 It's crazy when you think about all the different kinds of foods we eat. We just swallow and hope it all works out for the best. Well, it turns out there are better ways to think about keeping our bodies humming healthfully along. Welcome to Nutrition Facts. I'm your host, Dr. Michael Greger. It's time for the Nutrition Facts Grab Bag, where we look at the latest science on a whole variety of topics. We start with a story on how cannabis smoking may help with IBD symptoms in the short term. Medical marijuana, a panacea, or scourge. For 5,000 years, cannabis has been used throughout the world for medicinal purposes, even prescribed by American physicians early on, a fact that's often used by medical marijuana proponents to justify modern medical applications. But the field of old-timey medicine was fraught with patent medicine, snake oil nonsense, not to mention bloodletting and other questionable and harmful remedies. Skeptics criticized the medical marijuana movement as the medical excuse marijuana movement insinuating that epileptic children and the terminally ill are just being used as props to trojan horse in the legalization of recreational use or to pedal outlandish claims about miracle cancer cures, frustrating researchers in the field who just want to get at the science. For example, what about the therapeutic use of cannabis for inflammatory bowel diseases like Crohn's disease and ulcerative colitis? Conventional therapies mainly work by suppressing the immune system to try to tamp down the inflammation, given the limited therapy options and known adverse side effects from these drugs. Often people suffering these diseases ended up having to get inflamed sections of their bowels removed surgically, so you can see whether there's so much interest in alternative approaches. About 1 in 6 IBD patients who use marijuana say it helps with their symptoms, so researchers decided to put it to the test. 13 patients with inflammatory bowel disease were given a third of a pound of marijuana to smoke at their leisure over a period of three months, and they felt significantly better. Now there's no control groups, you don't know if they would have gotten better anyway, or what role the placebo effect may have played. It's like some of the studies of cannabis used for pediatric epilepsy. Response rates of over 30%, seizure frequency cut in half in a third of the kids, that's amazing! Until you realize you can sometimes get the same kind of amazing response giving kids nothing, giving them a sugar pill placebo. That's why it's critical to do randomized double-blind placebo-controlled trials, but there weren't any on cannabis and IBD until 2013. 21 patients with Crohn's disease, for which nothing seemed to help, so they randomized them to either smoke two joints a day of real pot or a look-alike placebo pot, and 90% of the subjects in the cannabis group got better compared to only 40% of the placebo group. The cannabis group cut their symptoms in half. They acknowledged that long-term cannabis use is not without risks, but may be a cakewalk compared to the potential adverse and even life-threatening side effects of some of the more powerful conventional therapies, so the study was heralded as offering high hope for digestive disorders. Now the study was funded by a medical marijuana advocacy organization, in fact the main supplier in the country, so there may have been expectations placed on the subjects on how much better this stuff was going to make them feel, in other words, a setup for the placebo effect. But they controlled for that, right? Those getting the real stuff did significantly better than those randomized to get the placebo pot. Oh wait a second, the whole point of a placebo is to be indistinguishable from the real thing that the subjects don't know which group they're really in. How do you do that with a psychoactive drug? You can't. Which is the problem? They tried to hide which group people were in by recruiting only patients who'd never tried pot before in hopes that they wouldn't notice, but of course most of them did. And what we're left with is basically another unblinded study. They asked them a bunch of subjective questions, how you're feeling, and those who mostly knew they were taking the drug said they were feeling better. There was no change in the objective lab values like CRP, a sign of inflammation. So maybe the marijuana is just masking symptoms without actually affecting intestinal inflammation. Another indicator the cannabis may not be affecting the course of the disease itself is how quickly the symptoms rebounded. Two weeks after the study ended, the cannabis group was right back up to where they started. So no difference in objective inflammatory markers. And given the rapid rebound, it seems more plausible that cannabis ameliorated the symptoms of Crohn's disease rather than actually modulating the disease itself. Okay, yeah, but the symptoms are terrible. A reduction in pain is a reduction in pain. From the point of view of the patients, a marked symptomatic improvement and ability to resume normal life is not trivial, whether or not the inflammation persists. I mean, unless of course cannabis somehow made the disease worse in the long run, and this survey study published the following year, found that cannabis provided that same immediate symptomatic relief but was associated with a worse disease prognosis over time. Patients with inflammatory bowel disease reported that cannabis improved their pain, cramping and diarrhea, but used for more than six months in Crohn's patients appeared to be a strong predictor of them ending up in surgery, five times the odds of them ending up under the knife. Now, there's two possible explanations for this. It's quite possible that it was the increased severity that led to the cannabis use, and not the other way around. But the alternative explanation is that cannabis use may worsen the prognosis leading to greater surgeries and hospitalizations. That's why we really need prospective clinical trials, where we follow people over time to see which came first. But until then, maybe we should consider cannabis use and IBD as potentially harmful, not just air on the side of caution, but there was this other study on hepatitis C patients that found that daily cannabis use was associated with nearly seven times the odds of worse liver fibrosis, which is like scar tissue. And so, hey, if cannabis really does make fibrosis worse, then that could potentially explain why cannabis users with IBD may be more likely to end up on the operating table. In our next story, we look at the leading risk factor for death in the United States, the American diet. About a decade ago, the American Heart Association expressed concern that their 2020 target of improving cardiovascular health by 20% by 2020 would not be reached if current trends continued. By 2006, most people were already not smoking and had nearly achieved their goal for exercise, but when it came to a healthy diet score, only about 1% got a 4 or 5 out of their 0 to 5 diet quality score, and that's with so-called ideal criteria of being like drinking less than 4 1⁄2 cups of soda a week. In the last decade, they saw a bump up to like 1% of Americans even reaching this kind of basic criteria, but given their aggressive goal of improving that by 20% by 2020, we hope to turn that 1% into like 1.2%. OK, so how'd we do? Let's look at the 2019 update, and it looks like we've slipped down to as low as 1 in a thousand, and American teens got a big fat zero. No wonder perhaps that for all mortality-based metrics, the US rank declined to like 27th or 28th among 34 industrialized countries. Americans living in countries with a substantially lower GDP and health expenditures per capita have lower mortality rates than those in the United States. Slovenia beat us by three countries, coming in at 24th, and life expectancy to our 27th. And more recently, we seem to have slipped to 43rd, even though we spent trillions on health care more than anyone else. What's the leading risk factor for death in the United States? What we eat. The standard American diet is just to die for, literally. Those trillions in health care spending aren't addressing the root cause. Approximately 80% of chronic disease and premature death could be prevented by not smoking, being physically active, and adhering to a healthful dietary pattern. But what exactly is meant by a healthy diet? Unfortunately, what we hear about nutrition in the media is often inconsistent and confusing. There's a pressure within today's competitive journalism market for sensationalism. There may even be a disincentive to prevent the facts in context to sell more magazines. In fact, about three quarters of a century ago, it was noted that, unfortunately, the subject of nutrition seems to have a special appeal to the credulous, the social zealot, and, in the commercial field, the unscrupulous. A combination calculated to strike despair in the hearts of the sober objective scientist. The most important health care problem we face may be our poor lifestyle choices based on misinformation. It's like the climate change deniers. Healthy dietary vice is overshadowed by critics, diabetics, industry interests, and misguided information in the media. Maybe what we need is like an IPCC of nutrition. These days, no single expert, regardless of academic stature or reputation, has the prominence to overcome the obstacles created by confusing media messages and effectively deliver the fundamental principles of healthy living to the public. However, what if there was a global coalition consisting of a variety of nutrition experts who collectively represent the views held by the majority of scientists, physicians, and health practitioners? It could serve as a guiding resource of sound nutrition information for improved health and prevention of disease. Boom! The True Health Initiative was conceived for that very purpose. A nonprofit coalition of hundreds of experts from dozens of countries agreed to a consensus statement on the fundamentals of healthy living. Check out www.truehealthinitiative.org. Spoiler alert, the healthiest diet is one generally comprised of minimally processed plants. Finally, today we look at how the incidence of side effects from statins is low in clinical trials, but high out in the real world. There is now overwhelming evidence to support reducing LDL cholesterol, bad cholesterol, to reduce atherosclerotic cardiovascular disease, the number one killer of men and women. So why is adherence to cholesterol-lowering statin drug therapy such a major challenge? The majority of studies reported at least 40%, and as much as 80% of patients did not comply fully with statin treatment recommendations. Three quarters make flat-out stop taking them, or sometimes up to nearly 90% discontinue treatment. When asked why, most former statin users or discontinuers cited muscle pain. A side effect is the primary reason for stopping the pills. By far, the most prevalent and important adverse events, up to 72% of all statin side effects, are statin-associated muscle symptoms. Taking coenzyme Q10 supplements as a treatment for statin-associated muscle symptoms was a good idea in theory, but they don't actually appear to help. Normally side effect symptoms go away when you stop the drug, but sometimes can linger a year or more. There's evidently growing evidence that statin intolerance is predominantly psychosocial, not pharmacological, meaning, wait, maybe it's mostly just in people's heads? Statins have developed a bad reputation with the public, one editorial read, a phenomenon driven largely by proliferation on the internet of bizarre and unscientific criticisms of these drugs. Maybe it's Google that leads to statin intolerance. But come on, people have been going off statins for decades before there even was an internet. What kind of data has doctors suggesting that patients are falsely misattributing normal aches and pains to be statin side effects? Well, if you take people, claim to have statin-related muscle pain and randomize them back and forth between statins and an identical-looking placebo in three-week blocks, they can't actually tell whether they're getting the real drug or the sugar pill. The problem with that study, though, is that it may take months to not only develop statin-induced muscle pain, but months before it goes away. I mean, so no wonder three weeks on, three weeks off may not be long enough for the participants to discern which is which. But these data are more convincing. 10,000 people were randomized to a statin or sugar pill for a few years. They had to stop the study early because so many more people were dying in the sugar pill group, and so everyone was then offered the statin. What they noted was that there was no excessive reports of muscle-related adverse effects among patients assigned to the statin over those assigned to the placebo, but then when the placebo phase was over and the people knew they were on a statin, then they reported more muscle side effects than those who knew they weren't. These results illustrate the so-called nocebo effect, kind of like the opposite of the placebo effect. Placebo effects are positive consequences, falsely attributed to a treatment, whereas nocebo effects are negative consequences, falsely attributed to a treatment. There was an excess rate of muscle-related adverse effects reported only when patients and their doctors were aware that statin therapy was being used, and not when it was being concealed. They hope these results will help assure both physicians and patients that most adverse events associated with statins are not actually caused by the drug, and should help counter exaggerated claims about statin-related side effects. As these kind of results from placebo-controlled randomized trials that are said to have shown it definitively, that almost all the symptomatic adverse events that are attributed to statin therapy and routine practice are not actually caused by the drug. Now, only a few patients will believe this, that their statin-associated muscle symptoms are of psychogenic origin, meaning all just in their head, but their denial may have deadly consequences. Discontinuing statin treatment may be a life-threatening mistake. The mortality of those who stopped their statins after having a possible adverse reaction compared to those who stuck with them. This translates into about one excess death for every 83 patients who discontinued treatment within a four-year period. So, when there are media reports about statin side effects and people stop taking them, this could result in thousands of fatal and disabling heart attacks and strokes which would otherwise have been avoided. Seldom in the history of modern therapeutics have the substantial proven benefits of a treatment been compromised to such an extent by serious misrepresentations of the evidence for its safety. But is it a misrepresentation to suggest statin therapy caused the side effects enough to a fifth of patients? I mean, that is actually what you see in clinical practice. Between 10% to 25% of patients placed on statins complain of muscle problems. But because we don't see anywhere near those kinds of numbers in controlled trials, patients are accused of being confused. Why in clinical trials is the incidence of side effects from statins so low but out in the real world appear to be so high? For example, take this meta-analysis of clinical trials, finding muscle problems, not in one in five, but only one in 2,000 patients. So, hey, maybe everyone over a certain age should be on them. But of course, every single one of those trials was funded by the statin manufacturers themselves. So for example, how could the randomized controlled trials mis-detecting statin-related adverse side effects such as muscle pain by not asking? A review of 44 statin trials revealed that only one directly asked about muscle-related adverse effects. So are the vast majority of side effects just being missed in all these trials? Or are the vast majority of side effects seen in clinical practice just some figment of patients' imagination? Bottom line, we don't know. But there's certainly an urgent need to figure it out. We would love it if you could share with us your stories about reinventing your health through evidence-based nutrition. Go to nutritionfacts.org slash testimonials. We may share it on our social media to help inspire others. To see any graphs, charts, graphics, images, or studies mentioned here, please go to the nutrition facts podcast landing page. There you'll find all the detailed information you need, plus links to all the sources we cite for each of these topics. For our timely texts and the pathogens that cause pandemics, you can order the e-book out of your book or hard copy of my latest book, How to Survive a Pandemic. For recipes, check out my new How Not to Diet Cookbook. Beautifully designed with more than 100 recipes for delicious and nutritious meals. And all the proceeds I receive from the sales of all my books goes to charity. NutritionFacts.org itself is a nonprofit, science-based public service where you can sign up for free daily updates on the latest in nutrition research via bite-sized videos and articles. Everything on the website is free. There's no ads, no corporate sponsorship. It's strictly non-commercial. I'm not selling anything. I just put it up as a public service as a labor of love as a tribute to my grandmother whose own life was saved with evidence-based nutrition.