Optimal Bowel Movement Frequency

Optimal Bowel Movement Frequency.jpeg

Lasting for 3,000 years, ancient Egypt was one of the greatest ancient civilizations--with a vastly underestimated knowledge of medicine. They even had medical subspecialties. The pharaohs, for example, had access to dedicated physicians to be "guardian[s] of the royal bowel movement," a title alternately translated from the hieroglyphics to mean "Shepherd of the Anus." How's that for a resume builder?

Today, the primacy of the bowel movement's importance continues. Some have called for bowel habits to be considered a vital sign on how the body is functioning, along with heart rate, blood pressure, and breathing rate. Medical professionals may not particularly relish hearing all about their patients' bowel movements, but it is a vital function that nurses and doctors need to assess.

Surprisingly, the colon has remained relatively unexplored territory, one of the body's final frontiers. For example, current concepts of what "normal" stools are emanated primarily from the records of 12 consecutive bowel movements in 27 healthy subjects from the United Kingdom, who boldly went where no one had gone before. Those must have been some really detailed records.

It's important to define what's normal. When it comes to frequency, for example, we can't define concepts like constipation or diarrhea unless we know what's normal. Standard physiology textbooks may not be helpful in this regard. One text implies that anything from one bowel movement every few weeks or months to 24 in just one day can be regarded as normal. Once every few months is normal?

Out of all of our bodily functions, we may know the least about defecation. Can't we just ask people? It turns out people tend to exaggerate. There's a discrepancy between what people report and what researchers find when they record bowel habits directly. It wasn't until 2010 when we got the first serious look. In my video, How Many Bowel Movement's Should You Have Everyday? you'll see the study that found that normal stool frequency was between three per week and three per day, based on the fact that that's where 98% of people tended to fall. But normal doesn't necessarily mean optimal.

Having a "normal" salt intake can lead to a "normal" blood pressure, which can help us to die from all the "normal" causes like heart attacks and strokes. Having a normal cholesterol level in a society where it's normal to drop dead of heart disease--our number-one killer--is not necessarily a good thing. Indeed, significant proportions of people with "normal bowel function" reported urgency, straining, and incomplete defecation, leading the researchers of the 2010 study to conclude that these kinds of things must be normal. Normal, maybe, if we're eating a fiber-deficient diet, but not normal for our species. Defecation should not be a painful exercise. This is readily demonstrable. For example, the majority of rural Africans eating their traditional fiber-rich, plant-based diets can usually pass without straining a stool specimen on demand. The rectum may need to accumulate 4 or 5 ounces of fecal matter before the defecation reflex is fully initiated, so if we don't even build up that much over the day, we'd have to strain to prime the rectal pump.

Hippocrates thought bowel movements should ideally be two or three times a day, which is what we see in populations on traditional plant-based diets. These traditional diets have the kind of fiber intakes we see in our fellow Great Apes and may be more representative of the type of diets we evolved eating for millions of years. It seems somewhat optimistic, though, to expect the average American to adopt a rural African diet. We can, however, eat more plant-based and bulk up enough to take the Hippocratic oath to go two or three times a day.

There's no need to obsess about it. In fact, there's actually a "bowel obsession syndrome" characterized in part by "ideational rambling over bowel habits." But three times a day makes sense. We have what's called a gastrocolic reflex, which consists of a prompt activation of muscular waves in our colon within 1 to 3 minutes of the ingestion of the first mouthfuls of food to make room for the meal. Even just talking about food can cause our brains to increase colon activity. This suggests the body figured that one meal should be about enough to fill us up down there. So maybe we should eat enough unprocessed plant foods to get up to three a day--a movement for every meal.

I know people are suckers for poop videos--I'm so excited to finally be getting these up! There actually is a recent one--Diet and Hiatal Hernia--that talks about the consequences of straining on stool. Hernias are better than Bed Pan Death Syndrome, though, which is what I talk about in in my video, Should You Sit, Squat, or Lean During a Bowel Movement?

Here are some older videos on bowel health:

For more on this concept of how having "normal" health parameters in a society where it's normal to drop dead of heart attacks and other such preventable fates, see my video When Low Risk Means High Risk.

In health,

Michael Greger, M.D.

PS: If you haven't yet, you can subscribe to my free videos here and watch my live, year-in-review presentations:

Image Credit: Sally Plank. This image has been modified.

Original Link

Optimal Bowel Movement Frequency

Optimal Bowel Movement Frequency.jpeg

Lasting for 3,000 years, ancient Egypt was one of the greatest ancient civilizations--with a vastly underestimated knowledge of medicine. They even had medical subspecialties. The pharaohs, for example, had access to dedicated physicians to be "guardian[s] of the royal bowel movement," a title alternately translated from the hieroglyphics to mean "Shepherd of the Anus." How's that for a resume builder?

Today, the primacy of the bowel movement's importance continues. Some have called for bowel habits to be considered a vital sign on how the body is functioning, along with heart rate, blood pressure, and breathing rate. Medical professionals may not particularly relish hearing all about their patients' bowel movements, but it is a vital function that nurses and doctors need to assess.

Surprisingly, the colon has remained relatively unexplored territory, one of the body's final frontiers. For example, current concepts of what "normal" stools are emanated primarily from the records of 12 consecutive bowel movements in 27 healthy subjects from the United Kingdom, who boldly went where no one had gone before. Those must have been some really detailed records.

It's important to define what's normal. When it comes to frequency, for example, we can't define concepts like constipation or diarrhea unless we know what's normal. Standard physiology textbooks may not be helpful in this regard. One text implies that anything from one bowel movement every few weeks or months to 24 in just one day can be regarded as normal. Once every few months is normal?

Out of all of our bodily functions, we may know the least about defecation. Can't we just ask people? It turns out people tend to exaggerate. There's a discrepancy between what people report and what researchers find when they record bowel habits directly. It wasn't until 2010 when we got the first serious look. In my video, How Many Bowel Movement's Should You Have Everyday? you'll see the study that found that normal stool frequency was between three per week and three per day, based on the fact that that's where 98% of people tended to fall. But normal doesn't necessarily mean optimal.

Having a "normal" salt intake can lead to a "normal" blood pressure, which can help us to die from all the "normal" causes like heart attacks and strokes. Having a normal cholesterol level in a society where it's normal to drop dead of heart disease--our number-one killer--is not necessarily a good thing. Indeed, significant proportions of people with "normal bowel function" reported urgency, straining, and incomplete defecation, leading the researchers of the 2010 study to conclude that these kinds of things must be normal. Normal, maybe, if we're eating a fiber-deficient diet, but not normal for our species. Defecation should not be a painful exercise. This is readily demonstrable. For example, the majority of rural Africans eating their traditional fiber-rich, plant-based diets can usually pass without straining a stool specimen on demand. The rectum may need to accumulate 4 or 5 ounces of fecal matter before the defecation reflex is fully initiated, so if we don't even build up that much over the day, we'd have to strain to prime the rectal pump.

Hippocrates thought bowel movements should ideally be two or three times a day, which is what we see in populations on traditional plant-based diets. These traditional diets have the kind of fiber intakes we see in our fellow Great Apes and may be more representative of the type of diets we evolved eating for millions of years. It seems somewhat optimistic, though, to expect the average American to adopt a rural African diet. We can, however, eat more plant-based and bulk up enough to take the Hippocratic oath to go two or three times a day.

There's no need to obsess about it. In fact, there's actually a "bowel obsession syndrome" characterized in part by "ideational rambling over bowel habits." But three times a day makes sense. We have what's called a gastrocolic reflex, which consists of a prompt activation of muscular waves in our colon within 1 to 3 minutes of the ingestion of the first mouthfuls of food to make room for the meal. Even just talking about food can cause our brains to increase colon activity. This suggests the body figured that one meal should be about enough to fill us up down there. So maybe we should eat enough unprocessed plant foods to get up to three a day--a movement for every meal.

I know people are suckers for poop videos--I'm so excited to finally be getting these up! There actually is a recent one--Diet and Hiatal Hernia--that talks about the consequences of straining on stool. Hernias are better than Bed Pan Death Syndrome, though, which is what I talk about in in my video, Should You Sit, Squat, or Lean During a Bowel Movement?

Here are some older videos on bowel health:

For more on this concept of how having "normal" health parameters in a society where it's normal to drop dead of heart attacks and other such preventable fates, see my video When Low Risk Means High Risk.

In health,

Michael Greger, M.D.

PS: If you haven't yet, you can subscribe to my free videos here and watch my live, year-in-review presentations:

Image Credit: Sally Plank. This image has been modified.

Original Link

Are Sugar Pills Better than Antidepressant Drugs?

Do Antidepressant Drugs Really Work.jpg

We've learned that exercise compares favorably to antidepressant medications as a first-line treatment for mild to moderate depression (in my video Exercise vs. Drugs for Depression). But how much is that really saying? How effective are antidepressant drugs in the first place?

A recent meta-analysis sparked huge scientific and public controversy by stating that the placebo effect can explain the apparent clinical benefits of antidepressants. But aren't there thousands of clinical trials providing compelling evidence for antidepressant effectiveness? If a meta-analysis compiles together all the best published research, how could it say they don't work much better than sugar pills?

The key word is "published."

What if a drug company decided only to publish studies that showed a positive effect, but quietly shelved and concealed any studies showing the drug didn't work? If you didn't know any better, you'd look at the published medical literature and think "Wow, this drug is great." And what if all the drug companies did that? To find out if this was the case, researchers applied to the FDA under the Freedom of Information Act to get access to the published and unpublished studies submitted by pharmaceutical companies, and what they found was shocking.

According to the published literature, the results of nearly all the trials of antidepressants were positive, meaning they worked. In contrast, FDA analysis of the trial data showed only roughly half of the trials had positive results. In other words, about half the studies showed the drugs didn't work. Thus, when published and unpublished data are combined, they fail to show a clinically significant advantage for antidepressant medication over a sugar pill. Not publishing negative results undermines evidence-based medicine and puts millions of patients at risk for using ineffective or unsafe drugs, and this was the case with these antidepressant drugs.

These revelations hit first in 2008. Prozac, Serzone, Paxil and Effexor worked, but so did sugar pills, and the difference between the drug and placebo was small. That was 2008. Where were we by 2014? Analyses of the published data and the unpublished data that were hidden by drug companies reveals that most (if not all) of the benefits of antidepressants are due to the placebo effect. And what's even worse, Freedom of Information Act documents show the FDA knew about it but made an explicit decision to keep this information from the public and from prescribing physicians.

How could drug companies get away with this?

The pharmaceutical industry is considered the most profitable and politically influential industry in the United States, and mental illness can be thought of as the drug industry's golden goose: incurable, common, long term and involving multiple medications. Antidepressant medications are prescribed to 8.7 percent of the U.S. population. It's a multi-billion dollar market.

To summarize, there is a strong therapeutic response to antidepressant medication; it's just that the response to placebo is almost as strong. Indeed, antidepressants offer substantial benefits to millions of people suffering from depression, and to cast them as ineffective is inaccurate. Just because they may not work better than fake pills doesn't mean they don't work. It's like homeopathy--just because it doesn't work better than the sugar pills, doesn't mean that homeopathy doesn't work. The placebo effect is real and powerful.

In one psychopharmacology journal, a psychiatrist funded by the Prozac company defends the drugs stating, "A key issue is disregarded by the naysaying critics. If the patient is benefiting from antidepressant treatment does it matter whether this is being achieved via drug or placebo effects?"

Of course it matters!

Among the side effects of antidepressants are: sexual dysfunction in up to three quarters of people, long-term weight gain, insomnia, nausea and diarrhea. About one in five show withdrawal symptoms when they try to quit. And perhaps more tragically, the drugs may make people more likely to become depressed in the future. Let me say that again: People are more likely to become depressed after treatment by antidepressants than after treatment by other means - including placebo.

So if doctors are willing to give patients placebo-equivalent treatments, maybe it'd be better for them to just lie to patients and give them actual sugar pills. Yes, that involves deception, but isn't that preferable than deception with a side of side effects? See more on this in my video Do Antidepressant Drugs Really Work?

If different treatments are equally effective, then choice should be based on risk and harm, and of all of the available treatments, antidepressant drugs may be among the riskiest and most harmful. If they are to be used at all, it should be as a last resort, when depression is extremely severe and all other treatment alternatives have been tried and failed.

Antidepressants may not work better than placebo for mild and moderate depression, but for very severe depression, the drugs do beat out sugar pills. But that's just a small fraction of the people taking these drugs. That means that the vast majority of depressed patients--as many as nine out of ten--are being prescribed medications that have negligible benefits to them.

Too many doctors quickly decide upon a depression diagnosis without necessarily listening to what the patient has to say and end up putting them on antidepressants without considering alternatives. And fortunately, there are effective alternatives. Physical exercise, for example can have lasting effects, and if that turns out to also be a placebo effect, it is at least a placebo with an enviable list of side effects. Whereas side effects of antidepressants include things like sexual dysfunction and insomnia, side effects of exercise include enhanced libido, better sleep, decreased body fat, improved muscle tone and a longer life.


There are other ways meta-analyses can be misleading. See The Saturated Fat Studies: Buttering Up the Public and The Saturated Fat Studies: Set Up to Fail.

More on the ethical challenges facing doctors and whether or not to prescribe sugar pills in The Lie That Heals: Should Doctors Give Placebos?

I've used the Freedom of Information Act myself to get access to behind the scenes industry shenanigans. See, for example, what I found out about the egg industry in Who Says Eggs Aren't Healthy or Safe? and Eggs and Cholesterol: Patently False and Misleading Claims.

This isn't the only case of the medical profession overselling the benefits of drugs. See How Smoking in 1956 is Like Eating in 2016, The Actual Benefit of Diet vs. Drugs and Why Prevention is Worth a Ton of Cure (though if you're worried about your mood they might make you even more depressed!)

In health,

Michael Greger, M.D.

PS: If you haven't yet, you can subscribe to my free videos here and watch my live, year-in-review presentations:

Image Credit: GraphicStock. This image has been modified.

Original Link

Are Sugar Pills Better than Antidepressant Drugs?

Do Antidepressant Drugs Really Work.jpg

We've learned that exercise compares favorably to antidepressant medications as a first-line treatment for mild to moderate depression (in my video Exercise vs. Drugs for Depression). But how much is that really saying? How effective are antidepressant drugs in the first place?

A recent meta-analysis sparked huge scientific and public controversy by stating that the placebo effect can explain the apparent clinical benefits of antidepressants. But aren't there thousands of clinical trials providing compelling evidence for antidepressant effectiveness? If a meta-analysis compiles together all the best published research, how could it say they don't work much better than sugar pills?

The key word is "published."

What if a drug company decided only to publish studies that showed a positive effect, but quietly shelved and concealed any studies showing the drug didn't work? If you didn't know any better, you'd look at the published medical literature and think "Wow, this drug is great." And what if all the drug companies did that? To find out if this was the case, researchers applied to the FDA under the Freedom of Information Act to get access to the published and unpublished studies submitted by pharmaceutical companies, and what they found was shocking.

According to the published literature, the results of nearly all the trials of antidepressants were positive, meaning they worked. In contrast, FDA analysis of the trial data showed only roughly half of the trials had positive results. In other words, about half the studies showed the drugs didn't work. Thus, when published and unpublished data are combined, they fail to show a clinically significant advantage for antidepressant medication over a sugar pill. Not publishing negative results undermines evidence-based medicine and puts millions of patients at risk for using ineffective or unsafe drugs, and this was the case with these antidepressant drugs.

These revelations hit first in 2008. Prozac, Serzone, Paxil and Effexor worked, but so did sugar pills, and the difference between the drug and placebo was small. That was 2008. Where were we by 2014? Analyses of the published data and the unpublished data that were hidden by drug companies reveals that most (if not all) of the benefits of antidepressants are due to the placebo effect. And what's even worse, Freedom of Information Act documents show the FDA knew about it but made an explicit decision to keep this information from the public and from prescribing physicians.

How could drug companies get away with this?

The pharmaceutical industry is considered the most profitable and politically influential industry in the United States, and mental illness can be thought of as the drug industry's golden goose: incurable, common, long term and involving multiple medications. Antidepressant medications are prescribed to 8.7 percent of the U.S. population. It's a multi-billion dollar market.

To summarize, there is a strong therapeutic response to antidepressant medication; it's just that the response to placebo is almost as strong. Indeed, antidepressants offer substantial benefits to millions of people suffering from depression, and to cast them as ineffective is inaccurate. Just because they may not work better than fake pills doesn't mean they don't work. It's like homeopathy--just because it doesn't work better than the sugar pills, doesn't mean that homeopathy doesn't work. The placebo effect is real and powerful.

In one psychopharmacology journal, a psychiatrist funded by the Prozac company defends the drugs stating, "A key issue is disregarded by the naysaying critics. If the patient is benefiting from antidepressant treatment does it matter whether this is being achieved via drug or placebo effects?"

Of course it matters!

Among the side effects of antidepressants are: sexual dysfunction in up to three quarters of people, long-term weight gain, insomnia, nausea and diarrhea. About one in five show withdrawal symptoms when they try to quit. And perhaps more tragically, the drugs may make people more likely to become depressed in the future. Let me say that again: People are more likely to become depressed after treatment by antidepressants than after treatment by other means - including placebo.

So if doctors are willing to give patients placebo-equivalent treatments, maybe it'd be better for them to just lie to patients and give them actual sugar pills. Yes, that involves deception, but isn't that preferable than deception with a side of side effects? See more on this in my video Do Antidepressant Drugs Really Work?

If different treatments are equally effective, then choice should be based on risk and harm, and of all of the available treatments, antidepressant drugs may be among the riskiest and most harmful. If they are to be used at all, it should be as a last resort, when depression is extremely severe and all other treatment alternatives have been tried and failed.

Antidepressants may not work better than placebo for mild and moderate depression, but for very severe depression, the drugs do beat out sugar pills. But that's just a small fraction of the people taking these drugs. That means that the vast majority of depressed patients--as many as nine out of ten--are being prescribed medications that have negligible benefits to them.

Too many doctors quickly decide upon a depression diagnosis without necessarily listening to what the patient has to say and end up putting them on antidepressants without considering alternatives. And fortunately, there are effective alternatives. Physical exercise, for example can have lasting effects, and if that turns out to also be a placebo effect, it is at least a placebo with an enviable list of side effects. Whereas side effects of antidepressants include things like sexual dysfunction and insomnia, side effects of exercise include enhanced libido, better sleep, decreased body fat, improved muscle tone and a longer life.


There are other ways meta-analyses can be misleading. See The Saturated Fat Studies: Buttering Up the Public and The Saturated Fat Studies: Set Up to Fail.

More on the ethical challenges facing doctors and whether or not to prescribe sugar pills in The Lie That Heals: Should Doctors Give Placebos?

I've used the Freedom of Information Act myself to get access to behind the scenes industry shenanigans. See, for example, what I found out about the egg industry in Who Says Eggs Aren't Healthy or Safe? and Eggs and Cholesterol: Patently False and Misleading Claims.

This isn't the only case of the medical profession overselling the benefits of drugs. See How Smoking in 1956 is Like Eating in 2016, The Actual Benefit of Diet vs. Drugs and Why Prevention is Worth a Ton of Cure (though if you're worried about your mood they might make you even more depressed!)

In health,

Michael Greger, M.D.

PS: If you haven't yet, you can subscribe to my free videos here and watch my live, year-in-review presentations:

Image Credit: GraphicStock. This image has been modified.

Original Link

Why Smoothies are Better Than Juicing

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Studies such as a recent Harvard School of Public Health investigation found that the consumption of whole fruits is associated with a significantly lower risk of type 2 diabetes, whereas fruit juice consumption is associated with a higher risk, highlighting the dramatic difference between eating whole fruits and drinking fruit juice. Cholesterol serves as another example. If we eat apples, our cholesterol drops. On the other hand, if we drink apple juice, our cholesterol may actually go up a little. Leaving just a little of the fiber behind--as in cloudy apple juice--was found to add back in some of the benefit.

We used to think of fiber as just a bulking agent that helps with bowel regularity. We now know fiber is digestible by our gut bacteria, which make short chain fatty acids (SCFAs) out of it. SCFAs have a number of health promoting effects, such as inhibiting the growth of bad bacteria and increasing mineral absorption. For example, experimentally infused into the rectum of the human body, SCFAs can stimulate calcium absorption, so much so that we can improve the bone mineral density of teenagers just by giving them the fiber naturally found in foods like onions, asparagus, and bananas.

Our good bacteria also uses fiber to maintain normal bowel structure and function, preventing or alleviating diarrhea, stimulating colonic blood flow up to five-fold, and increasing fluid and electrolyte uptake. The major fuel for the cells that line our colon is butyrate, which our good bacteria make from fiber. We feed them, and they feed us right back.

If the only difference between fruit and fruit juice is fiber, why can't the juice industry just add some fiber back to the juice? The reason is because we remove a lot more than fiber when we juice fruits and vegetables. We also lose all the nutrients that are bound to the fiber.

In the 1980's, a study (highlighted in my video, Juicing Removes More Than Just Fiber) found a discrepancy in the amount of fiber in carob using two different methods. A gap of 21.5 percent was identified not as fiber but as nonextractable polyphenols, a class of phytonutrients thought to have an array of health-promoting effects. Some of the effects associated with the intake of dietary fiber in plants may actually be due to the presence of these polyphenols.

Nonextractable polyphenols, usually ignored, are the major part of dietary polyphenols. Most polyphenol phytonutrients in plants are stuck to the fiber. These so-called missing polyphenols make it down to our colon, are liberated by our friendly flora and can then get absorbed into our system. The phytonutrients in fruit and vegetable juice may just be the tip of the iceberg.

For those that like drinking their fruits and vegetables, these findings suggest that smoothies may be preferable. I can imagine people who eat really healthy thinking they get so much fiber from their regular diet that they need not concern themselves with the loss from juicing. But we may be losing more than we think.

For those that like drinking their fruits and vegetables, this suggests smoothies are preferable. I can imagine people who eat really healthy thinking they get so much fiber from their regular diet that they need not concern themselves with the loss from juicing, but they may be losing more than they think.

Why are polyphenol phytonutrients important? See, for example, my video How to Slow Brain Aging by Two Years

Not that fiber isn't important in its own right. Check out:

For more on smoothies, check out:

In health,
Michael Greger, M.D.

PS: If you haven't yet, you can subscribe to my free videos here and watch my live year-in-review presentations Uprooting the Leading Causes of Death, More Than an Apple a Day, From Table to Able, and Food as Medicine.

Image Credit: Craig Sunter / Flickr

Original Link

Drugs vs. Lifestyle for Preventing Diabetes

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In just one decade, the number of people with diabetes has more than doubled. According to the Center for Disease Control and Prevention, by 2050, one out of every three of us may have diabetes.

What's the big deal?

Well, the "consequences of diabetes are legion." Diabetes is the number one cause of adult-onset blindness, the number one cause of kidney failure, and the number one cause of surgical amputations.

What can we do to prevent it?

The onset of Type 2 diabetes is gradual, with most individuals progressing through a state of prediabetes, a condition now striking approximately one in three Americans, but only about one in ten even knows they have it. Since current methods of treating diabetes remain inadequate, prevention is preferable, but what works better: lifestyle changes or drugs? We didn't know until a landmark study, highlighted in my video, How to Prevent Prediabetes from Turning into Diabetes, was published in the New England Journal of Medicine.

Thousands were randomized to get a double dose of the leading anti-diabetes drug, or diet and exercise. The drug, metformin, is probably the safest diabetes drug there is. It causes diarrhea in about half, makes one in four nauseous, about one in ten suffer from asthenia (physical weakness and fatigue), but only about 1 in 67,000 are killed by the drug every year.

And the drug worked. Compared to placebo, in terms of the percentage of people developing diabetes within the four-year study period, fewer people in the drug group developed diabetes.

But diet and exercise alone worked better. The lifestyle intervention reduced diabetes incidence by 58 percent, compared to only 31 percent with the drug. The lifestyle intervention was significantly more effective than the drug, and had fewer side-effects. More than three quarters of those on the drug reported gastrointestinal symptoms, though there was more muscle soreness reported in the lifestyle group, on account of them actually exercising.

That's what other studies have subsequently found: non-drug approaches superior to drug-based approaches for diabetes prevention. And the average 50 percent or so drop in risk was just for those instructing people to improve their diet and lifestyle, whether or not they actually did it.

In one of the most famous diabetes prevention studies, 500 people with prediabetes were randomized into a lifestyle intervention or control group. During the trial, the risk of diabetes was reduced by that same 50-60 percent, but only a fraction of the patients met the modest goals. Even in the lifestyle intervention group, only about a quarter were able to eat enough fiber, meaning whole, plant foods, and cut down on enough saturated fat, which in North America is mostly dairy, dessert, chicken and pork. But they did better than the control group, and fewer of them developed diabetes because of it. But what if you looked just at the folks that actually made the lifestyle changes? They had zero diabetes--none of them got diabetes. That's effectively a 100 percent drop in risk.

I often hear the diet and exercise intervention described as 60 percent effective. That's still nearly twice as effective as the drug, but what the other study really showed it may be more like 100 percent in people who actually do it. So is diet and exercise 100 percent effective or only 60 percent effective? On a population scale, since so many people won't actually do it, it may only be 60 percent effective. But on an individual level, if you want to know what are the chances you won't get diabetes if you change your lifestyle, then the 100 percent answer is more accurate. Lifestyle interventions only work when we do them. Kale is only healthy if it actually gets into our mouth. It's not healthy just sitting on the shelf.


How about preventing prediabetes in the first place? See Preventing Prediabetes By Eating More and my video How to Prevent Prediabetes in Children.

Some things we may want to avoid can be found in my videos Eggs and Diabetes and Fish and Diabetes.

And what if we already have the disease? See Diabetics Should Take Their Pulses and my live presentation From Table to Able: Combating Disabling Diseases with Diet.

What if you don't have time for exercise? Check out Standing Up for Your Health.

In health,
Michael Greger, M.D.

PS: If you haven't yet, you can subscribe to my free videos here and watch my live year-in-review presentations Uprooting the Leading Causes of Death, More Than an Apple a Day, and Food as Medicine.

Image Credit: Heather Aitken / Flickr

Original Link

Gluten Sensitivity Put to the Test

NF-Feb18 Is Gluten Sensitivity Real?.jpeg

In 1980, researchers in England reported a series of women with no evidence of celiac disease (the autoimmune disorder associated with gluten intolerance), who nevertheless resolved their chronic diarrhea on a gluten-free diet. The medical profession was skeptical at the time that non-celiac gluten sensitivity existed, and even 30 years later, such patients were commonly referred to psychiatrists. Psychological testing of such patients, however, found no evidence that they were suffering from any kind of psychosomatic hysteria.

The medical profession has a history of dismissing diseases as all in people's heads--post-traumatic stress disorder, ulcerative colitis, migraines, ulcers, asthma, Parkinson's disease, and multiple sclerosis. Despite resistance from the prevailing medical community at the time, these health problems have subsequently been confirmed to be credible physiologically-based disorders rather than psychologically-based confabulations.

On the flipside, the internet is rife with unsubstantiated claims about gluten free diets, which has spilled over into the popular press to make gluten the diet villain du jour, with claims like "17 million Americans are gluten sensitive." However, it must be remembered that the gluten-free food industry is a big business. When literally billions are at stake, it's hard to trust anybody. As always, it's best to stick to the science.

What sort of evidence do we have for the existence of a condition presumed to be so widespread? Not much. The evidence base for such claims has been unfortunately very thin because we haven't had randomized controlled trials demonstrating that the entity even exists. The gold-standard for confirming non-celiac gluten sensitivity requires a gluten-free diet, followed by a double-blind, randomized, placebo-controlled food challenge. For example, give people a muffin and don't tell them if it's gluten-free or gluten-filled--to control for placebo effects--and see what happens. The reason this is necessary is because when you actually do this, a number of quote-unquote "gluten-sensitive" patients don't react at all to disguised gluten and instead react to the gluten-free placebo.

We never had that level of evidence until 2011, when a double-blind, randomized placebo-controlled trial was published, which tested to see if patients complaining of irritable bowel symptoms who claimed they felt better on a gluten free diet--despite not having celiac disease--actually could tell if they were given gluten containing bread and muffins or gluten-free bread and muffins.

Subjects started out gluten-free and symptom-free for two weeks and then were challenged with the bread and muffins. In my video, Is Gluten Sensitivity Real?, you can see what happened to the 15 patients who got the placebo, meaning they started out on a gluten-free diet and continued on a gluten-free diet. They got worse. Just the thought that they may be eating something that was bad for them made them feel crampy and bloated. This is what's called the nocebo effect. The placebo effect is when you give someone something useless and they feel better; the nocebo effect is when you give someone something harmless and they feel worse. On the other hand, the small group that got the actual gluten, felt even worse still. The researchers concluded that non-celiac gluten intolerance may therefore indeed exist.

It was a small study, though, and even though the researchers claimed the gluten-free bread and muffins were indistinguishable, maybe at some level the patients could tell which was which. So in 2012, researchers in Italy took 920 patients that had been diagnosed with non-celiac gluten sensitivity and put them to the test with a double-blinded wheat challenge by giving them capsules filled with wheat flour or filled with placebo powder. More than two-thirds failed the test, such as getting worse on the placebo or better on the wheat. But of those that passed, there was a clear benefit to staying on the wheat-free diet. The researchers concluded that their findings confirmed the existence of a non-celiac wheat sensitivity. Note I said "wheat sensitivity," not "gluten sensitivity."

Gluten itself may not be causing gut symptoms at all. Most people with wheat sensitivity have a variety of other food sensitivities. Two thirds are sensitive to cow's milk protein, and many are sensitive to eggs. If we put people on a diet low in common triggers of irritable bowel symptoms, and then challenge them with gluten, there's no effect. We find the same increase in symptoms with high gluten, low gluten, or no gluten diets, calling into question the very existence of non-celiac gluten sensitivity.

Interestingly, despite being informed that avoiding gluten didn't seem to do a thing for their gut symptoms, many participants opted to continue following a gluten-free diet as they subjectively described "feeling better." So researchers wondered if avoiding gluten might improve the mood of those with wheat sensitivity. Indeed, short-term exposure to gluten appeared to induce feelings of depression in these patients. Whether non-celiac gluten sensitivity is a disease of the mind or the gut, it is no longer a condition that can be dismissed.


More than 10,000 articles have been published on gluten in medical journals--intimidating even for me! Combined with the multi-billion dollar financial interests on both sides, it makes for a difficult task. But I think I did it! This is the first of a 3-part series summarizing the best available science on gluten. Also check out: Gluten-Free Diets: Separating the Wheat from the Chat and How to Diagnose Gluten Intolerance.

Why this apparent increase in food sensitivities in recent decades? It could be because of pollutant exposure (see Alkylphenol Endocrine Disruptors and Allergies and Dietary Sources of Alkylphenol Endocrine Disruptors).

What can we do about preventing so-called atopic diseases (like allergies, asthma, and eczema)? See my videos Preventing Allergies in Adulthood and Preventing Allergies in Childhood. The weirdest example of an emerging food sensitivity may be the tick-bite related meat allergy story I review in Alpha Gal and the Lone Star Tick and Tick Bites, Meat Allergies, and Chronic Urticaria.

In health,
Michael Greger, M.D.

PS: If you haven't yet, you can subscribe to my free videos here and watch my live year-in-review presentations Uprooting the Leading Causes of Death, More Than an Apple a Day, From Table to Able, and Food as Medicine.

Image Credit: Guillaume Paumier / Flickr

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Making Your Own Mouthwash

NF-Jan26 Making Your Own Mouthwash.jpeg

The effects of a vegetarian diet on systemic diseases like cancer, diabetes, and heart diseases have been studied and have revealed predominantly less systemic diseases in those eating plant-based diets. However, there have only been a few studies on oral health, which I covered in my videos Plant-Based Diets: Oral Health and Plant-Based Diets: Dental Health.

What's the latest? In a study of 100 vegetarians compared to a 100 non-vegetarians, the vegetarians had better periodontal conditions, showing less signs of inflammation like gum bleeding, less periodontal damage, and better dental home care, brushing and flossing 2.17 times a day compared to 2.02 times a day. The difference in home hygiene is not that large, though, so maybe it was something about their diet. However, vegetarians may have a healthier lifestyle overall beyond just avoiding meat. The researchers controlled for smoking, but other factors like obesity can adversely affect oral health, so there may be confounding factors. What we need is an interventional study, where researchers take people eating the standard Western diet, improve their diets, and see what happens. But no such study existed... until now.

With professional support of nutritionists, the participants of the study (highlighted in my video What's the Best Mouthwash?) with existing periodontal disease changed their dietary patterns to so-called "wholesome nutrition," a diet emphasizing veggies, fruits, whole grains, potatoes, beans, peas, lentils, and spices, with water as the preferred beverage. To make sure any changes they witnessed were due to the diet, researchers made subjects maintain their same oral hygiene before and after the dietary change. What did they find? They found that eating healthier appeared to lead to a significant reduction of probing pocket depth, gingival inflammation, and levels of inflammatory cytokines, which mediate the tissue destruction in periodontal disease. Therefore, the researchers conclude that wholesome nutrition may improve periodontal health.

Why might diet help? Plant-based diets have a number of nutritional benefits in terms of nutrient density, but it also may be about improving balance between free radicals and our antioxidant defense system. Traditionally, dietary advice for oral health was just about avoiding sugar, which feed the bad bacteria on our teeth. We now realize that some foods and beverages, like green tea, possess antimicrobial properties to combat the plaque producing bacteria directly.

If plaque is caused by bacteria, why not use antibiotics? Many such attempts have been made, however undesirable side-effects such as "antibiotic resistance, vomiting, diarrhea and teeth stains have precluded their use." In a petri dish, green tea phytonutrients effectively inhibit the growth of these bacteria, but what about in our mouths? Researchers found that rinsing with green tea strongly inhibited the growth of the plaque bacteria on our teeth within minutes. Seven minutes after swishing with green tea, the number of harmful bacteria in the plaque scraped from people's teeth was cut nearly in half.

If you swish sugar water in your mouth, within three minutes the pH on our teeth can drop into the cavity formation danger zone. But if 20 minutes before swishing with sugar water, you swished with some green tea, you wipe out so many plaque bacteria that the same sugar water hardly has any effect at all. The researchers conclude that using green tea as a mouthwash or adding it to toothpaste could be a cost effective cavity prevention measure, especially in developing countries.

In the "civilized world," we have antiseptic mouthwashes with fancy chemicals like chlorhexidine, considered the gold standard anti-plaque agent. If only it didn't cause genetic damage. DNA damage has been detected in individuals who rinsed their mouths with chlorhexidine-containing mouthwashes, and not just to cells in the mouth. 13 volunteers rinsed their mouths with the stuff for a few weeks, and there was an increase in DNA damage both in the cells lining their cheeks as well as in their peripheral blood cells, suggesting that chlorhexidine was absorbed into their bodies. It reduced plaque better than other antiseptic chemicals, but it's doubtful whether chlorhexidine can still be considered the golden standard considering how toxic it is to human cells.

Are we left with having to decide between effectiveness and safety? How about a head to head test between chlorhexidine and green tea? Researchers found that green tea worked better than chlorhexidine at reducing plaque. Using green tea as a mouthwash may be cheaper, safer, and better. If, as a bonus, you want to sprinkle some amla powder (dried Indian gooseberry powder) into it, you may make it an even better plaque buster. Amla evidently shows an outstanding cavity-stopping potential not by killing off the bacteria like green tea, but by actually suppressing the bacteria's plaque forming abilities.

I now keep a mason jar filled with cold-steeped green tea (Cold Steeping Green Tea) with a spoonful of amla in the fridge and swish and swallow a few times a day. For extra credit you can gargle a bit with it too (see my video Can Gargling Prevent the Common Cold?).

Green tea shouldn't be the primary beverage of children, though, as the natural fluoride content may cause cosmetic spots on the teeth. For more check out my video Childhood Tea Drinking May Increase Fluorosis Risk.

Another reason we may want to avoid antibacterial mouthwashes is that they can kill off the good bacteria on our tongue that are instrumental in enhancing athletic performance with nitrate-containing vegetables (See Don't Use Antiseptic Mouthwash). For more on this, check out my video from yesterday, Antibacterial Toothpaste: Harmful, Helpful, or Harmless?

Need a reminder what amla is? More on dried Indian gooseberry powder power in:

In health,
Michael Greger, M.D.

PS: If you haven't yet, you can subscribe to my free videos here and watch my live year-in-review presentations Uprooting the Leading Causes of Death, More Than an Apple a Day, From Table to Able, and Food as Medicine.

Image Credit: Norio Nakayama / Flickr

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Probiotics During Cold Season?

 

 

 

 

 

 

 

 

Probiotics During Cold Season?

Babies delivered via caesarean section appear to be at increased risk for various allergic diseases. The thought is that vaginal delivery leads to the first colonization of the baby’s gut with maternal vaginal bacteria. C-section babies are deprived of this natural exposure and have been found to exhibit a different gut flora. This concept is supported by research noting that a disturbance in maternal vaginal flora during pregnancy may be associated with early asthma in their children. This all suggests our natural gut flora can affect the development of our immune system (for better or for worse).

In adulthood, two studies published back in 2001 suggested that probiotics could have systemic immunity-enhancing effects. Subjects given a probiotic regimen saw a significant boost in the ability of their white blood cells to chomp down on potential invaders. (You can watch a video of white blood cells doing their thing in my video Clinical Studies on Acai Berries. A must-see for biology geeks :). And even after the probiotics were stopped, there was still enhanced immune function a few weeks later compared to baseline (check out my 4-min video Preventing the Common Cold with Probiotics? to see the graph). A similar boost was found in the ability of their natural killer cells to kill cancer cells.

Improving immune cell function in a petri dish is nice, but does this actually translate into people having fewer infections? For that, we had to wait another 10 years, but now we have randomized double-blind placebo controlled studies showing that those taking probiotics may have significantly fewer colds, fewer sick days, and fewer symptoms. The latest review of the best studies to date found that probiotics, such as those in yogurt, soy yogurt, or supplements, may indeed reduce one’s risk of upper respiratory tract infection, but the totality of evidence is still considered weak, so it’s probably too early to make a blanket recommendation.

Unless one has suffered a major disruption of gut flora by antibiotics or an intestinal infection—in other words unless one is symptomatic with diarrhea or bloating—I would suggest focusing on feeding the good bacteria we already have, by eating so-called prebiotics, such as fiber. After all, as I noted in Preventing and Treating Diarrhea with Probiotics, who knows what you’re getting when you buy probiotics. They may not even be alive by the time we buy them. Then they have to survive the journey down to the large intestine (Should Probiotics Be Taken Before, During, or After Meals?). Altogether, this suggests that the advantages of prebiotics—found in plant foods—outweigh those of probiotics. And by eating raw fruits and vegetables we may be getting both! Fruits and vegetables are covered with millions of lactic acid bacteria, some of which are the same type used as probiotics. So when studies show eating more fruits and vegetables boosts immunity, prebiotics and probiotics may be playing a role.

How else might we reduce our risk of getting an upper respiratory infection? See:

The immune boosting fruit and vegetable video I reference in Preventing the Common Cold with Probiotics? is Boosting Immunity Through Diet. See also Kale and the Immune System and the subject of my post last week, Boosting Immunity While Reducing Inflammation.

-Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live year-in-review presentations Uprooting the Leading Causes of Death and More Than an Apple a Day.

Image credit: stevendepolo / Flickr

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Probiotics and Diarrhea

 

 

 

 

 

 

 

 

Preventing & Treating Diarrhea With Probiotics

Probiotics have slowly moved from the field of alternative medicine into the mainstream, particularly for the prevention of antibiotic-associated diarrhea and the treatment of gastroenteritis.

After taking antibiotics, up to 40 percent of people experience diarrhea. Administering probiotics along with the antibiotics, though, may cut this risk in half. Which kinds and how much? Lactobacillus rhamnosis and Saccharomyces boulardii appeared to be the most effective strains, and studies using more than 5 billion live organisms appeared to achieve better results than those using smaller doses. For example, taking 100 billion organisms seemed to work nearly twice as well as 50 billion in preventing antibiotic-associated diarrhea.

Of course the best way to avoid antibiotic-associated diarrhea is to avoid getting an infection in the first place. See, for example:

We can also try to avoid consuming antibiotics in our diet: Lowering Dietary Antibiotic Intake and More Antibiotics In White Meat or Dark Meat?

The second well-established indication for the use of probiotics is in the treatment of acute infectious diarrhea, shortening the duration of symptoms by about a day. We still don’t know the best probiotic doses and strains. Studies have used between 20 million organisms a day to 3 trillion, and there are thousands of different strains to choose from. Then, even if we wanted a particular strain, odds are the label is lying to us anyway. Less than a third of commercial probiotic products tested actually contained what the label claimed. About half had fewer viable organisms than stated, and half contained contaminant organisms–including potentially pathogenic ones–as well as mold.

The mislabeling of probiotic supplements will come as no surprise to those who’ve been following my work. For example:

Ideally, we’d repopulate our gut with the whole range of natural gut flora, not just one or two hand-picked strains. This has been attempted for serious infections, starting back in 1958. Patients were given a fecal enema. Gut bacteria was taken from a healthy colon and inserted into someone else's unhealthy colon. Or we can go the other route and administer the donor stool through the nose. Evidently, this route of administration saves time, is cheaper, and less inconvenient for the patient.

Preferred stool donors (in order of preference) were spouses or significant others, family members, and then anyone else they could find (including medical staff). Doctors pick a nice soft specimen, whip it up in a household blender until smooth, put it through a coffee filter and then just squirt it up the patient’s nose through a tube and into their stomach. Don’t try this at home!

How receptive were the patients to this rather unusual smoothie recipe? None of the patients in this series raised objections to the proposed stool transplantation procedure on the basis that it “lacked aesthetic appeal.”  However, since production of fresh material on demand is not always practical, researchers up in Minnesota recently introduced frozen donor material as another treatment option.  All described in great detail in the latest review on the subject out of Yale entitled, “The Power of Poop.”

Another mention of frozen “poopsicles” can be found in my video Relieving Yourself of Excess Estrogen.

Preventing and Treating Diarrhea with Probiotics is the first of a four-part series on the current state of probiotic science. See also:

-Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live year-in-review presentations Uprooting the Leading Causes of Death and More Than an Apple a Day.

Image credit: Groume / Flickr

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