"UK professor says supplements are a waste of time". That was one of the headlines in a recent edition of NutraIngredients.com (1). The article quotes a Scottish professor of nutrition and dietetics saying that "People who take multivitamin supplements are probably just wasting their money and boosting the profits of vitamin companies".

He isn′t the first to speak out against the use of dietary supplements. Earlier this year NutraIngredients.com commented on a study of supplement use among American children and adolescents participating in the 1999 to 2004 National Health and Nutrition Examination Survey (NHANES) (2). About one third of children and youths between 2 and 17 in that survey took dietary supplements. The investigators suggested that "health care providers in the country should discourage the use of supplements by children with healthy diets" (2).

Last year NutraIngredients.com quoted a member of the Harvard School of Public Health saying that dietary supplements will not provide the nutritional boost a poor diet requires (3). His exact quote, "A supplement is called a supplement because it′s supposed to be supplementing a healthy lifestyle", is actually quite amusing and presumably not what he meant. He is saying in effect that you need supplements even if you follow a healthy lifestyle, which surely includes the proverbial "balanced diet". Proponents of dietary supplementation couldn′t have put it any better!

How widespread is this anti-supplement attitude among doctors? The Council for Responsible Nutrition (CRN), a trade association representing the dietary supplement industry, conducted a couple of surveys among health care professionals to find out. What they discovered was that dietary supplement use was just as common among health care professionals as among the general public.

The first CRN survey, conducted in 2007, questioned 900 physicians and 277 nurses about their thoughts on dietary supplements (4). The survey revealed that 51% of the doctors and 59% of the nurses took dietary supplements regularly, comparable to supplement use in the general population. 79% of the physicians and 82% of the nurses also recommended dietary supplements to their patients, whether they themselved took supplements or not. The list of supplements taken and recommended included things like fish oils, in addition to vitamins and minerals.

The second CRN survey, released in 2008, questioned around 1200 orthopedic specialists, cardiologists and dermatologists (5). Among the orthopedic specialists 73% took supplements themselves; 94% of those who took supplements also recommended them to their patients. For the cardiologists surveyed those figures were 57% and 86%, and for the dermatologists 75% and 79%. Even many of the doctors who did not take dietary supplements still recommended them to their patients.

Are these health care professionals "just as naive and gullible as the general public"? I doubt it. The doctors and nurses surveyed may not be nutrition experts, but they see the extent and consequences of poor eating habits and sedentary lifestyles in their medical practices; they just have to look at their patients′ expanding waistlines. How do you get obese on a "balanced diet"? Given the shear number of the overweight and the obese, how could most people possibly get all the micronutrients they need from the food they eat?

In 2007 investigators from the U.S. Centers for Disease Control and Prevention (CDC) examined the dietary habits of about 100,000 high school students to find out how many ate the recommended two servings of fruits and three servings of vegetables per day. The results of the survey, released just recently (6,7), were sobering. Only 32% got two daily servings of fruit and only 13% the recommended three servings of vegetable. Less than one in ten high school students surveyed ate enough of both. The adults questioned in the same survey didn′t do much better. So much for the balanced diet.

I let the Independent Vitamin Safety Review Panel, a group of physicians, academics and researchers, have the last word on this subject:

"In the past, over-conservative government-sponsored standards have encouraged dietary complacency. People have been led to believe that they can get all the nutrients they need from a 'balanced diet' of processed foods. That is not true. For adequate vitamin and mineral intake, a diet of unprocessed, whole foods, along with the intelligent use of nutritional supplements, is more than just a good idea: it is essential." (8)

Sources:

1. Shane Starling. UK professor says supplements are a waste of time. NutraIngredients.com Sept. 10, 2009.
   http://www.nutraingredients.com/content/view/print/259495
2. Lorraine Heller. Most children don′t need supplements, says study. NutraIngredients.com Feb. 4, 2009.
   www.nutraingredients-usa.com/content/view/print/235056
3. Shane Starling. Harvard professor slams supplements. NutraIngredients.com Jul. 7, 2008.
   http://www.nutraingredients-usa.com/content/view/print/173318
4. Dickinson A, Boyon N, Shao A. Physicians and nurses use and recommend dietary supplements: report of a survey. Nutr J 2009;8:29
   http://www.nutritionj.com/content/8/1/29
5. Lorraine Heller. Doctors reveal supplement recommendations. NutraIngredients.com Dec. 11, 2008.
   http://www.nutraingredients-usa.com/content/view/print/229798
6. 9 in 10 teens fall short on fruits and veggies. Associated Press Sep. 29, 2009.
   http://www.msnbc.msn.com/id/33071814/ns/health-diet_and_nutrition/
7. State indicator report on fruits and vegetables. Department of Health and Human Services, Centers for Disease Control and Prevention.
   http://www.fruitsandveggiesmatter.gov/downloads/StateIndicatorReport2009.pdf
8. Doctors say, raise the RDAs now. Orthomolecular Medicine News Service Oct. 30, 2007.
   http://orthomolecular.org/resources/omns/v03n10.shtml

"If you are an editor, author, reviewer, or reader of medical journals, or if you depend on your doctor or health care provider getting unbiased information from medical journals, then the 1,500 documents now hosted on the PLoS Medicine Web site [1] should make you very concerned and angry. Because, quite simply, the story told in these documents amounts to one of the most compelling expositions ever seen of the systematic manipulation and abuse of scholarly publishing by the pharmaceutical industry and its commercial partners in their attempt to influence the health care decisions of physicians and the general public."

So starts an editorial, "Ghostwriting: The dirty little secret of medical publishing that just got bigger", in the September 2009 issue of PLoS Medicine (1). This is not the first time that PLoS editors and contributors have spoken out against this practice. What is different this time around is that a clear paper trail detailing these shenanigans surfaced in the course of litigation involving Wyeth and its HRT drug Prempro. Lawyers for PLoS Medicine and the New York Times were instrumental in getting these documents made public (2), and the New York Times ran a piece about this in their Aug 4, 2009 edition (3).

What is medical ghostwriting? The term refers to the Pharma practice of having writing firms produce manuscripts to the company′s specifications, paying "respected" academics to pose as authors, and getting these articles published in medical journals — without acknowledging the company′s involvement of course. As the PLoS Medicine editors put it:

"…articles highlighting specific marketing messages written by unattributed writers, but "authored" by academics, are strategically placed in the medical literature …" (2).

These ghostwritten articles are typically reviews favourable to drugs sold by the company commissioning the manuscript; benefits are exaggerated and side effects are minimized. However, even research papers and clinical trial results may be "authored" by ghostwriters. As cruder methods of persuasion lost their effectiveness, pharmaceutical companies turned to "educating" and influencing medical doctors by faking scholarly articles and submitting them to respectable academic publications.

"What, a cynical reader might ask, can I truly trust as being unbiased? The answer is that, sadly, for some or even many journal articles, we just don't know." (1)

The term "ghostwriting" is actually a bit misleading. It isn′t the writing firms that are the problem; it′s the academics posing as authors. Their names and reputations give credence to articles that are little more than ads masquerading as scholarly publications; the unsuspecting reader can′t tell the difference. Clearly, these "authors"and the pharmaceutical companies recruiting them are guilty of fraud.

"How did an industry whose products have contributed to astounding advances in global health over the past several decades come to accept such practices as the norm?" (1)

Well, judging by the recent scandals in the banking and financial sectors, corruption seems to be endemic in American business. Power tends to corrupt, Lord Acton said. Big Business is certainly powerful, and they are proving him right.

Sources:

1. The PLoS Medicine Editors. Ghostwriting: The dirty little secret of medical publishing that just got bigger. PLoS Medicine 2009;6(9):e1000156.
   http://dx.doi.org/10.1371/journ al.pmed.1000156
2. Wyeth ghostwriting archive. PLoS Medicine.
   http://www.plosmedicine .org/static/ghostwriting.action
3. Natasha Singer. Medical papers by ghostwriters pushed therapy. NY Times Aug 4, 2009.
   http://www.nyti mes.com/2009/08/05/health/research/05ghost.html

You say you never heard of orthorexia nervosa? Well, neither had I until I read Jenny Thompson′s article "April [Fool′s Day] in August" in the September 8, 2009 edition of the HSI e-Alert (1). Here is how she introduced the subject:

"Do you read nutrition labels to avoid hidden trans fats, harmful additives, and sugar-substitutes? Do you choose organic foods to keep your intake of pesticides and herbides to a minimum? Do you even go out of your way to purchase free-range meat so you′ll get a maximum of omega-3 fatty acids and a minimum of trace antibiotics and growth hormones? If you answered yes to any of these questions, don′t be surprised if your doctor breaks the bad news: You have an eating disorder."

That supposed eating disorder — orthorexia nervosa — is an obsession with healthy eating, an obsessive compulsive disorder centered around food.

Here is what an article in the Observer (2) had to say about this grave new "disease":

"Eating disorder charities are reporting a rise in the number of people suffering from a serious psychological condition characterised by an obsession with healthy eating. The condition, orthorexia nervosa, affects equal numbers of men and women, but sufferers tend to be aged over 30, middle-class and well-educated."

A serious psychological condition characterized by an obsession with healthy eating? Hm.

"I am definitely seeing significantly more orthorexics than just a few years ago", the chairwoman of the mental health group of the British Dietetic Association was quoted as saying. "[Orthorexics] are solely concerned with the quality of food they put in their bodies, refining and restricting their diets according to their personal understanding of which foods are truly ′pure′."

What kinds of foods do these seriously disturbed orthorexics refuse to touch? Sugar, salt, caffeine, alcohol, wheat, gluten, yeast, soya, corn, and dairy foods are mentioned, as well as anything likely to contain pesticides, herbicides, and artificial additives. A bit strict maybe, but hardly a sign of a serious psychological problem. Even mainstream nutritionists warn against excess sugar, salt, and alcohol consumption. Gluten (wheat) as well as dairy products cause problems for many, and when did unfermented soy beans become food? I also try to avoid pesticides and herbicides; I should think you do too.

Who came up with this new-fangled disease called "orthorexia nervosa"? The term was introduced in 1997 by one Steven Bratman, M.D., who describes the affliction this way:

"Many of the most unbalanced people I have ever met are those who have devoted themselves to healthy eating. In fact, I believe some of them have actually contracted a novel eating disorder for which I have coined the name ′orthorexia nervosa.′ The term uses ′ortho,′ meaning straight, correct, and true, to modify ′anorexia nervosa.′ Orthorexia nervosa refers to a pathological fixation on eating proper food." (3)

"[people concerned with healthy eating] are sometimes affectionately called ′healthfood junkies.′ However, in some cases, orthorexia goes beyond a mere lifestyle choice. Obsession with healthy food can progress to the point where it crowds out other activities and interests, impairs relationships, and even becomes physically dangerous. When this happens, orthorexia takes on the dimensions of a true eating disorder, like anorexia nervosa or bulimia." (4)

To better understand Bratman and his "disease", one has to read his (short) original essay on orthorexia (3). It describes his experience with the lunatic fringe of the health food movement at a commune of health fanatics. He himself was part of that commune, before he was brought back to his senses; he is a "recovering orthorexic" himself. On reading this article (3) it becomes clear that he doesn′t apply the term orthorexia nervosa to people who simply focus on healthy eating. It is meant to describe someone with cockamamie ideas about food and a tendency toward obsessive compulsive behaviour.

Bratman is apparently quite sincere in his belief that orthorexia nervosa is an affliction to be taken seriously, a genuine disease requiring treatment. I suppose such misguided eating can actually lead to health problems. But does your typical "orthorexic" believe he needs treatment? And would he take nutritional advice from the medical establishment? Mainstream nutritional advice may be less extreme, but can be just as wrong-headed (dangers of cholesterol and saturated fat, etc).

I have to admit though that the term orthorexia nervosa appeals to my sense of humour. The lunatic fringe of the health food movement deserves a good ribbing, and orthorexia nervosa describes them wonderfully well. Still, there is something very sad about the extent to which we have lost our way in such a simple everyday matter as food.

Sources:

1. Jenny Thompson. April in August. HSI eAlert Sep 8, 2009.
   http://mail.live.com/default.aspx?wa=wsignin1.0
2. Amelia Hill. Healthy food obsession sparks rise in new eating disorder. The Observer Aug 16, 2009.
   http://www.guardian.co.uk/society/2009/aug/16/orthorexia-mental-health-eating-disorder
3. Steven Bratman, M.D.. Original essay on orthorexia.
   http://orthorexia.com/index.php?page=essay
4. Steven Bratman, M.D.. What is orthorexia?
   http://orthorexia.com/Index.php?page=katef

If we were asked to name the leading causes of death, most of us would name cardivascular disease and cancer. These are indeed the primary pathophysiological conditions identified at the time of death, but they are not the root causes. Diseases are the result of a combination of (unmodifiable) genetic and (modifiable) lifestyle factors. The real question therefore is what factors make the most significant contributions to these and other diseases.

A 1993 paper (1) attempted to answer that question. The authors searched the scientific literature from 1977 to 1993 for articles that quantitatively related lifestyle factors with disease. Coupled with actual U.S. death rates for 1990, they arrived at the following table of top risk factors and associated death tolls:

1. tobacco 400,000
2. diet/activity patterns 300,000
3. alcohol 100,000
4. microbial agents 90,000
5. toxic agents 60,000
6. firearms 35,000
7. sexual behavior 30,000
8. motor vehicules 25,000
9. illicit drug use 20,000

These ten factors (poor diet and sedentary lifestyle were lumped together) were estimated to account for about 50% of all U.S. deaths in 1990. Smoking, bad diets and lack of exercise are seen to be by far the major problems, accounting for 19% and 14% of all deaths, respectively.

The authors of a 2004 paper (2) put the U.S. death toll from smoking and poor diet/physical inactivity, the leading causes of death in the 1993 article, at 430,000 and 400,000, respectively. Their estimates are based on a survey of the relevant literature from 1980 to 2002 and actual numbers of U.S. deaths in 2000. As these authors point out, poor diet and lack of physical activity may soon overtake smoking as the leading cause of death in the United States.

The authors of a 2009 paper (3) analyzed data from the Potsdam, Germany, segment of the multi-center European Prospective Investigation Into Cancer (EPIC-Potsdam) study to estimate the risks associated with smoking, poor diet, lack of physical activity and high body mass index (a rather strange choice, given its dependence on diet and activity level). People who had none of these risk factors turned out to be 78% less likely to develop any chronic disease compared to those who smoked, ate poorly, were inactive and too heavy. Specific risk reductions were estimated to be 93% for diabetes, 81% for heart attacks, 50% for stroke, and 36% for cancer.

The authors of these papers emphasize that their numbers are only rough estimates of the death toll from perfectly avoidable risks. But these figures show very convincingly just how many of our chronic health problems are self-inflicted.

Sources

1. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270 (18):2207-2212.
   http://jama.ama- assn.org/cgi/reprint/270/18/2207
2. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA 2004;291:1238-1245.
   http://jama.ama- assn.org/cgi/content/abstract/291/10/1238 [Free Abstract]
3. Ford ES, Bergmann MM, Kröger J, Schienkiewitz A, Weikert C, Boeing H. Healthy living is the best revenge. Findings from the European Prospective Investigation Into Cancer and Nutrition - Potsdam Study. Arch Intern Med 2009;169:1355-1362.
   http://archinte.ama- assn.org/cgi/reprint/169/15/1355

In the Aug 27, 2009 edition of The Scientist a UCLA infectious disease specialist makes an impassioned plea to help push for funding for the development of new antibiotics (1). Brad Spellberg, the author of a new book on the antibiotic resistance crisis, Rising plague (2), entreats scientific and lay communities for help in the quest for new weapons against antibiotic-resistant bacteria:

"This crisis will not be averted without your support, without a grassroots movement to put pressure on all sides — political, medical, pharmaceutical, and consumer — to band together to act. I will tell you what can be done, but we need your help to do it." (1)

Why does he need our help? Don′t we have the pharmaceutical industry to save us and keep us healthy? Apparently not:

"The problem here is not scientific. New antibiotics are dying before they have a chance to enter the marketplace due to a murky regulatory landscape and also due to unfavorable economics (i.e., the relatively low rate of return on investment afforded by sales of short-course antibiotics compared to sales of drugs for chronic conditions, such as hypertension, dementia, cancer, arthritis, and high cholesterol). Big Pharma has largely exited the scene. (1) [emphasis added]

Does he really mean to say that the wealthiest of all the multinational companies are unwilling to fund the necessary work, just because there is more money to be made elsewhere — even if our very survival is at stake? And I thought "capitalism" and "free markets" would solve all our problems!

Sources:

1. Spellberg B. Rising Plague. The Scientist Aug 27, 2009.
   http://www.the-scientist.com/news/display/55951/
2. Brad Spellberg. Rising plague: The global threat from deadly bacteria and our dwindling arsenal to fight them. Prometheus Books, Amherst, New York, 2009.

In my last two posts I talked about the importance of ω3 polyunsaturated fatty acids (PUFAs). In this post I want to focus on their role as precursors for a group of hormone-like substances collectively known as eicosanoids. The information presented here is largely taken from a recent review article on dietary lipids in inflammatory disorders like cardiovascular disease (1). Some of that material is also summarized on a couple of U.S. National Institutes of Health (NIH) websites (1).

Our bodies make these eicosanoids from two C-20 polyunsaturated fatty acids, the ω3 PUFA eicosapentaenoic acid (EPA) and the ω6 PUFA arachidonic acid (AA). Eicosanoids regulate important physiological functions like inflammation (prostaglandins), blood clotting (thromboxanes), and the immune response (leukotrienes). These are obviously vital defense mechanisms, but when they get out of hand the result is tissue damage and disease.

What could cause these defense mechanisms go awry? Physiological responses regulated by the ω6 PUFA derivatives are usually much stronger and more dangerous than the hormonal effects of EPA-derived prostaglandins, thromboxanes or leukotrienes. Imbalances in the ω3/ω6 ratios therefore have serious health consequences. The higher the ω6/ω3 eicosanoid ratio, the greater the danger of overreaction and disorders like chronic inflammation.

What determines the eicosanoid ω3/ω6 ratio? We can make neither ω3 nor ω6 PUFAs; they have to come from our diets. The ω3/ω6 eicosanoid ratio in our fat stores simply reflects the dietary mix of ω3 and ω6 polyunsaturated fatty acids, This in turn determines the ω3/ω6 ratio of PUFAs incorporated into cell membrane phospholipids, the precursors for eicosanoid synthesis.

Our bodies don′t seem to preferentially make either ω3 or ω6 eicosanoids. Phospholipid-bound ω3 and ω6 PUFAs are equally likely to be released and used as precursors. The elongation of shorter PUFAs to the C-20 fatty acids — linoleic acid to AA and α-linolenic acid to EPA — is catalized by the same enzymes. Other enzymes convert both EPA and AA to eicosanoids, and the ω3- and ω6-derived eicosanoids compete for the same receptors.

There are some quantitative differences in conversion rates and receptor binding between ω3 and ω6 eicosanoids. Nevertheless, the ω3/ω6 eicosanoid ratios are largely determined by the mix of phospholipid-bound ω3 and ω6 PUFAs, and therefore ultimately by the dietary ω3/ω6 mix. There is a clear correlation between the phospholipid PUFA fraction belonging to the ω6 series and death from cardiovascular disease — the higher the ω6 percentage, the greater the death toll (1).

What causes this ω3/ω6 PUFA imbalance in our diets? It is largely due to the excessive consumption of vegetable oils. Canola oil has the least unfavourable ω3/ω6 ratio at about 1:2. That ratio for corn oil is about 1:9, and the other commonly used oils aren′t any better. You can find a table of PUFA compositions for the more common cooking oils on one of the NIH websites quoted in the reference list (1).

Rebalancing the ω3/ω6 polyunsaturated fatty acid mix really requires both a reduction in dietary ω6 PUFA intake and an increase in ω3 PUFA consumption. Given the accumulated excess of ω6 PUFAs in our tissues, taking fish oils is much more effective than adding α-linolenic acid from sources like flax seeds. The conversion from the C-18 PUFA α-linolenic acid to EPA is simply too inefficient; preformed EPA itself is 15 times more effective at raising EPA levels than α-linolenic acid (2).

Compensating for excess ω6 fatty acids is by no means the only role of ω3 fatty acids, nor are imbalances in eicosanoids solely responsible for cardiovascular disease. There can be little doubt, however, that imbalances in dietary polyunsaturated fatty acid intake contribute to heart disease. This connection is both firmly established clinically and physiologically plausible.

So, Eat fatty fish or take EPA/DHA supplements! It is a simple and effective way to reduce your risk of cardiovascular disease and other inflammatory disorders.

Sources:

1. Lands B. A critique of paradoxes in current advice on dietary lipids. Progr Lipid Res 2008;47:77-106. See also
   http://dx.doi.org/10.1016/j.plipres.2007.12.001 [Free Abstract]
   http://ods.od.nih.gov/eicosanoids/ and
   http://efaeducation.nih.gov/
2. Brenna JT, Salem Jr. N, Sinclair AJ, Cunnane SC. α-Linolenic acid supplementation and conversion to n-3 long-chain polyunsaturated fatty acids in humans. Prostaglandins Leukotrienes Essential Fatty Acids 2009;80:85-91.
   http://www.plefa.com/article/S0952-3278(09)00016-7/abstract [Free Abstract]

In my last post I reviewed an article about health risk factors and premature deaths (1). One of the authors′ more surprising findings was that, in the U.S. alone, an estimated 84,000 lives could be saved annually if everyone′s omega-3 fatty acid intakes were optimized, either through diet or supplementation. By comparison, cholesterol-lowering strategies were estimated to save about 113,000 lives annually. I was of course aware of the importance of n-3 (omega-3) fatty acids, but I was surprised by the numbers. Maybe I shouldn′t have been.

In 2003 the Nutrition Committee of the American Heart Association (AHA) had this to say about omega-3 fatty acids and cardiovascular disease (2):

"Omega-3 fatty acids have been shown in epidemiological and clinical trials to reduce the incidence of cardiovascular disease. Large-scale epidemiological studies suggest that individuals at risk for coronary heart disease benefit from the consumption of plant- and marine-derived omega-3 fatty acids, although the ideal intakes presently are unclear. Evidence from prospective secondary prevention studies suggests that EPA + DHA supplementation ranging from 0.5 to 1.8 g/day (either as fatty fish or supplements) significantly reduces subsequent cardiac and all-cause mortality. For α-linolenic acid, total intakes of ∼ 1.5 to 3 g/day seem to be beneficial."

The authors go on to say that even patients with existing heart disease can benefit from omega-3 supplementation (2):

"A dietary (i.e. food-based) approach to increasing omega-3 fatty acid intake is preferable. Still, for patients with coronary artery disease, the dose of omega-3 (∼1 g/day) may be greater than what can readily be achieved through diet alone. These individuals, in consultation with their physician, could consider supplements for CHD risk reduction. Supplements could also be a component of the medical management of hypertriglyceridemia, a setting in which even larger doses (2 to 4 g/day) are required."

In 2005 a meta-analysis of randomized controlled trials of the effects of various lipid-lowering interventions on all-cause and cardiovascular deaths appeared (3). In all, 97 trials involving nearly 140,000 patients and a roughly equal number of controls were included in that analysis. The lipid-lowering interventions consisted of statins, fibrates, resin, niacin, n-3 fatty acids or dietary intervention. This is how the authors summarized their findings (3):

"Statins and n-3 fatty acids are the most favorable lipid-lowering interventions with reduced risks of overall and cardiac mortality."

The actual risk ratios for all-cause mortality were 0.87 for statins and 0.77 for n-3 fatty acids. For death from cardiovascular disease the corresponding values were 0.78 for statins and 0.68 for n-3 fatty acids. The authors point out, though, that in the n-3 fatty acid intervention group the risk reduction was significant only in secondary prevention, i.e. for patients who already had cardiovascular disease.

They might have added that the reduction in the risk of death was even greater in the n-3 fatty acid than in the statin group, that n-3 fatty acids don′t come with the side effects of statins, and that they are a good deal cheaper as well.

The authors do suggest though that "future trials should explore whether n-3 fatty acids in combination with statins lead to additional reductions in coronary heart disease mortality, especially in patients with metabolic syndrome". It′s possible that combination therapy might confer additional benefits, since statins and n-3 fatty acids act differently. Statins reduce cholesterol synthesis, whereas n-3 fatty acids tame inflammation.

n-3 and n-6 polyunsaturated fatty acids are precursors for a group of hormone-like substances — summarily referred to as eicosanoids — which control, among other things, the body′s inflammatory response. Eicosanoids derived from n-6 fatty acids up-regulate inflammation, whereas n-3 eicosanoids keep it in check.

We cannot interconvert n-3 and n-6 fatty acids, which means that the dietary mix of n-3 and n-6 fatty acids determines our ability to initiate and control inflammation. Unfortunately, we get far too much dietary n-6 fatty acids from seed oils (sunflower, safflower, peanut, canola), which leaves us at risk for chronic inflammation, atherosclerosis and cardiovascular disease.

By increasing our intake of n-3 polyunsaturated fatty acids, either through diet or supplementation, and/or by decreasing n-6 fatty acid consumption, we can rebalance the inflammatory response and reduce our risk of cardiovascular and other inflammatory diseases.

Sources:

1. Danaei G, Ding EL, Mozaffarian D et al. The preventable causes of death in the United States: Comparative risk assessment of dietary, lifestyle, and metabolic risk factors. PLoS Medicine April 2009;6(4)
   http://dx.doi.org/10.1371/journal.pmed.1000058
2. Kris-Etherton PPM, Harris WS, Appel LJ. Fish consumption, fils oil, omega-3 fatty acids, and cardiovascular disease. Arterioscler Thromb Vasc Biol 2003;23:e20-e30.
   http://dx.doi.org/10.1161/01.ATV.0000038493.65177.94
3. Studer M, Briel M, Leimenstoll B, Glass TR, Bucher HC. Effect of different antilipidemic agents and diets on mortality. A systematic review. Arch Intern Med 2005;165:725-730.
   http://archinte.ama-assn.org/cgi/reprint/165/7/725

"Omega-3 deficiency causes 96,000 US deaths per year, say researchers". That was the headline of a recent NutraIngredients article (1). The title highlights one of the more surprising finding of a study on "The preventable causes of death in the United States: Comparative risk assessment of dietary, lifestyle, and metabolic risk factors" (2).

A group of researchers set out to identify the lifestyle, dietary and metabolic health risk factors responsible for the greatest number of premature and preventable deaths in the United States. Metabolic risk factors are physiological indicators like blood pressure, glucose levels, LDL-cholesterol, etc. For any given risk factor to be included in their analysis, a number of conditions had to be met:

• it had to be a known cause of disease-specific mortality,
• a quantitative relationship between magnitude of risk and likelihood of death from a specific disease had to be available from observational or controlled studies,
• the risk factor had to be controllable through lifestyle changes or medical intervention, and
• representative risk factor distribution data for the general population had to be available.

If one knows the distribution of a given risk factor in the general population, and if the relation between its magnitude and the probability of disease-specific death from that risk factor can be quantified, then one can estimate the proportional reduction in the number of deaths that could be achieved by eliminating that risk factor. With this information it is then a simple matter to estimate the actual number of premature deaths that could be avoided by eliminating that risk factor; it is the product of the proportional reduction in the number of deaths and the actual number of deaths from that disease.

Here are the author′s estimates (2) for the number of deaths that could have been prevented in the U.S. in 2005, if the following twelve risk factors had been eliminated (confidence intervals in parentheses):

• smoking 467,000 (436,000 - 500,000)
• high blood pressure 395,000 (372,000 - 414,000)
• overweight-obesity 216,000 (188,000 - 237,000)
• physical inactivity 191,000 (164,000 - 222,000)
• high blood glucose 190,000 (163,000 - 217,000)
• high LDL-cholesterol 113,000 (94,000 - 124,000)
• high dietary sodium 102,000 (97,000 - 107,000)
• low dietary omega-3 fatty acids from seafood 84,000 (72,000 - 96,000)
• high dietary trans fatty acids 82,000 (63,000 - 97,000)
• excessive alcohol use 64,000 (51,000 - 69,000)
• low intake of fruits and vegetables 58,000 (44,000 - 74,000)
• low dietary polyunsaturated fatty acids (PUFAs) 15,000 (11,000 - 20,000)

Not surprisingly, smoking and high blood pressure were found to be by far the most serious risk factors for premature death. The high health risk posed by obesity, physical inactivity and high blood glucose had to be expected as well. The most surprising finding, though, has to be the importance of omega-3 fatty acids from fish. A lack of EPA and DHA in the diet turned out to be nearly as large a risk factor as high LDL-cholesterol or sodium levels, and more of a risk than trans fatty acids and low intakes of fruits and vegetables.

Some of the variables in this list seem like strange choices. For example, blood pressure and sodium intake aren′t independent of one another; increased sodium intake increases blood pressure. Similarly, there has to be a connection between overweight-obesity and physical inactivity. On the other hand, a number of well-known risk factors — caloric intake, triglyceride and HDL-cholesterol levels — were excluded, because their causal connections to specific diseases are less well established. Vitamin D is another surprising omission.

Be that as it may, these considerations are unlikely to put the omega-3 results in question. So, if you don′t like fish, supplement with EPA/DHA. It′s one of the most affordable and effective health measures you can take.

Sources:

1. Shane Starling. Omega-3 deficiency causes 96,000 US deaths per year, say researchers. NutraIngredients June 26, 2009.
   http://www.nutraingredients- usa.com/content/view/print/252050
2. Danaei G, Ding EL, Mozaffarian D et al. The preventable causes of death in the United States: Comparative risk assessment of dietary, fifestyle, and metabolic risk factors. PLoS Medicine April 2009;6(4).
   http://dx.doi.org/10.1371/journ al.pmed.1000058

There have been a number of negative reports on the health effects of vitamin/mineral supplements. Several studies concluded that supplements were either ineffective or made matters worse. The latest negative article on this topic claims that taking vitamins C and E suppresses the health benefits of exercise (1).

How could this be? After all, exercise does create free radials, and free radicals do cause damage. Since I too take supplements, I decided to have a closer look.

The title of the article, "Antioxidants prevent health-promoting effects of physical exercise in humans", is actually misleading. The investigators really set out to determine if and how antioxidant supplementation interferes with the beneficial effect of physical exercise on insulin resistance. Here is how they went about it.

Forty healthy non-diabetic young men were recruited for a two-part trial. Sixteen of the 40 completed the first part; the rest were used in the second stage. Each exercise session consisted of running or cycling (20 min), circuit training (45 min), and warm-up and cooling off periods (20 min). All 40 volunteers were randomly assigned to receive either placebo or 2×500 mg vitamin C and 1×400 IU vitamin E per day.

The first trial part was designed to test whether the chosen exercise regimen generated reactive oxygen species (ROS) — popularly known as free radicals — and whether the chosen antioxidant cocktail suppressed them. The sixteen participants, half getting placebo, exercised on three consecutive days. Muscle tissue samples were taken before and after the intervention and analyzed for ROS content. This stage confirmed that the chosen exercise protocol generated ROS, and that the antioxidants suppressed these ROS, i.e. that the experimental setup worked.

The second trial part was designed to answer the question if and how ROS formation improved insulin sensitivity, and if and how antioxidant supplementation interfered with that effect. In this trial part the remaining 24 recruits completed four weeks of exercise, five days per week. Blood and muscle tissue samples were taken before and after the intervention.

Analysis of the blood samples established that the 4-week exercise regimen improved insulin sensitivity, but only in the placebo group. No significant improvement was observed in the supplement group, i.e. the antioxidant cocktail suppressed the exercise effect on insulin sensitivity.

Analysis of the tissue samples revealed the reason why. In the placebo group, exercise strongly increased the gene expression of known molecular regulators of insulin sensitivity. In the supplement group this effect was much smaller. In other words, antioxidant supplementation largely eliminated the exercise-induced increase in insulin sensitivity.

Interestingly, ROS formation also increased the production of the antioxidant enzymes superoxide dismutase (SOD) and glutathione peroxidase (GPx). If the exercise-generated free radicals aren′t suppressed by antioxidant supplementation, the body will generate its own defenses against them — while simultaneously improving insulin sensitivity.

In summary, this study convincingly demonstrated that, and why, supplementation with antioxidant vitamins C and E suppresses a valuable exercise effect — improved insulin sensitivity.

Does all this mean that supplementation with vitamins C and E is useless? Not at all. These two antioxidants are after all vitamins, which are defined as substances that we need but cannot make at all or only in insufficient amounts. Nothing can take their place where they are needed, but they cannot be used like drugs. In this particular case the exercise-induced free radicals actually played a vital regulatory role — suppressing them backfired.

As the authors put it:

"… antioxidant supplements prevent the induction of molecular regulators of insulin sensitivity and endogenous antioxidant defense by physical exercise"

and

"… we propose that transiently increased levels of oxidative stress reflect a potentially health-promoting process at least in regards to prevention of insulin resistance and type 2 diabetes mellitus"

Sources:

1. Ristow M, Zarse K, Oberbach A et al. Antioxidants prevent health-promoting effects of physical exercise in humans. Proc Nat Acad Sci, published online before print May 11, 2009;
   doi:/10.1073/pnas.0903485106

Are vegetables more nutritious raw or cooked? If you are an omnivore, you probably don′t care — you are used to cooked food. Meat eaters may eat raw vegetables in salads, with dips, or possibly juiced. But we eat our meat cooked, and we want the rest of our dinner cooked as well.

Vegetarians are a different story. If you are a firm believer in the health benefits of a vegetarian diet, you probably want to know if cooking enhances or diminishes the nutritional value of food. Of course, raw foodists are already convinced that raw is the way to go. So what is more nutritious, raw or cooked vegetables? It turns out that there is no simple answer to that question.

There are advantages and disadvantages to cooking vegetables (1,2). On one hand, cooking softens food by breaking down plant cell walls, making nutrients more accessible. Cooking also denatures proteins and softens starches, making them more digestible. On the other hand, heating damages some vitamins and phytonutrients, as well as destroying vegetable enzymes. Frying does more damage than steaming or boiling; the higher temperatures can damage unsaturated fats, which in turn uses up antioxidants. So what′s better, raw or cooked? It′s pretty well a toss-up.

Given today′s industrial food production and distribution system, I doubt very much that we can get enough vitamins and minerals from our vegetables, no matter how we eat them. I am convinced that eating vegetables is more important for their effect on macronutrient intake — carbohydrates, proteins, and fats — that for their micronutrient content.

You can always compensate for what you should have gotten from your food but didn′t — vitamins and minerals; you can take supplements. You′ll end up paying twice for your nutrients, first for food and then again for the supplements. But at least you eat right.

It is a good deal more difficult to compensate for what you ate but shouldn′t have — excess calories. The best way to cut back on high-calorie foods is to add more vegetables to your diet. Vegetables are excellent sources of dietary fiber. Soluble fiber gives you a sense of fullness — you′ll likely eat less. They also slow nutrient digestion and absorption. Insoluble fibers help keep you "regular".

The bottom line? Eat your vegetables any way you like them, but eat them! Learning to prepare tasty vegetable side dishes may well be the easiest way to control your waist-line.

But add a quality nutritional supplement to your diet to ensure that you are getting the vitamins, minerals, and phytonutrients you need.

Sources

1. Sushma Subramanian. Fact or fiction: Raw veggies are healthier than cooked ones. Scientific American March 31, 2009.
   [Full Text}
2. Jon Barron. Food – raw versus cooked. Jon Barron′s Alternative Health Newsletter March 16, 2009.
   [Full Text]