Teaching Doctors About Supplements

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In late May, the Food and Drug Administration (FDA) in partnership with the American Medical Association (AMA) released two short videos to teach physicians about dietary supplements, plus a third aimed at consumers.

The first video spent time defining and explaining what a dietary supplement is, the delivery systems companies use such as tablets,  gummies, bars, etc., and the role the FDA plays in the process. The second video focused on adverse events, how to report them, and a sample conversation between a doctor and patient. I encourage you to watch the videos at the links below.

I think there are two important points of the videos. First, the FDA does not approve dietary supplements in the same way that they approve pharmaceuticals—obviously their main point because it was repeated several times. In exchange for allowing supplements to be introduced quickly, companies do not have to prove safety or effectiveness. However, if they make any health claim, they must report that to the FDA within 30 days of making the claim. Those claims are restrictive; a company can’t say on the bottle or promotional materials “cures heart disease” but can say “contributes to a healthy heart.”

Second, you should always discuss the supplements you take with your physician, especially if you take medications. It can be a pain if you take a lot of supplements, but you must do it because there can be interactions. For example, calcium, whether from food or a supplement, interferes with the absorption of thyroid medications. They should not be taken together (which is tricky because it’s recommended thyroid meds be taken at bedtime when you may be taking a calcium-magnesium supplement to aid sleep).

Those are what I see as the positives of these videos that cover supplement companies and patients; there’s no information about how supplements work or which supplements do what. I’ll cover that aspect of the videos on Saturday. In the meantime, take the time to watch both 10-minute videos.

What are you prepared to do today?

        Dr. Chet

References:
1. https://www.youtube.com/watch?v=GYJYPCJmspE
2. https://www.youtube.com/watch?v=qqyP-vbtlZY

Myths Busted: Eat Your Fruit

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If you’ve watched the video, you know Dr. Berry gave three myths of the sugars in fruit. We addressed Myth One and Myth Two in Tuesday’s Memo. Today let’s examine Myth Three, and then consider whether fruit will cause non-alcoholic fatty liver disease.

Myth Three: Fiber, Vitamins, Minerals, and Phytonutrients Aren’t Important

This myth is sort of grasping at straws to try to prove a point. He claims that the fiber, vitamins, minerals, and phytonutrients in fruit are meaningless because of all the sugar in the fruit. He makes the comparison of adding those nutrients to a 20-ounce cola and then asking if we would feed that to our child.

Let’s get the facts straight. A 3.3 ounce orange contains a total of 8.5 grams of sugars with all the associated nutrients that he’s saying aren’t important, and he’s comparing that to a 20-ounce cola with 65 grams of high-fructose corn syrup with some of those nutrients added. While the molecules may be identical (Myth Two), there are differences in metabolism between sucrose and high-fructose corn syrup he doesn’t seem to understand. A better way would have been to use equivalent serving sizes. Even better, don’t force an issue that’s marginal, at best, and uses observational science as the foundation.

Okay, I’ve used the term “observational science” several times—what does that mean? Dr. Berry appears to be a very good physician who has helped many people overcome type 2 diabetes and other metabolic disorders using a ketogenic diet. He deserves credit for that, but when you use what you observe as the basis for recommendations for everyone, that’s stretching it.

According to an observational rooster, his crowing makes the sun rise every morning. Observation alone isn’t enough basis for these kinds of recommendations. Unless you have documentation that someone eating 3.3 ounces of lemon containing a total of 2.3 grams of all sugars will spike her insulin and glucose levels, the argument is baseless. In fact, every example he gave should have actual examples to support it, not from the published science but from actual experience. (That would be easy enough to do just by feeding subjects the food in question and then checking their blood sugar at certain intervals.) And it should be published as a case study in a medical journal, because that metabolic response would be unusual to say the least. Until then, it’s observational science and is not meaningful applied to anyone else. Leave the observational science behind unless you have the data to support it.

The Bottom Line

In doing the background research, I found that eating fruit does not appear to be a cause of non-alcoholic fatty liver disease or even a fatty liver. Obesity always seems to precede metabolic disorders that lead to a fatty liver in the vast majority of people. The DASH Diet and the Mediterranean diet, which both recommend fruit, are often recommended to treat a fatty liver, and research shows they work—and that’s the complete opposite of what he recommends.

If you’re concerned about a fatty liver, don’t give that banana or bowl of berries a second thought; focus instead on weight reduction. As always, the key is the calories. Eat less. Eat better. Move more.

What are you prepared to do today?

        Dr. Chet

References:
1. Br J Nutr. 2020 Jul 14; 124(1): 1–13.
2. Iran J Public Health. 2017 Aug; 46(8): 1007–1017.

Fruit and Fatty Liver Disease

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Non-alcoholic fatty liver disease (NAFLD) is on the rise in the U.S. and around the world. Estimates are by 2030, NAFLD will be the primary cause of liver transplants in the world. NAFLD is caused by obesity; associated conditions such as type 2 diabetes and metabolic syndrome are contributing factors. But does fruit intake contribute to NAFLD? According to one physician it does; that inspired him to record a video titled “Secret Sugar in Fruit” or as he calls it, the Three Myths of Fruit. He’s an advocate of the ketogenic diet, as many people are today, but is he correct about fruit? I thought I’d check it out.

Myth One: Fruit Contains Only Fructose

His opening statement about fruit is that nutritionists and Internet gurus are suggesting that fructose is the only sugar in fruit. He gives examples of the breakdown of sugars in five fruits, based on the USDA Food Database. No problem with that. But to say that most nutritionists don’t know that fruit contains a variety of sugars means he’s never had a basic nutrition class on macronutrients, because it’s certainly taught in those classes. Anyone who’s ever looked up any type of fruit on the database would clearly see there’s more than one type of sugar.

He also claims that the sugar in some small servings of fruit with as little as two grams of glucose or sucrose will spike blood sugars and insulin levels and that five grams of fructose will cause a fatty liver. He offers no evidence to support those claims.

Myth One contains some accurate facts but is more observational science than fact. Myth One: busted.

Myth Two: The Chemical Structure of Sugars

According to Dr. Berry, nutritionists claim that the chemical structure of glucose, fructose, and sucrose are different in fruit than soda. Not exactly true; they’re chemically identical, but there’s more to it than that. Myth Two: mostly busted.

I’ll cover the third myth on Saturday and set the record straight on fruit and NAFLD. You can watch the short video at the link below. He’s a personable guy, committed to keto, but reliant on observational science. We’ll talk about why that’s a problem next time.

What are you prepared to do today?

        Dr. Chet

References:
1. Gastroenterology. 2020 May;158(7):1851-1864.
2. https://www.youtube.com/watch?v=URMLzoK95V4

Cleaning Up and Moving On

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I look around my desk, and what used to be a dumping ground for unopened mail, notes written on legal pads, sticky notes, and the backs of envelopes, is almost pristine. It was time to clean up and move on. I’m prepared to do the same thing with my Memo list of subscribers; next month I’ll be deleting those who haven’t opened emails in a year or more.

I know habits change. New email addresses are created without deleting the old account. People may not be interested in getting the Memo any more. The Memo may go directly into their spam folder. In some cases, the mailbox is full and the email gets bounced. In the email world, any of those actions show as red flags and can impact how email is treated by servers. Purging the list keeps my email address in good standing in the email world and helps keep me out of your spam folder.

You may notice that I sometimes put in links for you to click to save you time if you want further information. In some cases, that will send the Memo to your spam folder. If you don’t get two Memos per week, that’s a good place to look; you can also designate my email address as Safe or Not Spam.

Did you know that forwarding a Memo to someone can get you unsubscribed? If whomever you forwarded the Memo to clicks the Unsubscribe button at the very bottom, they unsubscribe your email address, not theirs, and there’s no way for me to know that’s not what was intended. If that happens, you’ll get an email from me saying you’ve been unsubscribed. I appreciate that you want people to read what I write, but be aware that can happen. It’s safer (although more cumbersome) to scroll down to the bottom of the Memo text and click the turquoise “Forward” icon. In most email systems, you can also forward the Memo after cutting off the large green box at the bottom where the Unsubscribe button appears. Of course, subscribing is free so you can always go to drchet.com and subscribe again if you’re no longer getting the Memo; if you subscribe and get the message that you’re already subscribed, then you definitely should check your spam folder.

Tuesday, we’re back to health news. Enjoy the rest of your weekend.

What are you prepared to do today?

        Dr. Chet

Purge Week

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An Insider sent me an interesting link about meat—more specifically, the red liquid that’s often at the bottom of the plastic bag when you bring home meat from the grocery store or the butcher. I’ll bet you thought it was blood because that’s what it looks like, but that would be incorrect. It’s called purge by butchers and meat scientists.

If you understand three things, purge will be easy to understand.

  • All the blood is drained immediately from animals after slaughtering; if not, it will coagulate quickly and cannot be removed.
  • Muscle in animals is about 73% water. Depending on several factors, including temperature, that water starts to drain from the meat.
  • Muscle has an iron-containing protein called myoglobin that can store oxygen; myoglobin is dark red.

When the protein degrades, myoglobin leaves with the water; it’s red and that’s why people think it’s blood. If you purchase your meat very cold, purge will be released as the temperature rises, depending on which muscle the cut of meat was from, how the meat has been handled and processed, and how long it takes you to shop and drive home. And if you like your steak “bloody,” I’m sorry to tell you that’s not blood; that’s purge.

To purge also means to eliminate. I’m going to do that to my email lists. If people haven’t opened an email in the past year, it’s time to remove them from my list. I don’t make that decision lightly, because there was a reason they subscribed in the first place. In Saturday’s email, I’ll explain why I’m going to trim my list in August.

What are you prepared to do today?

        Dr. Chet

Reference: American Meat Science Association. www.meatscience.org.

The Facts on Collagen Supplementation

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After covering collagen basics on Tuesday, two questions remain. Are collagen supplements absorbed or are they digested just like any other protein? Second, does research support the use of collagen supplementation to improve skin quality? Let’s take a look.

Collagen Absorption

The data on collagen absorption is sparse. In almost every study, dipeptides or tripeptides are used; then the change in serum peptides over several hours after ingestion is measured. There’s enough data to suggest that the tripeptides are absorbed as a whole without being broken into individual amino acids.

What hasn’t been tested yet is whether protein ingestion from a meal may interfere with the digestion and absorption process.

Is Collagen Supplementation Effective?

Several review articles have summarized the absorption of collagen. Eleven studies with just over 800 subjects were included in the latest review; eight of those studies used collagen hydrolysate, 2.5 to 10 grams per day, for eight to 24 weeks. They tested whether the supplemental collagen benefitted people with pressure ulcers, dry skin, aging skin, and cellulite, with generally positive results. Two studies used collagen tripeptides, three grams per day for four to twelve weeks, with notable improvement in skin elasticity and hydration. Again, positive results.

I was disappointed to find no research on whether collagen may benefit other connective tissue such as tendons and ligaments. That may help the recovery from rotator cuff or Achilles tendon surgery, among many other conditions.

Practical Application

Based on the data, it appears that collagen tripeptides are absorbed intact to some degree, although I’m still concerned about the absorption in relation to meals. I’m already recommending that essential amino acids be taken at least 15 minutes or longer before a meal. But I think to help with absorption, take collagen tripeptides, usually collagen I and III, about 15 minutes before a meal if it contains protein or a couple of hours afterward. Giving the digestive system a head start may increase absorption. I put mine in my second cup of coffee because it has no flavor and the heat doesn’t impact the tripeptides.

The Bottom Line

Although the evidence is not overwhelming, there are positive results using collagen supplements to benefit your skin. Research shows that it will be absorbed in a form that can help the body make structural collagen for the skin. While the studies I cited used differing amounts of collagen for varying amounts of time, I would try 5 to 10 grams per day for at least 90 days to see results. And pay attention to your muscles and joints; you may find they benefit as well.

What are you prepared to do today?

        Dr. Chet

References:
1. Biol Pharm Bull. 2016;39(3):428-34.
2. StatPearls. Biochemistry, Collagen Synthesis. Marlyn Wu; Kelly Cronin; Jonathan S. Crane. 2021. PMID: 29939531
3. J Drugs Dermatol. 2019;18(1):9-16.

Are Collagen Supplements Effective?

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I spent the past weekend with a few thousand of my closest friends, some in person and others via live broadcast; that always means I get some good questions, including one about collagen I couldn’t answer.

A healthcare professional had told one attendee that collagen supplements were broken down into individual amino acids before being absorbed, as proteins are from any source, thus he was wasting his money buying collagen supplements. I decided that the answer could benefit everyone, so this week we’ll cover collagen basics.

Collagen is a protein and therefore is made up of amino acids. We can manufacture it, but just like other characteristics of aging, we make less as we get older. Collagen provides structure to all connective tissue such as skin, tendons, bones, and ligaments. We notice it most in our skin. Crepe skin? Smile lines around the eyes? Those come courtesy of reduced collagen. There are close to 30 types of collagen that have been discovered, but the most prevalent are types I–IV. Of that, over 90% are type I.

Collagen is made of repeating sequences of tripeptides or three amino acid blocks; they form three chains that twist to make a triple helix. The primary amino acid sequence of collagen is glycine-proline-X or glycine-X-hydroxyproline where X can be any of the other 17 amino acids. Glycine is the amino acid with the smallest structure; that allows the collagen triple helix to twist tightly and thus adds strength to the structure wherever it’s used, including the skin.

That’s the structure of collagen. On Saturday, we’ll answer the absorption question and look at how to use collagen most effectively. In tomorrow night’s Insider conference call, I’ll cover collagen more in depth as well as comment on the recent United States Preventive Services Taskforce on vitamin supplementation. If you become an Insider before 8 p.m. Eastern Time tomorrow, you can join me live to get your questions answered.

In the meantime, maybe you should just be proud of those smile lines—you’ve earned them, after all.

What are you prepared to do today?

        Dr. Chet

Reference: StatPearls. Biochemistry, Collagen Synthesis. Marlyn Wu; Kelly Cronin; Jonathan S. Crane. 2021. PMID: 29939531

It’s Still All About the Calories

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The keto vs. Mediterranean diet study was interesting for a variety of reasons. The researchers deserve a lot of credit for even attempting to try a study of this magnitude; 40 subjects may not seem like a lot, but to provide food via delivery together with instructions on preparation is very expensive and labor intensive. It should be noted that a portion of the study took place during the lockdown phase of COVID-19; that delayed some testing, but to their credit, the subjects affected continued the particular diet they were on for the two weeks until testing could be scheduled. Here are my thoughts on the results.

Blood Lipids

  • Subjects on the keto diet showed a greater decrease in triglycerides (TG) than those on the Mediterranean diet.
  • On the other hand, those on the Mediterranean showed a greater decrease in LDL-cholesterol than did the keto diet subjects.

While the researchers discussed it at length, I don’t think it was relevant. All subjects began with average fasting TG in the normal range. While both diets decreased TG, that the keto diet reduced it slightly more isn’t earth shattering when you start at a normal reading.

The same holds true for the LDL-cholesterol. Yes, the Mediterranean diet reduced it while the keto diet increased it, but the net was 6 mg/dl over the initial readings. What could have been concluded was that neither diet reduced LDL-cholesterol by an amount that was clinically meaningful.

The Microbiome

There were no tests of the changes in the microbiome under each diet reported—at least not yet. Subjects had a definite decline in fiber intake, especially when they provided their own food in the keto diet. The Mediterranean diet saw an increase in fiber intake when subjects provided their own food.

Why mention this at all? The microbiome controls the initial processing of nutrients. In addition, the immune function begins in the gut. While the keto diet may have provided some benefit related to HbA1c, at what cost? We simply don’t know. What we do know based on other research is that the lack of fiber changes the probiotic content of the microbiome.

The Bottom Line

The data showed that the subjects averaged 200 to 300 fewer calories per day regardless of diet and maintained the reduction over both diets. They ate better, they ate less, and they lost weight.

I think this study was important because it leaves us with better questions to ask in the future, such as: how would health measures be affected if subjects reduced calories another way? It also proves what I’ve been saying for years. The average weight loss after the study was 13 to 17 pounds, and that was maintained during the follow-up period. This was not a weight loss study, yet regardless of the initial diet, the subjects lost weight. I’ve said it before and I’ll say it again: regardless of the type of diet, it’s still all about the calories.

What are you prepared to do today?

        Dr. Chet

Reference: AJCN doi.org/10.1093/ajcn/nqac154

Face-Off: Mediterranean vs. Keto

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Last week ended with the publication of an interesting study on two popular diets, Mediterranean and ketogenic, and their potential benefits for people with elevated HbA1c levels; HbA1c is a blood test that measures your average blood sugar levels over the past three months. I use the word “diet” as a description of the type of foods eaten, not as a weight loss program.

The researchers constructed what they termed the Well-Formulated Ketogenic Diet plan to compare with a Mediterranean diet. Both approaches reduced sugar, refined carbohydrates, and starchy vegetables; the Mediterranean diet added unprocessed whole grains, beans, and fruit. The subjects had either prediabetes or type 2 diabetes. The primary goal of the 36-week program was to monitor changes in HbA1c along with a variety of secondary measures including blood lipids.

The 40 subjects were randomly assigned to using the keto diet for 12 weeks and then switching to the Mediterranean diet for 12 weeks or vice versa. Food was delivered to all subjects for the first four weeks of both phases, which I think is brilliant—one of the hardest parts of learning a new way of eating is discovering how the foods can be combined and prepared, along with getting used to the different tastes. After those four weeks, they provided their own food that fit within the particular diet they were on at the time. The final 12 weeks were left up to the subjects.

The results demonstrated both dietary approaches reduced HbA1c about the same amount, and the decrease was maintained regardless of which diet they began with. However, there were some differences as well. I’ll give you those on Saturday.

What are you prepared to do today?

        Dr. Chet

Reference: AJCN doi.org/10.1093/ajcn/nqac154

Citric Acid: Stone Killer?

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Increasing fluid intake can reduce the risk of developing stones of all types: kidney stones, gall stones, bladder stones, or uric acid crystals. But there’s one more thing you could do to reduce the risk—add some citric acid to the fluids you drink. While the research on using a form of pharmaceutical is not clear yet, this is one thing we can do with diet.

We expect electrolytes such as sodium, potassium, magnesium, and calcium in sport drinks, but adding citric acid can help your blood’s pH as well as reduce the formation of stones. The simplest approach would be to drink limeade or lemonade; fresh squeezed or a manufactured drink, citric acid makes the drink tart and sour. The food with the highest amount of citric acid is lime, with lemon a close second. I typically use sugar-free lemonade and add the juice from one lime in a 16-ounce container. It’s very tart but not inedible.

Avoid the mentality of “if some is good, more must be better.” Research hasn’t shown that to be true, so let’s stick to what we know. And while citric acid is a weak acid, it may still give you an upset stomach if you have too much. One lime or lemon per day seems to reduce stone formation.

What are you prepared to do today?

        Dr. Chet

Reference: Korean J Urol. 2014 Dec; 55(12): 775–779.