Eskimos, Fish Oils and EPA Deniers


Eskimos: More than half a century ago, Danish researchers Bang and Dyerberg made the astute discovery that Eskimos residing in the Danish territory of Greenland experienced a much lower rate of coronary heart disease than Europeans living in Denmark.  As Eskimos consumed high amounts of marine derived omega-3 fatty acids from whale blubber (see photo above), salmon and other fish, they reasoned that the low incidence of myocardial infarction was due to a diet enriched in EPA. 

As it turns out, Bang and Dyerberg were right! 

With the results of RESPECT-EPA presented at last week’s American Heart Association Scientific Sessions, we now have 4 clinical outcome trials and 2 arteriographic studies pointing in the same direction; simply stated, purified EPA reduces coronary (CAD) events, arteriographic CAD progression and overall cardiovascular risk.  Whether studies included patients in primary prevention, secondary prevention or post-ACS, they have generated reproducible results in favor of EPA therapy. In effect, icosapent ethyl the purified form of EPA (marketed in the U.S. as Vascepa, the abbreviated form of Vascular EPA) is currently indicated for patients with high triglycerides (HTG) and CAD or for Type 2 diabetes mellitus (T2DM) with additional CAD risk factors.    Now admittedly, RESPECT-EPA had shortcomings that included an open-label design and was underpowered (low event rates/high early withdrawal rates) that would not have garnered significant attention despite the 22% reduction in the primary endpoint (cardiovascular [CV] death, nonfatal myocardial infarction, nonfatal stroke, revascularization and unstable angina requiring hospitalization) (p=0.054) and 27% reduction in the secondary endpoint (CAD events, stroke and mortality) (P=0.03) in Japanese patients with stable CAD assigned to 1.8 grams of EPA daily. However, when RESPECT-EPA is placed within the context of other EPA based studies, there is a clear and consistent trend of improved cardiovascular risk.  These results are directionally aligned with the much larger REDUCE-IT trial that used 4 grams daily of highly purified icosapent ethyl (IPE) in men and women with elevated triglycerides and CAD or T2DM that resulted in 25% and 26% reductions in the primary and secondary endpoints, respectively (P< 0.0001; P< 0.0001).  In the earlier JELIS study of nearly 20,000 Japanese patients with elevated cholesterol there was an overall 19% reduction in risk of coronary events (p=0.011).  Finally in the study by Nosaka and colleagues, assignment to 1.8 grams EPA within 24 hours following percutaneous coronary intervention in the setting of an acute coronary syndrome was associated with a 58% reduction in cardiac events during the 1-year follow-up period (P=0.02).  Two angiographic studies CHERRY and EVAPORATE further demonstrated reduced atherosclerotic progression when EPA was added to statin therapy.   

Taken together, ALL 6 EPA trials demonstrate improvement in cardiovascular risk.

Fish Oils: In contrast to EPA only studies, the use of fish oils, most commonly a combination of EPA/DHA has not been successful in lowering CV risk. Some have suggested that the daily dose of fish oils used was too low (e.g., 1 gram daily), thereby limiting the rise of circulating EPA levels (that many believe to be the primary basis for the CV benefits)  and/or did not test a sufficiently high-risk study population.  Nonetheless, the STRENGTH study that used 4 grams of fish oil daily in a high-risk population (HTG and CAD/CAD risk factors) also failed to demonstrate benefit.  So why have EPA-only but not EPA/DHA studies improve cardiovascular risk? In this regard, basic science investigations led by my colleague, Dr. Preston Mason has repeatedly shown that DHA offsets favorable actions of EPA (e.g., cellular inflammation, oxidative stress, etc).  Does this mean that we should recommend avoiding DHA containing foods?  That would not be my recommendation because DHA is 1) vital for brain growth and development (most pronounced during the first 5 years of life) and 2) cardioprotective marine-derived fish contain both EPA/DHA. Thus, while we don’t recommend discontinuing fish consumption, we do  recommend purified EPA for our high-risk patients based upon REDUCE-IT inclusion criteria.

Supplements: The most common dietary supplements in the U.S. are fish oil derived. Unfortunately, while the FDA regulates over-the-counter (OTC) drugs, they do not regulate dietary supplements because they are considered food derived products.  Not only are fish oil supplements ineffective in reducing cardiovascular risk but they may also contain contaminants such as atherogenic saturated fatty acids.  Hence, we do not recommend fish oil supplements and would be very wary of any physician/health care professional who does…even if/especially if they run for Congress!

EPA Deniers: EPA deniers have found a variety of reasons to minimize the fact that purified EPA is highly effective.  For one, they point to the open label design (as is customary in Japan) even though both REDUCE-IT and EVAPORATE drew similar/positive conclusions using placebo-controlled groups.  Then they will complain that the CV benefit was not due to EPA per se, but rather the mineral oil placebo group that inflicted damage and accelerated CVD events due to LDL-C and hs-CRP elevations.  Surely if this were the case, placebo-treated subjects with the highest on-treatment LDL-C or hs-CRP levels would have markedly greater CVD event rates than placebo treated patients without such elevation.  However, that line of reasoning was faulty because there were no differences in CVD events irrespective of on-treatment LDL-C or hsCRP in the mineral oil group. In fact, IPE reduced CVD events similarly in these groups.  Finally, they will extol that mineral oil caused such severe increases in inflammatory biomarkers that that must have been the reason for the success of REDUCE-IT.  Yes, it is true that the mineral oil group evidenced increases in biomarkers that included a 28.9% increase in interleukin-1β (0.06 to 0.08 pg/ml) and 16.2% increase in interleukin-6 (3.27 to 3.76 pg/ml) after 1 year.  On the surface this appears to be problematic until the normal range is revealed: interleukin-1β (0.5-12 pg/ml), interleukin-6 (0-43.5 pg/ml). In other words, while there were statistically significant increases in these levels, they were still within the normal range! One is certainly hard-pressed in this case to equate statistical significance with clinical relevance.  Hence, the modest effects of mineral oil can in no way account for the sizeable benefits observed in REDUCE-IT, a fact corroborated by the FDA upon issuing their approval indications for IPE in 2019 following unanimous agreement of the scientific advisory team.   

Moving forward, let’s direct our focus towards optimizing lipid lowering treatment for our patients at highest CVD risk.  The proof is in the pudding when it comes to LDL-C lowering (statins/ezetimibe/PCSK9 inhibitors) and TG lowering (icosapent ethyl) and our patients should receive these therapies as indicated.  We await novel therapies currently in clinical trial testing that may provide incremental risk reduction to benefit our patients.

Michael Miller, MD is a cardiologist and Chief of Medicine at the Corporal Michael J Crescenz VA Medical Center and Vice Chair of Medicine at the Hospital of the University of Pennsylvania. Dr. Miller is Scientific Advisor to Amarin, Inc and 89bio. Prior to his arrival in Philadelphia, he was Professor of Cardiovascular Medicine, Epidemiology and Public Health at the University of Maryland School of Medicine. He is the author of numerous scientific publications and several books, including Heal Your Heart published by Penguin Random House. Check him out on twitter: @mmillermd1

More Feathers in the Cap of Icosapent Ethyl


I am reminded of my late mentor, Dr. Peter O. Kwiterovich, Jr. who used to say when we published new research findings that “this is another feather in your cap”! Well, this expression could not be truer than what we have been witnessing with icosapent ethyl (IPE), the highly purified omega-3 fatty acid, EPA. First there was the landmark study, REDUCE-IT where IPE reduced the risk of cardiovascular death, heart attack, stroke, bypass/stent placement and rehospitalization for unstable by an astounding 25% in statin treated men and women with high triglycerides and cardiovascular risk. To date, IPE remains the best treatment for patients at similar underlying risk.

Last week, 2 new feathers were added to the IPE cap during presentations at the European Society of Cardiology (ESC), one of medicine’s premier international meetings. The first paper presented by my colleague, Dr. Deepak Bhatt found IPE to reduce the risk of the 2 types of heart attacks (ST and non-ST elevation) by 40% and 27%, respectively. The second feather was the result of another analysis showing that IPE eradicated the excess risk of cardiovascular events attributable to cigarette smoking; the manuscript is published in the European Heart Journal Cardiovascular Pharmacotherapy. For a comprehensive review of other IPE “feathers”, check out the excellent new review by Dr. Prakriti Gaba published in JCL.

During an ESC presentation, the prominent Danish Professor and Lipid Expert, Dr. Borge Nordestgaard, commented to me that every analysis performed for IPE has shown strikingly positive results. Could the reason for IPEs success be that the compound has unique characteristics that other fatty acids don’t? In fact, my colleague Dr. Preston Mason has performed a number of elegant studies demonstrating that to be the case. Specifically, IPE reduces inflammation and oxidative stress while improving endothelial function.

You certainly don’t have to convince me that IPE acts different fatty acids. Decades ago, we examined the role of purified EPA in human cells and found favorable effects that were not observed with other fatty acids- perhaps a presage of good things to come for IPE.

Michael Miller, MD is a cardiologist and Chief of Medicine at the Corporal Michael J Crescenz VA Medical Center and Vice Chair of Medicine at the Hospital of the University of Pennsylvania. Prior to his arrival in Philadelphia, he was Professor of Cardiovascular Medicine, Epidemiology and Public Health at the University of Maryland School of Medicine. He is the author of numerous scientific publications and several books, including Heal Your Heart published by Penguin Random House. Check him out on twitter: @mmillermd1

When Athletes and Physicians Promoted Smoking!


It’s hard to believe that not too long ago, revered athletes like Mickey Mantle and even our medical community promoted cigarette smoking! Yet despite the numerous bans, beginning with the cessation of Ads on TV (January 2, 1971), Billboard Ads (April, 1999) and most recently, the FDA’s process to ban JUUL cigarettes, smoking continues to be the #1 most preventable cause of heart disease.

Notwithstanding the cutback/elimination of advertising, nearly 8 million yearly deaths continue to be attributed to cigarettes worldwide; in the U.S., 500,000 tobacco related cardiovascular deaths are anticipated in 2022.

A recent review by the American Heart Association found that compared to non-smokers, tobacco use was associated with the development of heart disease at an earlier age in men and women aged 40-59 years, (5 and 4 years in men and women, respectively). In fact, middle-aged women without a history of heart disease who smoked, doubled their risk of sudden death; in middle-aged men, the risk was increased by 80%. Smoking also increased the risk of stroke in young men and women (less than 40 years of age) and heart failure in middle and older aged men and women.

Today, more than 34 million adults in the United States continue to smoke cigarettes. While these numbers are undoubtedly lower than during the era of incessant tobacco advertising campaigns, the ravaging, long-term health consequences attributable to daily tobacco use persists.

Unfortunately, in the absence of successful smoking cessation efforts, effective therapies to reduce tobacco related cardiac events are highly limited. I can think of 2 (statins and aspirin). Wouldn’t it be nice if there were other treatments available/associated with reduced risk?

Michael Miller, MD is a cardiologist and Chief of Medicine at the Corporal Michael J Crescenz VA Medical Center and Vice Chair of Medicine at the Hospital of the University of Pennsylvania. Prior to his arrival in Philadelphia, he was Professor of Cardiovascular Medicine, Epidemiology and Public Health at the University of Maryland School of Medicine. He is the author of numerous scientific publications and several books, including Heal Your Heart published by Penguin Random House. Check him out on twitter: @mmillermd1

30 Years of Heart-Related Discoveries/Advances at the University of Maryland School of Medicine

cholesterol, Diabetes, dietary fat, fish consumption, Health & Wellness, heart disease prevention, laughter, Uncategorized

As my 30-plus years as a faculty member at the University of Maryland School of Medicine and Medical Center has drawn to a close, I fondly recall 10 heart-related findings/discoveries and newsworthy events that gained worldwide attention, ending with the first genetically altered pig heart transplanted at UMMS last week.  Here they are in no special order.

1.         Poe likely died of rabies, doctor’s review shows:

2.         Having high cholesterol levels early in life leads to heart problems by middle age:

3.         Air Pollution and Diabetes:’ve%20long%20known%20that,fatty%20diet%20can%20promote%20diabetes.

4. U.S. Amish gene trait may inspire heart protection:

5.         Want a McMuffin? Take your McVitamins:

6.         UMMC Implants the World’s Smallest Pacemaker:

7.         University Of Maryland School of Medicine Study Shows Laughter Helps Blood Vessels Function Better:

8.         Study finds no value in heart supplement: CoQ10 not shown to relieve symptoms, UM cardiologist says:

9.         Secondhand Smoke Ups Heart Disease in Unique Group of Female Nonsmokers – Amish Women:

10.       In a First, Man Receives a Heart from a Genetically Altered Pig

Dr. Michael Miller is Chief of Medicine, Corporal Michael J Crescenz VAMC in Philadelphia, PA   Check him out on twitter: @mmillermd1

On Babe Ruth, Hobbies and the Heart


As we get set to leave Baltimore for Philadelphia, I can’t help but reminisce of the great friendships and memories made in “Charm City”.   As a baseball enthusiast, moving to Baltimore in the mid-80s brought me an even greater appreciation of GH (Babe) Ruth, the hometown hero and legendary “Sultan of Swat”.  Over the past several decades, my hobby of collecting baseball memorabilia rose to a new depth as I pursued Ruth-related collectibles.  Of the 7 baseball cards illustrated, 5 are of the Bambino himself (from the 1933 Goudey and 1948 Leaf set), 1 is of his teammate, Lou Gehrig (1934 Goudey) and on the upper right, is the 1909 T-206 Ty Cobb (green background) acquired from the estate of Babe Ruth’s cousin shortly after my move to Baltimore from Cincinnati.   

It is no surprise that we commonly refer to Baltimore as “Small”-timore because there are so many interconnections…in the case of Babe Ruth, I pass by his birth home nearly every day as the University of Maryland Hospital is just a block away.  Ironically and many decades earlier, my wife’s family (generations of native Baltimoreans) at one time owned the pub where Babe Ruth’s father was employed (currently the centerfield area of Camden Yards).  Even our 13-year-old cockapoo is aptly named “George Herman”!

Listed below are reasons to engage in a hobby that is appealing to you.

  1. Hobbies have a positive impact on the heart by improving psychological health.  Studies have shown that psychological health is an important component of wellness/well-being for patients at risk of heart disease (CVD).
  2. A recent study in spouses who were caregivers of patients with Alzheimer’s disease found that participation in pleasant leisure activities was associated with improvement in cardiovascular risk factors such as blood pressure and emotional stress.
  3. Engagement in a variety of art forms (2 hours each week) such as the performing arts, visual arts and literature is associated with better emotional and heart health (improved heart rate variability).
  4. A study conducted in Pittsburgh found that engaging in enjoyable activities was associated with lower blood pressure, stress hormone (cortisol) levels, waist circumference, and body mass index as well as a better overall perception of physical function.
  5. A study of 4,200 Swedes aged 60 and over found that gardening and do-it-yourself projects to be associated with a 25-30% lower risk of heart attack, stroke or death from cardiovascular disease over a 12 year follow-up period.
  6. Enjoyment of a hobby is associated with an 8-fold lower risk of future cardiovascular events such as heart attack or stroke due to improvement in vascular health.
  7. A newly published study conducted in Japan over a 16-year follow-up period found that compared to those that have no hobbies, engaging in 1 or multiple hobbies was associated with a 10-20% lower risk of cardiovascular events.
  8. Engagement in activities such as jigsaw and crossword puzzles reduce stress hormone (cortisol) levels; a recent study found that elevated levels of urinary cortisol predates the development of hypertension.

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

audiology, blood pressure, cholesterol, Diabetes, fish consumption, Hearing, Heart Health, Nutrition, omega 3's, Uncategorized

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. 

“Go with your Gut”: Unlocking Secrets of Centenarians

Brain Health, centenarians, gut microbes, Health & Wellness, heart disease, Heart Health, Nutrition, Uncategorized

Despite the ravages bestowed by COVID-19, more than 500,000 men and women worldwide have attained centenarian status (living to 100 years and beyond), including nearly 100,000 residing in the U.S.  Among this special group was my beloved father-in-law, Paul Miller, who taught math for 80 years and lived to the ripe young age of 104!

Many of us both inside/outside the medical profession find these individuals to be awe inspiring especially when they are still in relatively good physical and mental health upon reaching this major milestone. While we appreciate that exceptional longevity may be more heavily concentrated in a “Blue Zone“, the overwhelming majority of centenarians do not live in these regions.  In fact, there are nearly 2,000 centenarians living in the great (though non-Blue Zone U.S.) state of Maryland!

Now a new study published in the prestigious journal, Nature, is assisting scientific efforts toward unlocking secrets for healthy aging and longevity.  The study conducted in Japan, found that centenarians had high levels of protective gut byproducts.  Also known as isoalloLCA, these secondary bile acids, contribute to gut health by inhibiting gut bacteria that promote inflammation and disease (such as C. difficile). While a cause-effect relationship between protective gut byproducts and longevity has yet to be established, this study is an important step in furthering our understanding of the relationship between gut and overall health.

Listed below are other secrets to enhance the likelihood of healthy longevity.

  1. Keep Saturated Animal Fats at BayA study that we conducted with Dr. Stan Hazen and colleagues at the Cleveland Clinic found that a low fat Ornish diet was associated with reduced levels of the gut byproduct TMAO compared to a high saturated fat Atkins diet.  High levels of TMAO are associated with an increased risk of heart disease.
  2. Think Positively about Aging: A study from the Yale School of Public Health found that older men and women who were genetic carriers of a gene that promotes dementia (APOE4 variant) were 50% less likely to develop dementia if they felt positively about the aging process.
  3. Be Resilient: In a study of centenarians from Georgia and Japan, personality traits included a high degree of resiliency as characterized by high levels of openness and extraversion and low levels of hostility and neuroticism.
  4. Have a Sense of Humor:Jeanne Louise Calment, the world’s oldest woman who died at age 122, credited her sense of humor for successful aging. In fact, a 15-year study from Norway found that women with a strong sense of humor experienced a nearly 50% higher survival rate compared to those lacking a sense of humor even with pre-existing heart disease or other chronic ailments.
  5. Engage in Mentally Stimulating Activities: A Mayo clinic study found that participating in 3 mentally stimulating activities such as reading books, craft activities (e.g., quilting, or sewing) or playing card games/doing crossword puzzles ~age 70 was associated with a 45% reduction in cognitive decline over the subsequent 5 years.
  6. Volunteer: Volunteering, especially over age 60 is associated with meaningfully positive effects on health and overall well-being.

Dr. Michael Miller is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore, Maryland.  Check out his updated author page on Amazon.




Move over Wheaties: The New Breakfast of Champions is…

chocolate, Gut Health, Health & Wellness, Nutrition, Uncategorized

It’s been nearly a century since Wheaties featured Lou Gehrig as the first of many star athletes to grace the cereal box cover and represent “the breakfast of Champions”.   While Wheaties continues to have its fair share of dedicated breakfast fans, a new study suggests that at least from a heart health perspective another food source rises to the top when it comes to the breakfast of champions.  No, I am not referring to cheerios, oatmeal or egg white omelettes.

In fact, this breakfast is not only decadent and mood uplifting but also lowers blood glucose and burns fat.  And the answer is….chocolate!

In the new study conducted in Spain, female volunteers were assigned to consume 3.5 ounces (100 grams), the size of an average bar of milk chocolate.  Beyond their typical food intake, the women were randomly assigned to complete 3 phases; no chocolate phase, chocolate for breakfast phase or chocolate for dinner phase.

The results found that despite the additional ~500 calories from chocolate, there was surprisingly no weight gain when chocolate was added to breakfast.  In fact,  300 fewer calories were consumed on average per day with shrinkage of waist size and reduced cortisol (stress) levels.  Eating chocolate in the morning was also associated with 4.4% decrease in fasting blood glucose levels (by slowing carb digestion) and increased concentration of powerful antioxidants, such as epicatechins.

Bottom line: Women who ate the equivalent of a bar of milk chocolate for breakfast were less hungry throughout the day and consumed less fat and carbs. In addition, the compound theobromine derived from cacao beans, is thought to have contributed to the increased fat breakdown (oxidation) and smaller waist circumference provided that the chocolate was consumed within 1 hour of awakening.  If these benefits were derived with milk chocolate, imagine what a dark chocolate breakfast can do for you!

Listed below are more reasons to start your day with chocolate, the (new) breakfast of champions!

  1. Reduces Cholesterol: Combining dark chocolate with almonds and cocoa powder reduces LDL cholesterol; lower LDL is associated with lower risk of heart disease. 
  2. Affects Platelet Function: Casual consumption of chocolate was shown to reduce platelet clumping (aggregation).  These antiplatelet effects contribute to the reduction in heart disease associated with consumption of flavanol-enriched foods.
  3. Lowers Blood Pressure: The equivalent of 30 calories of dark chocolate (1 Hershey’s dark chocolate kiss) was shown to lower blood pressure. This is due to  blood vessel dilation and improvement in endothelial function (nitric-oxide mediated).
  4. Improves Memory: Consuming a drink containing cocoa flavanols improves memory and reduces several measures of age-related cognitive decline.  As a rich source of cocoa flavanols, not only do I add CocoaVia to my morning coffee but I recommend the same for my patients.

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: The Positive Emotions Prescription to Prevent and Reverse Heart Disease.”: published by Penguin Random House.



More Justification to Enjoy Java in June

Coffee, Health & Wellness, heart disease, Heart Health, Uncategorized

Several new studies out this year continue to point in a favorable direction when it comes to your morning (and afternoon) cup of java as it related to cardiovascular health.  The first study analyzed coffee drinking in more than 20,000 men and women in the U.S. and found that compared to non-consumers, drinking 2 cups of caffeinated coffee daily correlated with a 31% lower risk of developing heart failure.  Although the specific mechanism(s) underlying this effect has yet to be established, coffee is a rich source of antioxidants such as polyphenols that may in turn limit/prevent cell damage and minimize adverse changes to heart function over time for those who regularly consume this beverage.

A second study of more than 170,000 Koreans aged 40 and older found that compared to non-drinkers, 1-3 cups of coffee each day was associated with a 38% reduced risk of cardiovascular death over the ~9 year follow-up period.  The authors believe that chlorogenic acid, was a prime contributor to this effect due to its robust anti-inflammatory, anti-oxidant and anti-diabetic properties (see also below).

The third study found that adding caffeine, or a cup of coffee (for the purpose of this post) approximately 30 minutes prior to an aerobic workout (preferably in the afternoon), increases breakdown of fat.  Though not tested in this study, anticipated benefits of boosting fat oxidation over a prolonged period might include weight loss, triglyceride reduction and improved cardiometabolic health.

For my patients who enjoy their java, I recommend 1-2 cups daily, with the 2nd cup consumed in the early afternoon, at least 8-10 hours prior to bedtime to reduce insomnia.  In addition, because of cancer concerns related to the toxin acrylamide that is released when coffee beans are roasted, I recommend staying away from instant and light roasted coffee brands (due to higher amounts of acrylamide) and stick with medium and dark roasted varieties.

Below are additional health benefits from your morning (and afternoon) mug.

  1. Improves Mood and Concentration: The sweet spot to boost mood and alertness is a moderate dose of caffeine (100-300 mg) whereas higher doses (above 400 mg) may result in anxiety and impaired performance. For example, a  “Grande” cup of Starbuck’s coffee varies in caffeine content from 260 mg (dark roasted) to 360 mg (blonde roasted) whereas a large cup (20 ounce) of Dunkin’ Donuts is ~300mg.
  2. Reduces Glucose Levels: Coffee contains the phytochemical, chlorogenic acid that slows the absorption of carbs, thereby lowering blood glucose levels and possibly the risk of type 2 diabetes.
  3. May Reduce Risk of Several Cancers: According to the American Cancer Society, drinking coffee has been associated with reduced risk of several cancers including prostate, liver and uterine cancer.
  4. May help Asthmatics. Coffee contains trace amounts of theophylline that dilates lung airways and at higher medicinal doses is used as a treatment for asthma.  In fact, caffeine has been shown to improve lung airway function for up to four hours, in people with asthma.

Dr. Miller is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore, Maryland USA and a member of the American College of Cardiology Nutrition Workgroup.  His latest book is   “Heal Your Heart: The Positive Emotions Prescription to Prevent & Reverse Heart Disease“.

Another Reason to Eat an Apple a Day…

Diabetes, Gut Health, Health & Wellness, heart disease, Heart Health, Nutrition, Uncategorized


The original proverb, “Eat an apple on going to bed and you’ll keep the doctor from earning his bread,” is well recognized in its simplified form (“an apple a day…”) and may now also “keep diabetes away” based on a study released earlier this week.   The new Australian study surveyed dietary habits in more than 7,500 men and women and found that consumption of at least 2 servings of fresh fruits daily was associated with ~35% decrease in developing Type 2 diabetes over the 5-year follow-up period.

Fruits that contributed to this benefit were apples, bananas, oranges and other citrus fruits whereas drinking fruit juice had no effect.   Among the individual fruits tested, only apples were independently associated with lower blood glucose levels and improved insulin sensitivity.

In addition to being a rich source of fiber that slows the absorption of glucose (thereby keeping the pancreas from overworking/overproducing insulin that over time may lead to insulin resistance), apples also contain the flavonoid, quercetin, that suppresses inflammation, a chronic process that promotes insulin resistance.

Because there is a tight intersection between metabolic syndrome, Type 2 diabetes and heart disease, cardiologists are becoming more involved in coordinating care with our diabetes and endocrine specialists.  Ironically, two of the newer classes of medications used to treat diabetes, the SGLT2 inhibitors and GLP1 agonists are being embraced by heart specialists because of proven benefit in reducing cardiovascular risk.

Below are some useful tools to reduce the risk of diabetes and/or lower heart related complications associated with Type 2 diabetes.

  1. A new study suggests that eating  an apple a day may also keep diabetes away!
  2. If you are overweight and prediabetic (fasting blood glucose 100-125 mg/dL), losing 5-7% of body weight is associated with ~50% reduction in conversion to diabetes; losing 10% of body weight correlated with an 85% decreased risk.
  3. The flavonoid quercetin has potent anti-inflammatory properties to combat insulin resistance. Foods with the highest quercetin content include onions, apples, blueberries, broccoli and kale.
  4. Large waist size (at least 35 inches in women/40 inches in men) is associated with a greater than 20-fold increased risk of diabetes compared to smaller waist size (less than 31 inches in women/37 inches in men).
  5. Treatment with the highly purified EPA compound, Icosapent Ethyl reduced the risk of a heart attack, stroke or death from cardiovascular disease in Type 2 diabetics with elevated triglycerides.
  6. Treatment with the diabetic medication known as SGLT2 inhibitors (dapagliflozin, empagliflozin) reduces the combined risk of cardiovascular death or hospitalization from heart failure (with low ejection fraction) in the presence or absence of diabetes.
  7. Treatment with the diabetic medication known as GLP1 agonists (liraglutide, semiglutide, dulaglutide) reduces the risk of heart attack, stroke and heart-related deaths in diabetic patients with a history of heart disease, or in the case of dulaglutide, with or without heart disease.
  8. The GLP1 agonist, semiglutide used to treat diabetes was just approved by the FDA as a weight management drug to treat overweight/obese adults with diabetes, hypertension or high cholesterol in addition to lifestyle (diet and physical activity) measures.

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.