For decades, triglycerides (TGs) took the proverbial back seat in the lipid/lipoprotein hierarchy. In recent years, however, TGs have gained increasing traction as a bonafide and independent biomarker of cardiovascular risk based on a series of well conducted epidemiologic and genetic (Mendelian randomization) studies.
Earlier this month, the American College of Cardiology released a new document that systematically outlines a series of decision trees that clinicians and health care professionals might consider when treating patients with elevated TG levels. It was a great privilege to work with colleagues and “lipid luminaries” in an highly engaging effort spearheaded by Drs. Salim Virani and Pam Morris.
Listed below are some of the highlights of the document that can be accessed by clicking here.
- Lifestyle interventions should be initiated in adults with fasting triglyceride levels of 150 mg/dL or non-fasting triglycerides of 175 mg/dL or higher.
- Among lifestyle recommendations for treating high triglycerides, weight loss is among the most robust (10-20% reductions on average) with up to 70% reductions potentially achievable.
- Dietary recommendations to lower elevated triglyceride levels include switching from a low-fat, high carbohydrate diet to a higher-fat (predominantly mono/polyunsaturated) and low-carb diet (30-40% of calories).
- In men and women with the metabolic syndrome, a high protein/weight loss diet (greater than 25% of energy intake/500 calorie per day deficit) is associated with ~35% reduction in triglycerides.
- Physical activity and exercise may contribute up to a 30% reduction in triglyceride with both resistance training and aerobic activity contributing to these effects.
- Excess alcohol consumption, especially with pre-existing high triglyceride levels can precipitate pancreatitis.
Dr. Michael Miller is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore, Maryland.
In his classic/catchy tune, “Movin’ Out” (AKA, “Anthony’s Song”), Billy Joel once lamented to Howard Stern that the song reflected friends taking jobs to fulfill others rather than themselves. Beyond the colorful characters, Mama Leone, Sergeant O’Leary and Mr. Cacciatore, it’s poor Anthony (among others) for whom it’s suggested that “working too hard can give you a heart attack…”
We’ve known for some time that working too many hours is associated with increased risk of cardiovascular disease. For example, a study of more than 600,000 men and women published in the Lancet found that those who worked at least 55 hours each week experienced a 13% higher risk of a heart attack over a 5-year period, and 33% greater likelihood of a stroke, compared with those who worked 35-40 hours.
Let’s suppose that Anthony experienced his first heart attack after working more than 55 hours a week in the grocery store. A new study now shows that if Anthony continues to work more than 55 hours a week he is 67% more likely to have another heart attack (or more than a 2.5 fold increased risk if there is associated job strain), compared to other heart attack survivors who dropped their workload down to 40 hours or less per week.
Bottom Line: Working 55 hours or more per week may be hazardous to your health, unless of course, you thoroughly enjoy what you do. After all, as my late father-in-law, Paul Miller (who taught math for 80 years) used to say “if you love what you do, you’ll never work a day in your life!”
Below are additional tips related to workplace stress and the heart
- Jobs that are of high-demand, low-control are associated with increased risk of heart disease. They include factory workers, firefighters and postal workers.
- Jobs that are of low-demand, high-control are associated with reduced risk of heart disease. They include architects, dentists and sales representatives.
- A study conducted in Germany found that job stress was associated with increased inflammation and 2-fold increased risk of a heart attack over an 11-year follow-up period.
- Stressful working conditions are associated with reduced life expectancy of 2 and 1.5 years in men and women, respectively.
Dr. Michael Miller is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore, Maryland.
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.
- Keep Saturated Animal Fats at Bay: A 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.
- 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.
- 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.
- 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.
- 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.
- 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.
Having recently celebrated my 30th anniversary at the University of Maryland School of Medicine and upon hearing the Beatle’s tune, “In My Life”, I was struck by the verse “and these memories lose their meaning”. Though highly unlikely that John (Lennon) wrote this verse with “dementia” in mind, the words can certainly be consistent with memory loss.
Yet while tremendous strides have unfolded in treating cardiovascular disease (heart attacks, strokes, etc) in recent decades, the pace of progress has been slower when it comes to prevention/treatment of Alzheimer’s disease and other forms of dementia. The initial exhuberance following FDA’s approval of Biogen’s Alzheimer’s disease drug, (aducanumab or “Aduhelm”) last month, despite mixed study results, was met with immediate skepticism and calls for a federal investigation as to whether there was sufficient justification to warrant approval. Undoubtedly, stakes are high with an estimated 6.2 million Americans (~1 in 9) aged 65 and older having some form of dementia.
However, hope may be on the horizon as a new study out this week sheds important insights into how memory loss may be reversed. The study conducted in the United Kingdom examined PNNs (perineuronal nets), highly specialized structures involved in regulating neuroplasticity (the way the adaptive brain learns and develops new memories). In early childhood, there is increased neuroplasticity but as the brain ages, PNNs decrease and neuroplasticity wanes. An important compound in PNNs that promotes neuroplasticity is chondroitin-6-sulfate (C6S). The new study found that administration of C6S to aged mice restored their ability to quickly recognize objects at levels similarly observed in younger mice.
Bottom Line: while more animal studies are required to confirm the effects of C6S on memory before progressing to human trials, the new study may turn out to be a memorable discovery for dementia.
In the meantime, listed below are lifestyle related tools that may help sharpen your memory:
- Reduce Sugary Beverages: Drinking more than 1 sugared beverage (soda, juice) daily was associated with reduced memory and lower brain volume compared to minimal or no sugary beverage intake.
- Add Blueberries: 1 cup of fresh blueberries daily is associated with fewer learning errors and improved cognition in men and women aged 60 years and older.
- Practice Mind–Body Exercises: Participating in mind-body exercises such as Tai Chi, yoga and dancing mindfulness movements improve learning, memory and adaptable brain responses (neuroplasticity).
- Aerobic Activity: Moderate aerobic activity (walking at a pace of 3-5 mph) was shown to improve cerebral blood flow and cognitive function in men and women with mild cognitive impairment over a 12-month period.
- Sneak in an Afternoon Nap: Power napping for as little as 30 minutes in the afternoon is associated with improved memory and cognitive function.
- Stay Hydrated: Dehydration is associated with impaired cognitive function. Drinking 6 ounces of water each hour over a 10 hour period will help keep your mind sharp.
Dr. Michael Miller is Professor of Medicine at the University of Maryland School of Medicine.
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.
- 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.
- 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.
- EPA but not DHA exhibits heart protective antioxidant, anti-inflammatory and membrane/plaque stabilizing properties that help to reduce the risk of cardiovascular disease.
- In the MESA study, higher blood levels of OM3 (inclusive of EPA) were associated with reduced risk of hospitalization for bleeding events.
- 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.
- 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…“
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.
- 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.
- Parvalbumin, a protein enriched in carp, cod, herring and redfish has been shown to prevent the buildup of proteins associated with Parkinson’s disease.
- 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.
- A Norwegian study found that fish consumption at least once weekly was associated with a lower risk of the Metabolic Syndrome.
- 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“.
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!
- Reduces Cholesterol: Combining dark chocolate with almonds and cocoa powder reduces LDL cholesterol; lower LDL is associated with lower risk of heart disease.
- 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.
- 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).
- 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.
Clues revealed during physical examination can inform physicians and other health care providers about potential heart related concerns. In this regard, examination of the hands can be quite revealing, especially if the patient had been unaware that any such issue existed. Shown below are some hand-related clues that we’ve encountered in our medical center.
- Yellowish-orange discoloration in palm creases: Yellowish-orange discoloration in palm creases of the hand may be seen in a rare medical condition (familial dysbetalipoproteinemia) associated with high triglycerides and increased risk of heart disease.
- Little Bumps on the back of the hands: Cholesterol deposits on tendons (known as xanthomas) may appear as little bumps resembling knuckles on the back of the hand. They are due to very high levels of LDL cholesterol found in a rare medical condition (familial hypercholesterolemia) and associated with an increased risk of cardiovascular disease.
- Bony swellings in the thumb and fingers: These swellings occur in the base of the thumb, fingertip joint and the middle joint of the fingers due to “wear-and-tear” or osteoarthritis. Inflammation results in painful hands and increased risk of heart disease.
- Blue clubbed fingernails. First described by Hippocrates, clubbing or enlargement of the fingertips and downward sloping of the nails occurs when blood levels of oxygen are low over time and is associated with certain types of congenital heart disease.
- Raised red circular nodules. “Osler’s nodes” are raised reddish appearing nodules that are tender to touch and found on fingers and fleshy area of the hand (thenar eminence). They consist of small clots (micro-emboli) due to endocarditis (bacterial/fungal infection of the heart).
- White spots on the fingernails. White spots on the fingernails may be a sign of calcium or zinc deficiency. Severe calcium deficiency adversely affects the heart’s conduction system and may cause a dangerous heart rhythm (Torsade de Pointes).
- Discoloration of the Fingers. Raynaud’s disease includes discoloration of the fingers/toes (red/white/blue) in response to cold temperatures or emotional stress and is associated with reduced blood flow to heart muscle and increased risk of cardiovascular death.
Michael Miller, MD is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore, Maryland. For additional clues to protect your heart, check out Dr. Miller’s latest book, “Heal Your Heart“.