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It is disconcerting when the medical community reverses course. They seem to do that every decade or so, as with the purported value of vitamin C, estrogen and so forth. The latest about face, in case you haven’t yet heard, is on the matter of taking baby aspirin. For years we have been urged to take a baby aspirin each day to ward off all sorts of ills: heart attacks, strokes, dementia, colorectal cancers and who knows what else. Those tiny pills that can dissolve in seconds against the roof of one’s mouth, or be popped into it, seemed capable of miracles.

Now, with a shot heard truly around the world, an Australian research team at Monash University in Melbourne concluded that not only may aspirin not help, it may in some cases actually harm. The results of their study, which included more than 19,000 people over 4.7 years, were published in three articles this past Sunday in the prestigious New England Journal of Medicine and summarized by The New York Times on Monday, and by just about all other major media.

The study included whites 70 and older, and blacks and Hispanics 65 and older. Each took 100 milligrams — slightly more than the 81 milligrams of a baby aspirin — or a placebo each day. While doing so did not lower their risks of diseases, it did increase “the risk of significant bleeding in the digestive tract, brain or other sites that required transfusions or admission to the hospital,” according to The Times.

So what does all that mean, especially for those already at risk for the conditions aspirin was supposed to protect against?

I am going to quote from The Times very carefully here because this can get confusing due to mixed messages. “Although there is good evidence that aspirin can help people who have already had heart attacks or strokes, or who have a high risk that they will occur, the drug’s value is actually not so clear for people with less risk, especially older ones,” wrote reporter Denise Grady.

So can aspirin prevent cardiovascular events in people with diabetes, for example, or is the benefit outweighed by the risk of major bleeding? Does dose matter in that heavier people might require more aspirin to be prophylactive?

Here’s what the study tells us: Healthy older people should not begin taking aspirin. This will no doubt disappoint Bayer, St. Joseph and others who manufacture the drug. But those who have already been using it regularly should not quit based on these findings, according to Dr. John McNeil, leader of the Australian study. Rather they should talk with their doctors first because the new findings do not apply to those who have already had heart attacks or strokes, which involve blood clots. Aspirin is known to inhibit clotting.

The name of this study is Aspree and it was funded by the National Institute on Aging, along with the National Cancer Institute, Monash University and the Australian government. Bayer supplied the aspirin and placebos but had no other role, according to The Times.

The study focuses on preventive medicine, especially how to keep older people healthy longer. It included 16,703 people from Australia and 2,411 from the United States, starting in 2010. Serious bleeding occurred in 3.8 percent of the aspirin group as opposed to 2.7 percent in the placebo group.

McNeil does suggest the possibility that aspirin’s protective effect against colorectal cancers might still exist but not show up for a longer time span than the study. The Times article does go on to say that the good doctor, who is 71 and specializes in epidemiology and preventive medicine, does not himself take aspirin.

Don’t know what to do? As they say in the commercials, consult your doctor.

This Thanksgiving, offer healthy dessert options like dairy-free pumpkin pudding, above, or fruit salad.
Eating well can set the table for a year of well-being

By David Dunaief, M.D.

Dr. David Dunaief

Many of us give thanks for our health on Thanksgiving. Well, let’s follow through with this theme. While eating healthy may be furthest from our minds during the holidays, it is so important.

Instead of making Thanksgiving a holiday of regret, eating foods that cause weight gain, fatigue and that increase your risk for chronic diseases, you can reverse this trend while maintaining the traditional theme of what it means to enjoy a festive meal.

What can we do to turn Thanksgiving into a bonanza of good health? Phytochemicals (plant nutrients) called carotenoids have antioxidant and anti-inflammatory activity and are found mostly in fruits and vegetables. Carotenoids make up a family of more than 600 different substances, such as beta-carotene, alpha-carotene, lutein, zeaxanthin, lycopene and beta-cryptoxanthin (1).

Carotenoids help to prevent and potentially reverse diseases, such as breast cancer; amyotrophic lateral sclerosis, also known as Lou Gehrig’s disease; age-related macular degeneration; and cardiovascular disease — heart disease and stroke. Foods that contain these substances are orange, yellow and red vegetables and fruits and dark green leafy vegetables. Examples include sweet potato, acorn squash, summer squash, spaghetti squash, green beans, carrots, cooked pumpkin, spinach, kale, papayas, tangerines, tomatoes and Brussels sprouts.

Let’s look at the evidence.

Breast cancer effect

We know that breast cancer risk is high among women, especially on Long Island. An American woman has an average risk of 12.4 percent for getting breast cancer (2). Therefore, we need to do everything within reason to reduce risk.

In a meta-analysis (a group of eight prospective or forward-looking studies), results show that women who were in the second to fifth quintile blood levels of carotenoids, such as alpha-carotene, beta-carotene and lutein and zeaxanthin, had significantly reduced risk of developing breast cancer (3).

Thus, there was an inverse relationship between carotenoid levels and breast cancer risk. Even modest amounts of carotenoids can have a resounding effect in potentially preventing breast cancer.

Amyotrophic lateral sclerosis: Lou Gehrig’s disease

ALS is a disabling and feared disease. Unfortunately, there are no effective treatments for reversing this disease. Therefore, we need to work double time in trying to prevent its occurrence.

In a meta-analysis of five prestigious observational studies, including The Nurses’ Health Study and the Health Professionals Follow-Up Study, results showed that people with the greatest amount of carotenoids in their blood from foods like spinach, kale and carrots had a decreased risk of developing ALS and/or delaying the onset of the disease (4). This study involved over 1 million people with more than 1,000 who developed ALS.

Those who were in the highest carotenoid level quintile had a 25 percent reduction in risk, compared to those in the lowest quintile. This difference was even greater for those who had high carotenoid levels and did not smoke, a 35 percent reduction. According to the authors, the beneficial effects may be due to antioxidant activity and more efficient function of the power source of the cell: the mitochondria. This is a good way to prevent a horrible disease while improving your overall health.

Positive effects of healthy eating

Despite the knowledge that healthy eating has long-term positive effects, there are several obstacles to healthy eating. Two critical factors are presentation and perception.

Presentation is glorious for traditional dishes, like turkey, gravy and stuffing with lots of butter and creamy sauces. However, vegetables are usually prepared in either an unappetizing way — steamed to the point of no return, so they cannot compete with the main course — or smothered in cheese, negating their benefits, but clearing our consciences.

Many consider Thanksgiving a time to indulge and not think about the repercussions. Plant-based foods like whole grains, leafy greens and fruits are relegated to side dishes or afterthoughts. Why is it so important to change our mindsets? Believe it or not, there are significant short-term consequences of gorging ourselves.

Not surprisingly, people tend to gain weight from Thanksgiving to New Year. This is when most gain the predominant amount of weight for the entire year. However, people do not lose the weight they gain during this time (5). If you can fend off weight gain during the holidays, just think of the possibilities for the rest of the year.

Heart attack risk: Even in the short term

Also, if you are obese and sedentary, you may already have heart disease. Overeating at a single meal increases your risk of heart attack over the near term, according to the American Heart Association (6). However, with a little Thanksgiving planning, you can reap significant benefits. What strategies should you employ for the best outcomes?

• Make healthy, plant-based dishes part of the main course. I am not suggesting that you forgo signature dishes, but add to tradition by making mouthwatering vegetable-based dishes for the holiday.

• Improve the presentation of vegetable dishes. Most people don’t like grilled chicken without any seasoning. Why should vegetables be different? In my family, we make sauces for vegetables, like a peanut sauce using mostly rice vinegar and infusing a teaspoon of toasted sesame oil. Good resources for appealing dishes can be found at www.PCRM.org, www.DrFuhrman.com, www.EatingWell.com, www.wholefoodsmarket.com and many other resources.

• Replace refined grains. A study in the American Journal of Clinical Nutrition, showed that replacing wheat or refined grains with whole wheat and whole grains significantly reduced central fat, or fat around the belly (7). Not only did participants lose subcutaneous fat found just below the skin but also visceral adipose tissue, the fat that lines organs and causes chronic diseases such as cancer. For even better results, consider substituting finely chopped cauliflower for rice or other starches.

• Create a healthy environment. Instead of putting out creamy dips, processed crackers and candies as snacks prior to the meal, put out whole grain brown rice crackers, baby carrots, cherry tomatoes and healthy dips like hummus and salsa. Help people choose wisely.

• Offer healthy dessert options. Options might include dairy-free pumpkin pudding and fruit salad.

The goal should be to increase your nutrient-dense choices and decrease your empty-calorie foods. You don’t have to be perfect, but improvements during this time period have a tremendous impact — they set the tone for the new year and put you on a path to success. Why not turn this holiday into an opportunity to de-stress, rest and reverse or prevent chronic disease by consuming plenty of carotenoid-containing foods.

References: (1) Crit Rev Food Sci Nutr 2010;50(8):728–760. (2) SEER Cancer Statistics Review, 1975–2009, National Cancer Institute. (3) J Natl Cancer Inst 2012;104(24):1905-1916. (4) Ann Neurol 2013;73:236–245. (5) N Engl J Med 2000; 342:861-867. (6) www.heart.org. (7) Am J Clin Nutr 2010 Nov;92(5):1165-71Givi.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

Cocoa components reduce cardiovascular risk

By David Dunaief, M.D.

Dr. David Dunaief

Valentine’s Day is one of the wonderful things about winter. For many, it lifts the mood and spirit. A traditional gift is chocolate. But do the benefits of chocolate go beyond Valentine’s Day? The short answer is yes, which is good news for chocolate lovers. However, we are not talking about filled chocolates, but primarily dark chocolate and cocoa powder.

The health benefits of chocolate are derived in large part from its flavonoid content — compounds that are produced by plants. These health benefits are seen in cardiovascular disease, including stroke, heart disease and high blood pressure. This is ironic, since many chocolate boxes are shaped as hearts. Unfortunately, it is not necessarily the chocolates that come in these boxes that are beneficial.

Let’s look at the evidence.

Effect on heart failure

Heart failure is very difficult to reverse. Therefore, the best approach is prevention, and dark chocolate may be one weapon in this crusade. In the Swedish Mammography Cohort study, those women who consumed dark chocolate saw a reduction in heart failure (1). The results were on a dose-response curve, but only to a point. Those women who consumed two to three servings of dark chocolate a month had a 26 percent reduction in the risk of heart failure.

For the dark chocolate lovers, it gets even better. Women who consumed one to two servings per week had an even greater reduction of 32 percent. However, those who ate more than these amounts actually lost the benefit in heart failure reduction and may have increased risk. With a serving (1 ounce) a day, there was actually a 23 percent increased risk.

This study was a prospective (forward-looking) observational study that involved more than 30,000 women over a long duration, nine years. The authors comment that chocolate has a downside of too much fat and calories and, if eaten in large quantities, it may interfere with eating other beneficial foods, such as fruits and vegetables. The positive effects are most likely from the flavonols, a subset of flavonoids, which come from the cocoa solids — the chocolate minus the cocoa butter.

Impact on mortality from heart attacks

In a two-year observational study, results showed that chocolate seemed to reduce the risk of cardiac death after a first heart attack (2). Again, the effects were based on a dose-response curve, but unlike the previous study, there was no increased risk beyond a certain modest frequency.

Those who consumed chocolate up to once a week saw a 44 percent reduction in risk of death, and those who ate the most chocolate — two or more times per week — saw the most effect, with 66 percent reduced risk. And finally, even those who consumed one serving of chocolate less than once per month saw a 27 percent reduction in death, compared to those who consumed no chocolate.

The study did not mention dark or milk chocolate; however, this was another study that took place in Sweden. In Sweden, milk chocolate has substantially more cocoa solids, and thus flavonols, than that manufactured for the U.S. There were over 1,100 patients involved in this study, and none of them had a history of diabetes, which is important to emphasize.

Stroke reduction

I don’t know anyone who does not want to reduce the risk of stroke. We tell patients to avoid sodium in order to control blood pressure and reduce their risk. Initially, sodium reduction is a difficult thing to acclimate to — and one that people fear. However, it turns out that eating chocolate may reduce the risk of stroke, so this is something you can use to balance out the lifestyle changes.

In yet another study, the Cohort of Swedish Men, which involved over 37,000 men, there was an inverse relationship between chocolate consumption in men and the risk of stroke (3). Those who ate at least two servings of chocolate a week benefited the most with a 17 percent reduction in both major types of stroke — ischemic and hemorrhagic — compared to those who consumed the least amount of chocolate. Although the reduction does not sound tremendous, compare this to aspirin, which reduces stroke risk by 20 percent. However, chocolate consumption study was observational, not the gold standard randomized controlled trial, like aspirin studies.

Blood pressure

One of the most common maladies, especially in people over 50, is high blood pressure. So, whatever we can do to lower blood pressure levels is important, including decreasing sodium levels, exercising and even eating flavonoid-rich cocoa.

In a meta-analysis (a group of 20 RCTs), flavonoid-rich cocoa reduced both systolic (top number) and diastolic (bottom number) blood pressure significantly: −2.77 mm Hg and −2.20 mm Hg, respectively (4). These studies involved healthy participants, who are sometimes the most difficult in whom to show a significant reduction, since their blood pressure is not high initially. One of the weaknesses of this meta-analysis is that the trials were short, between two and 18 weeks.

Why chocolate has an effect

Consuming a small amount of dark chocolate twice a week may lower the risk of heart disease.

Chocolate has compounds called flavonoids. The darker the chocolate, the more flavonoids there are. These flavonoids have potential antioxidant, antiplatelet and anti-inflammatory effects.

In a small, randomized controlled trial comparing 22 heart transplant patients, those who received dark flavonoid-rich chocolate, compared to a cocoa-free control group, had greater vasodilation (enlargement) of coronary arteries two hours after consumption (5). There was also a decrease in the aggregation, or adhesion, of platelets, one of the primary substances in forming clots. The authors concluded that dark chocolate may also cause a reduction in oxidative stress.

It’s great that chocolate, mainly dark, and cocoa powder have such substantial effects in cardiovascular disease. However, certain patients should avoid chocolate such as those with reflux disease, allergies to chocolate and diabetes. Be aware that Dutch-processed, or alkalized, cocoa powder may have lower flavonoid levels and is best avoided. Also, the darker the chocolate is, the higher the flavonoid levels. I suggest that the chocolate be at least 60 to 70 percent dark.

Moderation is the key, for all chocolate contains a lot of calories and fat. Based on the studies, two servings a week are probably where you will see the most cardiovascular benefits. Happy Post-Valentine’s Day!

References: (1) Circ Heart Fail. 2010;3(5):612-616. (2) J Intern Med. 2009;266(3):248-257. (3) Neurology. 2012;79:1223-1229. (4) Cochrane Database Syst Rev. 2012:15;8:CD008893. (5) Circulation. 2007 Nov 20;116(21):2376-2382.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.