Natural Foods to Combat Depression During the Holiday Season

While the holiday season is jovial and celebratory for the majority of Americans, it can also be a source of despondency and despair for others. This is especially true for those afflicted with seasonal affective disorder or have great fear and anxiety leading to self-imposed travel restrictions in the midst of the COVID pandemic.

Fortunately, as of this writing, the most recent evidence suggests that if you’ve been vaccinated and “boosted”, the latter should be less of an overriding concern.

Nevertheless, as compared to the pre-COVID pandemic era, levels of depression and anxiety have also risen to unforseen heights.  With the Holiday Season upon us, presented below is a heart healthy selection of foods/drinks proven to enhance mood and combat/limit depression and make your holiday season a more enjoyable one.

1. Mushrooms: A new study of nearly 25,000 men and women found that compared to non-consumers, those who ate mushrooms on a regular basis were less likely to experience signs of depression.  Mushrooms are an excellent source of ergothioneine (ERGO), an amino acid with antioxidant properties shown (in rodent studies) to alleviate symptoms of depression.  Other good food sources of ERGO are beans (black, kidney) and oat bran.
2. Cranberries:  Cranberries are also rich in antioxidants and in the brain protective and anti-inflammatory compound ursolic acid.  Ursolic acid not only reduces growth of certain tumors but has also been shown to improve memory and reduce mood disorders, especially anxiety and depression. Try a handful of cranberries or 4 ounces of pure cranberry juice each day to reap the benefits.
3. Prebiotics: Non-digestible carbohydrate foods (prebiotics) such as garlic, Jerusalem artichokes, leeks and onions, promote the growth of healthy gut bacteria to reduce neuroinflammation and improve symptoms of anxiety and depression.
4. Dark chocolate: A study of ~13,600 adults found that compared to non-consumers, daily consumption of dark chocolate (3.5 ounces) was associated with ~60% lower risk of depression.
5. Coffee: Compared to minimal or no consumption, coffee drinkers have a 25% lower risk of depression. The most favorable results were observed with an average amount of 13.5 ounces consumed daily.
6. Mediterranean Style Diet: A Mediterranean style diet (vegetables, fruits, legumes, nuts, whole grains, fish) is associated with improved mental health in men and women with depression.
7. Kiwi: A recent study found that consuming a kiwifruit daily was associated with improved mood and overall well-being that was attributable to more than the high Vitamin C content.
8. Bivalves: Mussels, oysters, clams and scallops are good/excellent sources of selenium associated with reduced depression and improved mood.
9. Bananas: Bananas are an excellent source of Vitamin B6 with anti-anxiety, antidepressant properties. A banana a day may keep the psychiatrist away!
10. Pumpkin Seeds: Try a small handful of pumpkin seeds daily. The rich content of tryptophan, zinc and magnesium may reduce anxiety and combat depression.

Dr. Michael Miller is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore, Maryland.  Check him out on twitter: @mmillermd1

Let’s Shake on It: Surprising Clues to Heart Disease & Overall Health

Observant physicians can identify important clues about the heart (and overall) health of their patients simply by being attentive to physical appearance and interactions.   While telemedicine has provided an invaluable service during the COVID19 pandemic, many, if not most of us have missed the informative “personal touch”  we have with our patients.

Perhaps the first clue we receive when patients walk through the door is through a simple handshake.  While some of my patients continue to feel more comfortable with a fist/elbow bump greeting since COVID-19, a sizeable proportion have returned to handshakes following vaccination.

As it turns out, grip strength is a strong predictor of cardiovascular and all-cause mortality.

Grip strength can be measured using a hand dynamometer that is relatively inexpensive and readily commercially available. One study found that for each 11% decrease in grip strength, there was a 17% increased risk of death from heart disease. Another study showed that in men and women aged 60 and over, reduced grip strength was also associated with reduced mobility, functional status and cognitive function.

A third study of 500,000 men and women conducted in the United Kingdom also found reduced grip strength to be associated with a 15-30% higher risk of lung and heart disease as well as certain cancers (breast, colon, lung) over the 7 year follow-up period.  Finally, a more recent UK study in 68,000 middle aged men and women (average age, 63.8 years) found greater grip strength to be associated with a diet enriched in omega-3 fats (oily fish such as salmon and sardines) and magnesium (greens, nuts, seeds, whole grains, dark chocolate).

Listed below are several other physical signs that provide important clues when it comes to increased risk of cardiovascular disease.

1. Progressive skin tanning: In the absence of sun exposure, progressive skin tanning may be indicative of acquired hemochromatosis, a condition of iron overload due to excessive intake of iron or multiple blood transfusions.  In this condition tanning may be seen throughout the body, including the face and upper eyelids. Affected individuals should avoid Vitamin C supplementation because of increased iron availability that in turn, may promote disease progression.
2. Bilateral carpel tunnel syndrome:  While carpel tunnel syndrome can occur with repetitive motion/ overuse of a wrist such as from continuous typing/surfing the internet, the development of carpel tunnel syndrome in both hands especially in the absence of repetitive motion/overuse may be due to transthyretin cardiac (hATTR) amyloidosis. This disorder results from the accumulation of abnormal (amyloid) proteins that deposit in various organs and tissues.  Fortunately, treatment is now available for this condition.
3. Blueish Tint of Eye Whites (sclera): In adults, the appearance of blue sclera may be indicative of Ehlers Danlos Syndrome, a connective tissue disorder characterized by joint hypermobility (“double jointed”), skin that is easily stretchable (and susceptible to bruising) and heart involvement (e.g., aortic dilation).
4. Brown discoloration on Neck and Armpits: Also known as Acanthosis Nigricans, dark velvety patches occur in the back of the neck, below the breasts, armpits and groin regions that occur in association with insulin resistance, metabolic syndrome and diabetes.
5. Premature Graying and Baldness: A study of nearly 1400 young men (under age 40) from South Asia found that premature thinning or graying of hair was also associated with a 5-6 fold increased likelihood of premature heart disease.
6. Poor Dentition: A recent study found that spending less than 2 minutes tooth brushing twice daily was associated with a greater than 2-fold increased risk of poor vascular health (as measured by endothelial function).
7. Painful Mouth Sores: Consider Behcet’s disease in someone with a history of recurrent (painful) mouth sores and new onset heart failure.
8. Large Tongue: In addition to amyloid, a large tongue (macroglossia) may be observed with an underactive thyroid (hypothyroidism) especially when accompanied by high levels of (LDL) cholesterol.
9. Split Uvula: A split or bifid uvula is seen in the Loeys-Dietz Syndrome, a disorder affecting connective tissue and associated with aortic enlargement/dissection. The disorder is named after Dr. Bart Loeys and my colleague, Dr. Hal Dietz.
10. Yellowish-Orange Tonsils: Yellowish-orange tonsils is a classic feature of Tangier Disease, a disorder characterized by extremely low levels (e.g., less than 10 mg/dL) of HDL (the good cholesterol).
11. Nodules on the legs: Clues to the diagnosis of sarcoidosis are tender raised reddish bumps (nodules) on the front of the lower legs (Erythema nodosum) combined with heart-related symptoms such as palpitations, dizziness or progressive shortness of breath.
12. Itchy Rash on Chest, Back & Arms:  Very high levels of triglycerides (e.g., greater than 1000 mg/dL) may be associated with a yellowish-red (papular) rash on the chest, back and arms and is often due to poorly controlled diabetes.

Dr. Michael Miller is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore, Maryland.  Check him out on twitter: @mmillermd1

 

Did You Hear That? If Not, Blame it on Your Heart

As we age, the loss of high frequency sounds becomes a common sign of hearing impairment due to degenerative changes in the inner ear.  High frequency hearing loss is common in the U.S. (~1 in 5 adult men and women are affected) and the classic sign is a decreased ability to hear high pitched sounds (voices of children/women) as well as to decipher conversations in a crowded room.  Loss of low frequency sounds (voices of men, thunder, bass) is less common but is also an important cause of hearing loss.

A study from the Yale School of Medicine suggests that having a history of cardiovascular disease or at least 1 cardiovascular risk factor (diabetes, high blood pressure, history of smoking) also raises the risk of both high and low frequency hearing loss.

Bottom Line: While heart related risk factors may promote hearing loss, it still remains to be determined whether intensive management of these risk factors delays progression of this process.

Listed below are some tips related to hearing and cardiovascular health

1. High frequency hearing loss is common in patients with diabetes (Type 1 and Type 2) due to disease of small blood vessels of the (cochlear) inner ear.
2. Treatment of high cholesterol with statins has been shown to improve tinnitus (ringing of the ears).
3. In a study of 274 men and women aged 45-64 years, hearing loss was 2-fold greater among those with hypertension (140/90 or higher) than with normal blood pressure.
4. A study conducted in Korea found that obese men and women with elevated cholesterol and triglyceride levels were at increased risk of high frequency hearing loss.
5. Data from the Nurses’ Health Study found that women who consumed 2-4 fish meals per week experienced a 20% lower likelihood of hearing loss compared to women who consumed less than 1 fish meal per month over the 18-year followup period.
6. Cigarette smoking cessation eliminates the excess risk of hearing loss within 5-years of quitting.

Dr. Michael Miller is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore, Maryland. 

EPA versus EPA/DHA: What Have Clinical Trials Taught Us?

Our new review paper out this week entitled “A Fishy Topic: VITAL, REDUCE-IT, STRENGTH and Beyond; Putting Omega-3 Fatty Acids into Practice in 2021” was designed to reduce the confusion surrounding the use of the marine derived omega 3 fatty acids, EPA (eiscosapentanoic acid) and DHA (docosahexanoic acid).  Coincidentally, this paper compliments last week’s publication in the Lancet journal, EClinical Medicine entitled, “Effect of omega-3 fatty acids on cardiovascular outcomes: A systematic review and meta-analysis” led by my colleagues,  Drs. Safi Khan and Deepak Bhatt and showing that EPA but not the combination of EPA+DHA was associated with reduced risk of cardiovascular events such as heart attacks, strokes and heart related death (see Figure).

As both EPA and DHA are extracted from oily fish including salmon, sardines, anchovies and herring and both lower triglycerides to a similar degree, why have clinical trials using EPA compared to EPA+DHA shown contrasting results?   Elegant work from Dr. Preston Mason and his co-workers have provided important insights at the cellular level demonstrating that EPA possesses cardioprotective anti-inflammatory, anti-oxidant, endothelial normalizing and membrane stabilizing properties that become suppressed in the presence of DHA.  Thus while DHA plays a pivotal role in brain growth and development, clinical trials to date have not borne out similar benefits with respect to cardioprotection.

I’ve been intrigued with EPA for more that a quarter century after we first observed dramatic differences in the way EPA was processed into cellular lipids when compared to prototypic saturated and monounsaturated fatty acids.   As differences between EPA, DHA and other fatty acids continue to emerge, listed below are a series of highlights related to the intake of these fats whether as a supplement or in medicinal form.

1. Dietary supplements such as “fish oil” capsules are NOT regulated by the FDA and should not be viewed in the same context as OTC products (such as Advil) that are regulated.
2. Fish oil capsules, a dietary supplement not regulated by the FDA, has been shown to contain a number of impurities such as saturated fat and oxidized lipids that impair its effectiveness.
3. EPA but not DHA exhibits heart protective antioxidant, anti-inflammatory and membrane/plaque stabilizing properties that help to reduce the risk of cardiovascular disease.
4. In the MESA study, higher blood levels of OM3 (inclusive of EPA) were associated with reduced risk of hospitalization for bleeding events.
5. In the REDUCE-IT USA study, 4 grams of Icosapent ethyl, the prescription form of highly purified EPA, was associated with a 30% reduction of death from all causes.
6. In the REDUCE-IT trial, total primary events (cardiovascular death, heart attack stroke, stent placement, bypass surgery or hospitalization for unstable angina) were reduced by 30%.

Dr. Michael Miller is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore,MD.  He is a Scientific Advisor for Amarin, Corp. and Steering Committee Member of the REDUCE-IT trial.  Dr. Miller is also the author of several books; including his most recent,  “Heal Your Heart…“

Reel in Your Migraines with “Brain Food”

As kids, many of us were told to eat our fish because it was “brain food”. Evolutionarily speaking, expansion of early human (hominid) brains occurred with consumption of aquatic animals (turtles, crocodiles) with further brain maturation/development accelerating as Homo sapiens migrated to coastal regions.  Now, in addition to serving as brain food, a new study suggests that consuming fish may also relieve migraine headaches.

The study, supported by the National Institutes of Health and published in the British Medical Journal, found that a diet enriched with omega-3 fatty acids (predominantly fish and shellfish) and low in linoleic acid (as derived from vegetable oils) reduced the frequency and intensity of migraine headaches by ~1/3 over the 4-month study period.  Potential mechanisms for these benefits include anti-inflammatory and pain-relieving properties from compounds (oxylipids) released by the omega-3’s, EPA and DHA coupled with pro-inflammatory properties associated with linoleic acid.

Bottom Line: if you have a history of migraines, try enriching your diet with omega-3 containing fish (e.g., salmon, sardines, herring) while reducing products high in linoleic acid (e.g., sunflower, corn, hempseed oil).

Listed below are additional health benefits attained through fish consumption.

1. An Australian study found that men and women aged 50 and older who consumed 2 or more fish meals each week experienced  a 40% lower likelihood of hearing loss over the 5-7 year follow-up period.
2. Parvalbumin, a protein enriched in carp, cod, herring and redfish has been shown to prevent the buildup of proteins associated with Parkinson’s disease.
3. A study from the United Kingdom found that addition of 6 ounces of fatty fish daily (salmon, sardines, kipper and herring) for 6 weeks was associated with improvement in long-standing psoriasis.
4. A Norwegian study found that fish consumption at least once weekly was associated with a lower risk of the Metabolic Syndrome.
5. A Swedish study in school children found that fish eaten at least once a week was associated with greater academic achievement than no fish consumption.

For other posts on this topic check out:

https://wp.me/p6flfR-152 and https://wp.me/p6flfR-14Q

Dr. Michael Miller, is Professor of Medicine at the University of Maryland School of Medicine in Baltimore, and author of several books, including his most recent “Heal Your Heart“.

Are the Benefits of Omega 3’s Outweighed by Potential Side Effects?

In last week’s post, I highlighted differences between two omega 3 preparations, 1) purified EPA (Icosapent ethyl) and 2) combination of EPA/DHA as it relates to the risk of heart disease.

This past week we published a new study that examines the association between blood levels of omega 3 -fatty acids and the risk of major side effects (bleeding and atrial fibrillation).   Led by my colleagues Drs. Karan Kapoor and Michael Blaha, the study was designed to determine the extent to which these side effects might occur in participants of MESA (Multi-Ethnic Study of Atherosclerosis), a national study of men and women being monitored for the development of heart related events over a multi-year period.

Decades earlier, Danish physicians Jørn Dyerberg and Hans O. Bang reported that heart disease was rare but bleeding risk increased among Greenlandic Eskimos that they proposed was due to their high consumption of EPA from whale blubber, herring and other omega-3 enriched fish. These studies gained worldwide attention and laid the foundation for the hypothesis that omega-3 supplementation intake might reduce the risk of heart disease.

As an aside, I had the opportunity to meet Dr. Dyerberg when I presented some of our earlier work on triglycerides and heart disease at the International Society for the Study of Fatty Acids and Lipids in Lyon, France in 1998.

And although an increased risk of abnormal heart rhythms was not reported in Greenlandic Eskimos, two recent clinical trials that used high doses of purified EPA (REDUCE IT) or the combination of EPA/DHA (STRENGTH) identified an increased risk of atrial fibrillation.

Back to our study, not only was there a significantly lower (rather than higher) risk of major bleeding in men and women participants from MESA, but also the risk of atrial fibrillation was not increased.

Bottom Line: Adding omega 3 containing fish to your diet in place of saturated animal fat, is heart healthy- based on our current study it is also safe from major bleeding complications and atrial fibrillation. Purified EPA (Icosapent ethyl) as used in the REDUCE-IT study lowered the risk of cardiovascular events. Even though atrial fibrillation was slightly increased in REDUCE-IT, stroke rates-a primary complication of afib- were decreased.

Below are additional reasons why adding omega-3’s to your diet may improve overall health.

1. We recently found supplementation with Icosapent ethyl to maintain bone mineral health in men and women with the Metabolic Syndrome.
2. For each 1 serving per week increase in fish consumption, there is an approximate 7% lower risk of Alzheimer’s disease.
3. Eating salmon 3x weekly may lower blood pressure by 3-5 mmHg.
4. Consumption of fatty fish improves tear production and symptoms related to dry eyes.
5. Adding 1.5 grams of omega-3 fatty acids daily is associated with reduced mental stress and anxiety.
6. High blood levels of omega-3 fatty acids is associated with a trend towards reduced death from COVID-19.
7. In men and women with heart failure, the addition of 1 gram of omega-3 fatty acids may reduce the risk of re-hospitalization for heart failure.

Michael Miller, MD is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore, Maryland and author of  “Heal Your Heart….”: published by Penguin Random House.  He served on the International Steering Committee for the REDUCE-IT trial.

Fishing for the Truth…Omega 3’s & your Heart

This past week, the American College of Cardiology’s (ACC) virtual scientific sessions included several presentations that centered around the relationship between the omega 3’s, EPA and DHA and the risk of heart disease.

Before discussing the contentious omega 3 study presented, let me provide a brief historical overview that has led to the current controversy and stems from multiple studies demonstrating heart-related benefits with purified EPA but not with the combination of EPA and DHA.

On the one hand, one might have thought that EPA (eicosapentanoic acid) and DHA (docosahexanoic acid) would behave in a similar manner when it comes to heart protection. After all, eating fish containing EPA and DHA has been shown to be cardioprotective, especially when these polyunsaturated fats replace other animal based saturated fat.  In addition, EPA and DHA reduce high triglyceride (fat) levels associated with elevated cardiovascular risk.

To date, however, all studies testing purified EPA have shown favorable results.  The first study, entitled JELIS (click here for details) was a Japanese study that found purified EPA to be associated with an approximate 20% reduction in initial and recurrent heart attack events.  At the time, many of us were surprised by these results because we did not expect such a robust benefit in a population that already consumes an EPA enriched fish on a regular basis.

Then a second study, entitled REDUCE-IT (click here for details) tested another purified EPA compound (icosapent ethyl) in men and women with high triglycerides and established heart disease or at high risk of a heart attack/stroke (due to a history of diabetes/other risk factors).

REDUCE-IT was embraced by the cardiology community because of the impressive results seen, namely a 25% reduction in heart-related events.  Two additional studies known as EVAPORATE (click here for details) and CHERRY (click here for details) provided further evidence of benefit with purified EPA that included less plaque buildup in coronary arteries.

But what about studies testing purified DHA to prevent heart disease?  Surprisingly, they don’t exist.  Instead, studies assessing DHA have traditionally incorporated EPA and this combination has repeatedly failed to demonstrate cardiovascular benefit.  Among the criticisms voiced for the consistent negative results were the relatively low doses of EPA/DHA used and the lack of testing a population with high triglycerides.

To address these limitations, the STRENGTH study was undertaken (click here for details).  This was a well conducted study that tested men and women with high triglycerides and used sufficiently high doses of EPA/DHA to lower triglycerides.   Unfortunately and like its EPA/DHA predecessors, results of this study were disappointingly neutral with no reduction in cardiovascular events observed.

In other words, all studies to date using purified EPA have shown benefit whereas all studies using the combination of EPA/DHA have not.  In fact, pioneering research by my friend and colleague, Dr. Preston Mason has found opposing effects between EPA and DHA, with EPA exhibiting anti-inflammatory, anti-oxidant and other heart protective properties whereas DHA appears to mitigate these as effects.  Dr. Mason’s groundbreaking research (summarized here) provides the basis for what has been confirmed in clinical trials, namely, that EPA benefits the heart whereas DHA blunts/attenuates these effects.

To return to last week’s ACC meetings, a sub-study from STRENGTH found no benefit in those subjects who achieved the highest blood levels of EPA in the trial.  While these results might appear to directly contradict that of REDUCE IT, it turns out that EPA and DHA were significantly correlated with each other.  In other words, patients with the highest levels of EPA were also more likely to exhibit high, if not the highest levels of DHA.  As we have seen time and again, DHA and EPA don’t mix well when it comes to optimizing heart health because based on current evidence, DHA offsets the benefits of EPA.

Food for thought: If a bar of gold were contaminated with other metals/alloys, would it still be worth its weight in gold?

As we reel in highlights related to Omega-3’s and your heart, remember these:

1. Omega-3 supplements containing EPA and DHA have not been shown to reduce the risk of a heart attack or stroke.
2. The prescription form of purified EPA (Icosapent ethyl) reduced heart attacks, strokes & cardiovascular death by 25% in men and women with high triglycerides (135 mg/dL or greater) and elevated heart disease risk.
3. For each gram of omega-3 fatty acids consumed, triglyceride levels are reduced 8-10%.
4. Fish with a high content of omega-3s are anchovies, herring, mackerel, salmon & sardines.
5. Replacement of animal based saturated fat with plant/fish based polyunsaturated fat reduces the risk of heart disease by nearly 30%!
6. Excellent sources of plant-based omega-3’s include chia seeds, flaxseeds, soybeans and walnuts.
7. Compared to a diet high in saturated animal fats, a diet enriched in plant and fish based omega-3s is associated with a lower risk of heart disease.

Michael Miller, MD is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore, Maryland and author of  “Heal Your Heart….”: published by Penguin Random House.  He served on the International Steering Committee for the REDUCE-IT trial.