[Examine Newsletter] August 2023 Updates

See what’s new at Examine over the past month!  ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ [Examine]( [View in browser]() Hello! Here’s your recap of Examine’s August 2023 updates. --------------------------------------------------------------- Why don't multivitamins work better? Aug 31, 2023 [Multivitamins](=) should be more effective than study results show. What’s going on? Some background In order to be healthy, you have no choice but to consume enough of each of the 13 essential vitamins (except for [vitamin D](=), which is synthesized in sun-exposed skin). The definition of enough varies by person, but you catch my drift. Some of these vitamins can be produced by your gut bacteria, such as [vitamin K](=) and certain B-group vitamins, but production levels are highly variable based on your microbiome composition and age, among other factors. Don’t count on your gut bugs to save you from a nutrient-poor diet. The central importance of vitamins was illustrated by the legendary biochemist Bruce Ames, who came up with something called triage theory. It states that when your micronutrient intake is low, your body prioritizes their use for short term survival processes over long term survival processes. This could make chronic diseases more likely to develop. How have multivitamins done in studies? Imagine the cat as the multivitamin, and the box as the study. Or something. Really?? Got any examples? The majority of multivitamin meta-analyses haven’t found benefit, for uses ranging from [cognition in cognitively healthy people](=) to [prevention of cancer and cardiovascular disease](=). This might be hard for you to believe. Vitamins have a sheen of efficacy powered by tradition and ubiquity that’s hard to look past. I didn’t know much about this until 20 years ago, when I had a doctor’s appointment and we started chatting about nutrition. When I told him that I was involved in a nutrition project for school, I thought I was pretty dang impressive. Big man on campus. After the appointment, I looked him up, and found that he was the primary investigator for a landmark study in which antioxidants miserably failed. If my cheeks were capable of blushing, they would have. Anyway, I digress … What could explain these findings? - Baseline vitamin intake can be high enough to leave little room for benefit from supplementation. It’s tough to know exactly who to enroll in a trial — a broad cross-section of people, or mostly those who are at lower intake levels? And in real world situations, people who take multis [tend to already eat more vitamin-rich diets]() compared to people who don’t. In other words, the people who could most benefit from multivitamins are less likely to use them. - Multivitamins work for a small number of targeted uses. Maybe not everyone should take a multivitamin for general disease prevention. But multivitamins have promising randomized trial evidence for a few specific uses, such as [immune health]() and [cognitive function](=) specifically for older adults. - They might take a long, long time to provide benefits. In nutrition, a two or three-year trial is quite an accomplishment. Not many multivitamin trials go out past five years, so they might not capture all the potential benefits of extended, consistent use. That said, in 12 years of follow-up, the [Physicians’ Health Study II]() found no benefit of multivitamins for cognitive function. It’s tough to know how other facets of health would fare in long term studies, though. - There’s rarely a single magic bullet. Chronic conditions can be tough to treat. Maybe multivitamins give some people a fighting chance, but for others there might not be much that helps, save for pharmaceuticals or high-effort combination treatments, such as meditation plus a healthy diet plus good sleep hygiene — which can be tough to follow if you’re already struggling with a chronic condition! - You can easily go 2 Fast 2 Furious. Have you noticed that very few multivitamins stop at 100% of a nutrient’s requirement? Nowadays, partly to compete with other brands, vitamin levels go higher and higher, often well over 1,000% of the requirement. This can result in potentially detrimental [excess vitamin intake]() when combined with vitamins from food. While this nutrient excess doesn’t apply as much to most studies, it definitely applies to the real world impact of multivitamins. That wasn’t an exhaustive list of possible explanations, but I think you get the picture. Multivitamins are tough to study for a variety of reasons, and the results can be unexpected. These surprises also extend to smaller combinations of vitamins and lifestyle factors, such as the potentially [increased mortality rates in smokers](=) who supplemented with [vitamin E](=) and [beta carotene](=) (which is technically a provitamin, not a vitamin). A good rule to keep in mind: when it comes to supplementation, learn as much as you can (from Examine and other reliable sources … although we’re obviously the best 🙂), and then account for what you don’t know. That means you should leave some room for error. Don’t try a bunch of supplements all at once if you can help it, don’t assume all studies are 100% reflective of reality just because they’re peer reviewed, and don’t think because you’re taking “just vitamins” that they’re obviously safe. As the old saying goes, your body is your temple! And entrants to your temple need to be thoroughly screened. --------------------------------------------------------------- Lost at sea: The story of José Salvador Alvarenga Aug 25, 2023 In 2012, a fisherman named José Salvador Alvarenga was lost at sea. He continued drifting for a mind-melting 14 months. By the time he was rescued, he was still in a relatively healthy state, all things considered, save for dehydration and anemia from parasites. What can this edge case of human experience teach us about health and nutrition? And perhaps more importantly, what can’t it teach us? Did this really happen? Yes. Mr. Alvarenga sailed out with a fishing partner near Mexico and encountered a storm that flooded his engine. His fishing partner passed away after two and a half months, leaving Mr. Alvarenga alone. He initially ate turtles and (small) shark liver, then subsisted on birds as he drifted further and further away from shore. Why didn’t he die from scurvy? Over two million sailors are estimated to have died from scurvy during long distance sailing voyages between the 1500s and 1800s. How did Mr. Alvarenga avoid scurvy during the 14 months of his extreme diet? Fresh, raw meat [contains some vitamin C](), with organ meats having much higher concentrations than muscle meat. Cooking meat reduces and sometimes eliminates its [vitamin C](), but data isn’t available on the specific effects of different cooking methods and temperatures. Interestingly, fermentation seems to help preserve meat’s vitamin C, but I’m guessing not that many people partake of fermented meat. Technically, eating enough fresh, raw meat can get you up to vitamin C’s estimated average requirement (enough to meet the needs of half of the population) or more rarely even the recommended dietary allowance (enough to meet the needs of 97–98% of the population). Vitamin C requirements could theoretically be different in people eating mostly meat, though, due to the complex interplay of endogenous antioxidants along with myriad other factors. Lastly, note that it’s also possible Mr. Alvarenga consumed some seaweed or other aquatic plants while at sea, though he didn’t mention any when recounting his diet. He did mention once finding a floating trash bag containing a very small amount of half-rancid cabbage, carrots, and milk. So should humans only eat fresh, raw meat? No. But not for the reason you think. There is no “should” for most nutrition topics. Every choice of what you eat, drink, or supplement is a guess based on whether the pros outweigh the cons for you as an individual. When it comes to meat, humans have long taken to cooking it. Compared to raw meat, the cooked variety is easier to preserve (with food reserves being critical for survival!), makes some nutrients more bioavailable (but not vitamin C!), and is far less likely to kill you with a random pathogen. Cooked meat is also typically considered more palatable. That doesn’t mean raw meat should never be consumed. Again, it’s all a bite-by-bite personalized guess that weighs potential pros and cons. Some people live pretty healthy lives eating no meat at all, like my dear grandparents, whom I lived with as a kid, so I can certify they didn’t eat any meat or eggs. They passed away at 95 and 94 last year. And they were way smarter than me! Other people eat a ton of cooked meat and live long lives, while some people (many fewer, to be sure) have been eating most or all of their meat raw or lightly cooked for years. But just because some people seem to thrive on raw meat doesn’t mean you would. Namely, because … Nature is trying to kill you Fresh, raw meat is natural. And fresh, raw meat can kill or really hurt you. Just because Mr. Alvarenga did moderately okay (save for some parasites), doesn’t mean you will. Case in point: a couple months into the journey, Mr. Alvarenga’s companion may have died from eating a bird that had previously eaten a poisonous snake. And that’s a totally random non-germ example. There are a huge variety of possible pathogens in meat and water that can harm you. You might counter me with another point: “But Kamal, humans have long cooked meat over open fires. So it’s natural and totally healthy to eat cooked meat!” Alas, charred meat is [carcinogenic](), although that highly depends on how much you eat and what you eat it with. My point is that there is no such thing as a free lunch. Once you’re born, you start to constantly encounter natural things that can harm you, from the oxygen you inhale in each breath to the sun that shines above. The good news is that nature isn’t just trying to kill you. Natural exposures can also be very healthy (depending on the dose and the person), and most importantly, enjoyable. Just don’t go drifting in the ocean or hiking in the wilderness without having an emergency contact! Fasting is fine. Not fasting is fine. Fasting is not fine. Mr. Alvarenga went long periods without eating. Most people rarely (or even never) go even short periods without eating. The literature on fasting efficacy is mixed. If you’re curious, check out our pages on the [16:8](=) and [OMAD](=) fasting varieties. We’ll cover other fasting varieties in the coming months. But let’s zoom out and think about fasting with regards to survival versus surthrival. I borrowed the latter phrase from fairly terrible (but so entertaining!) survival shows I used to obsessively watch on TV. Humans can easily survive more than a couple days without food. That’s what our body fat is for! What, did you think our ancestors had access to grocery stores and restaurants? Of course we fasted, because of necessity created by famine, changing animal migration patterns, and other natural factors. But what does it take for surthrival? (Sorry, I’ll stop using that word now.) Nobody truly knows. Some people do great with one type of fasting, and poorly with another type. Others do poorly with all types of fasting. What I’m getting at is this: fasting effects are not one-size-fits-all! The tale of Mr. Alvarenga doesn’t tell us much more than we already know about fasting, since humans have purposely and nonpurposely fasted forever. Instead, what it tells us is that food availability is important, but not always paramount. For Mr. Alvarenga, greater challenges came in the form of crushing loneliness, incessant sun, and the ever-looming threat of dehydration. In other words, food is important, but possibly overrated as a lever to pull for health and happiness. Perhaps I shouldn’t say that as the co-founder of a website focused on diet and supplements. Or perhaps we should expand to other areas … like surthrival. If you liked or hated this different style of email, just reply and let me know. Your wish is my command when it comes to how these emails are structured! --------------------------------------------------------------- 📅 Top 5 Study Summaries for August Aug 17, 2023 Every month, we summarize 150+ recent studies for our [Examine+ Members](). You can read five of this month’s most favorited Study Summaries for free by clicking the links below. The Study Summaries marked with are Editor’s Picks, which provide more details about the study, mention related studies, and include helpful graphics. [Could supplementing with glycine and NAC improve “hallmarks of aging”?]() In this randomized controlled study, supplemental glycine and N-acetylcysteine improved a wide range of outcomes related to cardiometabolic health and physical function in older adult participants. However, despite including a placebo group, there was no direct comparison to determine whether these outcomes were statistically significant compared to a placebo. [The association between ultraprocessed food intake and cancer risk]() In this meta-analysis of observational studies, a higher intake of ultraprocessed food was associated with an increased risk of overall cancer. [Does salt restriction increase blood sugar?]() In this meta-analysis of randomized crossover studies, low-salt diets increased blood glucose levels in participants with hypertension or diabetes. [Take a deep breath to reduce your (oxidative) stress]() In this meta-analysis of randomized controlled trials, breathing exercises reduced markers of oxidative stress and increased markers of antioxidant status. [Beverage consumption and mortality among adults with type 2 diabetes]() In this cohort study of adults with type 2 diabetes, a higher intake of sugar-sweetened beverages was associated with an increased risk of all-cause death, whereas higher intakes of tea, coffee, plain water, and low-fat milk were associated with a decreased risk. You can also check out the [most-favorited summaries from previous months]().🔥 --------------------------------------------------------------- So, did you find something of interest? If not, please reply to this email to let me know which topics you’d like us to tackle. And if you’re ready to stay on top of the latest research, you can [try out Examine+ for free for 7 days](). --------------------------------------------------------------- We’ve overhauled our Muscle Size & Strength page Aug 10, 2023 It’s Nick, Lead Researcher at Examine. We just reworked one of our most popular pages and I wanted to tell you about it. We’ve turned the “Muscle Gain” page into “Muscle Size & Strength”. [Check it out here](). We made the change so that we could help you find interventions that would be most effective for boosting muscle size, strength, or both. Since size and strength are very closely related, it makes more sense to discuss them together. I say this to you all the time, but it’s hard to understate how big of a task it is to keep so much information organized. There are myriad different reasons why it’s a challenge, but a big one is that the same goal can be measured with different outcomes, and even require different interventions, based on the type of person you are. There were a lot of different goals and kinds of people being talked about on the old “Muscle Gain” page, which included an amalgam of studies conducted in people who were looking to get swole as well as people living with sarcopenia. Even though these populations may benefit from conceptually similar interventions (i.e., exercise), back squats at 8–9 RPE might be a bit much for an 80-year-old with sarcopenia. So our solution was to split things up. Now, we have pages for athletes, like “[general athletic performance]()” and “[rowing performance]()” (expect to see those pages fleshed out very soon), and “[Muscle Size and Strength]()” for people who aren’t looking to improve several aspects of a specific sport-based pursuit (outside of competitive bodybuilding and strength training, that is!). Instead, they’re looking to be stronger and more muscular. We think this change will make the information presented on each page more intuitive and useful. Of course, we didn’t just shift information around. We added tons of new information, too. (We just couldn’t help ourselves.) Here’s a small selection of the topics we discuss on the new page: - How does the response to a resistance exercise program vary between and within individuals? - What type of exercise is best for promoting muscle size and strength? - Do I need to be sore after resistance exercise to build muscle? - If I have limited time to exercise, how should I structure my training? - Are machines as good as free weights? - Are light weights as good as heavy weights? - Is an energy surplus required to gain muscle? - Does the distribution of protein intake throughout the day matter? I hope you enjoy the new page! As always, feel free to reply to this email with any topics you’d like us to cover. --------------------------------------------------------------- Monthly musings Aug 3, 2023 Let’s try something new. I’m about to speed through a few different topics, rather than focusing on just one. These are the things that have been on my mind lately. If you like or hate this format, reply back and let me know! So you have a sweet tooth, eh? Last month’s [aspartame email]() was our most popular, well-received email ever. Here’s the exact reply breakdown: - 112 readers sent positive replies - 1 reader sent a neutral reply - 1 reader sent a negative reply A few physicians and professors even asked if they could use the email as a handout! That means we’ll be working on at least one of these follow-ups in the coming weeks: - A YouTube video comparing sweeteners that Examine readers often decide between (e.g. monkfruit vs. stevia, sucralose vs. aspartame, etc.) - An email going into more detail on specific safety issues related to sweeteners (e.g. a summary of trials looking at sweetener effects on the gut microbiome) - A super duper secret sweetener project Minerals are underrated You’ve probably taken a [multivitamin]() before, but have you taken a dedicated multimineral? I’m not at all advocating for multiminerals, but I did want to highlight that minerals are way more important than the amount of attention they tend to receive. Vitamins have long had an aura of primary importance and healthfulness, while minerals sometimes seem like a tag-along to vitamins. After all, we say “vitamins and minerals”, not “minerals and vitamins”. I wonder if this is partly influenced by the momentous scientific discoveries of different vitamins over the past hundred years or so. Some minerals are too bulky to include in adequate amounts in multivitamin pills. And even if you could fit them in, it might be a bad idea. For example, too much supplemental calcium is linked to more heart disease, some minerals compete with each other for absorption, and so on. It’s also not a good idea to go overboard with supplementation of less bulky “trace” minerals. For example, iron is specifically excluded from many multivitamins because at high levels it’s a strong pro-oxidant and quite harmful, and can fairly easily poison children. As is typically the case, it’s a good idea to get nutrients from food when possible. Minerals just play so many biochemical roles in our bodies, not to mention we’re literally made out of them (and protein). While [magnesium]() has become the supplement du jour in the past few years, other minerals still aren’t getting enough attention. We’ll work on our mineral supplement pages over the next months to get them up to date with the latest evidence, and report back to you when we do, so you can see for yourself what I’m talking about. [Weight](): the king of confounders I can’t stop myself from reading diet and supplement forums. I started doing it in 1999, and still do it to this day. Yes, I’m a forum addict. People on forums can be tough to deal with, but you can glean a lot from personal experiences once you filter out the noise. After all, peer-reviewed studies don’t cover all topics, and are often years behind real-life experiences! The most common theme I’ve seen on diet forums is the weight confounding error. When people try a special diet and end up solving their health issues, they typically attribute this to the specific diet, even though weight loss alone is often independently a major factor in improving health issues. The key word here is “often”. A seasoned forum browser will try to figure out when the diet may have independently performed some magic, rather than simply being a conduit for weight loss. Here are some of the steps I go through to help tease that out: - How dogmatic is the dieter? If I’m to give credence to an anecdote, I want the dieter to be as rational about a diet they (currently) love as a diet they don’t love or haven’t tried. I want pros and cons listed, not fawning praise and blanket statements. - Did the dieter log their weight and health condition symptoms? The former is much more common than the latter, but when a dieter records both, it’s (anecdotal) gold! - I go through the dieter’s old posts to investigate their diet history. Are they more of a yo-yo dieter who loves a diet until they can’t sustain it or they find a shiny new diet, or do they give each diet the ol’ college try to truly see if it works for them? Once in a rare while, I’ll notice a dieter who attributes their health improvements to weight loss, then continues reporting on the diet to see if it has an independent effect even after their weight has stabilized. I save these experiences in my personal notes. If you’ve shared your diet experiences on forums, I want to thank you for doing this public service and helping others! Should we show our personalities more? Examine is different than other health websites. We spend most of our money on our researchers, not on marketing or other business pursuits. Our researchers tend to stay with us for many years, and are all insatiably curious and really, really nice people. (Seriously, this is our number one consideration when we hire someone.) But Examine straddles a tough line — we’re not a massive company like those we compete with in search engine results (their yearly revenue is literally 100 to 1,000 times greater than ours), and we’re not a personality-driven business like the health experts who have huge social media followings. These two extremes can both do really well financially, but we’re not in either group. But maybe we could learn something from the influencers. Do you want to know more about us? More about the people who are researching, writing, and reviewing what you read? Should we show some of our personalities in some fashion? Maybe through emails, videos, or podcasts? Some people don’t want to get to know us — they want all science all the time. Others just love to get into the minds and lives of people they probably won’t ever meet. I’m in the latter camp, but you may not be. So let me know, and we’ll go with whatever the majority says! And also let me know if you liked or hated this email format. If there’s enough support, I’ll consider sharing more monthly musings in the future. --------------------------------------------------------------- Sincerely, Kamal Patel, Nick Milazzo, and Morgan Pfiffner. Follow us on: [Facebook]( [Twitter]( [LinkedIn]( [Instagram](=) [About Examine]( | [Careers]() | [Member’s Area]() [Unlock Examine+]( PO Box 592, Station-P, Toronto, Ontario M5S 2T1 [Switch to weekly emails]() | [Opt out of all emails](