carotene was associated with an increased risk of lung cancer and other harmful outcomes in persons at high risk of lung cancer."We have published about how misleading labels of supplements are before - click here.The appeal of vitamins and supplements is the ability to extract the vital chemicals (like vital amines) antioxidants, and anti-inflammatory ingredients, place them into a pill so you can avoid having a healthy diet. Trust me, a healthy diet is clinically proven to work but it is a lot easier to eat a burger and pop a pill than to remember to eat some vegetables (I like Habit Burger).[caption id="attachment_9745" align="aligncenter" width="640"]V Yes, I do love a good burger - Habit is my favorite[/caption]But let's go back in history for a second and let you know that surgeons love vitamins. If you haven't listened to one of my favorite stories- listen to this about the first vitamin - click here. And let us not forget that the first evidence based study in the history showed that citrus fruits prevented scurvy - who was that person that showed that - was it a "nutritionist" or was it a surgeon? Oh yes, it was Dr. James Lind - a surgeon.Why the appeal of vitamins, besides my fantasy about eating burgers and popping a pill?First there is the "natural" fallacy - I don't know, I think natural is more eating fruits and vegetables than pills. People tend to think of vitamins as "good" or healthy, and they are. They seem to think of a vitamin as "natural" even though they were brought to us from the golden age of biochemistry. It is clear that the vitamin and supplement companies have taken advantage of that and use terms like "support gut health" or "support immune function" or "good for cardiovascular health, " - even if those statements are meaningless.Second, it is easier to think of things we believe we understand. Heart disease and cancer are complex topics (not that the true chemistry of vitamins aren't but they seem easy). We want to make things easy - like take vitamins and supplements for prevention or cure of cancer or heart disease, because if we start talking about scary statins or chemotherapy not only are there real side-effects but bad press. Of course with vitamins and supplements there can be real side effects - check here. My aunt's son, a Ph.D. in nuclear physics, died after taking a supplement that was to help him be "fit."But the simple truth is this: however the polychemistry there is in fruits, vegetables, legumes, whole grains, as well as balancing dairy, meats, fats and alcohol has proven effect - we call that the Mediterranean Diet (for more see here)[caption id="attachment_9746" align="aligncenter" width="640"]i Instead of vitamins and supplements from a pill - eat this[/caption]For whatever reason, eating a Mediterranean Diet or DASH diet continue to be the proven way to maintain your health.References1.Mishra S, Stierman B, Gahche JJ, Potischman N. Dietary Supplement Use Among Adults: United States, 2017-2018. NCHS Data Brief. National Center for Health Statistics; 2021. doi:10.15620/cdc:1011312.North America dietary supplements market report, 2021-2028. Accessed May 26, 2022. https://www.grandviewresearch.com/industry-analysis/north-america-dietary-supplements-market3.Arnett DK, Blumenthal RS, Albert MA, et al 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;140(11). doi:10.1161/CIR.0000000000000678Google ScholarCrossref4.Aune D, Giovannucci E, Boffetta P, et al. Fruit and vegetable intake and the risk of cardiovascular disease, total cancer and all-cause mortality-a systematic review and dose-response meta-analysis of prospective studies. Int J Epidemiol. 2017;46(3):1029-1056. doi:10.1093/ije/dyw319PubMedGoogle ScholarCrossref5.Bailey RL, Gahche JJ, Miller PE, Thomas PR, Dwyer JT. Why US adults use dietary supplements. JAMA Intern Med. 2013;173(5):355-361. doi:10.1001/jamainternmed.2013.2299ArticlePubMedGoogle ScholarCrossref6.Alissa EM, Ferns GA. Dietary fruits and vegetables and cardiovascular diseases risk. Crit Rev Food Sci Nutr. 2017;57(9):1950-1962. doi:10.1080/10408398.2015.1040487PubMedGoogle ScholarCrossref7.Bibbins-Domingo K, Grossman DC, Curry SJ, et al; US Preventive Services Task Force. Folic acid supplementation for the prevention of neural tube defects: US Preventive Services Task Force recommendation statement. JAMA. 2017;317(2):183-189. doi:10.1001/jama.2016.1

It turns out that the juice from beets may lower blood pressure in a sustained and lovely manner. Beets, you see, besides being a colorful vegetable, contain a high level of Nitrate (NO3-). And this is absorbed by the body and converted into nitric oxide. Nitric oxide is that amazing molecule that relaxes blood vessels and improves blood flow.How Your Body Gets Nitric OxideThe conversion of nitrate into nitrite, which is then converted into nitric oxide is a fun pathway. When you eat your greens (yes even lettuce has nitrates) your intestines absorb it and then it is secreted back into saliva where those bacteria in your mouth digest the nitrate (NO3-) into nitrite (NO2-) <-- for you chemistry major nerds. It is that nitrite that is converted to nitric oxide in the body as it needs it - and often it needs it.This particular study gave volunteers 250 ml of beet juice (what happens if you say that three times and fast?) - 34 of whom were on blood pressure medicine and 34 who were not (four people dropped out of the study).These people were randomized to receive, daily, one cup (250 ml) of beetroot juice (same as beet juice) daily, or the placebo which was nitrate free beet juice. No one could tell the difference in taste. BMI was constant in both groups, about 25-26. They measured, besides blood pressure, nitrates.What happened?There was a large increase in NOX (nitrates and nitrites) and cGMP (the signaling molecule ) but more importantly there was a sustained and real drop in blood pressure by 7.7 mm of Hg which was NOT seen in the nitrate free beet juice.The drop in systolic blood pressure was seen after the first week and the ultimate reduction of 8.1/3.6 Hg reduction was not altered by a change in heart rate.Two weeks after stopping this regimen the blood pressure returned to normal.Did you know that every increase of systolic blood pressure by 2 mm of Hg increases mortality of heart disease and stroke by about ten percent? This showed a reduction of 7.7 mm of Hg in systolic blood pressure.Dietary ImplicationsNitrates are not only found in beets, but also in many other vegetables. One of the clearest and classic papers for the use of the DASH diet showed that the adoption of this diet lead to blood pressure reduction in adults. While this diet was using salt as the major effector, it is clear that the increased use of vegetables with their high nitrate component is an additional determinant in nitrates and blood pressure reduction. [caption id="attachment_9737" align="aligncenter" width="640"] All vegetables, even the green ones have nitrates[/caption]It may be that the increase in vegetable servings in the DASH diet may be a secondary and important factor for blood pressure reduction in both the DASH and Mediterranean Diets. For a review of the diet and hypertension click here.But what is even more impressive is if we look back at people who have increasing vegetable intake with ultimate cardiovascular disease. The Danish report looked at this and concluded, " Moderate vegetable nitrate intake was associated with 12%, 15%, 17% and 26% lower risk of ischemic heart disease, heart failure, ischemic stroke and peripheral artery disease hospitalizations respectively." - see the reference below or click here. This goes against the Carnivore diet where they state there is no need for vegetables. Showing that vegetables are needed and produce improved quality of life. REFERENCES:Kapil V, Khambata RS, Robertson A, Caulfield MJ, Ahluwalia A. Dietary nitrate provides sustained blood pressure lowering in hypertensive patients: a randomized, phase 2, double-blind, placebo-controlled study. Hypertension. 2015 Feb;65(2):320-7. doi: 10.1161/HYPERTENSIONAHA.114.04675. Epub 2014 Nov 24. PMID: 25421976; PMCID: PMC4288952.Bahadoran Z, Mirmiran P, Kabir A, Azizi F, Ghasemi A. The Nitrate-Independent Blood Pressure-Lowering Effect of Beetroot Juice: A Systematic Review and Meta-Analysis. Adv Nutr. 2017 Nov 15;8(6):830-838. doi: 10.3945/an.117.016717. Erratum in: Adv Nutr. 2018 May 1;9(3):274. PMID: 29141968; PMCID: PMC5683004.Jakubcik EM, Rutherfurd-Markwick K, Chabert M, Wong M, Ali A. Pharmacokinetics of Nitrate and Nitrite Following Beetroot Juice Drink Consumption. Nutrients. 2021 Jan 20;13(2):281. doi: 10.3390/nu13020281. PMID: 33498220; PMCID: PMC7908977.Filippou CD, Tsioufis CP, Thomopoulos CG, Mihas CC, Dimitriadis KS, Sotiropoulou LI, Chrysochoou CA, Nihoyannopoulos PI, Tousoulis DM. Dietary Approaches to Stop Hypertension (DASH) Diet and Blood Pressure Reduction in Adults with and without Hypertension: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Adv Nutr. 2020 Sep 1;11(5):1150-1160. doi: 10.1093/advances/nmaa041. PMID: 32330233; PMCID: PMC7490167.Bondonno CP, Dalgaard F, Blekkenhorst LC, Murray K, Lewis JR, Croft KD, Kyrø C, Torp-Pedersen C, Gislason G, Tjønneland A, Overvad K, Bondonno NP, Hodgson JM. Vegetable nitrate intake, blood pressure and incident cardiovascular

Common Collagen Claims (taken from actual websites selling collagen supplements):“improves skin elasticity,”“support bone and joint health,”“strengthen hair, skin, and nails,” “may benefit the bodies cellular structure,”“support healthy skin, bone, and joints.”“will feed your skin health”“will improve nail appearance and strength”“lead to a noticeable hair thickness”Collagen as a supplement is not regulated by the Drug division of The Food and Drug AdministrationIf you look at the bottom of the websites, or on the bottles, you will see a disclaimer that the claims “have not been evaluated by the U.S. Food and Drug Administration. ” More telling is “these products are not intended to treat, diagnose, cure, or prevent any disease.” Such a disclaimer is provided by the lawyers because if one claims to cure, treat, or diagnose an actual medical condition then it must have passed a rigorous FDA approval. To be clear, there have been no FDA studies that show collagen as a supplement treats any disease.Supplements commonly will use “support xyz health” – where you can fill in the blank with hair, nails, joints, skin – in the case of collagen.One of the main issues with supplements is “If the composition and quality of ingredients cannot be reliably ensured, the validity of research on dietary supplements is questionable. Moreover, the health of the US public is put at risk.”Starr RR. Too little, too late: ineffective regulation of dietary supplements in the United States. Am J Public Health. 2015;105(3):478-485. doi:10.2105/AJPH.2014.302348As such, even when you look at the studies which promote collagen, or collagen byproducts, they do not meet the most basic of studies which are done to evaluate pharmaceuticals. In order to have an evaluation of a pharmaceutical you must have three phases in the trial:phase one is determining the dose for safety. While the supplement industry is happy if you think all supplements are good and all pharmaceuticals are evil – everything, every drug, every chemical from water to salt to formaldehyde has a toxic dosephase two is to test the drug for efficacy and side effects. Some people will react poorly to a supplement just as they will a drug. WE need to know what those side effects are. With a supplement people who don’t feel well often just stop it – or, like my cousin, die (yes, I had a cousin who died from a supplement).phase three testing is to determine if there is truly efficacy, what is the effectiveness and what is the safety.phase four is post-marketing surveillance in the public because even though you have gone through trials with a number of phases and under strict supervision when a drug is released to the public you have the chance to see millions of reactions.Thalidomide, for example, was released in Europe and even had two drug trials in the United States but was NEVER approved in the United States by the FDA because of insufficient data.Vioxx was a drug used worldwide and was taken off the market in 2004 because of the risk of a fatal heart attack, but was taken off after it had passed multiple drug tests previously.FDA testing is rigorous and specific, with the highest standards in the world. Collagen has NEVER had such rigorous testing performed. These tests have not risen to the level and in 2022 one report noted “More research is needed to establish knowledge of the effects and physiologic mechanism of collagen supplementation. Dermatologists should be aware of the unsubstantiated proclamations of collagen made by companies and in social media, as well as what evidence is established thus far, to be equipped to discuss collagen supplementation with patients.”Rustad AM, Nickles MA, McKenney JE, Bilimoria SN, Lio PA. Myths and media in oral collagen supplementation for the skin, nails, and hair: A review. J Cosmet Dermatol. 2022 Feb;21(2):438-443. doi: 10.1111/jocd.14567. Epub 2021 Oct 25. PMID: 34694676.One of the most quoted meta-analysis looked at 19 studies with 1125 participants – which is barely enough in any given study to make bold statements about safety, efficacy, toxicity, and side effects of hydrolyzed collagen supplementation.de Miranda RB, Weimer P, Rossi RC. Effects of hydrolyzed collagen supplementation on skin aging: a systematic review and meta-analysis. Int J Dermatol. 2021 Dec;60(12):1449-1461. doi: 10.1111/ijd.15518. Epub 2021 Mar 20. PMID: 33742704.So when someone states that study as the basis for use of the product, one has to have caution that there is not enough data, not enough rigorous data, and when studies do not include toxicity, this should be a major red flag.Collagen is regulated by the Center for Food Safety and Applied NutritionMeaning, collagen, like most supplements, is regulated as a food, not as a drug. This is not the celebrated division that worked hard to get a COVID vaccine or anti-viral medications, this is the division that is responsible for food safety. This is the division of the FDA that is slow-moving, fil

Diets. They work for some, but not for others. "You're just not on the right diet," purveyors of the latest trend will tell you. "You're just not on the right diet for your blood type, ethnicity, age, hair color," says another set of true believers.So what's right and what's wrong? Today on Fork U, a conversation between Dr. Terry Simpson, weight loss physician, and Dr. Bill Lagakos, nutritional biochemist and physiologist, where they expose the truth behind diets and why they may, and may not, work for you. And check out Bill's book, The Poor Misunderstood Calorie.TRANSCRIPT:Terry Simpson: Bill, there are a lot of weight loss programs out there. The one that I'm hearing the most about most often is the Keto movement, which says that they're going to cure everything from heart disease and cancer. Bill Lagakos: I think from a 30,000-foot view, Keto works for a lot of people. So does low fat. I like some of the recent work, the studies showing it's more about the level of processing of the food.So you can have a vegan diet or you can have a Ketogenic diet and as long as it is excluding a lot of processed foods, it tends to not be over eaten. And people that tout the magical benefit effects of any of these diets, 99% of the time it's due to weight loss. Terry Simpson: We actually had an experiment with Evo, who you met. He uhh did it several years, three or four years in a row for one month, Evo would go on a beer and sausage diet, rigorously kept his calories to 1500. We measured his liver function tests, his lipid panel. Every year he lost weight, kept it off, and every year his liver function was fine, surprising with the number of beers he had a day, which was limited to six. But it was, he had weight loss and he had sustained weight loss over the year with a, kind of this funky diet we sort of made up. Bill Lagakos: Well, that's terrific. And that's an awesome diet. I'm jealous. But, uh, yeah, that, that basically proves the point. I mean, even if it's not a lot of weight he lost, I think a weight loss is a major driver in a lot of the health improvements that people like to attribute to particular dietary trends. Terry Simpson: There doesn't seem to be a lot of long-term data in these diets. When I look at the sort of metadata, I see that if you eat really high on the low-fat side, you have a little lower lifespan. If you eat really high on the high-fat side, you have a little lower lifespan. If you have your carbs at about 55%, you seem to have a little longer lifespan. Is there much good data saying one diet versus another, other than the Mediterranean, has great long-term results?Bill Lagakos: I don't think so. I don't think it comes down to macros at all. I think that there's the confounding in those studies is so deep that I don't think the macronutrient composition of your diet is going to be what kills you in the end. Terry Simpson: Part of your job is helping people lose weight. What are sort of the big messages you try and get through to people?Bill Lagakos: One of the biggest things is the importance of adherence, which is why I try to say, you know, what do I know that, that you can adhere to 100%? It's what you've been doing because you've been doing it. So let's try and find the lowest hanging fruit that we can change so it doesn't turn your whole world upside down, which is something that would probably never work.Terry Simpson: So in other words, you're not going to change a Keto into a vegan or a vegan into a Keto. Bill Lagakos: Correct. However, I don't like to put those two at odds because there is, there have been a few studies on the vegan Ketogenic diet. Terry Simpson: So give me an example of some of the things for our audience, some of the things that they can do to incorporate it in their life now to help them lose weight and just feel a little better about themselves.Bill Lagakos: Well, feeling better about yourself and health outcomes and health profile, exercise can help with that a lot. I like to advocate all kinds of exercise. Cardio is good for the heart. Weights is good for quality of life and muscle mass, which also seems to bode well for quality of life. In terms of diet, probably nix the ultra-processed foods. Nobody needs single serves bags of potato chips lying around the house. Terry Simpson: Is that, that big, that great big bag? Is that the single serve? Bill Lagakos: [Laughing] No, no, but I know people that will go through multiple single serves in one sitting. Terry Simpson: Like when you see the Oreo cookie's just a hundred calories that you'd probably say it'd be better to have the apple?Bill Lagakos: Uh, yes. Yeah. And actually, even when it comes to the apple, one of the studies that was comparing processed to unprocessed foods, it was very interesting. I was trying to figure out how are they going to do this? And it was like an apple versus apple sauce. And that's sort of not an obvious comparison, but the people in the apple group tended to eat a little bit

In science, we don’t look to confirm what we know; we want to find out something that we don’t know. We love it when science proves us wrong.If your doctor told you that you have heart disease, were pre-diabetic, or said you should eat healthier, they likely will tell you to follow the Mediterranean Diet.When I introduce the Mediterranean Diet to my patients I get a response like this:“Sounds great!  Who doesn’t love red wine, olive oil, and fresh Italian tomatoes?”This is followed by asking for a recommendation of a book of recipes from the Mediterranean.The Mediterranean Diet seems to invoke sitting on a rooftop restaurant in Positano sipping wine while munching on fruit and waiting for pasta. The food and wine are part of the lifestyle, as is relaxing and breathing in the surroundings. You might not be on a rooftop restaurant in Positano (lucky if you are). You might be looking in your yard and seeing a squirrel or rabbit or flowers, and taking in that time to breathe and relax and maybe the glass of wine and thus transporting that lifestyle to your home.Which do you think is better for your heart and your brain: rushing home from a stressful day at work, grabbing a martini and letting the alcohol calm you or going outside, taking a deep breath of fresh air, maybe having a glass of wine?In the original Greek, the word “diata” was used to describe how one should live, what one should eat, how to maintain a healthy body. It is from diata that our word “diet” derives. There is no doubt what you eat impacts your health.While the origin of the Mediterranean Diet is what ‘some’ people in the Mediterranean ate, but that isn’t what we (doctors, scientists, registered dieticians) mean today.   Over the last fifty years over 150 foods have been studied to see their effect on humans, for better or for ill.  Years of research, studied on millions of people, and yet most people have the view of the Mediterranean lifestyle as hummus and fish. So let me introduce this diet, and this lifestyle to you, and why it may be the most important lifestyle you should understand.In spite of all the noise on the internet about low carb/keto, vegan, or other diets/lifestyles you will find that the Mediterranean Diet is consistently ranked as the number one or two diet in the United States. That is based on many studies showing how the diet leads to a decrease in heart disease, lower blood pressure, better control of diabetes, fewer strokes, and lowering the risk of dementia.The Mediterranean diet is neither low carbohydrate (it is about 50% carbohydrate) nor low fat (it is about 30% fat). It is not high protein (it is about 20% protein). Improvement in your health comes from eating certain foods, and not from counting macros (proteins, carbs, fats, and alcohol). Weight loss and better health are both touted from those who profess “low carb” or “low fat” and yet weight loss with the Mediterranean lifestyle is equal to or better than the low fat or low carb “diets”.Those who claim low-carbohydrate diets are the best for diabetes are often stunned that the Mediterranean diet provides superior long-term results for diabetes and insulin resistance. While they rightly point out that a diet rich in whole grains and fruits, will produce transient spikes in blood glucose levels, the long-term results from the Mediterranean lifestyle are superior to avoiding those foods – providing better control for diabetes.Back to those categories: Vegetables, Fruit and nuts, legumes, whole grains, meats, dairy, fats and oils, fish, and alcohol.Each one of those categories is worth a point, so you have a chance to get nine points total. For some categories, you get a point for eating a given quantity of food (more for some, less for others). We determine adherence to the diet based on how many points a day a person gets on average. The closer to nine points a person has on a daily basis, the healthier they are over the long term. Vegetables: The target is 9-10 ounces a day of vegetables. We count the pre-cooked weight of vegetables. If you bake 9 ounces of broccoli it will weigh about 4 ounces when cooked, but you still get credit for the 9 ounces. A medium carrot is 4 ounces - so two carrots a day gets you almost to your goal!There is a long list of vegetables and recipes in here to add them, but in case you want a refresher Asparagus, Beets, Brussels Sprouts, Cabbage, Celery, Collard Greens, Cucumber, Eggplants, Peas, Leeks, Lettuce, Onions, Peppers, Shallots, Spinach, Squash, Zuchinni... and those are just a few of them. Don't think of vegetables as a side dish - think of how you can incorporate them. One of my favorite is to put in cabbage in fish tacos to give it a lot of crunch. Add carrots, onions, peppers, celery to your tomato sauce for pasta. Your kids like chili? Any idea how many vegetables you can toss in there and they won't even know it? Add them to your chicken soup, or your dahl.Vegetable

In Vino, Veritas – or In Wine, Truth – by Pliny the ElderWhen the Holy Roman Empire was forming Charlemagne gave lands to the monks in order for them to plant vineyards to make wine for the Eucharist. Those first vineyards, planted by Benedictine monks, make some of the classic wines of all time.  Wine was in France centuries prior to Charlemagne, but it was those monks that we have a provenance of today’s wine. It was also from those Monks that we got the concept of terroir.Today terroir is the “in” thing that wine sommeliers will talk about. One of the myths is that you can taste the soil of the wine.  This traces back to those monks who would taste the soil in order to determine where the best wines would come from. What those monks didn’t know was that the vines get their ingredients from carbon dioxide and sunlight.Wine geology is complex, and recently Alex Maltman, a distinguished professor emeritus of geology, published a book about the geology of wine.  His book: Vineyards, Rocks, and Soils The Wine Lover’s Guide to Geology is a reference guide for those who want to know more about the geology of the wines they are drinking.Dr. Maltman was also a guest on the podcast where we talked about wine geology and dispelled the myth about tasting the soil.Dr. Maltman notes that the chalk of Champagne is the soil, and the soil is important to drainage of the vine, but the plant doesn’t take up chalk (which is a silicate compound), and when the inorganic compounds of chalk are broken down, and some of those minerals are taken up they are tasteless.What people taste are the many organic compounds that the plant makes from the carbon from carbon dioxide through photosynthesis and coded on the vineyards DNA. You also taste the byproducts of fermentation – as those compounds are put through yeast, bacteria. Where the confusion lies is that some of the organic compounds of the soil smell like some of the products of fermentation of the wine.The monks didn’t know about photosynthesis, nor did they know about DNA encoding for the proteins and organic chemicals, nor did they understand the complex chemistry of fermentation. They just knew wine is delicious- and sometimes the soil tastes a bit like the wine, so they assumed that the vine took up the soil and put it into the grape (the wine takes up the water, not the soil).Today Sommeliers everywhere love to talk about the geology of where the wine you are buying came from. They love telling you a story – because we love stories about our food. As Maltman points out, we love to know the provenance of our food, and in an era of large multinational corporations, wine is one of the few places you can know about where a grape was grown, harvested, what were the conditions that year, what is the makeup of the land – even what side of the mountain that wine came from.But what you cannot taste, is the soil from the rocks. That, my friends, is not only impossible because of how and what the plant takes from the soil (water and ionic forms of inorganic compounds, as Maltman points out in his book) but ignores the most glorious and complex part of wine.In our conversation, Maltman talks about the grapes that no one has heard of that are making a comeback in Greece, Croatia, and Eastern Europe.Oh, and we bust the myths of resveratrol and people who want to add this as a supplement for weight loss, long life, etc.-----Fork U is part of the Your Doctors Orders network of podcasts and is hosted by noted physician and surgeon Dr. Terry Simpson.Follow Dr. Terry Simpson on TikTok for bite-sized content on  healthy eatingVisit TerrySimpson.com for additional details on Dr. SimpsonFollow @DrTerrySimpson on Twitter for skepticism, travel, and much more.Fork U is produced by Simpler Media and is recorded in the studios of ProducerGirl Productions. 

This episode originally aired for the holidays in 2018. But it's solid advice, so we're playing it again, Sam!Diet season is soon upon us, but what happens if we have a system where you can lose weight during the times when you are most vulnerable: holidays, vacations, new relationships.Not a “lifestyle” or “long term” diet - but a simple ten-day plan to lose weight during the times when you need it.Full details: https://www.yourdoctorsorders.com/2018/12/10-day-holiday-diet/-----Produced and distributed by Simpler MediaFollow Dr. Terry Simpson on Twitter

The term "microplastics" was originally described in 2004 for plastic particles that are less than 5 millimeters in diameter, originally being seen on beaches. But everywhere scientists have looked on planet earth, they have been found. From fruit, vegetables, nuts, beer, baby bottles, in the air, in our water.Some have estimated that we ingest 100,000 microplastic particles per day or the equivalent of a credit card of microplastic in a year. That number will only increase, as we are producing over 400 million tons of plastics a year, and we have over 5 billion tons of plastics in landfills. Plastic degrades over time, from sunlight, from ocean water, from wind. Some of those plastics become so small they cross the blood-brain barrier in humans.These plastics come in all shapes and sizes. As they are exposed to the environment and degrade, they become smaller and smaller. They come with different types of plastics with different reactions, but mostly we don't know.The problem is we don't know what these plastics are doing to us. We don't know what the toxic levels of microplastics are. We don't know what, if any, physiological systems that microplastics would interfere with. We don't know if they increase cancer, heart disease, auto-immune disease, dementia, liver cirrhosis - we just don't know. We don't know if they inhibit the growth of children if they cause the loss of fetuses in women who are pregnant.We do know on larger levels; plastics cause issues with marine mammals. Shopping bags in the water look like the turtle's favorite feast, a jellyfish, and they will consume those, and those plastics become stuck in the turtle's digestive system clogging up their intestines and leading to their death. Most have seen the turtle whose nose was stuffed with a plastic straw. What we don't know is what happens when the small microplastics enter into cells, or cross the blood-brain barrier, or land in our lungs. Those finds led to the laws to decrease plastic one-use bags and plastic straws, but that is just the tip of what might be a more serious problem.We know that mice fed microplastics had lower sperm counts, smaller offspring, but again, mice are not men. We also don't know what the different types of microplastics will do - one type might be harmful, another type might be benign.Some plastics might pass through us like fiber, indigestible matter that has no consequence other than moving stool along.What can you do if you are worried? If you feed your child formula, use bottles instead of plastic. If you use your microwave, don't reheat food in plastic containers. Try not to use plastic containers for storage, and don't dispose of them so quickly. Water bottles - well, time to use reusable water bottles made of metal or glass.For now, we can do a small part, but it isn't the entire part. It is a problem that may be a larger problem or less of a problem. But it probably is an issue. We already know that some plastics do cause endocrine disruption, and those products have been outlawed.But it isn't just a marine problem; whether you are a vegan, pescatarian, vegetarian, omnivore, or carnivore, there will be plastics in everything you eat.-----Fork U is part of the Your Doctors Orders network of podcasts and is hosted by the noted physician and surgeon Dr. Terry Simpson.Follow Dr. Terry Simpson on TikTok for bite-sized content on  healthy eatingVisit TerrySimpson.com for additional details on Dr. SimpsonFollow @DrTerrySimpson on Twitter for skepticism, travel, and much more.Fork U is produced by Simpler Media and is recorded in the studios of ProducerGirl Productions.

Ever since the YouTube video of Dr. Lustig and the evils of fructose went viral in 2010, many have advocated that fructose is the single most common cause of obesity in the United States.The video had metabolic pathways that had the hypothesis that most fructose either becomes fat in the liver, or that it might go down a pathway to cause joint issues, leaky gut, and inflammation causing obesity.Here are the two chemical structures of glucose, also known as the "good sugar" and fructose, or the bad sugar. I cannot help but thinking of the good witch and the bad witch on the Wizard of Oz.Dr. Lustig's hypothesis was based on studies done in mice and rats. In those studies, published two years before the viral video, found that high fructose diets in mice lead to increased "gut leak" and led to liver damage (1). This was even confirmed with a small study of 8 men (2) who had their complex carbohydrates replaced by fructose and fed normal caloric diets - meaning, these eight men had increased liver fat, more de novo fat formation (de novo lipogenesis) .This all makes that logical sense since sugar-sweetened beverages are associated with chronic inflammation and these days everything to do with chronic inflammation increases the risk of obesity, diabetes, heart disease, and aging.Then came a double-blinded, randomized, crossover study where a group of people were fed a standard diet but drank 25% of their calories as either fructose (the evil sugar), or glucose (the good one) or a high fructose corn syrup sweetened beverage. Oddly, there was no difference in any of those groups with regard to markers of inflammation, intestinal permeability, or inflammation in the fat tissue.To quote from the study: "Excessive amounts of fructose, HFCS, and glucose from SSBs consumed over 8 d did not differentially affect low-grade chronic systemic inflammation in normal-weight to obese adults." SSB = sugar sweetened beverages.There have been a number of human trials looking at sugar-sweetened beverages and inflammation, and the results are not consistent. Even finding that people who drink large amounts of either glucose of fructose didn't find changes in inflammation or visceral fat.Mice are not men, and the link between gut permeability, leading to systemic and chronic inflammation, occurs in mice, but not men. And while in mice fructose can lead to inflammation and liver issues, this doesn't happen in human beings. (4)The key may not be fructose itself, but increased caloric intake.  If you eat more, you will increase in weight, but it is not fructose alone. It is, in fact, high caloric intake combined with sugars. Meaning, that great tasting snack with the high levels of sugars and fats act in concert with the increased calories consumed to give you that portly look.To be fair, all of the studies were short term, less than a couple of weeks. Fructose, over the long term, may still be a bad actor.What about fruit? It is exceedingly difficult to eat enough whole fruits to make this a problem. To eat the excess amount in some of these studies you would have to eat several pounds of apples, and most people simply cannot do that in a day. And whole fruit consumption, as a part of the Mediterranean diet reduces the burden of cardiovascular disease, diabetes, and even erectile dysfunction.(5)In fact less than 10% of most Western dieters have adequate levels of fruit (6) leading to a serious threat to human health. Maybe a couple of apples a day will keep the doctor away.-----Fork U is part of the Your Doctors Orders network of podcasts and is hosted by noted physician and surgeon Dr. Terry Simpson.Follow Dr. Terry Simpson on TikTok for bite-sized content on  healthy eatingVisit TerrySimpson.com for additional details on Dr. SimpsonFollow @DrTerrySimpson on Twitter for skepticism, travel, and much more.Fork U is produced by Simpler Media and is recorded in the studios of ProducerGirl Productions.  REFERENCES:(1)  Bergheim I, Weber S, Vos M, Krämer S, Volynets V, Kaserouni S, McClain CJ, Bischoff SC. Antibiotics protect against fructose-induced hepatic lipid accumulation in mice: role of endotoxin. J Hepatol. 2008 Jun;48(6):983-92. doi: 10.1016/j.jhep.2008.01.035. Epub 2008 Mar 14. PMID: 18395289.(2)  Schwarz JM, Noworolski SM, Wen MJ, Dyachenko A, Prior JL, Weinberg ME, Herraiz LA, Tai VW, Bergeron N, Bersot TP, Rao MN, Schambelan M, Mulligan K. Effect of a High-Fructose Weight-Maintaining Diet on Lipogenesis and Liver Fat. J Clin Endocrinol Metab. 2015 Jun;100(6):2434-42. doi: 10.1210/jc.2014-3678. Epub 2015 Mar 31. PMID: 25825943; PMCID: PMC4454806.(3)  Kuzma JN, Cromer G, Hagman DK, Breymeyer KL, Roth CL, Foster-Schubert KE, Holte SE, Weigle DS, Kratz M. No differential effect of beverages sweetened with fructose, high-fructose corn syrup, or glucose on systemic or adipose tissue inflammation in normal-weight to obese adults: a randomized controlled trial. Am J Clin Nutr. 2016 Aug;104(2):306-14.

On my tiktok channel (@drterrysimpson or terrysimpson309) putting up a review of red meat the comments are reflective of the polarization that makes politics look like gentle disagreements.Nutrition is nuanced - meaning, it is rare that something is good or bad for us, except for Death Cap Mushrooms, they will kill you, although I hear they are delicious. The same is true for red meat. What we have are rarely the types of nutrition studies where we feed people precise amounts of food and see the results (the DASH diet studies were great with this -ref 1 ). Instead we rely on what people tell us, which can be accurate, or not - and we look at markers for disease instead of the disease itself (looking at end points of heart disease we look at LDL, cholesterol, C-reactive protein, and rather non-specific markers.Red Meat and Glycemic Control and InflammationIn this study (ref 2) they examined the premise that red meat's has an effect on inflammatory markers and glycemic control. So the study  was a meta analysis of randomized control of glycemic control and inflammatory markers.Adults that were studied were given various quantities of red meats and then checked for glycemic control and inflammation. The end result "Total red meat consumption, for up to 16 weeks, does not affect changes in biomarkers of glycemic control or inflammation for adults free of, but at risk for, cardiometabolic disease. "Does this put this to bed - not really, but the proposed ill effect of red meat is not something that is seen in these studies.  Here are the markers they studied: glucose, insulin levels, HOMA-R, Hemoglobin A1c, C-reactive protein, IL-6, and TNF-alpha.This was a group of studies that went to about 16 weeks (four months) so any longer term issues with red or even red processed meats, were not seen. But there were clearly no indication found in these studies.What about other markers for heart disease?So the next question is the effect of red meat on lipids, lipoproteins and blood pressure(ref 3)? It turned out that increasing red meat did not affect those variables for heart disease.What if you check not just red meat, but "red meat with diets that replaced red meat with a variety of foods. We stratified comparison diets into high-quality plant protein sources (legumes, soy, nuts); chicken/poultry/fish; fish only; poultry only; mixed animal protein sources (including dairy); carbohydrates (low-quality refined grains and simple sugars, such as white bread, pasta, rice, cookies/biscuits); or usual diet. We performed random-effects meta-analyses comparing differences in changes of blood lipids, apolipoproteins, and blood pressure for all studies combined and stratified by specific comparison diets."- from ref 4.  They found that changing red meat for plant protein had a minimal effect, and yet other studies (ref 2) found that plant protein had no significant difference at all.Those short term studies, which are clear changes with specific amounts over a short period of time, appear to contrast with the studies of various groups where they look at the risk of type 2 diabetes and red meat consumption. Take reference 5, where they looked at the increase of diabetes in different groups based on self-reporting of red meat intake. These studies are not as powerful as the controlled trials above, and they are confounded by other variables - people who eat more red meat have higher caloric intake and more obesity, they also tend to drink more and to smoke more. It is not easy to isolate, statistically, those variables out and this is always the issue with large cohort studies.Take the many studies of the Seventh Day Adventist group, who are considered America's Blue Zone in Loma Linda, California. They don't eat meat, they live longer -- but there is more, that group tends to exercise more, they do not smoke, they do not drink, and they have a strong sense of community. When studied (reference 6) it appears to have an increased in all cause mortality with an increase in red meat and processed meat. But again, a cohort study where it is difficult to refine the variables is not as strong as a study where you feed people precise amounts and look for surrogate markers of disease.The other issue with following cohort groups is what else they consume. Red meat eaters who increase vegetables have lower long term risk of colo-rectal cancer or as we say - the risk of colon cancer is mitigated by increased vegetable and fibrous foods.  While looking at cohorts of meat eaters they tend not to eat much in the way of this food, in some studies they can account for this, in some studies they cannot and it becomes all the more confusing (ref 7).When looking at red meat and heart disease, researchers have wondered why poultry doesn't seem to cause an increase in heart disease as red meat. One thought is that it is the increased iron with red meat, or the heme protein. While this has never been proven, and there are no good an

The Carnivore diet is the most extreme of the low-carbohydrate diets, with its expressed point that humans did great on a diet of flesh and evolved to eat a diet high in fats. While we cannot make up what people ate in the past, we can see about the diet of the Yupik’s of Alaska.  These people have been studied extensively by the Center for Alaska Native Health Research (CANHR) at the University of Alaska in Fairbanks who partnered with Genetics of Coronary Artery Disease in Alaska Native people.First the CANHR found that Alaska Natives who ate processed meats (hot dogs, lunch meat, fried chicken) had higher triglycerides. Those Yupik’s who consumed lots of omega-3 fatty acids and ate lots of meats with saturated fats developed coronary artery disease. As much as we like to get our omega-3 fatty acids from the sources, and few in the world eat as many as the Yupik’s, that cannot protect you from coronary artery disease in the presence of the over-consumption of saturated and trans fatty acids. It further showed that, at least for the Yupik’s, consuming processed meats, and meats high in saturated fats like beef, pork, lamb and chicken with skin was not healthy for the Alaska Natives.The Carnivore diet excludes greens and berries, however sea greens and berries are a large part of the traditional Yupik diet. The diet that they have is high in marine mammals, fish, game animals, greens and berries that provide high levels of fat soluble vitamins (A,D,E, and K) as well as iron.The Biotruth of the Carnivore Diet:A biotruth is a logical fallacy, usually found to be a misunderstanding of evolution. In this case the idea that early human ancestors were meat eaters and that the adaptation of cultivation of crops led to chronic disease.When CT scans were looked at from 137 mummified remains from four geographical regions, ancient Egypt, Peru, the Pueblo, and Unangan from the Aleutian Islands were examined they found atherosclerosis in all of them. “Interpretation: Atherosclerosis was common in four preindustrial populations including preagricultural hunter-gatherers. Although commonly assumed to be a modern disease, the presence of atherosclerosis in premodern human beings raises the possibility of a more basic predisposition to the disease.”It should be noted that those were diverse diets from those who ate primarily marine mammals and fish to those whose diet was composed primarily of vegetation with little meat.The Myths of LDLThe low carbohydrate community propose that LDL isn’t an issue with heart disease. This flies in the face of the recent article in JAMA looking at 34 clinical trials and finding that lowering LDL-C not only decreased the risk of heart disease, but all causes of mortality. While the low-carb crowd likes to point out how sugar indeed has a role in development of heart disease, they quietly forget to point out that diets rich in meats are overwhelmingly an issue.-----Fork U is part of the Your Doctors Orders network of podcasts and is hosted by noted physician and surgeon Dr. Terry Simpson.Follow Dr. Terry Simpson on TikTok for bite-sized content on  healthy eatingVisit TerrySimpson.com for additional details on Dr. SimpsonFollow @DrTerrySimpson on Twitter for skepticism, travel, and much more.Fork U is produced by Simpler Media and is recorded in the studios of ProducerGirl Productions.  -----REFERENCESBrand-Miller JC, Griffin HJ, Colagiuri S. The carnivore connection hypothesis: revisited. J Obes. 2012;2012:258624. doi: 10.1155/2012/258624. Epub 2011 Dec 22. PMID: 22235369; PMCID: PMC3253466.Bersamin A, Luick BR, King IB, Stern JS, Zidenberg-Cherr S. Westernizing diets influence fat intake, red blood cell fatty acid composition, and health in remote Alaskan Native communities in the center for Alaska Native health study. J Am Diet Assoc. 2008 Feb;108(2):266-73. doi: 10.1016/j.jada.2007.10.046. PMID: 18237575; PMCID: PMC6542563.Ryman TK, Boyer BB, Hopkins S, Philip J, Beresford SA, Thompson B, Heagerty PJ, Pomeroy JJ, Thummel KE, Austin MA. Associations between diet and cardiometabolic risk among Yup'ik Alaska Native people using food frequency questionnaire dietary patterns. Nutr Metab Cardiovasc Dis. 2015 Dec;25(12):1140-5. doi: 10.1016/j.numecd.2015.08.003. Epub 2015 Aug 21. PMID: 26607703; PMCID: PMC4684467.Thompson RC, Allam AH, Lombardi GP, Wann LS, Sutherland ML, Sutherland JD, Soliman MA, Frohlich B, Mininberg DT, Monge JM, Vallodolid CM, Cox SL, Abd el-Maksoud G, Badr I, Miyamoto MI, el-Halim Nur el-Din A, Narula J, Finch CE, Thomas GS. Atherosclerosis across 4000 years of human history: the Horus study of four ancient populations. Lancet. 2013 Apr 6;381(9873):1211-22. doi: 10.1016/S0140-6736(13)60598-X. Epub 2013 Mar 12. PMID: 23489753.Bersamin A, Zidenberg-Cherr S, Stern JS, Luick BR. Nutrient intakes are associated with adherence to a traditional diet among Yup'ik Eskimos living in remote Alaska Native communities: the CANHR Study. Int J Circumpolar Health

Fish oil is the bomb - Greenland Yupik and the rise of fish oilFish oil first became a "hot topic" when a 1980 publication showed that Yupik in Greenland had a lower incidence of cardiovascular disease.Their paper concluded, "The rarity of ischemic heart disease in Greenland Eskimos may partly be explained by the antithrombotic effect of the long-chained polyunsaturated fatty acids, especially eicosapentaenoic acid prevalent in diets rich in marine oils." (Bang HO, Dyerberg J, Sinclair HM. The composition of the Eskimo food in north western Greenland. Am J Clin Nutr. 1980 Dec;33(12):2657-61. doi: 10.1093/ajcn/33.12.2657. PMID: 7435433).This led to more scientific bodies looking at the evidence for fish oil, and ultimately omega 3 fatty acids, and if it did reduce the incidence of cardiovascular disease. And even 22 years after the publication of that study, the American Heart Association put out a statement that fish oil was protective against cardiovascular disease. (Kris-Etherton PM, Harris WS, Appel LJ; American Heart Association. Nutrition Committee. Fish consumption, fish oil, omega-3 fatty acids, and cardiovascular disease. Circulation. 2002 Nov 19;106(21):2747-57. doi: 10.1161/01.cir.0000038493.65177.94. Erratum in: Circulation. 2003 Jan 28;107(3):512. PMID: 12438303)The other predictable tract this led on was the inevitable marketing of fish oils in the supplement industry trying to sell fish oil capsules, from whatever source, as a "must take" to prevent the number one killer in the United States. As with most supplements, being unregulated, they would make claims that their oil was better than others - because it came from krill, or it was vegan-based, or from cod, or pick something that sounds like it can be marketed. Some would claim their fish oil was more pure omega 3 fatty acids. Radio and television spots were secured, and when it was confirmed that the "good cholesterol" or HDL was indeed raised by omega 3 fatty acids it raised their game and intensity of marketing.Back in the world of science, testing continued and the results that came back didn't match the conclusions.Some papers would conclude that fish oil didn't produce a significant decrease in first time cardiac events but might help prevent secondary cardiac events (Yokoyama M, Origasa H, Matsuzaki M, Matsuzawa Y, Saito Y, Ishikawa Y, Oikawa S, Sasaki J, Hishida H, Itakura H, Kita T, Kitabatake A, Nakaya N, Sakata T, Shimada K, Shirato K; Japan EPA lipid intervention study (JELIS) Investigators. Effects of eicosapentaenoic acid on major coronary events in hypercholesterolaemic patients (JELIS): a randomized open-label, blinded endpoint analysis. Lancet. 2007 Mar 31;369(9567):1090-8. doi: 10.1016/S0140-6736(07)60527-3. Erratum in: Lancet. 2007 Jul 21;370(9583):220. PMID: 17398308).In 2004 the Cocharane database looked at 48 randomized controlled trials and concluded that taking fish oils did not reduce mortality from cardiovascular disease. It also concluded that it didn't matter where the fish oil came from, fish or plant sources, or other sources. This, as you might imagine, throws a monkey wrench into the statement by the American Heart Association that fish oils were good for you, especially coming two years later.Marketing moves faster than medicine, so while doctors and scientists were working to find out why there were inconsistent results, the marketing of fish oils continued to expand. Given that there was no regulation in the supplement industry, they continued to market the "benefits" of their product. By 2020 the sales of over-the-counter fish oil products became to a SIX BILLION dollar industry, (https://www.grandviewresearch.com/industry-analysis/omega-3-supplement-market).Scientists worked at looking at the different components of dietary, or essential fatty acids. Because the literature was confusing, and the American Heart Association had a bit of salmon egg on their face, they decided to get their best and brightest to review the data and come to a conclusion. They did come to some interesting conclusions: 8 percent of the US population in 2012 had consumed fish oil capsules in the previous 30 days. When they looked at the purity of the supplement they were pleased to find that "the analytical content of EPA and DHA was for the most part reflective of the labeled amounts." They found that free fatty acids were more bioavailable than the products containing ethyl esters. But the more interesting conclusions were:(a) people who have not had a heart attack, the supplementation with fish oils will not prevent one.(b) people who have diabetes, and thus at a higher risk of heart attacks, also had no benefit from taking fish oils(c) people who have a high risk of cardiovascular disease could not conclude that they would have a benefit from taking fish oils(d) they did recommend people who had had a previous heart attack might benefit from a lower dose of fish oil but their recommendation was a class 2b - me

Welcome to Fork U, the latest podcast from Dr. Terry Simpson.If you enjoyed the previous episodes of Culinary Medicine and Your Doctors Orders, you'll love these quick, impactful bits of information that are easily digestible. (See what I did there?) No need to adjust your podcast or subscribe to anything new, you are already here! With that, here is the first episode of the new podcast, Fork U, where you can learn a bit about food and medicine.