Awesome, just awesome.

Turns out the Associated Press doesn't read journal articles, either.

The NYTimes has a short piece about their recent discovery that decaf coffee actually has caffeine. Well, ok. 

Here's a little case report, about me, a cautionary tale about working too hard.

I had to go to Chicago for a case. It took three days.  It took a lot out of me.  There was the jet lag, and the work, and skipping meals, and sleep deprivation.   I barely sleep at home, but all I could get in the hotel was 2 hours/night.   I usually drink about 3 cups of coffee (16 oz each-- so I guess that's 6 actual cups)  a day, but with this level of stress and tiredeness I was drinking 4-5.  And, dare I admit it, I took a Provigil.

I could feel myself getting sick on the last day.  Just get through it, I thought.  Sick later.  Work today.  

I got home, exhausted.  The next morning I felt sick, wiped out, achy.  There you go, I said.  I have the flu.  I struggled through work, taking naps when I could.    

As the day progressed, I got worse.  Weakness, tiredness, horrible nausea, headache.  I gagged at the thought of food, but I forced myself to at least drink Gatorade.  Gatorade is the artificially sweetened sweat of male bicyclists.  Every word of that description disgusts me.  I drank the purple one.

Day 2 came, and I was worse, not better.  Not even the same-- much worse.  The headache was ruthless.   The nausea had become motion sickness-- turning my head was a lunar launch.  The arthralgias, bizarrely, had disappeared-- except in my neck, which had become very painful and stiff.  I couldn't turn my head well.  I could barely walk, I could barely think.

I went to work.

The weakness and lethargy had also changed-- into narcolepsy.  It wasn't weakness-- I was drugged.  I fell asleep for only a second at a time, but it overtook me every moment I wasn't active.  Driving.  Watching TV.  Standing at a urinal.  On an elevator.  During phone calls.  I could not stay awake.  Simply closing my eyes would drop me into Stage IV sleep.  I could still be talking, but if my eyes were closed I was asleep.  And what I said was nonsensical.

I was almost helpless.   I took Tylenol.  Motrin.  Tylenol + Motrin.  Nothing.  And I could not stay awake.  The head and neck hurt so much that the only solace was sleep, which I couldn't stop anyway.

What kind of flu was this?  And something worried me: why didn't I have a fever?

By day 3 I had what can only be described as the worst headache of my life.  The nausea was constant. 

Worst. Headache. Of. My. Life.

I rarely get sick, I rarely take pain relievers.  I do 3 sets of 50 push ups a day.  I'm pretty healthy, and I've never been incapacitated.  I only say this as background for my next sentence: I was so sick I could not see. 

Light hurt me, hurt my head.  I could not look at the monitor, or TV.  I wanted to be in a quiet, dark room-- asleep.  With morphine.  And the medical student in me solved the mystery: headache, stiff neck, photophobia, no fever.    I had finally done what I had been threatening to do for so long: I had popped an aneurysm.   I thought: so this is how it ends.

Nausea.  Headache.  Neck stiffness.  Exhaustion.

Exhaustion. 

Oh my God, could I be in caffeine withdrawal?

As soon as I thought it, I knew that was it.  I couldn't believe it.   I'd never felt it before because I'd never not had coffee before.  And that first day back, being a little off, I skipped it-- which made me worse, and then the withdrawal hit.

I made some coffee.  It smelled like battery acid.   I put ice in it and drank it, one cup all at once.  I gagged, twice. 

Within ten minutes, I was 10% better. In 30 minutes, I was 50% better.  In an hour I was 95% cured.  From unable to move, to almost complete cure.

Jesus.  

The cure was so total, the reversal so profound, that I actually couldn't remember how sick I was.  I thought I must have been exaggerating.

So my body reminded me.

Four hours later, I started to feel that motion sickness again.  By the fifth hour, I was on the floor again, same stiff neck and headache. And the nausea was worse: the thought of drinking the battery acid again was too much for me. 

But I did it.  And again, an hour later, I was completely cured. 

How "real" is caffeine withdrawal?  Clearly, my own experience takes it out of the theoretical realm.  But what about:

the average coffee junkie when he goes to the hospital? 

the psych patients who smoke 1 or 2 packs a day, 4 or 5 coffees a day, and get admitted on the unit where it's only decaf and a smoke break a shift? 

The case reports of neonates born to heavy caffeine drinking mothers, who went into serious withdrawal.  Three neonates had caffeine in their urine!  Symptoms include irritability, rigidity, hypertonia and hyperreflexia.

And then there are the kids.

What about all those kids who drink a lot of soda-- say, two cans/d (100mg total)--and maybe sometimes they don't get their dose?  One study of such 10year olds found that missing one dose of 100mg made them less alert, had more headache, and performed more poorly on cognitive tasks.  But how many parents (or doctors) would have thought about this? Another study also found kids in withdrawal got little headache, but get more myalgias than do adults. Who is savvy enough to attirbute these subtleties to caffeine?

Has anyone else wondered if the prevalence of ADHD doesn't parallel caffeine use and sleep deprivation, especially in kids (kids don't take naps anymore)?  And remarked that the main treatments are-- stimulants?

 

Referencing myself: What is the best and healthiest coffee to drink?

 

Is a glass or two of wine a day good for you?  You would think this would be an easy question to answer, but it's not, and that's because of this:

How many glasses of wine are in a bottle?

If you answered 4-5, continue reading.  Because guess what?  Apparently the answer is eight. No, I'm not kidding. Yes, they are serious.  Unplug your monitor and ram it into your skull as hard as you can. 

A short digression on my fourth favorite subject.

Does coffee raise blood pressure?  Does coffee elevate cholesterol?  Does coffee hurt your liver?  Does coffee taste delicious?

At the outset, you need to know that not all coffee preparations are the same.   The diterpenes cafestol and kahweol are the alleged cuplrits in the negative effects of coffee, especially raising cholesterol and increasing risk of coronoary artery disease.  However, these are lipid soluble and are almost entirely filtered out by paper filters. Mix coffee grounds and water in a pot, and boil.  Pour off the cofffee into a glass.  Drink.  Now look at the glass.  That oily residue is-- well, oily residue.  You don't get that with a filter.

For example, here is the breakdown of lipids in coffee: filtered coffee: 7mg/cup.  Boiled and  unfiltered (Turkish): 60-160mg/cup.  Metal screener (french press): 50mg/cup.  The types of lipids in each were the same (no selectivity in lipid filtration.)   So how you make your coffee matters.

Blood pressure: as long as you're a regular drinker, don't worry.

Reports of coffee elevating blood pressure are misleading, because they aren't done they way we drink coffee: daily.  Going from nothing to a triple espresso raises blood pressure; but chronic coffee drinking eventually allows for normalized blood pressure.

For example, the much repeated finding "unfiltered boiled coffee causes a significant elevation in blood pressure, especially in women" is misleading:  the study actually found that if you switch exclusively to boiled unfltered coffee from filtered coffe, your systolic blood pressure rises about 4mm Hg.  However, switching from filtered coffee to abstinence did not have any effect on blood pressure or heart rate.  Another study found a trivial change in blood pressure (-3.4mm Hg) after two months of abstinence (afgter 5 cups/d.)

Interestingly, a metaanalysis of 16 studies found that chronic caffeine (400mg/d) raised systolic blood pressure by 4 mm Hg. while 5 cups coffee/d (>500mg caffeine ) only raised it 1.2mm Hg.)  This was corroborated by another study finding >5 cups lead to 1.35mm Hg increase.

 

Cholesterol: raised slightly by unfiltered coffee, and possibly with filtered. 

Initial reports had found that drinking unfiltered coffee was associated with higher triglycerides and cholesterol levels than filtered coffee, because the filter removed almost all (80%) of the causative substance.  Another study found unfiltered caused higher cholesterol (but not TG) than filtered; filtered coffee had no effect on lipids over no coffee at all.

These findings were slightly contradicted in a recent study: Abstaining after 4 cups/d reduced cholesterol by about 12mg/dl.  Drinking filtered coffee raised cholesterol by about 11 mg/dL.  For perspective, 4 cups/d of whole milk would raise cholesterol by about 14mg/dL.

The question t ask here would be, how good was the paper filter? 

Coronary/heart disease: no. 

Retrospective analyses find that >4 cups/d, but not <2/d, had almost double the risk of coronary disease;  however, prospective studies found no increased risk.

A review identified possible explanations for an increased risk of heart disease in coffee drinkers  including a genetic predisposition to slower caffeine metabolism in some people, and the presence of diterpenes (which raise cholesterol) in unfiltered coffee .  However, the same review found several studies indicating a protective effect of moderate coffee drinking, which they conclude is related to the  antioxidants.

One study found heart attacks more frequent in coffee drinking women than abstainers: but was only usefully relevant at <7 cups/d, which doubled the heart attack risk.   However, a gigantic 85000 middle aged women prospective 10 year study found no effect of 6 or more cups coffee/d on coronary heart disease. 

For what it's worth, unfiltered coffee seems to be associated with higher rates of heart attacks than filtered. 

But it pays to wait: a week after I initially posted this, an 8 year  prospective study in the elderly found a dose dependent (i.e. greatest >4 servings) protective effect of caffeine in cardivascular mortality (reduced by 50%) (but, oddly, no effect on cerebrovascular mortality).  Importantly, these were normotensive individuals.

 

Suicide: Opposite of smoking: drink up.

Gigantic 10 year prospective study of 86626 female middle aged nurses:  suicide rate was reduced by 60-70% in those who drank more than 3 coffees/d, all other factors controlled.

A Finnish study of 43000 people over 14 years-- 216 suicides-- found that 2-5 cups/d moderately (30%) reduces suicide risk, while >8cups increases risk 1.5 times.  (For reference: "heavy drinking" (weirdly: 2 drinks/d) or smoking had about the same risk.)

A 1993 study looking at death from any cause found a reduction in suicide risk (RR 0.87 per cup) with increasing coffee. 

Liver cancer and cirrhosis: can't hurt, may help, especially if you're an alcoholic. 

The same 1993 study above also found a lower risk of cirrhosis (RR 0.77/cup).  The same authors, in a more recent study, again find such a reduction in risk, and find lower levels of liver enzymes ALT and AST. An Italian study found coffee reduced the risk of hepatocellular carcinoma from any cause (Hep B, C, alcohol, etc); same in the Japanese, and in the Japanese in a prosepctive trial.  And in Americans chronic liver disease rates were half in 2 cups/d drinkers.

Recent evidence suggests that this may be partly due to caffeine, but also to phenolic acid antioxidants which are not present in tea.  The authors cite reports of such ingredients' protective effect sagainst various forms of liver damage (including Tylenol.)  

So if you're going to drink coffee, there are two prudent things to do.  1) drink filtered coffee, made with a good filter.  2) drink medium roast, not dark roast.  The roasting process burns off volatile chemicals such as caffeine and the antioxidants. 

For this reason, my vote for best, healthiest, and most delicious coffee to drink is Dunkin' Donuts.