Bacteria, Heart Disease, and Red Meat and eggs?????

Bad News for Red Meat: Well, read the fine print
There are more bacteria in your colon than people on planet earth. Without bacteria people couldn’t survive or thrive. Bacteria are responsible for us being able to get vitamins, they break down fiber into chemicals that protect us against colon cancer. Now, in a study recently published in Nature, proposing that red meat leads to heart disease through bacteria.

The mechanism is a byproduct of the metabolism of some bacteria called TMAO (trimethylamine N-oxide) which, in some studies, is correlated with an increased risk of heart disease.

is red meat healthy

In the experiments conducted they took meat eaters and vegans and fed them steaks. Why I wasn’t invited to participate is clearly an oversight – after all, steaks…. They discovered when red meat eaters ate steak their level of TMAO went up, but not if vegetarians ate it. They even discovered it wasn’t the meat, but rather the carnitine in the meat that did this (a common supplement in protein drinks for those who want to look like Arnold Schwartzeneger on steroids).

Takes a bit of presumption doesn’t it. But lets work backwards from this hypothesis and start with a favorite saying:

Correlation does not equal Causation
The evidence that red meat causes an increase in coronary artery disease is mixed, at best. The latest study showed there was no evidence that this was an independent risk factor. Smaller studies such as the Nurses Health Study and Health Professional Follow-up study showed an association with a relative risk factor of much less than 2. I blogged a summary of those studies.

Your Gut and Bugs
The bacteria in your gut are important. They protect you- by simply occupying space, they prevent bacteria that are harmful to you from finding a home, as well as  parasites, yeast, and perhaps some viruses.  It has been estimated we have over four pounds of bacteria in our gut. Just a few other numbers that are fun: it is estimated there are over 100 trillion bacteria in our gut (the human  being is made up of about 10 trillion cells, so there are more of them than there are of us – or, a philosopher might ask – who are we really).  We have grown only about 70% of the bugs found in our gut, or so we guess. The byproducts of these bacteria include chemicals that prevent fungus from taking hold,  prevent other bacteria from getting close, and they alter the pH of the gut to keep it comfortable for us and our friendly bacteria, but not so much for the bad bacteria.

These friendly bacteria help produce vitamin K, and biotin. In addition to helping ferment other substances that our body cannot break down, and by breaking down those substances make them available for us to get nutrients from them. While humans cannot digest fiber, some of the bacteria in the gut can digest fiber, and the byproduct of that digested fiber is an agent that decreases the risk of colon cancer (our poop has stuff that bacteria eat and bacteria poop keep us from getting cancer). Is it possible that the bacteria in our gut could create something that makes it more likely for us to have heart disease, or cancer? Yes, it is quite possible.  What you eat does alter your gut bacteria. Who you kiss alters your gut bacteria. Who your parents are alter your gut bacteria. When you get an antibiotic, your gut bacteria change.

With some antibiotics and a combination of stomach acid reducing agents (Prevacid, Nexium, etc) a bacteria that overgrows the colon called Clostridium difficile  (C diff).  This bacteria so overgrows the colon and as a result people can develop ulcers, bleeding, toxic mega-colon, and perforation as well as death. This is a concern for surgeons, something we encounter far too often.

Some people can get overgrowth of bacteria in their small bowel that can lead to malabsorption of nutrients including bloating, nausea, diarrhea, constipation, and long term problems like  anemia from iron malabsorption, and has been linked with some auto immune diseases.

Think of your gut like an eco-system. If it is in perfect harmony, you benefit from it. If not, an overgrowth of one or another bacteria can lead to problems. 

Diet certainly affects which bacteria inhabit your gut. The big question remains, is there a diet, or set of foods, that will encourage the gut to have more “friendly” bacteria and less “bad” bacteria. Here is the realm of speculation – other than a diet rich in fiber being healthy, we don’t have a great answer.  This doesn’t stop people from speculating about one diet or another being better.  In this case, the speculation would be that vegans and vegetarians eat a diet that keeps the bacteria that produce TMAO to a minimum.

And the colon- remember, people have been telling you for years about how bad the colon is- from Kellog and his enemas (he died in his 60′s from heart disease, was a perfect vegetarian and loved colonics) to modern day colon cleansers.  No doubt there will be on Walgreen’s supplement shelves a pro-biotic that will get rid of the bugs that make TMAO.

Gut bugs and Diet
There are three types of gut flora that have been described based on the diet that people have. The “enterotypes” are descried as Prevotella, Bacteroides, and Ruminococcus.  Each one associated with a specific type of diet. Prevotella comes from diets with lots of simple sugars, or high-glycemic index carbohydrates. Bacteroides is associated with animal proteins, or the typical western diet. It is those people who have the Prevotella species that had a higher TMAO blood level. Oddly 3 our of 4 of the subjects that had the Prevotella species were omnivores.

In another study showed that these broad enterotypes were associated with long-term diets. When people were fed a controlled diet the enterotypes remained the same during the ten day study. While some bugs changed quickly, it appears your gut ecology takes a while to change – which, if you think about it, is not surprising.

You are probably thinking- 100 trillion bacteria, and the population of some types more than others?  Think of the United States with its population and other countries with their population. In Norwegian countries there are more Scandinavians, in Italy there are more Latins – now think of your gut. In Vegans, there are going to be more bacteria that do well with their host who eats vegetables – and in omnivores, the bacteria that populate it will likely be more of those that like chewing on remnants of meat.  The hypothesis here is that those bacteria produce more TMAO, and thus meat eaters, when given meat, make that harmful substance that leads to more cardiac deaths (forget that this is a poor correlation in any study looked at, just go with it for a bit). Now- bacteria don’t just eat meat and poop out TMAO – there are enzymes involved in the conversion to this “deadly” substance – and one of them is Vitamin B2, which is typically LOW in vegetarians.

What about TMAO and the Nature Article?
One arm of the human study was with six people.  Five of them were meat eaters and there was one vegan. This is little more than an observation, and hardly  enough of an observation to make headlines.  That one vegan didn’t make TMAO means nothing. It could be that the vegan had antibiotics recently, it could be that they are an exception, it could be a lot of things. The one vegan was a male, and the non-vegans were females – and when the statistics were examined carefully – well, not a difference. But significant, even as an observation – nope.

Of course of the 23 vegans/vegetarians and 30 omnivores they looked at the bacteria in their stool (reminds me of the movie The Madness of King George – when they were obsessed with his stool) – and found the different types of bacteria attempting to correlate those bacteria with meat eaters or vegetarians. The problem was, some of the individuals with the “good bacteria” were omnivores.

The Nature article also looked at a mouse study. Mice are not humans, but with mice they didn’t feed them steaks. Instead they used carnitine. Carnitine is an amino acid, often used in supplements, but your body makes this amino acid naturally. To date there have not been studies that show that carnitine rich foods increase TMAO, in fact the one food that elevates TMAO is some seafood. Seafood, by the way, is associated with decreased risk of heart attack.

In the mouse study they fed them enough carnitine to the equivalent of a human eating about a thousand steaks a day. And I would submit if you eat that many steaks a day you might have some problems. The other issue is this: the gut bacteria of the mouse are not the same as the gut bacteria of the human. Are you a man or a mouse can apparently be answered by checking your fecal bacteria.

AND NOW EGGS?

It is the same argument and discussion for eggs. Turns out that the correlation with eggs and heart disease is zip. In fact, one of our patients finished a month of eating nothing but eggs and saw his cholesterol drop! Again, this is just a bad article with a lot of bad press.

A House of Cards
This study and news report is a part of a house of cards. Conclusions built upon conclusions, with a benign observation from one vegan, and a study in mice. In their conclusion the Nature paper stated that this went along with evidence of risk reduction for non red meat eaters and they cited the Mediterranean diet study in NEJM.  What they fail to grasp is that diet didn’t show a decrease in heart attacks, or heart related events, only a decrease in risk of dying from a stroke – and no absolute decreased risk of dying.

This study again falls into the “red meat is bad,” and shows two things: studies that make headlines in newspapers show that in the slow death spiral of print media they fired their science reporters first  and second, if you want your study to get headlines, find something that shows what the popular press thinks is true.

Saturated fat and cholesterol in beef don’t cause heart problems, and your body makes more carnitine than you get from your diet by a factor of six (unless you are a mouse that is force fed).  TMAO is a huge byproduct of fish, and fish eaters seem to have longer lives and less heart disease.

So- this study make sense to you? Is there maybe a message here? One thing is certain: vegetables are not bad things for you. While some of the omnivores in this group had “good gut bacteria” it could be because they ate a lot of vegetables. So- if I were you, I’d make sure I had plenty of that good old fashioned fiber in my diet.  Who knows, maybe that helps the good bacteria from having heart attacks.

steak and beans

REFERENCES:

The red meat article, published originally on Nature.com

Intestinal microbiota metabolism of l-carnitine, a nutrient in red meat, promotes atherosclerosis. Nat Med. 2013 Apr 7  Koeth RA, Wang Z, Levison BS, Buffa JA, Org E, Sheehy BT, Britt EB, Fu X, Wu Y, Li L, Smith JD, Didonato JA, Chen J, Li H, Wu GD, Lewis JD, Warrier M, Brown JM, Krauss RM, Tang WH, Bushman FD, Lusis AJ, Hazen SL. PMID: 23563705

Here is the article showing that fish and other sea products give rise to increases in TMAO more than meats.

Dietary precursors of trimethylamine in man: a pilot study. Food Chem Toxicol. 1999 May;37(5):515-20.  Zhang AQ, Mitchell SC, Smith RL. PMID: 10456680

Here is an outstanding article by Chris Masterjohn that gives a far more in depth analysis than I did.

The Bad Fat isn’t Bad and the Good Fat isn’t Good

President Eisenhower followed a low-cholesterol diet with military precision. But his cholesterol continued to climb. Even with exercise and strictly eating no foods with fat. He listened to the best medical advice of the day- and they were wrong.

President Eisenhower could not have been more frustrated. Following the advice of his cardiologist and General Thomas Mattingly, and the famed Paul Dudley White, Eisenhower was eliminating all cholesterol and fat from his diet. But every time they would take his blood level his cholesterol was higher.  He was no stranger to exercise, he gave up smoking in 1949, and days he would just have grapefruit with some melba toast.  The blood cholesterol would come back, higher than before. It was so frustrating that the White House physicians seeing him would make up numbers to tell him that it was getting better. But it didn’t. Eisenhower was crippled in retirement by his heart disease – determined to eat as prescribed, he ended his days as a cardiac cripple.

Lyndon B Johnson had a heart attack while he was a senator. General Thomas Mattingly was also his physician. Mattingly prescribed the same low fat diet that he had given to President Eisenhower. For months after his first attack Johnson followed it to the letter, shedding some 4o pounds and feeling better. But still his cholesterol was high.

LBJ, a heart patient, tried the “low cholesterol, low fat” diet, but realized his cholesterol didn’t change – so he gave it up. Remarkably, once he started eating the beef from his ranch his cholesterol decreased.

Johnson fell back into his old habits, and had another heart attack, which derailed his presidential ambitions for a while. Finally, in retirement Johnson started to follow the regime again – but noticed that when he started to eat beef from his ranch, his cholesterol went down. He came to his own conclusions, stopped trying to avoid beef- and enjoyed the bounties of his retirement. He enjoyed friends coming to the ranch, with frequent barbecues – often coming late for dinner.

For years America was told that saturated fat is bad for your heart. It was based on a faulty principle – that the fat in the arteries came from the fat in the blood which came from the fat in the diet. While it makes sense, it wasn’t until after Johnson and Eisenhower died that science discovered that dietary fat contributes only a small amount to blood lipid levels. The idea was popularized by Ancel Keys.

But in spite of evidence to the contrary, once a popular notion is in the press, it stays there. Which brings us to President Clinton. The president enjoyed his burgers, and when he had his heart attack he began to examine the notion that plant based diets would reverse heart disease. His disease arteries bypassed, he turned to Dr. Dean Ornish. Ultimately, Clinton became a vegan. Was it a wise choice? President Clinton is a smart fellow, but if he were to critically go through medical journals he might question his choice. ,

It has been 16years since Dean Ornish published his data showing a 3 per cent reduction in the plaques seen by coronary angiograms on a select group of patients who followed his Ornish diet and “lifestyle” plan. To be exact: the 28 patients who followed his plan had a 1.75% decrease in atherosclerotic plaque after one year and 3.1% decrease after five years. With the control group there was an increase of 2.3% in one year and 11.8% at five years.

In 16 years no one has reproduced that data. No one. Still, from one old paper Dean Ornish has made a career; first being the anti-Atkins, and riding the anti-cholesterol, low-fat band wagon with the same religious fervor as Keyes did thirty years before. Ornish has since become the lead health-blogger for Huffington Post, has influenced Bill Clinton – turning him into a vegan, and is favorably mentioned by Dr. Oz.

The difficulty is this: science has caught up with him, and we know a lot more about how atherosclerotic plaques form. We know that dietary lipids and their carriers are far less important that what the body makes. We know that the dietary component is far more related to the trigycerides – and triglycerides are raised much more by the grains and pastas that Ornish preaches on (in his trial, the “Ornish lifestyle” patients had a rise in their triglycerides).

What Ornish and his crew call a landmark paper, would not be accepted by the same journals today for a number of reasons:

(a) No one compares angiograms – a two-dimensional photograph of an artery – because they can be manipulated so easily and interpreted differently from one experienced radiologist or cardiologist to another. Depending on the angle you take the angiogram from, you can show a reduction in plaque by varying the recorder by a few degrees. Today intra-vascular ultrasound is the test of choice – this gives us a three dimensional view of the artery, from within the artery. The recent article in The New England Journal of Medicine, comparing lipid medications and their long-term effect on atherosclerotic plaque, is the most accurate measurement of plaque and its formation.

(b) We know about the science of lipids, plaque formation, and how we can manipulate those to provide a better answer for atherosclerosis that does not involve severe manipulations of a diet. For example, it appears it is the carrier proteins that cause the damage to the arteries – and more carrier proteins are made in response to certain stimuli (triglycerides being one).

(c ) There were deep and troubling issues with the groups of patients serving as controls. For example, we do not know how many pack-years of smoking were in one group or the other. This is not a minor flaw, as science understands the highly inflammatory changes that are made with smoking as opposed to those made with hyperlipidemia.

(d) Lipid lowering drugs were used in some, and not others – however, the drugs today are far better, and more targeted than before.

To this day when most talk about saturated fat we are given “alternatives” like margarine, olive oil, oils from nuts, seeds, and the like.  They are suppose to be better for us than “animal fat.” They are not.

We built pyramids – food pyramids, based on avoiding certain foods. We went out of our way to define the chemical nature of fats: polyunsaturated, monounsaturated, a trans-fats. We made charts so we could keep track of which fats were the “good fats,” so we could tell patients to eat these.

Monounsaturated fat Polyunsaturated fat
Olive oil Corn oil, Grapeseed oil
Avocados Fatty fish
Almonds, peanuts, macadamia nuts Walnuts, sunflower seeds, flaxseed
 

 

Then of course we had to tell people what was “bad” because it caused problems so we made tables like this:

Saturated fat Trans fat
Beef, lamb, pork Margarine (stick form)
Ice cream Fried foods (french fries, breading)
Milk, cream Crackers, popcorn, chips
Lard Shortening

 

But wait – then we had to tell what to change in their diet so we made tables like this one:

 

Less Healthy Better Choice
Beef that is corn-fed Beef that is grass-fed
Butter Olive oil
Standard eggs Eggs high in omega-3 fatty acids
Ice cream Frozen yogurt
Milk Fat-free milk, soy milk, almond milk
Shortening, lard Grape seed oil, canola oil, vegetable oil

Did I mention we were wrong?

In science we make a hypothesis – then we test the hypothesis – then based on our findings we refine things, test again, and somewhere we develop a theory that explains the nature of things. In this case – food.

When the USDA and Europeans looked at the data to make recommendations about fat, they cherry-picked the data about saturated fats. Meaning, in spite of studies showing that saturated fat did not increase heart disease, in spite of studies showing that polyunsaturated fats may be worse than saturated fats, they pressed through guidelines and recommendations that were based not on critical thinking, but the bias of the committee members.

Remember: in those days, everyone had the thought that the fat laden arteries of people with coronary artery disease came from butter, animal fat, and the like.

Heart artery plaque- low fat diet doesn’t prevent this

What do we do?

It turns out that saturated fat is not bad for a person, and the studies showing we should substitute with other fats were wrong.

Still the ideas of eating “healthy” for many people means avoiding red meat, avoiding saturated fats, even though the evidence for this is almost non-existent.

How We Live:

Which brings us to one simple fact: how we live is more important than how when we die- especially if the quality of life is less than satisfying. I doubt Eisenhower enjoyed his last days as much as Lyndon Johnson.

But let me bring one simple point: learn to cook. Appreciate fresh food. Yes, you can live on processed food but you cannot thrive.

 

REFERENCES:

In 2003, a meta-analysis of over 50 trials was published examining the relationship of dietary fat to serum cholesterol levels (Mensink RP, Zock PL, Kester AD, Katan MB. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serumlipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am J Clin Nutr 2003;77:1146–55.).  The conclusion was that saturated fat increases the levels of low-density lipoprotein (LDL) and high-density lipoprotein (HDL) but without changing the ratio of total to the HDL cholesterol.   They concluded that using cholesterol alone as a marker of risk was unreliable. This was because if you replace the saturated fat with carbohydrates or tropical oils if you examine the effects on HDL and apolipoprotein B. They concluded that “… we can never be sure what such fats and oils do to coronary artery disease risk.” To translate that from doctor-scientist language: we can improve some laboratory markers, but really not by any mechanism that makes a difference from what we know.

While a systematic review of randomized trials showed that when saturated fats are replaced by polyunsaturated fats there is a reduction in the laboratory marker for risk of heart disease, there was no association with mortality from heart disease.  To emphasize this: the laboratory values of the patients studied improved, but their mortality didn’t. The review also showed that monounsaturated fat intake significantly increased cardiac events, but no effect from the intake of saturated or polyunsaturated fat. Let me emphasize that: Monounsaturated fats, by at least one study, not only didn’t improve issues with the heart- the patients in that study did worse.

When examining other prospective studies about the risk of saturated fat and cardiovascular disease, there has been a consistent lack of an association between fat intake and heart disease, stroke, or total cardiac events.

Cohort studies show that by replacement of saturated fats with unsaturated fats, or carbohydrates – and examining the hazard ratios for heart attacks and deaths from heart disease were as follows: 0.87 for polyunsaturated fat, 1.19 for monounsaturated fat, and 1.07 for carbohydrates.  For those not familiar with statistics, these are essentially no difference, and if these small statistical numbers are accepted than polyunsaturated fat shows an alarming trend. So here is a study that indicates (with as much precision as most studies these days) that polyunsaturated fats are worse for you than saturated fats.

There is a difference between protection against what we define as risk of heart disease and death from heart disease.  Risk reduction means that we lower the laboratory values of factors we associate with risk – but the end point is death.  In a meta-analysis published in 2010 (Ramsden CE, Hibbeln JR, Majchrzak SF, Davis JM. N-6 fatty acid-specific and mixed polyunsaturated dietary interventions have different effects on CHD risk: a meta-analysis of randomised controlled trials. Br J Nutr 2010;104:1586–600.) examined seven different trials, they found that there was a risk reduction but no change in mortality.  Another study (Skeaff CM, Miller J. Dietary fat and coronary heart disease: summary of evidence from prospective cohort and randomized controlled trials. Ann Nutr Metab 2009;55:173–201.  ) had eight trials found “There is probably no direct relation between total fat intake and risk of CHD (heart disease).

The advice of the USDA is reflected in places like WebMD, recounted in public service commercials, and recited as gospel by health care workers everywhere.  Giving false impressions about what an appropriate diet is.

 

Mummies & Eskimos with Heart Disease: it isn’t Modern Diets that are the Problem: The People of St. Paul

The recent study that came out showing that ancient people had heart disease, including a group of Alaska Natives whose mummified remains revealed that the perfect paleolithic diet did not protect from heart disease. Funny thing, Alaska Natives have known this for years. While some may want to say our diet is the ultimate, we have known it is just our way to survive – to live.   St. Paul is a small community of several hundred in the Pribilloff Islands. A remnant of the ancient people of Alaska, with only minimal changes from our paleolithic era.

Most people would never know about these islands were it not for the TV series, Most Dangerous Catch.  It is these islands that the crab fisherman come to process some of their crab. Viewers of the show will recognize the name of the place.

St George Island from St. Paul

In the distance is St. George, the smaller of the two islands. St. Paul is 7 miles wide, 14 miles long. Formed from volcanic activity.

Lonely islands, in the middle of the Bering Sea – but home to some of the most ancient people on earth. St Paul is a three hour flight from Anchorage. Sometimes the weather is so fierce that people have been unable to leave the island for several days.

Like their ancestors, these Alaska natives get their food from fishing. Halibut, crab, salmon, char, and the occasional seal. The only thing that has been introduced into their diet has been the reindeer herd on the island – that would provide a bit of our dinner that night. While there is a single grocery store, products from the lower-48 are expensive and not often used.

The recent Lancet article stated:

 

The presence of atherosclerosis in  pre-modern human beings suggests that the disease is an inherent component of human ageing and not  characteristic of any specific diet or lifestyle.

alaska Aleut

The Aleuts, or Unangan, peoples inhabit the western most part of Alaska – purple. The two little spots above the t in Alutiiq is where St. Paul Island is-

In the article they had studied   mummified remains of Alaska Natives, my ancestors. The Aleuts  live on the  islands in the western part of Alaska.   These islands, formed from mostly volcanic formation, to this day are rich in marine life, with abundant fish, seal, whales, and occasional berries.

I was last there when invited to a celebration in St. Paul because of their new clinic. A beautiful facility, staffed by physicians out of Anchorage. But this facility is vital to the community.

St Paul Seals

The island is a natural breeding ground for seals, who migrate here yearly. The Russians forced Aleuts to inhabit the island to harvest the seals

The island was originally uninhabited until the Russians arrived. Used primarily as a hunting area for natives, then the Russians discovered the great seal population they forcibly moved hundreds of Aleuts here to harvest the fur.  Those families still remain.

Why, you might ask, should you think about Aleuts?  Why do food scientists think about them? These were/are one of the great hunter-gathering societies, eating a diet of fish, meat – even getting their vitamin C, not from citrus, but from marine life. Those relatives, my ancestors, had a diet rich in omega-3 fatty acids, did not eat processed grains – in fact, they rarely had any food but what would be the ideal paleo-rich, non-processed, occasional berry (in season – fresh and local) diet.

For the study in Lancet, it was made possible to see what my ancestors ate because  the climate in these parts allows mother nature to mummify the body, making the bodies available to study.

St Paul

Main Street in St. Paul. They have one bar, one post office, one grocery store, and one church

This group was use to physical activity, without animals to transport them they relied on the kayak for whaling, fishing, and transportation to visit one another on other islands.  With Russians reporting that some of these peoples would go hundreds of miles in Kayaks.

kayak

Restoring an ancient Kayaks. Much larger than the individual ones used for modern sport

Kayak

A better view of how large these ocean going vehicles were

It has been postulated that the Eskimo (the Aleut are the same group as the Eskimo) would have the lowest incidence of coronary artery disease because of their diet. The hunter-gathering society had a “reported” low incidence – although as with many population studies have shown, you often find it when you look for it. For a more in depth discussion about population studies and how we have missed them see here. The Pima Indians, of Arizona, are called “the most studied group” in the world. It was once assumed they had no heart disease, and thus began an intensive study as to why they didn’t have heart disease- but as more studies were performed, turns out the Pimas, like many societies, have heart disease. In fact more of it than western societies. It is the same with the Eskimo health, whether from Greenland or other areas, when critically examined, this society has the same rate of heart disease as others.

Modern Man:

Some have speculated that the incidence of coronary artery disease among Eskimos is because of their interaction with modern man. The introduction of grains into their diets, tobacco, and machinery with less exercise. Not only did the study in Lancet article show that cardiac disease was present in those paleo-people, it is in line with laboratory studies of Aleuts showing they have the same markers for cardiac disease as the rest of us.

Smoking:

Aleut home Alaska Native Center

This is a modern representation of homes of the Aleuts. This from The Alaska Native Heritage Center in Anchorage, Alaska. A worthwhile place

While they did not have tobacco, all ancient peoples used fire. The Native Alaskas of the Aleutians  had homes built partially underground, and used community fires with smoke going out of a hole in the roof, or used fires to heat water that would heat the homes. This might have lead to increased exposure that would accelerate heart disease, but the dispersion of smoke from this would be hundreds of times less than exposure from those who inhale tobacco.

Seal oil was used for lamps. Which, like olive oil, burns quite brightly.

Today they use electricity.  So the second-hand smoke from fires and lamps is no longer a factor. They still eat a diet primarily of fish.  Still, as we found from this little clinic for a town of 400 people, there is  heart disease. Several times a year a person is evacuated out of this town to the city of Anchorage for advanced cardiac care.

One of the  mummified remains of an Aleut lady showed severe artery disease to the extent that if we saw this today she would undergo vascular surgery. This in a woman who was in her late 40′s to early 50′s. She may very well have died of a stroke.

 

St. Paul island birds

The people still get eggs, but they prefer the fresh ones from the cliff. Higher in omega-3 fatty acids than the ones from the chicken farms. These islands have some of the most unique birds in the world.

In fact, in the recent study published on-line by Lancet, they discovered atherosclerosis was prevalent in all areas of the world, over a 4000 year time span, and several continents, with peoples having ancient diets from rich in saturated fat, to near vegetarian, to pure paleo.

Exercise:

Exercise you say? Turns out that in ancient cultures, without the benefit of cars, bikes, or probably even animals- physical activity was normal- and lean and mean were simply natural. Like a six-pack, probably every ancient Alaska Native  person had one– but in their coronary arteries were plaques, that would make any modern, beer belly, sedentary modern human proud.

Diet:

These ancient ones didn’t have trans-fats, they didn’t have soda, they didn’t have wheat, they didn’t have dairy, they didn’t have cheese, but they did have heart disease. And today, they stil do.

Heart Disease:

The study showed that heart disease was found throughout ancient civilization. It wasn’t the diet that prevented it. In fact, probably was genetic like most of us thought all along. Like their ancestors before, the Aleuts of St. Paul have the same disease, virtually the same diet. Their lifestyle is better now, with indoor heat, better insulation. They still live a physical life. But one thing they need- much like many – is some statin drug like Lipitor  which works much better than their ancient diet, or any diet you can think of .

Ask an Alaska Native if their diet protected them from disease: they will tell you, it didn’t. Food wasn’t meant for medicine, food was meant to nourish the body. A lesson the ancient people knew – one that many doctors are still learning.

REFERENCES:

Atherosclerosis across 4000 years of human history: the Horus study of four ancient populations.Randall C Thompson, Adel H Allam, Guido P Lombardi, et.al. www.thelancet.com   Published online March 10, 2013

High prevalence of markers of coronary heart disease among Greenland Inuit. Jørgensen ME, Bjerregaard P, Kjaergaard JJ, Borch-Johnsen K.Atherosclerosis. 2008 Feb;196(2):772-8 PMID: 17306273

 

Meat and Mortality: Does Eating Meat Decrease Your Lifespan?

Is Meat Unhealthy?

Ribs on BBQDoes eating red meat decrease your lifespan? This is a discussion that has been going on for years, with vegetarians and vegans stating that meat is not only bad because of the cruelty to animals, but it will decrease your life. There have been a number of studies looking at this, and the results vary, but this week a new study showed -

 After correction for measurement error, red meat intake was no longer associated with mortality, and there was no association with the consumption of poultry.

 

While this is good news to the lovers of red meat – those who love bacon had different news:

The results of our analyses suggest that men and women with a high consumption of processed meat are at increased risk of early death, in particular due to cardiovascular diseases but also to cancer. In this population, reduction of processed meat consumption to less than 20 g/day would prevent more than 3% of all deaths.

You have to wonder about a publication with editors that would let that statement slip. Imagine if we could prevent any death – but I suspect all members of that study will die. Besides the grammar, the real issue of the processed meat portion is the variable of smoking.

We cannot exclude residual confounding, in particular due to incomplete adjustment for active and passive smoking. The sub-group analysis for processed meat showed heterogeneity according to smoking, with significant associations only in former and current smokers and no significant associations in never smokers, which is compatible with residual confounding by smoking. 

This is explained further in the article with these statistics:

There was also a statistically significant interaction between smoking and processed meat consumption (P-interaction 0.01), with mortality being significantly increased among former (HR = 1.68, 95% CI 1.29 to 2.18) and current smokers (HR = 1.47, 95% CI 1.18 to 1.83), but there was no association among never smokers (HR = 1.24, 95% CI 0.89 to 1.72). 

Since the relative risk of smoking is 20, and the relative risk of this was 1.14 one must assume that smoking is bad for your health. So it may be the person’s smoked lungs rather than the smoked pork.  Although clearly smoking was bad for the pig.

Increasing vegetables and fruits in the diet was almost a protective factor:

Those with a lower fruit and vegetable intake (below median intake) had a higher overall mortality in the highest consumption category of processed meat (160+ g/day) as compared to subjects with a fruit and vegetable intake above the median intake (P-interaction 0.001).

But the study was in contrast to the US study:

However, in contrast to the US cohorts , there was no statistically significant association of red meat consumption with risk of cancer or cardiovascular mortality. (see ref 7 and 8 below)

The problem with the US studies has more to do with the basis of their data gathering than anything else. We blogged about the topic of red meat related to mortality last year. The basis of those studies is this: a bunch of people are given a questionnaire about what they eat. They fill it out. Depending on the study, their health is followed for a number of years, and using statistical analysis determination is made about what factors influence their health.

Human beings are not hardwired to remember what they ate a year ago, even a week ago. The flaws in this type of study are the data gathering, expecting people to remember what they ate over the last year.

The European study avoided this by having clinics that did more measuring and in depth analysis, and their data has less flaws than the US Data, but still, the basis is sketchy.

All Meat is not the Same
The other missing piece is this: meat is processed differently by different places, and the meat is handled differently. Animals that are raised on grass have higher levels of Omega-3 fatty acids, where animals raised on grains have higher levels of Omega-6 fatty acids.  If you process your meats in Italy, there is a different production than in Northern Germany, which is different than in Iowa – some being more prone to harsh chemicals that may (or may not) linger.

Vegetarians v Vegans
One study that looked at all groups- it turns out that Vegans and meat eaters live to be about the same age, those that have the best survival advantage were fish eaters.  In fact, occasional meat eaters have a longer lifespan than vegans.

REFERENCES:

1. Meat consumption and mortality – results from the European Prospective Investigation into Cancer and Nutrition. Rohormann S, et. al.  BMC Medicine 2013, 11:63

2.Food-Based Validation of a Dietary Questionnaire: The Effects of Week-to-Week Variation in Food Consumption. Salvini S, HunterDJ, Sampson L, et al:. International Journal of Epidemiology 18:858-867, 1989
3. Reproducibility and validity of dietary patterns assessed with a food-frequency questionnaireHu FB, Rimm E, Smith-Warner SA, et al:. The American journal of clinical nutrition 69:243-249, 1999

4.  Lack of efficacy of a food-frequency questionnaire in assessing dietary macronutrient intakes in subjects consuming diets of known composition.Schaefer EJ, Augustin JL, Schaefer MM, et al: The American journal of clinical nutrition 71:746-751, 2000

5. Bias in dietary-report instruments and its implications for nutritional epidemiology.Kipnis V, Midthune D, Freedman L, et al: Public Health Nutrition 5:915-923, 2002

6.Red meat consumption and mortality: results from 2 prospective cohort studies. Pan A, Sun Q, Bernstein AM, Schulze MB, Manson JE, Stampfer MJ, Willett WC, Hu FB: Arch Intern Med 2012

7.Meat intake and mortality: a prospective study of over half a million people.Sinha R, Cross AJ, Graubard BI, Leitzmann MF, Schatzkin AArch Intern Med 2009, 169:562-571.

8.  Is It Time to Abandon the Food Frequency Questionnaire? Kristal AR, Peters U, Potter JD: Cancer Epidemiology Biomarkers & Prevention 14:2826-2828, 2005

9.Mortality in vegetarians and nonvegetarians: detailed findings from a collaborative analysis of 5 prospective studies. Key, T., et. al. Am J. Clin. Nutr March 2013, 97 (3)

MSG: Does Chinese Restaurant Syndrome Exist?

Mono-sodium-glutamate (MSG) – the cause of “Chinese Restaurant Syndrome.”  It turns out  this syndrome is a myth.

HISTORY OF THE MYTH:
The syndrome was first reported in a letter to The New England Journal of Medicine in April of 1968. A physician wrote that he developed a syndrome which he thought might be associated with salt or MSG, and asked the medical community to respond to this syndrome. He described the symptoms as “ numbness at the back of the neck, gradually radiating to both arms and the back, general weakness and palpitation.” He said several of his friends had it also. He speculated that it might be the cooking wine, or the soy sauce- although the restaurant he went to used the same brand of soy sauce he used. He also noted his friends suggested it might be the seasoning of MSG used by the restaurant. (1)  The next month ten letters responded – one didn’t think it was MSG, one noted it didn’t happen in all Chinese restaurants – and might be placebo, and another reported a patient developing a stroke after eating the food. The media picked up the new disease “Chinese Restaurant Syndrome” and it became a food-type allergy. Ten months later the journal Science reported that Monosodium L-glutamate “is the cause of the Chinese restaurant syndrome and can precipitate headaches.” (2)  The report in Science, was written by one of the people who wrote the letter back to NEJM that May, Dr. Schaumburg. In fact, a later one of his letters was initially done in great humor, “ With the enthusiastic co-operation of the Shanghai Cafe one of us ate Chinese food for breakfast, lunch and dinner until the search had been narrowed to either hot and sour soup or wonton soup, both of which produced the reaction. A rough filtrate of wonton soup also produced the reaction. Upon sampling of the individual ingredients, the dagger of suspicion pointed at monosodium glutamate. Further experiments confirmed this suspicion. The experiments were performed with the use of approved blind and double-blind technics on three volunteers. If the suspicion that irresponsible human experimentation was done has crossed your mind, be at ease. The days of Walter Reed are not past.” (3)

MSG

My mother had this in her kitchen. Pure MSG – it made food taste a lot better

The MSG Follow Up Research
Forty years after that original letter, and in spite of years of trials, and clinical trials, it was finally put to rest that “so-called ‘Chinese restaurant syndrome’ and in eliciting asthmatic bronchospasm, urticaria, angio-oedema, and rhinitis. Despite concerns raised by early reports, decades of research have failed to demonstrate a clear and consistent relationship between MSG ingestion and the development of these conditions.” (4)

In spite of good clinical data putting this myth to rest, there will be plenty of people whose confirmation bias tells them they cannot eat in Chinese Restaurants, and will blame MSG, all the while not realizing that without MSG their bodies would cease to function, and that there is more MSG in the Italian food they prefer, than the Chinese food they shun. In test after test, MSG was not any worse than the placebo given in random studies.

In 2011 the Food and Drug Administration’s committee on GRAS (Generally Recognized as Safe) substances stated this: “  There is no evidence in the available information on L-glutamic acid, L-glutamic acid hydrochloride, monosodium L-glutamate, monoammonium L-glutamate, and monopotassium L-glutamate that demonstrates, or suggests reasonable grounds to suspects, a hazard to the public when they are used at levels that are now current and in the manner now practices. However, it is not possible to determine, without additional data, whether a significant increase in consumption would constitute a dietary hazard.”  Much like salt, too much isn’t a good thing. (5)

Why MSG is so Important to you
Proteins are made up of molecules of amino acids – some of those amino acids our body can manufacture (they are called non-essential because we do not need to get them from our diet) and some amino acids we must obtain from our diet (called essential amino acids). Glutamic acid, and its form MSG, is a non-essential amino acid – meaning, our body produces glutamate and uses it to build the proteins we need. Without MSG you would be unable to build proteins, run the metabolism your body needs– without this amino acid you would not exist.While glutamic acid  is present in every food that contains protein, umami can only be tasted when it is separated from the protein – and functions as an individual amino acid.

MSG – It is one of the tastes you perceive
Before MSG was known for “Chinese Restaurant syndrome” it was used for the flavor it produced, to enhance food.  MSG  produces a  distinct savory flavor that is called Umami. MSG is a common additive in China- while visiting you would see it used almost as we would use salt here. In the United States MSG was sold under the name “Accent.”

China Lamb

In every market in China, such as here in Xi’an, one of the common flavors added to foods is MSG

We have discovered that humans have taste buds for  Glutamic acid  (MSG).  That flavor, umami, or savory (meat-like)  stimulates specific receptors located in taste buds, and is now recognized as one of the five basic tastes in addition to sweet, salty, sour, and bitter.  MSG is found in many foods, especially in parmesan cheese, tomatoes, soy sauce.  One would think if MSG was a real problem there would be an “Italian Restaurant Syndrome.”

There is no one region of the tongue that tastes sour, salt, bitter, sweet, or umami.  You may have seen “tongue” maps that show this, it turns out that the taste buds are distributed throughout the tongue. The entire tongue, has taste buds throughout – as well as the intestine (but that is for another blog).

Balance of flavor
If you ever eat something that is too salty, you want to balance it with sweetness – why we love dessert. But umami, that savory taste is why we love the balance in Italian cooking. We add Romano cheese to noodles to enhance the “flavor” – romano is filled with umami. America is in love with ketchup, and tomatoes provide that unique umami flavor. In Japan, instead of adding Romano or Parmesan to their noodles, they are judged by dashi – a broth that is made with seaweed (kombu) that has lots of MSG (and where some of the original MSG was derived from).

While in China, our favorite places to eat were on the streets – and beside almost every wok was a bowl of MSG – used to liberally season the foods, much like we use salt here. Street food in China is among the best food you can get. Some have even suggested that the balance of flavor that umami provides is one reason the Chinese are not subject to obesity (more about that later).

In Australia and the United Kingdom Vegemite and Marmite are all MSG or glutamate based – and all an essential part of that culture.

We are born to appreciate that flavor- human breast milk has almost 3o times higher glutamate than cow’s milk.

In my home state of Alaska, we prefer oysters, clams, and crabs when harvested in February through March – and it turns out they have their highest level of glutamates then. One would think that the Bering Sea would be better to harvest in the tranquil months of summer, but in August the lowest levels of glutamate are then, and Natives will tell you there just isn’t the flavor of the crab that you would like.

Whale Tale

August is great in Alaska to see whales, but not great for getting oysters, clams, or crab – the MSG levels are too low and they have less flavor

If you have an imbalance in flavor, then you compensate. Umami, it has been suggested, would provide a better balance if used more in foods. In other words, the emphasis on fat, sweet, and salty has led to some of the obesity, had there been more emphasis on umami, less food would be consumed, because there would be more of a balance. (6)

MSG and Obesity:

Apparently this “non essential” amino acid is now being blamed for obesity and short stature.  As you can see by reference (6) MSG can be used to help regulate appetite. Then came a paper in 2011 (7) claiming to show a correlation between MSG and obesity.  Sadly- this was one of the most poorly written papers, and was taken apart for multiple flaws in (7). To quote them: ”

Finally, even though observational studies often provide useful information for hypothesis formulation, given the significant questions and concerns raised in this study, it is premature to even generate a plausible hypothesis on MSG intake and obesity.

The current epidemic of obesity is worldwide, including in Asia. Because MSG has been extensively used as a flavoring agent in Asia, it could also potentially play an important role of enhancing palatability and acceptability of calorie-reduced diets. Until further confirmatory information becomes available, extreme caution needs to be exercised not to raise undue public safety concerns regarding MSG consumption.”

:

(1) Chinese-Restaurant Syndrome. Kwok, RHM. N Engl J Med 1968; 278:796April 4, 1968 (Letter to the editor)

(2) Monosodium L-glutamate: its pharmacology and role in the Chinese restaurant syndrome. Schaumburg HH, Byck R, Gerstl R, Mashman JH. Science. 1969 Feb 21;163(3869):826-8.PMID: 5764480

(3) Sin Cib Syn: Accent on Glutamate. Schaumburg HH, Byck R, N Engl J Med 1968; 279:105-106July 11, 1968 (Letter to the editor)

(4) Monosodium glutamate ‘allergy’: menace or myth?Williams AN, Woessner KM.Clin Exp Allergy. 2009 May;39(5):640-6. PMID: 19389112

(5) From the US Food and Drug Administration GRAS database.

(6) Umami flavour as a means of regulating food intake and improving nutrition and health. Mouritsen OG.  Health. 2012 Jan;21(1):56-75. PMID: 22544776

(7)↵ He K, Du S, Xun P, Sharma S, Wang H, Zhai F, Popkin B. Consumption of monosodium glutamate in relation to incidence of overweight in Chinese adults: China Health and Nutrition Survey (CHNS). Am J Clin Nutr 2011;93:1328–36.

(8)A lack of epidemiologic evidence to link consumption of monosodium L-glutamate and obesity in China.vBursey RG, Watson L, Smriga M.Am J Clin Nutr. 2011 Sep;94(3):958-60; author reply 960-1. doi: 10.3945/ajcn.111.020727.