Leafy Greens 6x/Day? (Followup to "nitric oxide production")

[brec]

Context: Esselstyn recommends consumption of leafy greens 6x/day to cardiovascular patients in order to provide antioxidants and to increase nitric oxide (NO) availability to endothelium. He personally recommended this to me in Dec. 2012. Here's a video of an Esselstyn presentation in which that recommendation "for at least the first 4-6 months" "to [his] cardiac patients" begins at the 40:00 point.

In the "nitric oxide production" thread of this date,

Lastly, in regard to the "6x a day" principle...

While I understand why Dr Esselstyn uses it as a "mantra," (like with the cholesterol of 150) we also have to put it in proper perspective.

While some pharmacological treatments must be given multiple a few times a day, (insulin, etc), many are not as their impact is much longer term than a few hours. Some actually last days. So, is the impact of nitrates on our endothelium, blood flow, BP, etc, short term or long term.

As we can see in these studies, when given as a "treatment," the effect [lasts] for many hours, in some of these studies, 4-6 hours or more and the overall impact may last for days.

http://www.atherosclerosis-journal.com/ ... 21-9150(13)00517-0/abstract

http://jap.physiology.org/content/107/4/1144

In neither of the linked studies (one abstract, one full text) did I find results indicating a lasting effect. The first tested exercise results during the last three of six days in which subjects were instructed to sip beet juice throughout the day. The second tested brachial artery response two hours after beet juice ingestion.

In one of his conversations with me, Esselstyn indicated that a patient whose angina was ameliorated by the recommended nutrition regimen had a return of angina very soon after he opted to discontinue the leafy greens 6x/day. My conclusion from this N=1 result was that the benefit of the 6x/day was dynamic, not structural.

And one of the main companies who is selling a supplement created from all the above studies, has just 420 mg in a a dose, which is recommended once per day.

http://www.neogenis.com/neo40-daily.html

After carefully reviewing the marketing materials of that vendor, my own conclusion is a lack of confidence. The entrepreneur, Dr. Nathan Bryan, is a significant contributor to research on the role of NO but the commercialization result of that research did not, let us say, sell me.

In short, I have yet to see persuasive evidence of the longevity of the NO effect of oral consumption of greens, beet juice, or Bryan's formulation. But I have not done much research specifically on the duration issue, so feel free to bring it on!

Remember, as I said above [in the other thread's post], "anyone including lots of plants as we recommend is already easily consuming quite a bit [of] plant nitrates *throughout the day.*"

So, let's put this together.

If you were on the standard American diet with little to no whole plant foods with virtually no dietary plant nitrate intake, and were suffering from high BP, poor blood flow and impaired endothelium health, might a "dose" of kale show improvement? Of course. If the subject refused to make any other change to their diet and lifestyle, might it be of some benefit to *dose* with it 3x a day or 6x a day? Maybe.

But that is not our scenario. Wouldn't it be better just to switch over to our recommendations?

Now take someone following the principles of the program as we recommend, who is already on a healthy lower fat, minimally processed, calorie adequate, nutrient sufficient, diet from a variety of minimally processed plant foods with already has a much higher, if not substantially higher content of dietary plant nitrates in it and getting them at every meal, who is also following a healthy lifestyle and exercising and getting some sun (both of which also raise nitric oxide production). Will adding in 6 servings a day be of even more benefit? Will it have to be 6x a day to be of benefit?

My answer to both questions is no.

This reads to me as contrary to Esselstyn's advice. I would not be surprised to find that was not your (Jeff's) intent, but that rather that intent was, as always, to focus on the overall approach and to avoid undue focus on any specific food or nutrient; and further that your intended audience is wider than us Esselstyn cardiac patients. Yet as written, it is contrary to what I'm pretty sure was Esselstyn's addition of the greens 6x/day recommendation to his pre-existing recommendation of a WFPB diet. Before initially talking to Esselstyn in Dec. 2012 I had read his book and everything then on or linked to from his web site, and the greens 6x/day that he brought up in conversation was new to me.

In Dec. 2012, I declined a double bypass, to route around severe non-stentable stenoses in a couple of coronary artieries [1], in favor of a nutrition approach. I am currently drinking a scant half cup of beet juice with some strawberries or other source of vitamin C on arising in the A.M., and leafy greens -- I have settled on Spring Mix -- 5x day thereafter. This is not a SAD add-on; since Nov. 26, 2013 I have been on a WFBP regimen that is consistent with Esselstyn's and McDougall's recommendations. My current plan is to continue with the "NO-generators" 6x/day. This is sometimes a nuisance -- specifically the mid-morning, mid-afternoon, and bedtime ones -- so if anyone (Jeff?) wants to argue that it's not "of more benefit" than merely eating WFPB breakfasts, lunches, and dinners, I'll certainly listen. Note that I am getting a lot more greens than I would otherwise.

Notes:
[1] No sympathy required; there are big mountains where I live and I can climb 'em faster than you [2].

[2] Probably, if you're an average reader of this forum; maybe, if you're Jeff.

[JeffN]

In Dec. 2012, I declined a double bypass, to route around severe non-stentable stenoses in a couple of coronary artieries [1], in favor of a nutrition approach. I am currently drinking a scant half cup of beet juice with some strawberries or other source of vitamin C on arising in the A.M., and leafy greens -- I have settled on Spring Mix -- 5x day thereafter. This is not a SAD add-on; since Nov. 26, 2013 I have been on a WFBP regiment that is consistent with Esselstyn's and McDougall's recommendations. My current plan is to continue with the "NO-generators" 6x/day. This is sometimes a nuisance -- specifically the mid-morning, mid-afternoon, and bedtime ones -- so if anyone (Jeff?) wants to argue that it's not "of more benefit" than merely eating WFPB breakfasts, lunches, and dinners, I'll certainly listen. Note that I am getting a lot more greens than I would otherwise.

Congratulations on your success. I understand your passion and enthusiasm for the way you have applied the principles of this way of life, to your life.

This reads to me as contrary to Esselstyn's advice. I would not be surprised to find that was not your (Jeff's) intent, but that rather that intent was, as always, to focus on the overall approach and to avoid undue focus on any specific food or nutrient; and further that your intended audience is wider than us Esselstyn cardiac patients.

My intent was to answer the question and put it in perspective, which I did.

My response stands, regardless.

No, I do not insist on anyone following the recommendation of what I referred to as the "greens mantra," though anyone is welcome to follow that advice or any advice, if they want. However, I will not ask you to not follow it if you are wanting to follow it. If what you are doing is working for you then please, stay the course.

As an FYI, neither does all of Dr Esselstyn's patients follow the greens mantra and I have counseled many of them over the years, many who he has sent to me, and I continue to do so. Nor do I recommend that a cholesterol of 150 makes everyone heart attack proof, which he also states, nor do I insist on it, as I explained in this forum before.

viewtopic.php?f=22&t=21177&p=344300

Not only do I not insist on the greens mantra, neither does any of the other medical doctors and "experts" in this field including Dr Ornish, Dr McDougall, Dr Barnard, Dr Campbell, Dr Goldhamer, the Pritikin Program (and their staff of 7 MD's), Dr Diehl and the CHIP Program (and their multitude of MD's who work with them), Dr Klaper, nor did Dr Kempner, Dr Rosatti, who replaced Dr Kempner, or any of the other MD's who work for the former Kempner program. The Intensive Cardiab Rehab (ICR) programs of both Priikin and Dr Ornish, are now covered by medicare because of their ability to document their benefit in treating and reversing heart disease. These programs have seen over 150K patients over the last 60 years and not one of them insists on the greens mantra. Yet, they have ~200 studies documenting their effectiveness.

I have been on a WFBP regimen that is consistent with Esselstyn's and McDougall's recommendations. My current plan is to continue with the "NO-generators" 6x/day. This is sometimes a nuisance -- specifically the mid-morning, mid-afternoon, and bedtime ones -- so if anyone (Jeff?) wants to argue that it's not "of more benefit" than merely eating WFPB breakfasts, lunches, and dinners, I'll certainly listen. Note that I am getting a lot more greens than I would otherwise.

Consistent with Dr McDougall's recommendations? Are you saying that Dr McDougall recommends the greens mantra or "NO-generators" 6x/day because I have worked side-by-side with him for 7 years at every McDougall program during that time and have not heard it once from him ever, nor are they served at every meal & snack.

You may want to review this recent post here on "How many non-starchy veggies should we eat?"

viewtopic.php?f=22&t=42701

Also, there is not one study that shows or even implies or even hints at an increased nitric oxide levels in a healthy, lower fat, minimally processed,WFPB diet with greens 6x a day vs the same diet with just the regular recommendations. There is not one study that shows or even implies or even hints at an increased nitric oxide levels and better outcomes in a healthy, lower fat, minimally processed, diet with greens 6x day vs one with them 2-3x day.

As I repeatedly say, if anyone truly wants to understand the bigger picture of how/why this "dietary pattern" has worked for so long with such incredible results and success, they have to understand the guideing principles behind it. I explained this in my article here...

http://www.jeffnovick.com/RD/Articles/E ... _Pt_1.html

"A diet that is (1) based predominately on a variety of minimally processed fruits, vegetables, starchy vegetables, roots/tubers, whole grains and legumes and (2) low in fat, saturated fat, calorie density, and (3) low in added sugars, oils and salt, has been documented to prevent and/or reverse disease - even for those who are seriously ill - in many published studies over the last 60 years. The results from these studies, which use differing specific diets in them, documents the importance and the effectiveness of this overall dietary pattern over any one specific version of this diet. This dietary pattern is commonly referred to as the Whole Food, Plant-Based Low/No SOS diet or simply the WFPB SOS or just WFPB.

When discussing the WFPB diet, it is important to understand that there is no one single program but there are some common denominators among all of the successful programs. While the programs are all very similar, they are not identical. Not all of the programs are vegetarian or vegan. Some of the programs allow for a small amount of certain animal products and some don't. Some allow for a small amount of non-fat dairy and some don't. Some allow for a small amount of oil and some don't. "

It is also really important to review these 2 discussions on these issues (effect size, dietary patterns, application, etc) as I linked in the other thread you referred to...

viewtopic.php?f=22&t=43681

viewtopic.php?f=22&t=28413

Now, if Dr Esselstyn's original study, or his more recent one of ~200 patients, included detailed dietary analysis on all the patients and stratified them by intake of green leafy veggies above and beyond the general recommendations and clearly showed that those who followed the program AND ate 3 servings of greens did better then those who followed the program but didn't and that those who followed the program AND ate 6 servings did better then all of them, then I would be the first to be shouting the greens mantra from the mountain tops and with a megaphone.

Till then, I will continue to teach the overriding principles as we best know them, which I have outlined here...

viewtopic.php?f=22&t=37450

Lastly, if what you are doing is working for you, including eating greens 6x a day, then please, stay the course.

In Health
Jeff

[brec]

I have been on a WFBP regimen that is consistent with Esselstyn's and McDougall's recommendations. My current plan is to continue with the "NO-generators" 6x/day. This is sometimes a nuisance -- specifically the mid-morning, mid-afternoon, and bedtime ones -- so if anyone (Jeff?) wants to argue that it's not "of more benefit" than merely eating WFPB breakfasts, lunches, and dinners, I'll certainly listen. Note that I am getting a lot more greens than I would otherwise.

Consistent with Dr McDougall's recommendations? Are you saying that Dr McDougall recommends the greens mantra or NO-generators" 6x/day because I have worked side-by-side with him for 7 years and have not heard it once [nor] are they served at every meal, or snack. ...

No, I wasn't saying that. I was just saying that my 6x/day was an add-on to an otherwise McDougall-compliant regimen and not an add-on to a SAD diet. (As to why I would say that, anyone interested [I expect no one] should see my initial post for the context.)

Also, there is not one study that shows or even implies or even hints at an increased nitric oxide levels in a healthy, lower fat, minimally processed,WFPB diet with greens 6x a day vs the same diet with just the regular recommendations. There is not one study that shows or even implies or even hints at an increased nitric oxide levels and better outcomes in a healthy, lower fat, minimally processed, diet with greens 6x day vs one with them 2-3x day.

I am assuming no such studies have been undertaken. But there have been studies that show positive effects from increasing NO, both for athletes and for at-risk atherosclerotic patients. The latter, I assume, is why a cardiologist prescribed nitroglycerin for me in 2012 and advised that I always carry the little bottle with me. (I did for a while, but it didn't survive a trip through my washer and dryer and I didn't replace it.)

So what implies or hints at the benefit of extra leafy greens is the logic of the benefit of NO for the endothelium of atherosclerotic patients. Further, there are no known -- not even hinted! -- harmful side effects of extra leafy greens.

Now, if the original study on Dr Esselstyn's original patients, or his more recent one of ~200 patients included detailed dietary analysis on all the patients stratified them by intake of green leafy veggies above and beyond the general recommendations and clearly showed that those who followed the program AND ate 3 servings of greens did better then those who followed the program but didn't and that those who followed the program AND ate 6 servings did better then all of them, then I would be the first to be shouting the greens mantra from the mountain tops and with a megaphone.

Till then, I will continue to teach the overriding principles as we best know them, which I have outlined here...

viewtopic.php?f=22&t=37450

Lastly, if what you are doing is working for you, including eating greens 6x a day, then please, stay the course.

I think we're talking past each other some. I'm not suggesting or hoping that you'll add (what you derisively [1] call) the greens mantra to your standard recommendation. I think it would be OK, but certainly not required, in rare contexts dealing with cardiac patients to mention it as possibly helpful -- not because of the as yet non-existent studies you've described but because of the logic that motivates Esselstyn's recommendation.

Regardless, with respect to your continuing to teach the overriding principles please stay the course!

Notes:
[1] The derisive component is the word "mantra," which connotes a religious or magical, rather than scientific or rational, basis. The other sense of "mantra" is just of something often repeated, but I've never seen reference to Dr. Esselstyn's (or McDougall's) "no-oil mantra" or "whole foods mantra."

[JeffN]

I was just saying that my 6x/day was an add-on to an otherwise McDougall-compliant regimen

I think it is important to understand that not only has Dr McDougall never given such advice, you might even say he recommends against it. He specifically states this diet is not a vegetable based diet, nor should the emphasis be on them, that green and yellow dishes should be no more than a side-dish and the only reason to increase them somewhat is to lower the calorie density of the diet for weight loss and not anything to do with heart disease, anti-oxidants or as a "NO Generator." And, one of his main concerns for his patients long-term success and compliance, is an over-emphasis/focus on non-starchy vegetables. It is not even Esselstyn compliant as he would strongly recommend against the use of beet-juice as a NO Generator.

But there have been studies that show positive effects from increasing NO, both for athletes and for at-risk atherosclerotic patients.

Many of them using one single dose per day with success.

So what implies or hints at the benefit of extra leafy greens is the logic of the benefit of NO for the endothelium of atherosclerotic patients.

Not really. There are the issues of diminishing returns, effect size, application and relevance.


There are all kinds of studies showing all kinds of benefits in all kinds of situation and that is why knowing relevance and application is so important. Whether that effect in these studies is even relevant to anyone on a diet that is already high in dietary nitrate rich plants food is relevant and an important issue. As I have shown many times in these forums, the benefit we often hear about in many other studies (i.e., nuts, wild foods, GI/GL, resistance starch, kale, etc) completely lose their relevance when applied to this population. In addition, we also have many studies from other programs showing the same success and outcomes without this specific focus.

Further, there are no known -- not even hinted! -- harmful side effects of extra leafy greens.

I disagree.

If you read my thread on How Many Non Starchy Vegetables, you will see that there is a concern of not only mine, but also Dr McDougall's and many others over long-term compliance, which even you said, doing this can be a real nuisance.. Remember, as I have also described in detail in the thread, Compliance on a Healthy Diet, long-term compliance is the biggest challenge facing us, not getting in enough greens.

Look through these forums. A few years ago you can find people saying their success is due to green smoothies every morning, others saying it is due to eating date/nut dressings on their food every day, others because they are eating only 3 (or 2 or 5 ) meals a day, or eating only according to "true hunger", or because of eating 2 lbs of greens every day, or eating greens only for breakfast. Yet, they shortly disappear or they hang around but after 6 months or a year or more, tell us it didn't work for them long term.

So, again, congratulations on your success so far. But, you are still relatively new at this. Let's have this conversation again in 10 years. I will look forward to it.

I'm not suggesting or hoping that you'll add (what you derisively

There is no derisiveness is my comment nor do I used it to represent a "religious or magical" basis. A mantra is also defined as ""A statement or slogan repeated frequently" (Oxford Dictionary) and Dr Esselstyn himself has referred to it as the greens mantra as I have to him.

not because of the as yet non-existent studies you've described but because of the logic that motivates Esselstyn's recommendation.

I, along with all the others I listed above who have run and/or taught these programs for decades, would disagree. We don't see the logic or we would be doing it. If it makes sense to you, and if it helps you feel confident in your program and it helps you stay on track, and it is working for you, then please, keep doing it.

Again, thanks for the discussion. If you have any other questions I can help with, please post them in the forum.

In Health
Jeff

[JeffN]

I am currently drinking a scant half cup of beet juice with some strawberries or other source of vitamin C on arising in the A.M., and leafy greens -- I have settled on Spring Mix -- 5x day thereafter. This is not a SAD add-on; since Nov. 26, 2013 I have been on a WFBP regimen that is consistent with Esselstyn's and McDougall's recommendations. My current plan is to continue with the "NO-generators" 6x/day. This is sometimes a nuisance -- specifically the mid-morning, mid-afternoon, and bedtime ones -- so if anyone (Jeff?) wants to argue that it's not "of more benefit" than merely eating WFPB breakfasts, lunches, and dinners, I'll certainly listen. Note that I am getting a lot more greens than I would otherwise.

Seems like a leading WFPB doc has an "all natural" solution for you and this "nuisance."

https://www.facebook.com/Trinogen-Targe ... 509143767/

And, it is gluten free, non-GMO & has no fillers!!

In Health
Jeff

[JeffN]

While this study is not about eating greens, it is about the ingestion of nitrates and their impact on blood flow and oxygenation. The same product has been used in several other studies as it has a standardizes amount of nitrates in it.

What they have found from their studies is that there is no additional benefit to taking the product, which contains 560 mg of nitrate, more then 1x a day and in this study, it was only 3x a week.

This is inline with everything I said above and in the original thread.

In Health
Jeff

Beet Root Juice: An Ergogenic Aid for Exercise and the Aging Brain
J Gerontol A Biol Sci Med Sci glw219.
DOI: https://doi.org/10.1093/gerona/glw219

http://news.wfu.edu/2017/04/19/beetroot ... k-younger/

Abstract

Background:
Exercise has positive neuroplastic effects on the aging brain. It has also been shown that ingestion of beet root juice (BRJ) increases blood flow to the brain and enhances exercise performance. Here, we examined whether there are synergistic effects of BRJ and exercise on neuroplasticity in the aging brain.

Methods:
Peak metabolic equivalent (MET) capacity and resting-state magnetic resonance imaging functional brain network organization are reported on 26 older (mean age = 65.4 years) participants randomly assigned to 6 weeks of exercise + BRJ or exercise + placebo.

Results:
Somatomotor community structure consistency was significantly enhanced in the exercise + BRJ group following the intervention (MBRJ = −2.27, SE = 0.145, MPlacebo = −2.89, SE = 0.156, p = .007). Differences in second-order connections between the somatomotor cortex and insular cortex were also significant; the exercise + BRJ group (M = 3.28, SE = 0.167) had a significantly lower number of connections than exercise + placebo (M = 3.91, SE = 0.18, p = .017) following the intervention. Evaluation of peak MET capacity revealed a trend for the exercise + BRJ group to have higher MET capacity following the intervention.

Conclusions:
Older adults who exercised and consumed BRJ demonstrated greater consistency within the motor community and fewer secondary connections with the insular cortex compared with those who exercised without BRJ. The exercise + BRJ group had brain networks that more closely resembled those of younger adults, showing the potential enhanced neuroplasticity conferred by combining exercise and BRJ consumption.

"Three times a week for six weeks, they drank a beetroot juice supplement called Beet-It Sport Shot one hour before a moderately intense, 50-minute walk on a treadmill."

Article

With beetroot juice before exercise, aging brains look ‘younger’
http://news.wfu.edu/2017/04/19/beetroot ... k-younger/

[brec]

Oboy, my thread is alive! Just a couple of minor notes:

I noticed that in my original post I said, "since Nov. 26, 2013 I have been on a WFBP regimen." That should say Nov. 26, 2012. I'm still on it.

Some time ago I replaced the 6x/day greens with a 1x/day huge greens-based salad containing also a variety of fruits and vegetables.

[JeffN]

Oboy, my thread is alive! Just a couple of minor notes:

I noticed that in my original post I said, "since Nov. 26, 2013 I have been on a WFBP regimen." That should say Nov. 26, 2012. I'm still on it.

Some time ago I replaced the 6x/day greens with a 1x/day huge greens-based salad containing also a variety of fruits and vegetables.

I keep most hot topics alive & current.

Thanks for the update!

In Health
Jeff