Vitamin C and the Cardiovasular System: Shashi K. Agarwal, MD

A recent study presented at the American Heart Association’s Annual Meetings in Orlando in November, 2011 showed that there was an inverse relationship between vitamin C levels and an increased risk of development of heart failure. This study examined otherwise healthy 9,187 men and 11,112 women aged 39 to 79 years participating in the “European Prospective Investigation into Cancer and Nutrition”. Their plasma vitamin C concentrations were correlated with incident fatal and non-fatal heart failure events. During a mean follow up of 12.8 years, Dr Roman Pfister and co-researchers from Europe found that for every increase of 20 μmol/L (1 SD) in plasma vitamin C concentration, there was an associated 17% relative decrease in risk for heart failure.

Two previous major studies have found no cardio-protective effect of vitamin C supplementation. In the Physicians’ Health Study II, supplementation with 500 mg of vitamin C every other day in 14,641 US male physicians over the age of 50, was compared with placebo. After 8 years of follow up, vitamin C did not have any beneficial effect on total mortality, heart attacks, stroke or cardiovascular disease death. This study was published in the Journal of the American Medical Association in the November 12, 2008 issue.

In another study involving 8171 women with a mean age of 60, during a follow up of 9 years, no overall benefit from vitamin C was observed for prevention of cardiovascular events. This study was done by Brigham and Women’s Hospital in Boston, with the results published in the August 13, 2007 issue of Archives of Internal Medicine.

Since vitamin C is an antioxidant, there has been great excitement regarding its potential cardio-protective effects. Oxidative stress is closely linked to the development of atherosclerosis and its major complications – heart attacks and strokes. Vitamin C has been primarily used to prevent scurvy. It is also beneficial in preventing gout by reducing serum uric acid levels. Its role in preventing common colds has not been scientifically validated.

Vitamin C is a water-soluble vitamin, with almost 90% of our intake coming from fruits and vegetables, especially citrus fruits, peppers, broccoli, and tomatoes. Kakadu plum, camu camu fruit and rose hips contain extremely high concentration of this vitamin. Vitamin C is also present in some cuts of meat, especially liver and raw oysters. In the United States, vitamin C supplements are widely used. It is available in a variety of forms, including pills, drink mixes and crystals, either naked or in capsules. However a review all the major studies on vitamin C and cardiovascular disease, demonstrates no scientific confirmation that nutritional supplementation with vitamin C is heart protective

Levels of plasma vitamin C correlate consistently with fruit and vegetable intake  and an increased intake of fruit and vegetables is associated with a significant increase in plasma vitamin C concentration. Since studies with vitamin C supplementation provide no support for cardiovascular protection and studies using vitamin C levels as a biomarker for fruit and vegetable intake appear to show distinct cardiovascular benefit, the ‘writing’ is on the wall – do not eat nutrients but eat foods rich in nutrients – namely plenty of fruits and vegetables. The cardiovascular benefits of fruit and vegetable intake may not be limited to vitamin C, as there are many other nutrients in fruits and vegetables, such as potassium and magnesium, that also have positive effects on the heart.

The North American Dietary Reference Intake in 2008 recommended 90 milligrams of vitamin C per day and no more than 2,000 milligrams per day. Toxicity is however rare, as excess intake is not absorbed, and excesses in the blood rapidly cleared in the urine.

ABO Blood Group – A Cardiovascular Connection: Shashi K. Agarwal, MD

Cardiovascular disease is now the number one killer in the world. Although the major risk factors such as hypertension, diabetes mellitus, hypercholesterolemia, obesity, physical inactivity and smoking are well known, some minor risk factors remain relatively unknown. The ABO blood group is one such minor risk factor.

Austrian scientist, Karl Landsteiner earned a Nobel Prize for the discovery of the ABO blood group system in 1901.  Inherited antigenic substances on the surface of the red blood cells allow a classification of the blood into different groups (blood type). Lawyers soon started using this in paternity suits, police in forensic science and anthropologists in the study of different populations. The Japanese, started believing that a person’s blood type is predictive of their personality, character and compatibility with others. Its major impact however, was in preventing fatal reactions to blood transfusions.

If transfusion is given without proper typing and cross-matching, naturally occurring antibodies in the recipients blood can bind to corresponding antigens on the transfused red blood cells resulting in an acute hemolytic transfusion reaction that can cause widespread intravascular blood clotting, shock, acute renal failure, and death.

Another major health impact was understanding the patho-physiology behind the hemolytic disease of the newborn. This dangerous reaction occurs as the anti A and anti B antibodies produced in the O blood group mother cross the placenta and enter the blood stream of her infant with type A or type B blood. However, due to lower number of fetal antigens, the reactions are usually less severe.

Recent reports have noticed an interesting connection of these blood groups with cardiovascular disease. In a presentation at the Annual Scientific Meetings of the American Heart Association in November 2011, researchers from the Harvard School of Public Health reported that men and women in the AB blood group had a  26% higher risk of developing stroke when compared with those with type O blood. Women with type B had a 15% higher risk of stroke, when compared with those with type O blood. They analyzed data from two major studies – the Nurses’ Health Study (NHS) which included 61,973 women and the Health Professionals Follow-up Study (HPFS) which included 27,808 men. The follow up was 26 years and 20 years.

In a study published in the New England Journal of Medicine in the December 9, 1971 issue, researchers investigating  10,000 Israeli male government employees 40 years of age and over as part of the Israeli Ischemic Heart Disease Project (five year duration) found that subjects with blood Groups A, B, and AB tended to have higher incidence rates of myocardial infarction than those with other blood groups. High rates were also noted in A and B subjects for angina pectoris. Subjects in blood Group O tended to have lower rates of infarction and angina pectoris than those of other groups.

Researchers reported a higher incidence of elevated cholesterol levels and ischemic heart disease in non-O group individuals in the British Medical Journal in June 1990. The results emanated from a prospective study of 7662 men with known blood groups. Many other studies have similarly found increased heart attacks in non-O blood group individuals.

In another study published in the February 2009 issue of the Journal of Thrombosis and Haemostasis, researchers reported a higher tendency for arterial and venous clotting in patients with non-O blood groups. Several studies have demonstrated the influence of the ABO blood group on plasma levels of von Willebrand factor. VWF is major player in blood clotting.

In summary, non-O blood group individuals suffer a higher risk of myocardial infarction, angina, cerebral strokes and venous thrombo-embolism than those with group O blood. This increased risk, although real, is not very significant. Since your blood group cannot be changed, non-O blood group people should follow heart healthy lifestyles more judiciously, to nullify any increased genetic risk conferred by their blood type.

Sugar Intake and Cardiovascular Risk Factors: A Direct Relationship by Shashi K. Agarwal, MD

Cardiovascular disease is the number one killer in the United States, both for men and women. These deaths exceed the number of deaths caused by cancer, accidents, and chronic lower respiratory disease combined. It is estimated that there is one death due to cardiovascular every 39 seconds in this country, amounting to more than 2,200 deaths every day. The major attention has been directed towards the usual risk factors such as cigarette smoking, hypertension, diabetes mellitus, hypercholesterolemia, obesity and physical inactivity. Very little attention has been paid to the adverse impact of increased dietary sugar on cardiovascular disease.

Dietary sugars come in many forms. Simple sugars are monosaccharides and disaccharides. The most common monosaccharide is fructose, which is found in fruits and vegetables. Common disaccharides are sucrose, lactose and maltose. Sucrose is found in sugar cane, sugar beets, honey and corn syrup, lactose is found in milk products while maltose comes from malt. Complex sugars are polysaccharides such as starch. Added sugars are extrinsic sugars such as sucrose or other refined sugars added to soft drinks, fruit drinks and other food products.

The average US sugar utilization per capita was 55 kg (120 lb) per year in 1970, and it reached 68 kg (150 lb) per year in 1995. The consumption of sugar has continued to rise steadily. In 2004, the intake of added sugars was 22.2 teaspoons per day, accounting for 355 calories. This increase is largely due to the advent of modern food-processing methods.

Sugars are carbohydrates and provide daily calories for bodily fuel needs. They also add palatabiity and desiribility to ingested foods. However excessive intake may have harmful effects. These include obesity, hypertension, disturbed glucose homeostasis and abnormal lipid balance.

It is estimated that 56%-85% of the school childrn consume at least one soft drink daily. There is a 1.6 times increased odds ratio of becoming obese with each additional can or glass of sugar sweetened drink consumed daily. Since soft drinks are responsible for the major source of added sugars in the diet, they remain a major culprit for obesity in children and adolescents. Obesity is a leading preventable risk factor for cardiovascular diseases.

The relationship between increased sugar intake and diabetes mellitus has been suggested but not convincingly established. Sugar intake is associated with a high glycemic index – a measure of the rise in glucose induced by the ingestion of a carbohydrate. Foods containing refined sugars have a high glycemic index and put individuals at higher risk of future diabetes. Further, excessive added sugar intake is related to obesity which in turn increases the risk of diabetes mellitus.

An inverse relationship exists between dietary sugar and the good HDL cholesterol. Data from Framingham and PROCAM studies have found for every 1 mg/dl decrease in HDL there is an associated 2-4% higher risk for cardiovascular diseases. Harmful plasma triglycerides are also elevated with diets high in sucrose.Hypertriglyceridemia is an independant cardiovascular risk factor. In a study published in the Journal of the American Medical Association in April of 2010, Welsh and his associates from Emory University reported a statistically significant correlation between dietary added sugars and blood lipid abnormalities in US adults.

Recently, a relationship between excessive sugar intake and high blood pressure has also been found. Forman and his colleagues from Harvard Medical School examined data from three large, prospective studies. These involved 88,540 females from the Nurses’ Health Study I, 97,991 females from the Nurses’ Health Study II, and 37,360 men from the Health Professionals’ Follow-Up Study. The follow up ranged from 16 to 26 years. They found that drinking at least one sweetened beverage a day was associated with a 6% to 20% greater relative risk of hypertension. The risk appears marginally higher in people drinking artificially sweetened drinks when compared to those drinking sugar sweetened drinks. This data was presented at the American Society of Nephrology meetings in November 2011, in Philadelphia.

Recent decades have witnessed a substantial increase in total consumption of sugar in the United States. This has largely come from an increase in added sugars. Added sugars are caloric sweeteners used as ingredients in processed or prepared foods. These include soft and fruit drinks, candies, pastries and cereals with high sugar content. Several studies have also established the negative impact of excessive sugar intake on cardiovascular risk factors. Excessive sugar intake has also been linked to other adverse health conditions including deficiency of essential nutrients and dental caries. Reduction of sugar derived calories to less than 100 calories per day in women and less than 150 calories per day in men should help lower the cardiovascular risk.

Cardiovascular Benefits of Yoga

Yoga is an ancient Indian discipline that has been practiced in the East for over 5000 years. It is gaining extreme popularity in the United States. According to the National Health Interview Survey,6.1% of US adults practiced yoga in the months immediately prior to the survey in 2007, compared with 3.7% in 1997 and 5% in 2002. The figures for 2011 are expected to be much higher.

Yoga was first introduced to the West by Swami Vivekananda, who toured Europe and the United States in the 1890s. More recently, Dean Ornish, a follower of Swami Satchidananda, published several studies legitimizing yoga exercises and yogic lifestyle for its cardiovascular benefits.

The Yoga Sutras are foundational texts of Yoga and are attributed to Patanjali, dating back to the 2nd century BC. According to Patanjali, yoga has eight limbs. These are:

1. Yama which encompasses non-violence, honesty, non-coetousness, non-sensuality and non-possesiveness.

2. Niyama which reflects purity, contentment, austerity and surrender to God.

3. Asana which refers to the seated meditation position.

4. Pranayama or controlled breathing exercises.

5. Pratyahara which indicates control of senses.

6. Dharana or concentration.

7. Dhyana or meditation and

8. Samadhi, the ultimate bliss.

This discipline of yoga described by Pantajali is commonly called Ashtanga Yoga. However, over the decades, Yoga has evolved into many different styles and intensities. Most yoga practices in the Western world consist of practice of Hatha Yoga: gentle exercise, stretching poses, controlled breathing and meditation.

Cardiovascular disease is the leading cause of death in the United States for both men and women. It claims more lives each year than cancer, chronic lower respiratory diseases, accidents, and diabetes mellitus combined. According to the CDC, in 2006, 631,636 people died of heart disease in the US. Almost 450,000 of these deaths were attributed to coronary artery disease. It is estimated that almost 800,000 Americans have a first heart attack each year, while another 470,000 who have already had one or more heart attacks have another attack. Heart disease costs over $300 billion each year, which includes the cost of health care services, medications, and lost productivity.

The major risk factors of cardiovascular disease are inactivity, obesity, hypertension, diabetes, abnormal lipid profile and chronic inflammation. Yoga appears to have beneficial effect on all of these. In a review of 37 studies from six countries, 75% of the studies showed improvement in blood pressure with yoga or yoga-based interventions. Overall, these studies demonstrated a 4.9% to 24.2% decline in diastolic blood pressure and a 2.6% to 21.3% decline in systolic blood pressure with yoga. There was also a decrease in resting heart rate and breathing rate. In 18 clinical trials between 1970 and 2004, yoga practice was associated with a 1.5% to 13.6% reduction in body weight. There have been at least 15 international studies demonstrating positive effects on the lipid profile – yoga practice was associated with a 5.8% to 25.2% decrease in total cholesterol, 22.0% to 28.5% reduction in fatty triglycerides, and a 12.8% to 26.0% reduction in the bad LDL cholesterol. Some studies have also demonstrated an increase in the good HDL cholesterol levels. Almost 13 studies have focused on studying the effects of yoga on diabetes mellitus and markers of insulin resistance. On an average, yoga practice was associated with a 5.4 to 33.4% reduction in fasting glucose, 24.5 to 27.0% reductions in postprandial glucose, and 13.3 to 27.3% reduction in glycohemoglobin (HbA1c). Studies have also demonstrated improvement in metabolic syndrome.

Yoga exercises will burn calories to help reduce weight. The mind-body connection benefits of yoga are backed by irrefutable scientific evidence. Yoga techniques improve physical and mental health through down-regulation of the hypthalamic-pituitary-adrenal axis and the sympathetic nervous system. Yoga has been found to decrease markers of inflammation such as high sensitivity C-reactive protein as well as inflammatory cytokines such as interleukin-614 and lymphocyte-1B. There is attenuation of oxidative stress. There is also decreased tendency to clot and brain scans have shown higher levels of GABA (low levels of GABA are associated with anxiety and depression) after an one hour yoga session.

The benefits of yoga extend beyond the cardiovascular system. The gentle stretching exercises improve muscle, ligament and joint function. There is an increase in flexibility, strength and endurance. The body posture is also improved. Chronic conditions such as asthma and arthritis have shown improvement. There is also an anti-depressive and anti-insomnia effect. Overall, most practitioners of yoga claim that they not only feel fitter and energetic, but happier and more peaceful.

The National Institute of Health is actively supporting clinical trials on yoga. An online check regarding clinical trials on yoga revealed 140 trials on the NIH site, clinicaltrials.gov, for a multitude of medical conditions including breast cancer, multiple sclerosis, cystic fibrosis, brain tumors and heart failure. A recent report in the November 1, 2011 issue of the Annals of Internal Medicine reported that yoga practice for 12 weeks in adults with chronic or recurrent low back pain resulted in greater improvement than usual care for up to 12 months.

Yoga is generally considered to be safe in healthy people when practiced appropriately. Studies have found it to be well tolerated, with few side effects. Some yoga ‘inverted’ poses should be avoided by people with disc disease of the spine, glaucoma, retinal detachment, ear problems, severe osteoporosis, or cervical spondylitis. These poses should also be avoided by people with very high or very low blood pressure, risk or history of blood clots and severe atherosclerotic vascular disease. Care should also be taken to avoid certain poses during pregnancy.

Yoga is easy to learn and easy to perform. It can be performed individually at any time and without any constraints due to weather conditions. Further, individuals find that it is easier to stick to yoga than other exercise methods. It is also very safe. It is free of any religious or cultural shackles and can be learnt and performed by everyone.

Caloric Restriction: A lifestyle intervention with compelling cardiovascular benefits.

Cardiovascular disease is the leading cause of death in the United States and is soon becoming the leading cause of death in most countries in the world. In the USA, cardiovascular disease claims more lives each year than cancer, chronic lower respiratory diseases, accidents, and diabetes mellitus combined. The increasing age along with the obesity and diabetes epidemic will continue to keep cardiovascular disease as the number one health problem in the world.

There has been a recent emphasis on lifestyle changes to prevent the development of cardiovascular risk factors. These include cessation of smoking, prevention of obesity, incorporation of a heart friendly diet and implementation of a regular exercise program. Caloric restriction is a major lifestyle intervention that is also generating increasing scientific interest as a method of reducing cardiovascular morbidity and mortality.

Caloric restriction is the only lifestyle intervention that has consistently been shown to increase the maximum life span in laboratory mice and rats. It achieves this by retarding the aging processes. These effects have been also seen in yeast, worms, fish, spiders and many other lower order animals. Caloric restriction is achieved by feeding animals 70%-75% as many calories as controls, in a nutritious balanced way, avoiding malnutrition.

Similar data, confirming lifespan extension, is emerging from studies in rhesus monkeys. Rhesus monkey is a nonhuman primate that has close evolutionary relationship to humans. It bears many similarities to humans including anatomy and and biochemical functions such as physiology, immunology, endocrinology and neurology. The rhesus monkey is also prone to common human diseases such as obesity, metabolic syndrome, diabetes mellitus and cardiovascular pathologies. As a result, there is considerable interest in experimentally retarding or reversing the aging processes in these ancestral cousins and its possible applicability to humans.

Studies in the rhesus monkeys show that caloric restriction induces the following positive changes on cardiovascular risk factors : 1.Reduction in weight of about 30% compared to the ad libitum group, mainly due to a decrease in visceral fat.2. Improved glucose homeostasis as evidenced by improved fasting insulin and glucose levels, improved HbA1c and decreased insulin resistance.3. Decreased blood pressure and improved lipid parameters. 4. Reduced body temperature more than that explained by the reduction in body mass

Several studies have shown improved cardiovascular morbidity and mortality in humans with calorie restriction. Epidemiological observations from different populations of the world have shown dramatic decreases in cardiovascular diseases, as a result of unintentional caloric restriction. World War II related food shortages in some European countries resulted in a sharp decrease in coronary heart disease mortality, only reversing after the war ended. Japanese living on the Okinawa island, generally eat 30% less calories than the average Japanese population, and experience an almost 35% lower rate of cardiovascular disease and cancer mortality. Similar changes were reported during the food rationing in Cuba due to a significant economic downturn from 1989 to 2000. Deaths caused by diabetes declined by 51%, coronary heart disease mortality dropped 35% and stroke mortality by 20%. Similar effects were noted in the Biosphere experiment. Due to declining food stores, caloric restriction was enforced on the eight individuals, for alamost 2 years. These individuals not only lost weight and fat mass, but also showed improvements in basal glucose, basal insulin, insulin sensitivity, and blood pressure. These effects basically replicated the experimental changes noted in non-human primates.

Reduction of caloric intake by 25%-30% on a consistent basis may be difficult to achieve. Further this reduction has to be nutritionally balanced, with adequate intake of essential macro and micro nutrients. The data on the beneficial cardiovascular effects of caloric restriction, however, are compelling. Calorie restriction may be an important life style intervention to dramatically reduce major cardiovascular risk factors and, and increase healthspan (healthy years) and lifespan in humans.

Socio-economic Status and Cardio-vascular Disease: An Inverse Relationship

Socioeconomic status is a strong predictor of a person’s morbidity and mortality for most diseases. Lifelong socioeconomic disadvantages also increase cardiovascular risk factors culminating in premature mortality.

Socio-economic disparity is usually evident in education, occupation and financial status. Education is a strong surrogate measure of socioeconomic status. A recent National Health and Nutrition Survey showed a strong inverse relationship between education level and mortality risk. Men aged 45-64 years, with education of 0-7 years had an almost double the risk of premature mortality than those with 12 or more years of education. In white women the risk was one and a half times more. A similar, although weaker, link exists between education and mortality in African American men and women.

Lack of employment and financial status, also have an effect on mortality. Compared to those who are employed, unemployed men and women, both white and black, have almost one and a half times increased mortality rates. Service or blue collar workers, usually earning less, almost universally have a higher rate of early death when compared to professional or white collar workers, who relatively earn more.

The relationships mentioned above also apply to cardiovascular disease morbidity and mortality. Cardiovascular disease studies have shown that lower levels of education are associated with early heart related mortality. Liu and colleagues also reported several epidemiology studies from Chicago, confirming the inverse relationship between education level and coronary heart disease. Similar data emanated from the Systolic Hypertension in the Elderly project, published in the American Journal of Epidemiology in 1987.

A steady high income helps pay for education, healthier lifestyle, and access to better medical care. In the National Longitudinal Mortality Study, both white men and women with incomes less than $5000 had a 1.8 and 1.3 times the mortality rate when compared to those with incomes more than $50,000. These ratios were worse for black men and women (2 and 1.8 respectively). The results of the National Mortality Study were published in the American Journal of Public Health in 1995. Studies have also demonstrated higher cardiovascular mortality in blue collar workers when compared to white collar workers. Some of this data in women came from the Framingham study and was published in the American Journal of Epidemiology in 1992 by Eaker and associates. In the Canadian Health, Canada Fitness Survey, and several other studies, people with low income had a higher atherogenic risk profile, with higher rates of smoking, hypertension, diabetes, obesity, physical inactivity and excessive alcohol consumption, and the resultant higher cardiovascular disease and death rates.

Lower socioeconomic status is also associated with living in impoverished neighborhoods. This results in unhealthy food choices, unsafe exercise options, more psychological stress and poor access to optimal health care. A recent study published in the October 20, 2011 issue of the New England Journal of Medicine, has shown that moving out from these neighborhoods leads to significant health benefits.

In summary, a higher socioeconomic status leads to better life style choices. Better education appears to confer a higher socio-economic status. Educated people are more likely to follow healthier lifestyles and acquire skills to ward off adverse health influences. The ultimate result is improved cardiovascular outcomes including a reduction in premature morbidity and mortality.

Multivitamin Intake: Improved Longevity or Premature Mortality?

By Shashi Agarwal MD

Epidemiological studies have shown that eating foods rich in antioxidants results in a reduced risk of heart attacks,strokes and cancer. Antioxidants reduce damaging oxidative stress caused by highly active free radicals in the blood. These detrimental effects have been implicated as a pathogenic factor in most diseases, including cardiovascular diseases and cancer. Antioxidant rich foods include fruits, vegetables, nuts and whole grains. Phytochemicals are strong antioxidants and are naturally present in these foods. For example, soybeans contain genisten, tomatoes and grapefruit contain lycopene, cabbage and brussel sprouts cotain indoles, garlic and onion contain allylic sulfides, tea contains tannins and most fruits and vegetables are rich in flavonoids. A diet rich in these foods is highly protective. This observation has led to the widespread use of synthetic multivitamins and anti-oxidants to prevent cancer and cardiovascular diseases, and increase life span. However taking these supplements have not shown protective benefits, and have actually been harmful in most people.

 

Dr. Jaakko Mursu and collegues recently presented disturbing data regarding life expentancy with the use of multivitamins and mineral supplements in healthy older women. They found that most supplements in older women were associated with a higher risk of total mortality. These supplements included multivitamins, vitamin B6, folic acid, and minerals such as iron, magnesium, zinc and copper. There was a 3% to 6% increased risk of death with taking vitamin B6, folic acid, iron, magnesium, and zinc supplements and an 18.0% increased risk for total mortality with copper supplementation. The increased rates appear when compared to individuals not taking these supplements. This large study involved a total of 38,772 older women, between the ages of 55 to 69 years. Their results were published in the October 10, 2011 issue of the Archives of Internal Medicine.

 

In an earlier review of 47 studies involving nearly 181,000 participants, Bjelakovic and colleagues reported that taking vitamin A supplements increased the risk of death by 16%, beta-carotene by 7%, and vitamin E by 4%. These findings were published in the Journal of the American Medical Association in 2007.

 

Meta-analysis of several studies have also documented that antioxidants do not prevent cancer. On the contrary, studies have implicated their intake with a higher incidence of some cancers. In a study by Lawson and associates and published in the Journal of the National Cancer Institute in 2007, the risk of fatal prostate cancer doubled in men who took multivitamins seven days a week, when compared with men who did not take any multivitamin supplements. Their study involed 295,344 men enrolled in the National Institutes of Health Diet and Health Study. Other studies have shown that mortality also appears to be increased in persons with gastrointestinal and lung cancers while ingesting anti-oxidant supplements.

 

The exact mechanism behind this harmful effect of multivitamin/anti-oxidant supplementation is not clear. It has been suggested that supplemental antioxidants may decrease free radicals and upset defensive mechanisms necessary to destroy precancerous and cancerous cells. Synthetic antioxidants may also possess pro-oxidant properties.

 

The American diet provides almost 120% the recommended daily allowances for β-carotene, vitamin A, and vitamin C. Except for calcium and prescribed supplementation for documented deficiency (for example Vitamin D), scientific data suggests that most multivitamins and mineral supplements should not be used in otherwise well nourished individuals.

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Fish Oil Supplementation – Heart Protective

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By: Shashi K. Agarwal, MD

Dyerberg and group in 1978 reported in the Lancet, a health paradox that they noted in the Greenland Eskimos. The Eskimos, despite a high-fat diet, had a low rate of coronary heart disease. The researchers postulated that a protective effect was provided by the fatty oils present in their diet, rich in meat from seals, caribou and fish. Since then, this inverse relationship between fish intake and cardiovascular disease has become well established.

Fish oils are rich in omega-3 fatty acids. Along with omega-6 fatty acids, they are called polyunsaturated fatty acids (PUFAs). Both of these fatty acids cannot be synthesized by humans and are therefore considered ‘essential’. Besides fish, omega-3 fatty acids are also found in walnuts, flaxseed, canola oil, broccoli, cantaloupe, kidney beans, spinach, grape leaves, Chinese cabbage, and cauliflower. Two omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), are health and heart protective. A third kind, alpha-linolenic acid, is less potent. Omega-6 fatty acids are detrimental to heart health, and have been associated with depression. Omega-6 fatty acids are abundant in refined vegetable oils commonly used for cooking.

What is the link between fish oil intake and cardiovascular disease protection?

Several studies have shown an inverse relationship between fish consumption and coronary heart disease and death. In the DART study, 2003 men with a previous history of a heart attack were divided into two groups and monitored – one group had an increased fish oil consumption, either by diet or by supplementation compared to the other group, The increased fish oil group had a 29% reduction in death. Studied by Burr and group, this data was published in Lancet in 1989.

In a large GISSI-Prevenzione trial, 11,324 patients with a history of a heart attack were randomly assigned into groups; each group was given either 850 mg omega-3 fatty acid, 300 mg vitamin E, both, or neither. The results showed that the group given the fatty acid alone had a 45% reduction in sudden death and a 20% reduction in all-cause mortality. This was published in Lancet in 1999.

In a review of 11 studies, Markmann and Granbaek found that in populations at a higher risk of coronary heart disease, intake of 40-60 grams of fish per day could reduce the risk of death by 40%-60%. They published their data in the European Journal of Clinical Nutrition in 1999.

How do omega-3 fatty acids protect against heart disease?

Fish oils lower blood pressure and serum triglyceride levels. They also have anti-arrhythmic, anti-thrombotic, anti-atherosclerotic, and anti-inflammatory properties. They also improve endothelial function. All these effects protect against heart attacks from coronary heart disease and sudden death due to an irregular heart rhythm.

How much omega-3 fatty acids do you need?

It is recommended that the daily intake of omega-3 fatty acid be 2.85 g/day. Healthy marine sources are fresh tuna, sardines, salmon, herring, trout and oysters. Fish should be grilled, baked, or broiled — not fried. Fried fish loses all of its benefits. This lack of benefit from fried fish was documented by Mozaffarian in the Cardiovascular Health Study published in Circulation in 2003. As noted earlier, omega-3 fatty acids are also found in walnuts, flaxseed, canola oil, broccoli, cantaloupe, kidney beans, spinach, grape leaves, Chinese cabbage, and cauliflower. Recently, omega-3 fatty acid enriched eggs have become available in the supermarkets and can help meet the daily requirements. If one is unable to eat enough fish or other food sources of omega-3 fatty acids, fish oil supplementation should be considered. The usual amount is 1 gm EPA and DHA per day, although your physician may recommend higher doses in certain situations.

Is fish safe?

Fish at the top of the food chain often contain significant levels of methylmercury, polychlorinated biphenyls, dioxins, and other environmental contaminants. These include mackerel, shark, swordfish, and tile fish (golden bass or golden snapper). The FDA advises pregnant women, women wanting to become pregnant, nursing mothers and children to avoid these fish as they may be at an increased risk of mercury intoxication.

Are fish oils safe?

In general, most fish oils sold over the counter in the USA are safe. The FDA in 1997 indicated that the consumption of up to 3 g EPA + DHA/day from all sources is safe for American adults. Fish oils do not interact with other drugs and usually have no side effects. Fishy aftertaste can be lessened by keeping the supplements in the freezer. Rarely nausea, bloating and belching can occur. Excessive intake may cause bleeding. There is only one FDA approved fish oil preparation in the USA. It is available by prescription under the trade name of Omacor. Because of a patented refining process, toxins such as mercury are completely removed, It also has more PUFAs – 90% compared with 60% in some commercially available products. This makes Omacor more reliable and efficacious.

Summary

The heart protective effects of omega-3 fatty acids are very compelling. These essential polyunsaturated fatty acids are abundant in fish and certain vegetables and nuts. People at a high risk of developing heart disease or who have established heart disease, should supplement their diet with fish oil capsules providing 1 gm EPA and DHA per day. It would be prudent to discuss this therapy with your physician.

Dr. Shashi K. Agarwal is a Board Certified Internist and Cardiologist with a private practice in New York City and New Jersey. He is also a diplomat of the American Board of Holistic Medicine and the American Academy of Anti-Aging Medicine.

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Liposuction: Cosmetic Only or Associated Cardioprotection?

By Shashi Agarwal MD

Liposuction, a cosmetic procedure, is commonly performed in the United States. It is estimated that approximately 400.000 of these procedures occur yearly. Most of these are women between the ages of 19 to 50. Through tiny incisions in the skin, cannulas are inserted and the abdominal fat is sucked out using medical grade vacuums. This fat is sometimes also removed from the arms or thighs for cosmetic remodeling.

The majority of patients undergoing liposuction are obese. Obesity is defined as a body mass index(BMI) of more than 30. Body mass index is calculated by dividing an individual’s body weight by the square of his or her height. BMI is categorized as follows in the United States: underweight: <18.5, normal weight: 18.5-24.9, overweight: 25-29.9 and obese: >30.

Obesity has become an escalating problem in the United States. It is estimated that between 60 and 70% of Americans (approximately75 million) are either overweight or obese. And, nearly one in three (31.7%) U.S. children (23,500,000) ages 2 to 19 are overweight or obese. Obesity is also becoming epidemic in many parts of the world.

Obesity has been linked to several dangerous conditions such as, high blood pressure and related cardiovascular diseases, diabetes mellitus, osteoarthritis, cancer, gall bladder disease, gout and sleep apnea. Cardiovascular disease (heart attacks, heart failure and stroke) remains the number one killer in the USA. It is estimated that more than 2,200 Americans die of cardiovascular disease every day or about one death every 39 seconds. The cardiovascular complications of obesity are partly due to high blood cholesterol, high triglyceride levels and low ‘good’ HDL cholesterol seen in these patients.

BMI is commonly used as a heuristic proxy for human body fat. However, BMI may also be high if there is a significant amount of muscle tissue and may falsely raise concerns about an increased cardiovascular risk. Excess fat around the waist appears to be a better marker for an increased risk. In men, a waist measurement of more than 35 inches and in women, a waist measurement of more than 40 inches indicates a higher propensity for cardiovascular disease when compared with people with smaller waist measurements. Since liposuction removes abdominal fat and reduces waist measurements, it has been suggested that liposuction should be associated with a decrease in cardiovascular risk.

The fat removed during liposuction is however, peripheral fat. Most scientific studies have shown that it is the central or visceral fat that is metabolically active and harmful. This fat is inside the abdomen in and around organs is the visceral fat, and is not removed during liposuction. A lack of benefit on the cardiovascular system from liposuction has been established in two studies. Scientific research reported by Klein and associates in 2004 and published in the New England Journal of Medicine, and Mohammed and associates in 2008 and published in Obesity, established that there was no improvement in cardiometabolic factors and glucose metabolism following removal of subcutaneous or peripheral fat.

A recent study however suggested that there may be some improvement in triglyceride levels following liposuction. In this study, presented at the American Society of Plastic Surgeons Annual Meetings in 2011, Dr. Swanson reported that following removal of subcutaneous fat, mean triglyceride levels decreased 26%. Triglyceride levels above 150 mg/dL have been associated with an elevated risk for metabolic syndrome, type 2 diabetes, stroke, coronary artery disease, and peripheral vascular disease.

This study also found no significant change in the total cholesterol, low-density-lipoprotein cholesterol (bad cholesterol), or high-density-lipoprotein cholesterol (good cholesterol).

Remember, visceral fat is reduced by reducing total caloric intake, reducing the amount of calories obtained from fats, and regular exercise. These lifestyle changes are cardioprotective. Liposuction should only be considered for cosmetic reasons and still remains only minimally cardioprotective. Further information on liposuction is available at these sites:

American Society for Dermatologic Surgery: http://www.asds.net/
American Academy of Cosmetic Surgery: http://www.cosmeticsurgery.org/

 

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Prediabetes: Pre(ventable) Diabetes

By Shashi Agarwal MD

Diabetes has grown to pandemic proportions. It is estimated that 8.3% of the US population,or 25.8 million people, have diabetes. About 95% of these have type 2 diabetes. Diabetes is the main cause of kidney failure, limb amputation, and new-onset blindness in American adults. People with diabetes are more likely than people without diabetes to develop and die from diseases of the heart and blood vessels, called cardiovascular disease. Adults with diabetes have heart disease death rates about two to four times higher than adults without diabetes. The risk for stroke is two to four times higher among people with diabetes.

Prediabetes refers to the intermediate metabolic states between normal and diabetic glucose homeostasis. This term was first introduced in 1979 to replace ‘borderline’ diabetes. Pre-diabetes is becoming more common and more recognized in the United States. The U.S. Department of Health and Human Services estimates that 79 million Americans had prediabetes in 2007. It is estimated that 314 million people worldwide have prediabetes, and the number is projected to grow to 418 million in 2025.

Why worry about prediabetes? It has been estimated that between 35% and 65% of adults with prediabetes will develop type 2 diabetes within six years of the prediabetes diagnosis. Even before progressing into full blown diabetes, these people have an increased rate of microvascular (retinopathy, protein in the urine, polyneuropathy) and macrovascular (heart attack and stroke) complications.

How do you diagnose Prediabetes? Prediabetes is usually diagnosed with any one or more of the following blood test readings: A fasting blood glucose level of:110 to 125 mg/dL (6.1 mM to 6.9 mM, according to the World Health Organization criteria or 100 to 125 mg/dL (5.6 mM to 6.9 mM), according to the American Diabetic Association criteria. A blood sugar level of 140 to 199 mg/dL (7.8 to 11.0 mM) at the end of two hours after ingesting a standardized 75 gm glucose solution as part of a two hour glucose tolerance test. A glycated hemoglobin (HbA1c) between 5.7 and 6.4 percent.

Are you at risk? There are certain indications that you have or may be at an increased risk of developing prediabetes. These include increasing age, inactivity, sleeping less than 6 hours per day and being overweight or obese. Certain races are at an increased risk, namely Asian Americans, Hispanics/Latinos and non-hispanic blacks. Other risk factors include abnormal lipids, especially high triglycerides and low HDL (the good cholesterol) and diagnosed cardiovascular disease. If you had gestational diabetes (high blood sugar during pregnancy), or gave birth to a child weighing more than 9 lbs, you are also at risk. Two other rather uncommon conditions, namely polycystic ovarian syndrome and acanthosis nigrans also indicate increased insulin resistance and predisposition to prediabetes and diabetes. And finally, patients with psychiatric disorders, especially schizophrenia, on multiple psychotropic drugs, also have a high incidence of prediabetes.

Symptoms: Prediabetes is often asymptomatic and suspicion often rests solely on risk factors mentioned above. If present, the symptoms of prediabetes, are the same as those of diabetes: constant hunger, increased thirst and urination, unexplained weight loss, weight gain, generalized malaise, blurred vision, slow healing from minor wounds like cuts and bruises, tingling or loss of sensation in the hands or feet, frequent or recurring gum, skin, vaginal or bladder infections.

How do you treat? The call for early treatment of prediabetes is gaining momentum. Several recent studies have evaluated the role of life-style changes and medications for the treatment of this malady:

1. Exercise: Regular physical activity prevents progression into diabetes. In the Da Qing IGT and Diabetes Study of 110,660 men and women in China( Diabetes Care 1997;20:537-44.), progression to diabetes decreased from 67.7% to 41.1%, when comparing an uncontrolled group to a controlled exercise group over a period of 6 years.

2. Diet: In a Finnish study (N Engl J Med 2001;344:1343-50), there was an incidence of 23% of progression into diabetes in a control group compared to only 11% in an intervention group over a period of 4 years. Interventions were aimed at reducing weight 5% or more, reducing dietary fat to less than 30% of the total caloric intake and increasing dietary fiber to at least 15g per 1000 calories ingested.

3. In al large study involving 27 clinical centers around the US(N Eng J Med, February 7, 2002),3234 prediabetic overweight participants were divided into two groups. One group received intensive training in diet, physical activity, and behavior modification. The aim was to reduce body weight by 7% and maintain the loss, and exercise 150 minutes a week. The second group received metformin 850 mg twice a day. At the end of the study, the lifestyle intervention group reduced diabetes progression by 58% compared to 31% in the metformin group.

4. A prediabetes task force (American Association of Clinical Endocrinologists 18th Annual Meeting, Houston,Tx. 2009) suggested a more aggressive therapeutic approach to these patients, recommending treating high-risk individuals with diabetic medications such as metformin, acarbose, glucagon-like peptide 1 agonists and thiazolidinediones. These treatments are not yet FDA approved for prediabetes, but are backed by strong scientific data indicating that battling insulin resistance early protects the pancreas and prevents progression into diabetes.

The health and monetary costs of prediabetes are not known. But diabetes is an expensive disease, costing about $174 b billion annually in the US alone. Direct medical costs account for about $116 billion and indirect costs such as disability payments, time lost from work, and premature death account for the remaining $58 billion.

Millions of lives and billions of dollars can be saved by aggressive life-style and therapeutic intervention in patients suffering from prediabetes.

Remember: Prediabetes means preceding diabetes. But it also means preventable diabetes.

Dr. Shashi K. Agarwal is a Board Certified Internist and Cardiologist with a private practice in New York City and New Jersey. He is also a diplomat of the American Board of Holistic Medicine and the American Academy of Anti-Aging Medicine.

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