Chocolate vs Stroke

We ended last week by looking at the effect of chocolate on blood pressure.  Therefore, I thought it would be appropriate to end this week and this month by looking at the effect of chocolate on stroke risk as published early online just 2 days ago in Neurology.  

In the first of two studies, the authors followed 37,103 Swedish men for over 10 years and noted that consumption of 63g/wk of chocolate was associated w/17% lower risk of stroke compared to those men who rarely or never ate chocolate.  Going against the current grain evaluating dark, high flavanol, chocolate specifically, it should be noted that milk chocolate is the chocolate of choice in Sweden, although milk vs dark was not assessed in this study.

The authors then performed a meta-analysis of 5 studies including a total of 4,260 stroke cases.  Compared to those who ate the least chocolate, those who consumed the most chocolate had a 19% lower risk of stroke.

What's this mean for you & me?  The two studies in this article support the fact that chocolate is good for you (when consumed in reasonable amounts) although it did not advance the case for dark chocolate.  Since neither of these were randomized, double-blind, placebo-controlled studies, we can only develop hypotheses as we have not yet proven cause & effect.  Still, it's hard for me to turn down a daily portion of high flavanol chocolate after a day seeing patients . . .

Follow @alvinblin
Tweet

Chocolate vs Blood Pressure Part 2

I thought I'd end this week on a sweet note by reviewing some studies about chocolate & cocoa.  Recently, I'd reported on studies linking chocolate to lower risk of heart failure, cardiovascular risk factors, body mass index, and even blood pressure.  So when we consider flukes & trends, it certainly appears that some correlation exists between chocolate & our health.  

In fact, in a meta-analysis published just last week in the Cochrane Library, well known for advocating evidence-based medicine, the authors noted that flavanol-rich chocolate & cocoa products have been demonstrated to produce a statistically significant lowering of blood pressure by 2-3mm Hg.  The authors arrived at their conclusion after sifting through studies to arrive at 20 involving 856 healthy participants randomized to flavanol-rich chocolate vs placebo.  The biggest problem noted was the variation in methodology ranging from 30-1,080mg of flavanols (average 545.5mg) to 2-18 weeks duration (average 4.4 weeks).

So while this is certainly not the last word on the benefit of chocolate, let's remember that the results are not predicated upon consumption of common Americanized milk chocolate candies that contains more sugar than flavanols but rather the more esoteric dark chocolate bars that typically advertise >75% cacao (cocoa). Believe me, it's an acquired taste (especially if you have a sweet tooth like me) . . .

Follow @alvinblin
Tweet

Cocoa Improves Cognition

Last week, I pointed out a 5 month randomized controlled trial suggesting that $46/d worth of tesamorelin (Egrifta) could improve both normal cognition & mild cognitive impairment (MCI).  But what if you don't have that kind of change laying around?  In a randomized, double-blind, parallel arm study published early online yesterday in Hypertension, the authors concluded that daily consumption of cocoa flavanols for 8 weeks improved cognitive function in MCI.  When you think about the hundreds of millions of dollars spent on failed research so far, it seems almost laughable that something so tasty could make a difference.

To arrive at their conclusions, the authors randomized 90 individuals w/MCI to high (990mg), intermediate (520mg), or low (45mg) flavanol drink daily.  After 2 months, insulin resistance & blood pressure improved in those randomized to high & intermediate amounts of flavanols daily compared to the low amount.  While there was no change/improvement in Folstein's Mini-Mental State Examination, Trail Making Test A & Trailing Making Test B (Trails A&B) results improved in those randomized to high & intermediate amounts of flavanol daily compared to low amount.  In verbal fluency, those randomized to high flavanols improved their scores compared to those randomized to low flavanol amounts.

So what are we to make of this study?  Well, let's remember that the trial only lasted 8 weeks such that it's impossible to determine or even guess long-term outcomes & safety.  On other hand, cocoa flavanols should be substantially less expensive than any other prescription medication approved for AD.  More telling is that for the price of one daily injection of Egrifta, one can probably purchase enough dark chocolate/cocoa to last  a month.

Follow @alvinblin
Tweet

Chocolate vs Blood Pressure

Have your cake and eat it, too.  That's my conclusion after reading a new study published last week in the American Journal of Clinical Nutrition concluding that chocolate (cocoa) can lower systolic & diastolic blood pressure by 2-4mm Hg via epicatechin, a flavanol.

Now, you have to understand that I'm a lumper, not a splitter.  I look at the big picture rather than the details, the theme rather than the individual pieces.  So while the article was really a meta-analysis of data from 15 randomized controlled trials regarding diastolic blood pressure and 16 randomized controlled trials regarding systolic blood pressure vs epicatechin, a monomer flavanol found in cocoa (chocolate), it turns out that pure epicatechin can increase nitric oxide which leads to vasodilation while decreasing vasocontricting compounds.

The important point that was repeated several times throughout the article was that 25mg/d of epicatechin lead to a 4mm Hg decrease in systolic blood pressure and a 2mm Hg decrease in diastolic blood pressure.  But the practical point was buried within the discussion: those 25mg of epicatechin can be obtained in 25-30g of cocoa rich (50%) chocolate.  This is nowhere near the 70-80% cocoa solids that has been espoused in other studies.  So while this study isn't recommending Americanized milk chocolate, it's quite possible that a palatable 50% cocoa will be adequate at least for blood pressure lowering purposes.

Follow @alvinblin
Tweet

Chocolate vs BMI

In the past, I've been ranting and raving about eating less & exercising more in order to get healthy.  But perhaps it's not so simple as calories in vs calories out.  Perhaps what we eats is as important as how much we eat.  For instance, would a diet of 1,500 calories daily of potato chips, ice cream & steak be truly healthy?  Or would 1,500 calories of non-fried fruits & vegetables, whole grains, poly- & monounsaturated fats, and lean protein be a better choice?  Yet the former diet is so much easier to consume (and fun, I might add).

Along this line of thinking, chocolate has traditionally been considered a fun food, perhaps even junk food.  Certainly, until recently, chocolate was not considered a health food.  And given that chocolate has been sold, at least in this country, as candy, that's not surprising.  But a number of studies have linked consumption of dark chocolate, not the more common & sweeter milk chocolate, to health benefits, eg heart failure, heart disease & cardiovascular risk factors.

And in a short research letter published in the Archives of Internal Medicine earlier this week, the authors studied chocolate consumption in close to 1,000 participants of a statin study.  After taking into account the usual confounders, they concluded that chocolate consumption was associated with lower BMI (body mass index) despite the fact that chocolate consumption was also associated with greater consumption of saturated fats and not associated with activity.

Now this cross-sectional study doesn't give you free permission to change your diet to 1,500 calories daily of chocolate candy, but it does make us reconsider whether what we eat is as important as how much we eat.  Anyone want to volunteer to be a research subject in future chocolate studies?

Follow @alvinblin
Tweet

Chocolate vs Cardiovascular Risk Factors

Perhaps I'm beating a dead horse.  But I prefer to think of this series of posts (Tuesday & Wednesday) re chocolate & heart disease as serendipity, where I actually found what I was looking for, unlike U2's 1987 hit from The Joshua Tree.  In fact, as I was researching these past two days, I also stumbled upon yet another systematic review & meta-analysis, this one published last November in Journal of Nutrition.

One thing I should point out, if it hasn't been yet made clear, is that there's chocolate, and there's chocolate.  More specifically, we're really interested in flavonoid-rich chocolate which we can purchase & consume as high-cacao (cocoa) content dark chocolate.  Typically, the higher the percentage of cacao or cocoa, the higher the flavonoid/flavanol content, which is what's been linked to the beneficial patient & disease oriented outcomes.  Of course, high cacao content chocolate is also more bitter (an acquired taste), rather than sweet like the milk chocolate most of us have grown up consuming.  So if you're looking for an excuse to eat a typical American candy bar, you'll need to look elsewhere.

Instead, 24 trials, half crossover & half placebo-controlled, involving just over 1,100 participants, most followed from 2 weeks to 8 weeks with one lasting 18 weeks, were analyzed, demonstrating that consumption of flavanoid-rich chocolate, compared to placebo, led to lower systolic blood pressure, lower LDL (bad) cholesterol, greater HDL (good) cholesterol, decrease in insulin resistance (as calculated by HOMA-IR), and improvement in flow mediated vasodilation.

Now before you take all these studies as gospel, remember that while these meta-analyses have been of placebo-controlled or cross-over trials, which are able to demonstrate cause & effect, the study durations have been too short and the study populations too varied to make definitive recommendations.  Still, if you like your dark chocolate, are able to limit yourself to one serving daily, and can skip something else of equivalent caloric content, then perhaps you might be able to improve some cardiovascular risk factors and thus your heart health.

Follow @alvinblin
Tweet

Chocolate vs Heart Disease

Let's say that you weren't all that impressed with yesterday's randomized, double-blind, placebo-controlled study of 20 patients with heart failure over 4 weeks comparing flavanol-rich chocolate to cocoa-liquor-free chocolate.  Just like any good salesperson might do, I'd like to direct your attention to a systematic review & meta-analysis to be published in next month's American Journal of Clinical Nutrition in which the authors assessed 42 randomized controlled trials of varying duration, but acute & short-term (<18wks) involving just shy of 1,300 participants.

Their (short & sweet) conclusion?  Chocolate, cocoa & cocoa flavan-3-ols, compared to controls, improved flow mediate vasodilation, diastolic blood pressure, mean arterial pressure, triglycerides, fasting insulin & insulin resistance (as measured & calculated via HOMA-IR).  Higher doses of flavan-3-ols were found to improve systolic blood pressure, too.  The statistics for increasing HDL while lowering LDL weren't as impressive after taking into account the usual suspects.

The good news is that these were all randomized studies.  In other words, they demonstrated cause & effect.  The not-good-enough news is that we need trials of longer duration with outcome measures that really matter.  Granted we talk all day with our patients about insulin resistance, blood pressure & cholesterol (triglycerides), but if we're going to recommend adding to one's diet dark chocolate (which is an acquired taste when you bite into 70% cacao), we also need to take into account the calorie issues.  After all, as a nation, we're already fat enough as it is.  So consider reminding your patients to substitute rather than add an extra 50g of chocolate daily that just might put us over the edge.  To paraphrase Monty Python's The Meaning of Life, a wafer-thin mint anyone?

Follow @alvinblin
Tweet

Chocolate vs Heart Failure

Well, Valentine's Day is just a week away so I thought I'd review a randomized, double-blind, placebo-controlled study published just under 2 months ago in European Heart Journal looking at the beneficial effect of flavanol-rich chocolate on patients with heart failure.  Specifically, the authors compared flavanol-rich chocolate to cocoa-liquor-free control chocolate, both manufactured by Nestle, the former commercially available as Nestle Noir Intense, in patients with typical systolic heart failure.  

Vascular effects were measure three times, acutely 12 hours after initial intake of 1 bar and chronically after 2 weeks and 4 weeks of daily consumption of 2 bars.  And the bars?  The Nestle Noir Intense contained 10.5g of sugar and 17.9g of fat per 40g serving with 70% cocoa content.  The cocoa-liquor-free control chocolate weighed in at 28.4g per serving but was equivalent in both sugar & fat content.

Now, in case you wondering if I have a financial stake in Nestle, I don't, at least not directly to my knowledge as all my investments are in mutual funds and who knows what the fund managers are buying & selling on a daily basis.  So in an attempt at fair play, I direct your attention to www.chocosphere.com (and, no I don't have a financial stake here either) or any other retail website devoted to chocolate.  The purpose of describing the chocolate used in this study in such detail is to allow you to replicate the study or at least find similar chocolates close by at home.  Unfortunately, milk chocolate and chocolate candy probably won't suffice.

Granted the study size was small, just 10 patients in each group, average age 58-60yo & predominantly male w/ejection fraction 30-35%.  Yet, the authors noted statistically significant improvements in endothelial and platelet function, both acutely and after 4 weeks consumption of flavanol-rich chocolate compared to cocoa-liquor-free chocolate.  

The next question is whether these results can be reproduced in a larger group and, more importantly, whether any clinically significant benefits can be demonstrated, eg decrease in mortality, or at least improvement in physical performance measures and/or quality of life.  In the meantime, look for flavanol-rich chocolate for your Valentine, especially if s/he has heart failure.

Follow @alvinblin
Tweet

Speaking English is apparently what kills you . . .

Some of you may already have read this medical Q&A, but just in case you haven't, my thanks go to Dr. E. who forwarded it.

Q: Doctor,  I've heard that cardiovascular exercise can prolong life.  Is this true?
A: Your heart only good for so many beats, and that it...don't waste on exercise.  Everything wear out eventually.  Speeding up heart not make you live longer; it like saying you extend life of car by driving faster.  Want to live longer?  Take nap.

Q: Should I cut down on meat and eat more fruits and vegetables?
A: You must grasp logistical efficiency.  What does cow eat?   Hay and corn.  And what are these?   Vegetables.  So steak is nothing more than efficient mechanism of delivering vegetables to your system.  Need grain?  Eat chicken.  Beef also good source of field grass (green leafy vegetable).  And pork chop can give you 100% of recommended daily allowance of vegetable product.

Q: Should I reduce my alcohol intake?
A:  No, not at all.  Wine made from fruit.  Brandy is distilled wine, that mean they take water out of fruity bit so you get even more of goodness that way.  Beer also made of grain.  Bottom up!

Q: How  can I calculate my body/fat ratio?
A: Well, if you have body and you have fat, your ratio one to one.  If you have two bodies, your ratio two to one, etc.

Q: What  are some of  the advantages of participating in a regular exercise program?
A: Can't think of single one, sorry.  My philosophy is: No pain...good! 

Q:  Aren't fried foods bad for you?
A:  YOU NOT LISTENING!  Food are fried these day in vegetable oil.  In fact, they permeated by it.  How could getting more vegetable be bad for you?!?

Q:  Will  sit-ups help prevent me from getting a little soft around the middle?
A: Definitely not!  When you exercise muscle, it get bigger.  You should only be doing sit-up if you want bigger stomach.

Q:  Is chocolate bad for me?

A:  Are you crazy?!?  HEL-LO-O!!  Cocoa bean!  Another vegetable!  It best feel-good food around!

Q:  Is swimming good for your figure?

A:  If swimming good for your figure, explain whale to me..

Q:  Is getting in shape important for my lifestyle?
A:  Hey!  'Round' a shape!

Well, I hope this has cleared up any misconceptions you may have had about food and diets.

And  remember:
Life should NOT be a journey to the grave with the intention of arriving safely in an attractive and well-preserved body, but rather to skid in sideways -- Chardonnay in one hand, chocolate in the other -- body thoroughly used up,  totally worn out and screaming "WOO-HOO, what a  ride!!" 
AND....

For  those of you who watch what you eat, here's the final word on nutrition and health.  It's a relief to know the truth after all those conflicting nutritional studies.

1. The Japanese eat very little fat
     and suffer fewer heart attacks than us.

2 The Mexicans eat a lot of fat
     and suffer fewer heart attacks than us. 

3. The Chinese drink very little red wine 
     and suffer fewer heart attacks than us.

4. The Italians drink a lot of red wine
     and suffer fewer heart attacks than us.

5. The Germans drink a lot of beer and eat lots of  sausages and fats
     and suffer fewer heart attacks than us. 

CONCLUSION:

Eat and drink what you like.
Speaking English is apparently what kills you.

Follow @alvinblin
Tweet

Eat More Chocolate!

Hot on the heels of my post last Thursday about eating (dark) chocolate to lower your cholesterol, the results of a meta-analysis were presented to the European Society of Cardiology yesterday and simultaneously published in the British Medical Journal, concluding that consumption of chocolate was associated with lower risk of cardiovascular disease and stroke.

Of course, some of the news agencies misrepresented the findings in their headlines as "Chocolate lowers heart, stroke risk".  Sure it's semantics, but in the case of medical research, there's a world of difference between associative conclusions derived from observational studies and cause & effect relationships derived from randomized controlled studies.

In this particular situation, the authors had to sift through 4,576 references to obtain 7 studies that met all their inclusion criteria, leading to a population of 114,009 participants followed for 8-16 years in 6 cohort & 1 cross sectional study.  More telling is the fact that none of these studies were randomized controlled trials, so all the data is observational in nature and thus any conclusions derived can only be used to generate hypotheses.

Of course, to make matters more difficult, each study used its own measure of chocolate consumption.  Worse, there was no differentiation between dark, milk and white chocolate, much less cacao (cocoa) content.  Therefore, the authors could only analyze greatest consumption vs least with respect to cardiovascular disease and stroke risk, noting 37% and 29% relative risk reduction respectively, regardless of the usual confounders, such as sex, age, body mass index, smoking, and other dietary factors, but without any benefit for heart failure.

So what's the bottom line for you and me?  Well, this study is consistent with all the other observational studies extant about which I've posted.  But due to the calorie & fat content, I would suggest moderation in consumption with focus on high quality, high cocoa/cacao content, dark chocolate.  Enjoy!

You Can Have Your Chocolate and Eat It Too!

After yesterday's post, it appears that all we need to do to lower our cholesterol without taking medications is to eat change to a vegan diet.  But does that mean we can't have any fun?  Luckily, it turns out that cocoa consumption can help lower cholesterol in a meta-analysis published early this month in the European Journal of Clinical Nutrition.

The authors analyzed 320 participants in 10 trials ranging from 2 to 12 weeks in duration.  Clearly, the results are only as good as the data and ideally, we'd like to study large numbers of individuals for longer periods of time.  Nevertheless, consumption of dark chocolate products led to a 5.9mg/dL drop in LDL (bad) cholesterol and a 6.23mg/dL drop in total cholesterol.  Not too shabby but not quite as impressive as eating a combination of plant sterols, soy protein, viscous fiber & nuts.

But we need to be clear that chocolate (at least here in the States) is not the same thing as cocoa.  Nor is hot cocoa necessarily good cocoa.  To obtain the benefits of cocoa that have been reported in multiple studies, you need to consume high cocoa content chocolate.  So if the first several ingredients listed are some sort of sugar, that particular product isn't something for you to eat regularly for your health.  Instead, you need to look for high cocoa content chocolate, otherwise known as dark chocolate.  The higher the cocoa content the better, but it should be at least 50-60% cocoa.  Just be warned that when switching from milk chocolate to dark chocolate, it requires an adjustment in taste & palate.  The really high cocoa content (70-80%) stuff can be pretty bitter if you're not used to it.

By the way, as an added benefit, the really good stuff also is a reasonable source of dietary fiber, another component of a healthy diet.  So it appears that you can have your chocolate and eat it, too!  Mangia!

PS Neither I nor my family have any financial connection to or benefit from Godiva (or it's corporate owner) or Trader Joe's (I just happen to live close to the latter and like their products and philosphy).

HDL vs Alzheimer's Disease

Known knowns.  Known unknowns.  Unknown unknowns.  Hmmm . . . We know that higher levels of physical are associated with lower risk of Alzheimer's disease (AD).  Multiple studies have demonstrated this over & over again.  We also know that physical activity tends to increase HDL, the good cholesterol.  But is there a link between HDL & AD?  As of this month's issue of Archives of Neurology there is!

The authors studied a cohort of 1,130 elderly (avg 76yo) free of cognitive impairment followed for just 4+yrs.  Those whose HDL was in the highest quartile (>56mg/dL) had a 60% lower risk of developing AD or probable AD compared to those in the lowest quartile (<38mg/dL), regardless of age, sex, education, ethnicity, and APOEe4 genotype. For what it's worth, average age at diagnosis was 83yo.

Ironically, there weren't enough cases of vascular dementia to arrive at a statistically significant answer, but the results suggested once more that high HDL is associated w/lower risk of vascular dementia, too.

Hmmm . . . that chocolate is looking pretty good to me right now to raise my HDL.