Today I have an article out in Synapse called “Wine May Increase Heart Healthy Fats in the Blood.” I am making an executive decision that it is too science-y for this blog, so instead I would like to open a discussion about how doctors should treat information like this.

For you uber-nerds (like me), here is the PubMed link to the original paper.

Let’s start with some excerpts from my article:

• “The beauty of this finding is that the improvement in fatty acid profile from wine consumption seems to be clinically relevant. Based on the current consensus, small dietary changes in fatty acid consumption have a large clinical effect, so a 38% to 50% increase in EPA levels among moderate wine drinkers is noteworthy. Similar levels of improvement in lipid profiles from studies of fish consumption have shown considerable benefit for cardiovascular outcome.”

• “Thus, the present finding may offer dietary intervention as a possible method of cardiovascular protection, particularly when combined with increased omega-3 consumption.”

• “In the present study, the difference between participants in the low fatty acid group who did not drink and those in the high fatty acid group who drank the most was an 83% increase in blood EPA, a change associated with a 50% to 75% reduced risk of heart attack. Such a dramatic difference represents a useful alternative to fish consumption for those who may not have access to seafood for whatever reason.”

• “Thus, increasing both dietary omega-3 fatty acids and wine consumption may be helpful to protect against cardiovascular events. Plant-derived omega-3 fatty acids are abundant in walnuts, soy, flax and canola oils, and one gram per day is the current recommendation for heart protection. “Moderate” alcohol intake is one glass per day for women and two for men.”

From a clinical perspective, the evidence that alcohol provides a tremendous protection against mortality from heart disease is undeniable. It is thought to work by both raising good HDL cholesterol and reducing blood clotting.

This effect is not limited to red wine, all spirits elicit substantial protection.

Despite these benefits, there are also a number of obvious reasons to avoid alcohol, particularly excessive consumption. Excessive alcohol consumption is associated with addiction, liver disease, stroke and can cause accidents and other behavioral problems.

Notably, benefits similar to those seen with alcohol can be conferred by increasing exercise amount or intensity.

If you want to experience the benefits of alcohol you need to use it in moderation, which is 1 drink per day for women and 2 for men, or possibly slightly more. More than one drink per day for women is associated with an increased risk of breast cancer, however this effect is attenuated by sufficient folate intake.

Doctors have been recommending increasing exercise for decades, but only a small percentage of the population makes an effort to get enough to make it as valuable against heart disease as alcohol. Also, there is a large population of individuals that have physical ailments that prevent them from performing vigorous cardiovascular exercise.

But to this day the American Heart Association–the same agency that recommended the low-fat, high-carb diet that many argue actually promotes heart disease–refuses to recommend moderate alcohol consumption. The basic tenet of their argument is that alcohol is not necessary because heart protection can be achieved in other ways, and the risks outweigh the benefits.

Is this right? I’m not so convinced.

Do you think doctors should discuss the potential benefits of alcohol with their patients? Should the AHA change their recommendation?

Vitamin D

For the past several years the data in support of increasing vitamin D intake for every living human has been mounting. This week the American Journal of Clinical Nutrition features a collection of new research articles addressing the trends in vitamin D status and optimal dose recommendations.

This week’s take home lesson: While current research indicates we should be getting more vitamin D than is presently recommended, as a whole our vitamin D levels appear to have decreased in the past 15 years. The best way to combat this deficiency is with vitamin D supplements.

Vitamin D is a fat-soluble prohormone and essential nutrient produced when ultraviolet radiation (UVB) contacts our skin. It is probably best known for its role in bone metabolism (it has been shown to be more important than calcium for maintaining bone health), however recent studies indicate that vitamin D is essential for other physiological process as well.

Low blood levels of vitamin D have now been associated with many different chronic diseases including cancer, coronary heart disease, multiple sclerosis, Alzheimer’s disease, tuberculosis, depression, hypertension, periodontal disease, schizophrenia, seasonal affective disorder and type 1 diabetes.

In light of these findings, many nutrition researchers have argued for increasing recommended levels of vitamin D intake, but making population-wide recommendations have proved difficult for world health agencies because of large variability and uncertainty in vitamin D requirements.

There are several things to consider when evaluating vitamin D status in an individual. Latitude (sun exposure) is probably the single best predictor of vitamin D status. Anyone living in San Francisco or further north cannot get enough sun exposure to achieve sufficient vitamin D status, particularly during the winter months.

Because vitamin D is fat-soluble, it is retained in body tissues for several months after sun exposure. For this reason, people living at far north latitudes are particularly vulnerable to vitamin D deficiency because they frequently do not store up sufficient vitamin D during the summer to sustain their needs during the winter.

To further complicate matters, it is incredibly difficult to obtain vitamin D through dietary sources. Fatty fish and eggs are the only natural sources of vitamin D, though they are probably insufficient to achieve optimal status. Milk and soy products are typically fortified with vitamin D, as are some juices.

Skin pigmentation, sun avoidance and body composition (high body fat) are all associated with vitamin D deficiency. Darker skin tones do not convert sunlight to vitamin D as easily as lighter skin tones. Sunscreen blocks virtually all vitamin D synthesis. Body fat reduces bioavailability of vitamin D tissue stores.

This week’s study by Anne Looker et al, suggests that increased body mass as well as awareness of skin cancer risk and use of sunscreen have contributed to a significant decline in vitamin D levels in north America in the past decade.

The good news is that supplementation does appear to be effective at improving vitamin D status. Though there is still some disagreement on what the optimum blood levels of vitamin D are, it is generally agreed that they are much higher than currently recommended by any world health organization. One of the principle motivations of the present studies is to inform new vitamin D recommendations.

Kevin Cashman et al offers estimations of dietary requirements of vitamin D for healthy adults. They performed a randomized, placebo-controlled study testing the effects of different vitamin D doses and how they effect blood vitamin D levels.

The absolute minimum amount of vitamin D supplementation recommended by the study is 8.7 ug/day, or approximately 400 IU. This was to maintain blood serum levels greater than 25 nmol/L, and is double the current FDA recommendation for people under age 50. However, this suggestion is only sufficient to avoid deficiencies associated with bone loss and not other chronic diseases.

“The data from the present study clearly show that vitamin D tissue stores, developed during summer via exposure of skin to sunshine, were not sufficient to maintain serum 25(OH)D concentrations of greater than 25 nmol/L in most of the population [during winter], and that dietary vitamin D is an absolute requirement to maintain status above this minimum threshold.”

But the recommendations do not stop here. To maintain blood serum levels of greater than 50 nmol/L–a range more consistent with lowering risk of chronic disease–the study recommends 28 ug/day or 1100 IU of vitamin D. To keep blood serum above 80 nmol/L (from all I have read this is what I would recommend), 41 ug/day or 1650 IU is needed.

Remember this is most important if you are overweight, live north of San Francisco, get little sun exposure or have darker skin. Very rarely do I recommend vitamin supplements (they are not usually effective and are sometimes dangerous), but in this case the evidence is unequivocal.

Vitamin D supplements are easier to find than in the past, but they are usually packaged with calcium and are insufficient in dosage. Men should be wary of excess calcium supplementation since it is associated with an increased risk of prostate cancer.

I will continue looking for a good vitamin D supplement and will post when I find one I am happy with. If you have any recommendations, please share them with us.

Look for supplements where vitamin D is in the form of cholecalciferol, or vitamin D3.

Obesity is quickly becoming America’s number one public health concern, and there is little doubt our changing food landscape is largely responsible. To combat negative press and present an image of public responsibility, food industry giants like McDonalds’s and Coca-Cola have announced policies that seem aimed to help consumers make healthier, informed lifestyle choices. However, leading nutrition and public health experts charge that these policies are disingenuous and are closer to advertising than sincere social responsibility.

In the October 15 issue of the Journal of the American Medical Association (JAMA), David Ludwig, MD, PhD, and Marion Nestle, PhD, MPH, published a commentary on the role of the food industry in public health. The question they seek to answer is, “Should the food industry be welcomed as a constructive partner in the campaign against obesity?”

The answer, they argue, can be found in the analysis of scientific data on food industry practices. One such study published in 2006 investigated United States food corporation practices in school nutrition and concluded that food companies “make public promises of corporate responsibility that sound good, but in reality amount to no more than [public relations].” Another study found that McDonald’s continued to use trans fats in their cooking oil until at least 2005, even though they claimed otherwise. (They were required to pay a settlement for deceptive advertising).

Trans fat! There is no amount of trans fat in the diet that is considered safe.

The food industry also heavily funds an independent firm, the Center for Consumer Freedom (CCF), that aggressively lobbies against “obesity-related public health campaigns, legislation to regulate marketing of junk food to children and scientists who advocate for healthier diets.” It is difficult to understand how these practices meet the proclaimed agenda of these companies to increase the health of society.

These issues then raise an interesting question. Why would a food company care about the health of society? Isn’t a food company’s primary goal to make profits for their shareholders? Of course it is, and that is fine. The problem is that the most healthful foods—unprocessed vegetables, fruits and grains—are not nearly as profitable as highly refined and processed foods. This fact makes the industry’s claims to promote health somewhat dubious.

The obvious answer to why a food company might claim to have concern for public health even if health is at odds with its product is that companies must work to maintain a positive image. Advertisers know very well that image and branding have a tremendous impact on sales. Generally our society does care about health and is willing to pay a premium for products they consider to be healthful. Thus these public health campaigns are indeed a form of advertising because they help shape the public image of a company and its products.

How then do these campaigns manifest in society? One example is the voluntary efforts of beverage companies (in conjunction with the American Heart Association and the William J. Clinton Foundation) in 2006 to curb the sale of sugary drinks in schools, one of the largest sources of excess calories for children. Though at first glance this seems like a noble effort by the companies, after much negotiation the agreement ultimately permitted several caloric drinks to remain on campuses, including sweetened vitamin waters and sports drinks. So much for getting those sugary drinks out of schools.

Also, the food industry invests enormous amounts of money to fund nutrition research. However a study published last year in the Public Library of Science (PLoS) journal found that studies fully funded by industry are 4 to 8-fold more likely to have conclusions favorable to industry compared to those with no industry funding. This raises the possibility of a “systematic bias” in scientific research when industry is involved.

Thus the authors conclude that the interests of the food industry are at odds with public health and should be separated from policy decisions. They go on to argue that while market-driven supply and demand works splendidly for many industries, it must be more carefully regulated when public health and safety are involved. This, they say, is the primary reason there are so many safety requirements on cars, and our food supply should be held to similar rigorous standards.

“Modifiable dietary factors cause substantially more illness and death than automobile crashes. Left unchecked, the economic costs associated with obesity alone will affect the competitiveness of the US economy.”

The authors recommend several courses of action. First, the government must “ensure that nutritional policies are based on solid science, rather than special interests.” Second, congress should provide more funding to nutrition research to “help counter the influence of the industry money.” Third, allow an independent body such as the Institute of Medicine to draft dietary guidelines (this task is currently under the control of the United States Department of Agriculture, which is primarily concerned with the well-being of the food industry and not public health). Fourth, restructure agriculture subsidies to “support public health, not commodity producers.” And finally, “reform campaign finance laws to prevent corporate political donations from leveraging the legislative process.”

These recommendations would be a good start to combating obesity in America, but it is important to remember that ultimately the responsibility for your health is in your own hands. If we as consumers decide we would rather buy healthier, less processed foods and purchase them in larger percentages than processed foods, the food industry will certainly notice.

This article can also be found at Synapse.

What role do you think the food industry should play in public health policy?