Dark Chocolate Put to the Test for Peripheral Artery Disease

One of the problems with publishing research on chocolate is that the press jumps on it, oversimplifying and sensationalizing the message, and then the money starts rolling in from candy companies and the message is muddied even more. As a result, an important idea is lost in all the frenzy: The flavanol phytonutrients in cocoa appear to be beneficial, as I discuss in my video Chocolate and Stroke Risk. Though the sugar, fat, and excess calories in chocolate aren’t good for us, “natural cocoa powder can be a health food.” So, adding cocoa to a smoothie or oatmeal, for example, would be health-promoting. Try to use unprocessed, undutched cocoa, though. The beneficial flavanols are what give cocoa its bitterness, so manufacturers try to process cocoa with alkali to destroy them on purpose. Thus, when it comes to cocoa, bitter appears to be better.

In my previous video Dark Chocolate and Artery Function, you can see how high-tech angiography showed that dark chocolate could improve the function of coronary arteries in the heart within two hours of consumption, but there are some blood vessels you can visualize with your own eyes: the blood vessels in your eyes. Two hours after eating dark chocolate, as I show at 1:18 in my Chocolate and Stroke Risk video, you can observe a significant improvement in the ability of the little veins in your eyes to dilate.

What about the blood vessels in our legs? Peripheral artery disease (PAD) is atherosclerosis in the arteries feeding our limbs, which leads to claudication, a crampy pain in our calf muscles when we try to exercise, due to impaired blood flow. So, maximal walking distance and time were studied in 20 PAD patients two hours after subjects ate either dark chocolate with at least 85 percent cocoa or milk chocolate with no more than 35 percent cocoa. After eating the dark chocolate, the subjects could walk about a dozen more yards and about 17 seconds longer than before they had the dark chocolate. In comparison, after the milk chocolate, they weren’t even able to walk as far as baseline and not for a single second longer. So, there does seem to be something in cocoa that’s helping, but a few seconds here and there isn’t much to write home about. How about reversing the atherosclerosis, which we didn’t even think was even possible until 1977.

1977? Dean Ornish didn’t start publishing on heart disease reversal until 1979. In actuality, the first demonstration of atherosclerosis reversal with a cholesterol-lowering diet and drugs wasn’t on the coronary arteries going to the heart, but on the femoral arteries going to the legs.

What have researchers observed regarding the arteries going to the brain? There is a noninvasive way to measure arterial function within the brain using transcranial ultrasound. At 2:49 in my video, you can see a chart of what happens when we hold our breath. Once we start, our brain starts opening up the arteries to increase blood flow to compensate. If the arteries in our brain are stiffened and crippled by atherosclerosis, however, they’re unable to open as much and as fast as they should, and so are said to have a smaller “breath holding index,” which can be a risk factor for stroke. So, researchers designed an experiment in which they compared the results of a target food to something neutral, like oatmeal. What target food did they choose? A spoonful of cocoa powder or something? No. They chose a randomized crossover trial of oatmeal versus a deep-fried Mars bar.

Why a deep-fried Mars bar? The study was published in the Scottish Medical Journal, and, evidently, the “deep-fried Mars bar (DFMB) is a snack…strongly associate[d] with Scotland.” Really? Yes, really. Researchers phoned a total of 627 fish and chips shops in Scotland “to ascertain the delicacy’s availability.” More than one in five shops said they did carry deep-fried Mars bars and sold up to 200 a week. (Batter-dipped and deep-dried Snickers was evidently less popular.) The researchers “conclude[d] that Scotland’s deep-fried Mars bars is not just an urban myth. Encouragingly, [they] did also find some evidence of the penetrance of the Mediterranean diet into Scotland, albeit in the form of deep-fried pizza.”

Could this be contributing to Scotland having among the highest stroke rates in Europe?  Interestingly, there was a significant drop in men compared to women, which you can see at 4:29 in my video. Maybe men are from Mars and women are from Snickers? Regardless, what about chocolate that’s not deep-fried? There have been a few population studies that have followed people over time that found that those who ate chocolate appeared to have lower stroke rates, which has since been confirmed by another study. Is it possible, though, that chocolate consumption just happens to be related to other behaviors that are heart- and brain-healthy? Maybe people who exercise a lot have to eat more food, so maybe they eat more chocolate? Researchers didn’t see any evidence of that, but you can’t account for everything. To prove cause and effect, people would need to be randomized into two groups, with half eating chocolate and the other half not, and then followed for a decade or two. To this, one researcher replied that “it would be hard to gain consent from most people to the possibility of being randomized to a ‘no chocolate’ arm. How many people would agree to forego chocolate for a ‘sufficiently long follow-up period’?” Ten to twenty years without chocolate is a pretty long time.

Want more chocolate? See:

For more on stroke prevention, 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 presentations:


How Much Vinegar Every Day?

Consuming vinegar with a meal reduces the spike in blood sugar, insulin, and triglycerides, and it appears to work particularly well in those who are insulin resistant and on their way to type 2 diabetes. No wonder the consumption of vinegar with meals was used as a folk medicine for the treatment of diabetes before diabetes drugs were invented.

Many cultures have taken advantage of this fact by mixing vinegar with high glycemic foods. For example, in Japan, they use vinegar in rice to make sushi, and, in the Mediterranean, they dip bread into balsamic vinegar. Throughout Europe, a variety of sourdough breads can lower both blood sugar and insulin spikes. You can get the same effect by adding vinegar to boiled white potatoes then cooling them to make potato salad.

Adding vinegar to white bread doesn’t just lower blood sugar and insulin responses—it increases satiety, or the feeling of being full after a meal. As you can see in my video Optimal Vinegar Dose, a study found that if you eat three slices of white bread, it may fill you up a little, but in less than two hours, you’re hungrier than when you began eating. If you eat that same amount of bread with some vinegar, though, you feel twice as full and, even two hours later, still feel nearly just as full as if you had just eaten the three pieces of bread plain. But this remarkable increase and prolongation of satiety took nearly two tablespoons of vinegar. That’s a lot of vinegar. What’s the minimum amount?

It turns out that even just two teaspoons of vinegar with a meal can significantly decrease the blood sugar spike of a refined carb meal, a bagel and juice, for instance. You could easily add two teaspoons of vinaigrette to a little side salad or two teaspoons of vinegar to some tea with lemon. Or even better you could scrap the bagel with juice and just have some oatmeal with berries instead.

What if you consume vinegar every day for months? Researchers at Arizona State University randomized pre-diabetics to take daily either a bottle of an apple cider vinegar drink—a half bottle at lunch, and the remaining half at dinner—or an apple cider vinegar tablet, which was pretty much considered to be a placebo control: While the bottled drink contained two tablespoons of vinegar, the two tablets only contained about one third of a teaspoon. So in effect, the study was comparing about 40 spoonfuls of vinegar a week to 2 spoonfuls for 12 weeks.

What happened? On the vinegar drink, fasting blood sugars dropped by 16 points within one week. How significant is a drop of 16 points? Well this simple dietary tweak of a tablespoon of vinegar twice a day worked better than the leading drugs like Glucophage and Avandia. “This effect of vinegar is particularly noteworthy when comparing the cost, access, and toxicities” associated with pharmaceutical medications. So the vinegar is safer, cheaper, and more effective. This could explain why it’s been used medicinally since antiquity. Interestingly, even the tiny amount of vinegar in pill form seemed to help a bit. That’s astonishing. And, no: The study was not funded by a vinegar company.

What about long-term vinegar use in those with full-blown diabetes? To investigate this, researchers randomized subjects into one of three groups. One group took two tablespoons of vinegar twice a day, with lunch and supper. Another group ate two dill pickles a day, which each contained about a half tablespoon’s worth of vinegar. A third group took one vinegar pill twice a day, each containing only one sixteenth of a teaspoon’s worth of vinegar. I wasn’t surprised that the small dose in the pill didn’t work, but neither did the pickles. Maybe one tablespoon a day isn’t enough for diabetics? Regardless, the  vinegar did work. This was all the more impressive because the diabetics were mostly well controlled on medication and still saw an additional benefit from the vinegar.

Make sure to check out my other videos on vinegar’s benefits:

This vinegar effect seems a little too good to be true. There have to be some downsides, right? I cover the caveats in Vinegar Mechanisms and Side Effects.

There are a few other foods found to improve blood sugar levels:

The best approach, of course, is a diet full of healthy foods:

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:

Sip Smoothies Slowly

A famous study in 2000 compared the impact of soda versus jelly beans. Researchers had people add 28 extra spoonfuls of sugar to their daily diet in the form of jelly beans or soda. Then, they measured how many calories participants ate over the rest of the day to see if their bodies would compensate for all that extra sugar. For the jelly bean group, their bodies registered all the extra calories from the handfuls of jelly beans and they ended up eating less of everything else throughout the day. So, they ate pretty much the same number of calories before and after adding the jelly beans to their diet. But, for the soda group, despite all the added calories from the cans of pop they were drinking every day, they kept eating about the same amount. No wonder they gained weight after a month of drinking soda. Their bodies didn’t seem to recognize the extra calories when they were in liquid form and therefore didn’t compensate by reducing their appetite for the rest of the day.

What if we drink a smoothie for breakfast instead of eating a solid meal? Will our body think we skipped breakfast and make us so ravenous at lunch we’d eat more than we normally would and end up gaining weight? To answer this, we first have to determine if this solid versus liquid calorie effect is real. Soda and jelly beans don’t just differ by physical form; they have different ingredients. That’s a problem with a lot of these kinds of studies: They use dissimilar foods.

Take, for example, the study comparing liquid to solid breakfasts in my video Liquid Calories: Do Smoothies Lead to Weight Gain?. Researchers gave participants breakfasts of either fruit juices and skim milk or oatmeal with blueberries and apples. Not so surprisingly, study subjects were less hungry after the oatmeal. But, that may not be a solid versus liquid effect, as the breakfasts were comprised of completely different foods.

To test for a solid versus liquid effect, you’d have to use the exact same foods in two different forms. Finally, a study did just that. Researchers looked at what happens if you have a fruit salad with raw apples, apricots, and bananas with three cups of water to drink versus blending the fruit with two of the cups of water to make a smoothie and then just drinking the third cup of water. It’s the identical meal—one in solid form and one in smoothie form. What happened? People felt significantly less full after the smoothie, although it was the same amount of food and fiber. In smoothie form, it didn’t fill people up as much as eating fruit au natural.

Originally, we thought it was due to the lack of chewing. The act of chewing itself may be an I’ve-eaten-enough signal that you don’t get just by drinking. Researchers had people chew either 10 or 35 times per mouthful and eat pasta until they felt comfortably full. Those forced to chew 35 times per bite ended up eating about a third of a cup less pasta than those who only chewed 10 times per bite. So there we have it: We had the proof of solid versus liquid effect and the mechanism. But, as so often happens in science, just when we have everything neatly wrapped up with a bow, a paradox arises.

In this case, the great soup paradox.

Pureed, blended soup—essentially a hot, green smoothie of blended vegetables—is more satiating than the same veggies in solid form. The same meal in liquid form was more filling than in solid form. So, it can’t be the chewing that has the satiating effect. In fact, there doesn’t appear to be a solid versus liquid effect at all since cold smoothies appear to be less filling, but hot smoothies appear to be more filling. They are so filling that when people have soup as a first course, they eat so much less of the main course, that they eat fewer calories overall, even when you add in the soup calories.

How can we explain this paradox? Maybe pureed fruit is less filling than solid, but pureed vegetables are more filling? To test this, Purdue University researchers used apple soup. They mixed about a cup of apple juice with two cups of applesauce, liquefied it in a blender, and heated it up. If you have people eat three actual apples, they started out pretty hungry, but, within 15 minutes of eating the apples, they were hardly hungry at all. Drinking three cups of apple juice didn’t cut hunger much, but what about the apple soup, which was pretty much just hot apple juice with applesauce mixed in? The apple soup cut hunger almost as much as the whole apples, even more than an hour later. It even beat out whole apples for decreasing overall calorie intake for the day.

What’s so special about soup? What does eating soup have in common with prolonged chewing that differentiates it from smoothie drinking? Time. It took about twice as long to chew 35 times. And think about how long it takes to eat a bowl of soup compared to drinking a smoothie. Eating slower reduces calorie intake.

Alternatively, maybe we just imagine soup to be filling, so it’s like a placebo effect. Feelings like hunger and fullness are subjective. People tend to report hunger more in accordance with how many calories they think something has rather than the actual caloric content. If you study people with no short-term memory, like the character in the movie Memento who couldn’t remember what happened more than a minute ago, they can overdose on food because they forgot they just ate, which shows what poor judges we are of our own hunger. It’s not just subjective effects, either. In a famous study called Mind Over Milkshakes, people were offered two different milkshakes, one described as indulgent, “decadence you deserve,” and the other a sensible, “guilt-free satisfaction.” People have different hormonal responses to them even though they were being fooled and given the exact same milkshake.

Finally, maybe it was just because the soup was hot, and warmer foods may be more satiating? How do we figure out if the solution to the soup mystery was time, thought, or temperature? If only the study we discussed earlier that had subjects eat either a fruit salad with three cups of water or drink the same exact foods in smoothie form had a third group—a liquid eating group, too. Well, it did!

Researchers also offered the fruit smoothie in a bowl to be eaten cold with a spoon. (Very un-soup-like.) So, if it were thought or temperature, the fullness rating would be down by the liquid drinking. However, if it was just the slowed eating rate that made soup as filling as solid food, then the fullness rating would be up closer to the solid eating rating—and it was exactly as high. The only real reason smoothies aren’t as filling is because we gulp them down, but if we sip them slowly over time, they can be just as filling as if we ate the fruits and veggies solid.

Wow, that study thought of everything. You don’t know the half of it! They also wanted to see if it would work with high-fat smoothies too. So, what, almond butter or walnuts? No, they used a liquefied fat smoothie of steamed pork belly.

I guess maybe  sometimes smoothies can suppress your appetite 🙂

I have a whole series of videos on smoothies: Are Green Smoothies Good for You?, Are Green Smoothies Bad for You?, Green Smoothies: What Does the Science Say?, and The Downside of Green Smoothies.

For videos on weight gain, see Do Fruit & Nut Bars Cause Weight Gain?, Does Chocolate Cause Weight Gain?, Nuts and Obesity: The Weight of Evidence, and How Diet Soda Can Make Us Gain Weight. 

For weight loss, check out How Much Exercise to Sustain Weight Loss, Brown Fat: Losing Weight Through Thermogenesis, Boosting Brown Fat Through Diet, Eating More to Weigh Less, and Can Morbid Obesity Be Reversed Through Diet?

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: