Should Fitness Be A Vital Sign?

The skeptical cardiologist routinely probes his patients’ activity and exercise levels and encourages them to engage in 150 minutes of moderate exercise weekly. However, I’m somewhat skeptical of the benefit of treating such assessments as a vital sign (like blood pressure or heart rate)  as a recent AHA scientific statement suggests.

I can only envision still another item  on a chart checklist that will have to be recorded in the EHR or already over-worked physicians will have their payments withheld.

The AHA statement suggests that ideally we should be measuring  our patients’ fitness by obtaining  maximal oxygen consumption (VO2 max) utilizing an expensive and rarely utilized cardiopulmonary exercise test. Failing that we should consider doing a treadmill stress test. Failing that, rather than utilizing my simple question to patients: “How active have you been?”,  the statement recommends doctors utilize some sort of formal questionnaire to estimate their patients’ cardiorespiratory fitness (CRF) such as the one at World Fitness Level.

I went online to take this CRF estimator (based on this paper) and I remain skeptical.

The online site and  a free smartphone app both ask the following questions:

  • Country and City
  • Ethnicity
  • Highest Level of Education
  • Gender/Age/Height/Weight
  • Resting and Maximal Pulse
  • How often do you exercise?
  • How long is your workout each time? (over/under 30 minutes)
  • How hard do you train? (I had to choose between “I go all out”or “Little hard breathing and sweating”)

 

screen-shot-2016-12-03-at-11-33-13-amWhen you have finished answering the questions you are given an estimate of your fitness age. When I did this online a few days ago and answered truthfully I got the result to the right: I had the fitness of a 41 year old with an estimated VO2 max of 49 ! (interestingly this estimate corresponds exactly with VO2 max derived from a recent stress test I completed.)

I used the app (which unlike the online version did not ask me my waistline measurement) and changed a few parameters:

  • I increased my resting heart rate or pulse  from 60 to 68 beats per minute (BPM)
  • I increased my maximal heart rate from what I know is 158 BPM to what the app calculated (173 BPM, which makes no sense)
  • I switched from exercising 2-3 times per week  and longer than 30 minutes  at “all out” level to the lowest level for all 3 questions.

The change was dramatic and depressing: I went from 39 years old to 67 years old in the bat of an eyelid!img_8073

 

 

 

The app and online site direct you to a non-profit site where you can get information on a 7 week program to increase your fitness level. I haven’t checked this out.

I’ll be trying out this CRF estimator on my patients: assessing whether it adds anything to my usual line of questioning on activity and fitness.

I encourage you to give the CRF estimator a try. Let me know in the comments how you feel it works for you. Does it motivate you to exercise more knowing that, for example, your fitness age is substantially higher than your chronological age?

AliveCor Mobile ECG Update: Successes and Failures

The  AliveCor/Kardia mobile ECG device is a really nifty way to monitor your heart rhythm. Since acquiring the third generation device (which sits within or on my iPhone case and communicates with a smartphone app) I have begun routinely using it  on my patients who need a heart rhythm  check during office visits. It saves us the time, inconvenience (shirt and bra removal) and expense of a full 12-lead ECG which I would normally use.

In addition, I’ve convinced  several dozen of my patients to  purchase one of these devices and they are using it regularly  to monitor their heart rhythms. Typically, I recommend it to a patient who has had atrial fibrillation (Afib)  in the past or who has intermittent spells of palpitations.

Some make daily recordings to verify that they are still in normal rhythm and others only make recordings when symptoms develop.

Once my email invitation request is accepted I can view the ECGs recorded by my patients who have AliveCor devices as I described here.

This monitoring has in many cases taken the place of expensive, obtrusive and clumsy long term event monitors.

In general, it has been very helpful but the device/app makes occasional mistakes which are significant and sometimes for certain patients it does a poor job of making a good recording.

Alivecor Success Stories

One of my patients,  a spry ninety-something year young lady makes an AliveCor recording every day, since an episode of Afib 9 months ago.

And when I say every day I mean it literally everyday. It could be because she is compulsive or perhaps she has programmed the AliveCor to remind her. When I log in to the AliveCor site and click on her name I can see  these daily recordings:Screen Shot 2016-06-17 at 12.40.07 PM

After a month of normal daily recordings, she suddenly began feeling very light headed and weak with a sensation that her heart was racing.

Screen Shot 2016-06-17 at 12.41.13 PMShe grabbed her trusty iPhone and used the AliveCor device attached to it to make a recording of her cardiac rhythm. This time, unlike the dozens of other previous recordings, the device indicated her heart rate was 157  beats per minutes , about twice as fast as usual.

After 5 hours her symptoms abated and by the time of Screen Shot 2016-06-17 at 12.46.52 PMher next recording she had gone back to the normal rhythm.

She made two other recordings during the time she felt bad and they both confirmed Afib at rates of 140 to 150 beats per minute.

In this case, the device definitely alerted her to a marked and dramatic increase in heart rate but was not capable of identifying this as Afib In my experience with several hundred recordings, the device accurately identifies atrial fibrillation about 80% of the time. On rare occasions (see here) it has misidentified normal rhythm with extra beats as atrial fibrillation

Review Options

AliveCor/kardia users  have the option of having their recordings IMG_6936-1interpreted for a fee by a cardiologist or a technician.

My patients can alert me of a recording and I can go online and read the ECG myself and then contact the patient to inform them of my interpration of their heart rhythm and my recommendations.

Another patient made the recording below:Screen Shot 2016-06-18 at 11.32.26 AMAlthough she is  at high risk of having a stroke during the times she is in Afib, we had been holding the blood thinner I had started her on because of bleeding from her mouth. I had instructed her to take daily recordings of her rhythm with the AliveCor until she was seen by her dentist to evaluate the bleeding.

In this case, the AliveCor performed appropriately, identifying correctly the presence of Afib which was the cause of her nocturnal symptoms.

AliveCor Failures

A young woman emailed me that her AliveCor device on several screen-shot-2016-11-27-at-5-18-23-amoccasions has identified her cardiac rhythm during times of a feeling of heart racing and palpitations as “possible atrial fibrillation.”  When she sent the recordings in to AliveCor to have a paid interpretation, however, the recordings were interpreted as sinus tachycardia with extra beats.  Indeed , upon my review her rhythm was not Afib. Clearly, when the device misidentifies Afib, this has the potential for creating unnecessary anxiety.

It is not uncommon for a full, 12-lead ECG done in the hospital or doctor’s office  by complex computer algorithms to misinterpret normal rhythm as Afib so I’m not surprised that this happens with AliveCor using a single lead recorded from the fingers.

The young woman was advised by AliveCor to try a few things such as using the device in airplane mode, sitting still and wetting her fingers which did not help. She was sent a new device and the problem persisted. She finds that putting the device on her chest gives a better chance of success.

She also runs into a problem I see frequently which is a totally normal recording labeled by the device as  “unclassified.”screen-shot-2016-11-27-at-5-35-05-am

In this example, although I can clearly see the p-waves indicating normal sinus rhythm, the voltage is too low for the device to recognize.

Send Me Your AliveCor Problems and Solutions

I’m interested in collecting more AliveCor/Kardia success and failure stories so please post yours in the comments or email me directly at DRP@theskeptical cardiologist.com.

In addition, I’m interested in any tips AliveCor users have to enhance the success of their recordings: What techniques do you use to make the signal strength and recording better? What situations have you found that tend to worsen the signal strength and recording quality?

Still Unclassified Yours,

-ACP

P.S. Tomorrow is Cyber Monday and I note that Kardia is running a “Black Friday” special through 11/28, offering the device at 25% off.

screen-shot-2016-11-25-at-6-00-14-amP.P.S. Kardia, You should change the statement on your website, “90% of strokes are preventable if you catch the symptoms early.”  makes no sense. I think you mean that some strokes are preventable (I have no idea where the 90% figure come from) if one can detect Afib by utilizing a monitoring device to assess symptoms such as palpitations or irregular heart beat.

 

 

Roasted vs. Raw Almonds: Which Are Healthiest And Most Cardioprotective?

As part of the Dr. P Heart Nuts Project, the skeptical cardiologist has been trying to determine what constitutes the best and most cardioprotective almonds.

Previously I decided  that i would not be consuming or handing out almonds pasteurized with propylene oxide (PPO). PPO was used as a racing fuel before being banned and is used in thermobaric weapons (one of my least favorite weapons of mass destruction) and in making polyurethane plastics and is a recognized carcinogen.
Since 2004 almost all “raw” almonds consumed in the US have been treated with PPO.

Cardioprotective Almonds: Best Raw or Roasted?

There are two issues with roasting: are we destroying good nutrients and are we creating bad chemicals?

Effects of Roasting on Good Nutrients

The cardioprotective component of nuts and almonds is presumed  related to phytochemicals, especially phenolics and flavonoids which may act as antioxidants. But truly we don’t know with any certainty which of the many potentially beneficial components-minerals, vitamins, fatty acids, proteins are helpful. And we have little understanding of how roasting, steaming, soaking, fermenting, germinating, or fumigating affects the cardioprotective components.

In terms of measurable important macronutrients, vitamins and minerals there is no significant difference between roasted and raw nuts.

One study  compared consuming roasted versus raw hazelnuts on various cardiovascular parameters. Compared with baseline, consuming both forms of hazelnuts significantly improved HDL-cholesterol and apolipoprotein A1 concentrations, total-C/HDL-C ratio, and systolic blood pressure. These changes would be expected to result in improved cardiovascular outomes.

One argument I hear frequently from patients worried about weight gain is that nuts are very energy dense and therefore will contribute to weight gain if added to the diet or consumed as a snack.

In the roasted versus raw hazelnut study:

However, no evidence for weight gain was observed with the consumption of either raw or dry roasted, lightly salted hazelnuts in the present study, and in fact, small reductions in weight were observed. Results of the present study further add to previous research, which suggests that regular nut consumption results in either no weight gain or less weight gain than predicted This may be explained by dietary compensation, inefficient energy absorption, and an increase in metabolic rate.

Thus, neither roasted nor raw nuts contribute to weight gain.

I particular like one line from the conclusions of this study:

both forms of nuts are resistant to monotony

Really! That is tremendously reassuring because I have always worried  about my nuts getting bored.

Bottom line: Probably little change in the good components of nuts and almonds with roasting.

Effects of Roasting Almonds on Increasing Bad Chemicals

About a third of almonds and nuts are consumed in roasted form because a majority of people prefer the taste created by the Maillard reaction during roasting. Almonds can be roasted at home and the typical recommendation is an oven temperature of 350 degrees which corresponds to 177 degrees Celsius.

An analysis from the Winnipeg Health Authority found that roasting at temperatures higher than 140 degrees Celsius has some potentially worrisome consequences:

Lipid oxidation

-High heat used during the processing of nuts has the potential to develop lipid oxidation products, which include trans fatty acids. Trans fatty acids, while not present in raw nuts, were found to be significantly higher in roasted pistachios, peanuts, and almonds (0.5-0.9g/100g).
-Trans fat is known to increase LDL cholesterol and decrease HDL cholesterol, leading to increased cardiovascular disease risk.
-While roasting temperature was found to substantially increase lipid oxidation, roasting time had less of an effect on lipid oxidation. It is therefore recommended to roast nuts at a moderate temperature (130-150°C), for a longer period of time, rather than roasting at high heat for a shorter period of time (reference here)

Acrylamide

-Acrylamide has been identified as a probable carcinogen to humans. The amount of free aspargine in almonds makes them more susceptible to the Maillard reaction, which results in acrylamide formation. Time and temperature are known determinants of acrylamide formation in foods. Hence, darkly roasted almonds were found to have a much higher amount of acrylamide than lightly roasted almonds. The amount of acrylamide that is initially formed after processing was found to decrease over time. Acrylamide content of almonds therefore differs widely depending on roasting time and temperature, as well as length of time after processing.
-It was observed that almonds processed under roasting temperatures of 140-180°C led to the accelerated production of acrylamide. It is therefore recommended to roast almonds below 140°C

The acrylamide study authors noted that:

Almonds of European origin contained significantly less free asparagine and formed significantly less acrylamide during roasting as compared to the almonds from the U.S. Roasted hazelnuts contained very little acrylamide because of the low content of free asparagine in the raw nut.).

Bottom Line: Roasting almonds has the potential for creating some bad chemicals which might negate their beneficial effects.

I asked Whole Foods (my typical almond source) about the roasting process for their roasted almonds and they responded thusly:

“PPO and chemical methods of pasteurization are against our Quality Standards. Our almonds are pasteurized with steam. Our almonds are roasted with canola oil at 148 degrees (celsius).”

Yikes! Canola oil! 148 degrees! (When I asked Whole Foods did they really mean 148 degrees Celsius, the response was , no, I meant 148 degrees Fahrenheit. The skeptical cardiologist wonders.)

img_7965
The first sack of cardioprotective nuts from Dr. Pearson’s nutshop. There are from the Superior Nut Company. I’m still working on the packaging. They are raw and not treated with PPO.

It appears even Whole Foods roasted almonds have the potential for containing harmful acrylamides and trans-fats therefore when the skeptical cardiologist starts handing out packets of his cardioprotective nuts the almonds will be raw and they will be from Spain just like the almonds consumed in the landmark PREDIMED study that established their heart benefits.

Happy Thanksgiving!I hope you are able to stay resistant to monotony during this festive season.

-ACP

Speaking of resisting monotony, did you know this about thermobaric weapons?

“The [blast] kill mechanism against living targets is unique–and unpleasant…. What kills is the pressure wave, and more importantly, the subsequent rarefaction [vacuum], which ruptures the lungs…. If the fuel deflagrates but does not detonate, victims will be severely burned and will probably also inhale the burning fuel. Since the most common FAE fuels, ethylene oxide and propylene oxide, are highly toxic, undetonated FAE should prove as lethal to personnel caught within the cloud as most chemical agents.”

 


 

Vote Yes on Missouri’s Amendment 3 To Cut Cigarette Smoking and Enhance Early Childhood Education

The skeptical cardiologist spent way too much time soliciting and analyzing the arguments against Amendment 3 on a gorgeous fall Sunday.

I found two sites to be very helpful in sorting through the “smokescreen” put up by opponents: Campaign for Tobacco-free Kids and the blog of Megan Green.  Both of these sites I have concluded are only interested in helping children and have unimpeachable credentials.

If you take the time to read these discussions I think you will conclude as I have that Amendment 3 should be supported as a measure that will both reduce cigarette smoking and enhance early childhood education in Missouri.

Megan Green points out that the complexity of the Amendment relates to :

Washington University in St. Louis put out studies in 2009 and 2012 about the reasons that the last two cigarette tax increases failed. It was largely because proponents of the tax were fighting big tobacco, wholesale tobacco, convenience stores, and pro-life, each of which are very powerful lobbies. It is nearly impossible to fight all of them and win.

Here’s what I concluded:

Misguided Argument 1 :There are restrictions on the money being used on stem cell research. This appears to be why Washington University sent an email to all their faculty urging them to vote no.

Megan Green, (self-described as Progressive | 15th Ward Alderwoman | PhD Student in Ed Policy | Change Agent | Social Justice Activist | STL City Advocate) who helped craft  A3 answers this clearly in a blog post:

Utilizing lessons learned from the 2006 campaign detailed in the study, an attempt was made to neutralize the opposition by adding specific language stating that the money would not be used to support abortions or stem cell research in the 2012 initiative, which also failed. As detailed in a 2012 study also from Washington University in St. Louis, the pro-life groups were still not satisfied, but were not as active as in prior campaigns due to the ballot language excluding funding of stem cell research.

Fast forward to 2016, and once again proponents of a cigarette tax took the recommendations of the Washington University in St. Louis study, (ironically, the same group that is now opposing us) and added the protective language to the policy. The Washington University report recognized the 2012 anti-abortion, anti-stem cell language helped, but it was not strong enough to stop all pro-life opposition. In order to neutralize opposition, we made adjustments and used the following language:

2016 language: “None of the funds collected, distributed, or allocated from the Early Childhood Health and Education Trust Fund shall be used for human cloning or research, clinical trials, or therapies or cures using human embryonic stem cells, as defined in Articles IX, section 38(d).”

The effect of this language is ensuring the revenue from this screen-shot-2016-11-07-at-6-45-19-amspecific 60-cent tobacco increase can only go towards early childhood and smoking cessation/prevention programs. The language does nothing to change Missouri’s existing laws as they relate to abortion or stem cell research or funding. A legal opinion was even issued by retired Missouri Court of Appeals Judge James R. Dowd where he stated that “It is evident that there is no risk that a Missouri court could read the proposed amendment as a repeal of Amendment 2 (the Amendment authorizing stem-cell research), either expressly or by implication.”

Misguided Argument #2. The measure will fund religious and private schools with public money.

Raise Your Hands for Kids (an excellent site devoted to supporting the amendment which addresses in detail all of these concerns)  has a succint document that addressess all the opponents issues which answers this concern by saying:

The Establishment Clause of the U.S. Constitution prohibits public dollars going towards religious instruction. Missouri education leaders suggest that to adequately serve our birth through 5 population and deliver quality pre-K, Missouri must have a blended funding model.

For a really detailed analysis of the early childhood education screen-shot-2016-11-07-at-6-45-03-amsituation in Missouri (which is shockingly lagging other states) take the time to read Megan Green’s answer to this argument:

As the daughter of a retired NEA Local President there are few things that matter more to me than the protection of public education. I also think that it is important to understand a few things about the landscape of early childhood education in Missouri. First, the Establishment Clause of the U.S. Constitution prohibits public dollars from going toward religious instruction. Funds cannot be used on religious education, period. With that said, religious organizations, such as the YMCA already receive public money to provide early childhood programing so long as that funding does not go toward religious education.

Second, it’s important to understand how the current system of early childhood education is funded. In Missouri we already have a blended funding model between public and private institutions. Private schools already receive early childhood programs and, in fact, most programs in this state are private. Parents receive child care subsidies, or for lack of a better term, vouchers. Programs also receive food and other health related government funding. In return, these programs must adhere to state licensing standards.

Although I would love for Missouri to have a completely public early education system, it is irrational to think we could move to a completely public system. Most of the supply in Missouri is in the private sector, and we also use public money at private institutions in the form of child care subsidies and child and adult food care program reimbursement. A prime example of this are Head Start programs, which are often private organizations, such as Grace Hill, the YWCA, and the Urban League, who receive government contracts to run the program.

Facilities have to be licensed or accredited in Missouri to receive those funds. Missouri recently passed a quality rating system this past year that ensures quality. Although I support when St. Louis Public Schools added pre-k programming to its elementary schools, the decision was done without the consultation of those in the private sector, and as a result, some really high quality programs serving low-income kids went out of business because they couldn’t compete with free.

The best delivery model for early childhood education services for children ages birth through 5 is a public/private model. Public schools are not in the business of taking care of infants and toddlers. The only way we can reach all children is through a blended model, and we already do that in Missouri — Head Start and Missouri Preschool Project public money’s go to private providers.

If we already had the bulk of our early childhood programs in the public sector, then I would be all for it going just to the public sector, but that is not the system we have. Only having the funds in the public sector would disenfranchise many children in rural areas where schools would have to build additions to accommodate rather than being able to use existing programs. Couple that with the travel times induced by closing programs in small towns and having to bus or drive kids that young to school districts is not in the best interest of kids. There has to be a public/private partnership where school districts can contract with quality programs to replicate their programs in a public setting rather than starting from scratch. I’m rarely on the opposite side as the teachers unions, but I am in this case because we have real financial, logistical, and educational reasons to not switch to a completely public system.

In sum, if we only want early childhood education in the public sector are we saying that we should defund programs like Head Start and the Missouri Pre-school Program? Then are we further saying that no non-profit organization should receive government funding because they do not operate in the public sector? I think not.

Unless we are ready to draw those hard lines in the sand, that no non-profit or Head Start Program should be receiving government money since they are not public entities, I encourage you to vote YES on Amendment 3.

Misguided Argument #3. Studies have shown that the increase in cigarette tax proposed is not enough to impact cigarette smoking. This seems to be the argument of the major health organizations that have come out against the tax.

I really searched hard to find any study that supports this claim and couldn’t find one. For a discussion of how effective cigarette taxes are in reducing smoking read this pdf from The Campaign for Tobacco-Free Kids

Misguided Argument #4. This is a regressive tax which will hurt the poor more than the affluent.

From a review in Tobacco Control:

The regressivity of existing taxes, however, does not necessarily imply that tax increases are regressive as well. In many countries, tobacco use among the lowest income/SES populations is most responsive to price, while use among the highest income/SES populations is least responsive. Thus, a tax increase that raises tobacco product prices will lead to the largest declines in smoking among the lowest income persons, and the burden of tax increase will fall more heavily on higher income consumers whose smoking behaviour changes little in response to the tax increase.

I urge all Missouri readers to educate yourself on Amendment 3 by reading the source documents and fully understanding the document.

I now strongly advocate voting yes for Amendment 3

Antinicotinely Yours

-ACP

And here’s some more stuff to ponder

The St. Louis Post Dispatch supports Amendment 3 after a judge ruled that verbiage in the Amendment would not limit funding for stem cell research in the state

Quotes from Transnational and U.S. Tobacco Companies (from tobaccofreecenter.org)

  • Tobacco companies have opposed tobacco tax increases by arguing that raising product prices would not reduce adult or youth smoking. But the companies’ internal documents, disclosed in the U.S. tobacco lawsuits, show that they know very well that raising cigarette prices is one of the most effective ways to prevent and reduce smoking, especially among kids.

    • Philip Morris: Of all the concerns, there is one – taxation – that alarms us the most. While marketing restrictions and public and passive smoking [restrictions] do depress volume, in our experience taxation depresses it much more severely. Our concern for taxation is, therefore, central to our thinking . . .
    • Philip Morris: When the tax goes up, industry loses volume and profits as many smokers cut back

    Higher Tobacco Taxes Reduce Tobacco Use / 4

    • Philip Morris: It is clear that price has a pronounced effect on the smoking prevalence of teenagers, and that the goals of reducing teenage smoking and balancing the budget would both be served by increasing the Federal excise tax on cigarettes.22
    • Philip Morris: Jeffrey Harris of MIT calculated…that the 1982-83 round of price increases caused two million adults to quit smoking and prevented 600,000 teenagers from starting to smoke…We don’t need to have that happen again.23
    • Philip Morris: A high cigarette price, more than any other cigarette attribute, has the most dramatic impact on the share of the quitting population…price, not tar level, is the main driving force for quitting.24[For more on cigarette company documents and price/tax increases see the 2002 study in the Tobacco Control journal, “Tax, Price and Cigarette Smoking: Evidence from the Tobacco Documents.”25]

Cigarette Smoking Kills: Should Missourians Vote Yes To Raise Cigarette Taxes?

Recent statistics show that cigarette smoking is  responsible for 167, 133 cancer deaths annually in the US or 29% of all cancer deaths.

Cigarette smoking also kills annually in the US  160,000 people by promoting cardiovascular disease.

Thus, from a health standpoint we should be doing everything possible to stigmatize and make more difficult cigarette smoking.

One approach to this is to tax cigarettes, raising the financial burden of smoking. Across the US, therefore, states have added cigarettes taxes which average 1.65$ per pack.

My state of Missouri has the lowest state tax on cigarettes of 17 cents per pack. Multiple ballot attempts to raise this amount have failed in the past.

However, on this Tuesday’s ballot there are two competing options that we can  vote on that will raise cigarette taxes: Amendment 3 (raises cig taxes  60 cents and earmarks funds for a newly created Early Childhood Education and Research Fund) and Proposition A (raises taxes 23 cents and earmarks funds for infrastructure.) (Links are to Ballotpedia, a reputable source of information nationwide.)

I’ve been researching both of these proposals over the last few days since receiving an email from a physician colleague urging  me to vote no on Amendment 3. Remarkably, a coalition of health organizations (The American Cancer Society Cancer Action NetworkAmerican Heart AssociationAmerican Lung Association in MissouriCampaign for Tobacco-Free KidsHealth Care Foundation of Greater Kansas City and Tobacco-Free Missouri) has come out against the propositions to raise cigarette taxes with the following statement :

Small increases to the tobacco tax – like the proposals being considered – will generate new revenue, but will not keep kids from becoming addicted to cigarettes or help adults quit.Tobacco taxes work when the price increase is substantial enough to motivate current smokers to quit and prevent kids from starting. A dime here or there is not sufficient. Tobacco companies are adept at finding ways to absorb small tax increases through adjusted pricing. What’s worse, these marginal increases could hamper future efforts; promising profitable returns for the tobacco industry at the continued expense of Missourians’ health…

Tobacco products in Missouri are too cheap and the health costs are too high. Our state is long overdue for a tobacco tax increase, but it needs to be one that will make a difference and save lives. A meaningful tobacco tax increase – of $1.00 per pack or more – has proven time and again to be an effective way to reduce tobacco use, cut healthcare costs and generate state revenue.[7]

Our local public radio station had a good discussion recently which is summarized here.

I found the PRO comments of Jane Dueker particularly persuasive as summarized below:

PRO: Jane Dueker wants people to vote “Yes” on Constitutional Amendment 3. Here are her main points:

Jane Dueker is a proponent of Constitutional Amendment 3.
CREDIT KELLY MOFFITT | ST. LOUIS PUBLIC RADIO
  • This tax would provide $300 million in funding for early childhood education, healthcare and smoking cessation programs. Right now, Missouri can’t even fund the K-12 Foundation Formula, so any extra funding is needed for early childhood education.

  • By filing this as an amendment, we were able to make a constitutional “lock box” that would keep the legislature and special interests from taking money that is specifically dedicated to this fund, like what happened with lottery funds.

  • Right now, only 3 percent of 4-year-olds in Missouri are in a publicly-funded preschool. Missouri is behind states like Oklahoma with 76 percent, Illinois with 27 percent and Arkansas with 38 percent.

  • Higher tobacco taxes have failed in 2002, 2006 and 2012. This is more reasonable and we don’t have a clause that says another tobacco tax could not be added on top of this one to give that “sticker shock” to consumers.

  • This closes a loophole that kept cheap cigarette companies from paying their fair share into a 1998 court settlement to recover some of state governments’ tobacco-related health-care costs. Now, smaller tobacco companies would pay a 67-cents-a-pack hike on low-cost cigarettes in addition to the 60 cent tax on all cigarettes. This would give Missouri $1 billion annually we currently don’t get. Missouri is the only state that hasn’t closed this loophole and the state is a “dumping ground” for the cheapest cigarettes in the country.

  • Groups that oppose this either think the tax is not high enough (health groups) or that they don’t get money from this fund (pro-choice and research institutions).

  • Missouri’s Foundation Formula public school funding starts at kindergarten and cannot fund early childhood education. This money could go to public or private early childhood education entities in a way it would not be distributed through the foundation formula.

  • $15-30 million dollars would be raised through this tax that would go to smoking cessation programs.

  • The fund will be administered by a board of unelected people because they have special experience in early childhood education. A “person of faith” is required on the board because of their position as a community anchor.

At this point, I’m leaning toward voting yes on Amendment 3 but confused as to why RJ Reynolds is supporting it to the tune of 12 million dollars and the “good guy” health organizations oppose it. I’d appreciate any input/comments on this from readers. I strongly urge everyone to read and learn as much as you can about the issue before walking into the voting booth.

By the way, I recently observed this Canadian cigarette package img_7957which I think excellently conveys the horror of cigarette smoking.

Truthily Yours

-ACP

Some more  stats to ponder from the CDC

Cigarette smoking causes premature death:

  • Life expectancy for smokers is at least 10 years shorter than for nonsmokers.
  • Quitting smoking before the age of 40 reduces the risk of dying from smoking-related disease by about 90%.

Exposure to secondhand smoke causes an estimated 41,000 deaths each year among adults in the United States:

  • Secondhand smoke causes 7,333 annual deaths from lung cancer.
  • Secondhand smoke causes 33,951 annual deaths from heart disease.

The Name For The Nuts Poll: Part Deux

The results of my request for reader input on naming the mixed nuts based on the PREDIMED study I plan to give out to my patients are hot off the presses.

screen-shot-2016-11-02-at-2-50-42-pm

 

 

The winner of the pre-specified names was “Pearson’s Health Nuts.”

Second place went to my personal favorite “Dr. P’s Stroke-bustin’ Nuts.

However, readers submitted some suggestions not in the poll:

screen-shot-2016-11-02-at-2-50-53-pm
And I had one patient bring in her suggestion with a design already created!:

img_7954-1

and one sketch out her suggestion on what appears to be a post-it note:

img_7959
I’ll term this heart (symbol)NUTZ in the poll

Consequently, I’m soliciting your input into a revised poll that incorporates some of the newer suggestions.

There is much excitement here at mixed nut central because the non-fumigated raw almonds have arrived!

Polldaddily Yours

-ACP

 

 

 

They Were in Normal Sinus Rhythm for Halloween

The skeptical cardiologist likes to see his afib patients stay in the normal rhythm (normal sinus rhythm) after they are cardioverted. On Halloween here in the office at Cardiac Specialists of St. Lukes three of our assistants helped drive home the message with a creative ensemble costume:

img_7951
Three marvelous medical assistants  help maintain normal sinus rhythm and battle the chaos of atrial fibrillation. (From left to right, Trish, Diane, and Jenny)

Speaking of Halloween, rather than handing out candy next Halloween, I’ll be handing out sacks of stroke-bustin’ nuts.

I’m sure the neighborhood kids will love the alternative to all that high fructose corn syrup!

Frightfully Yours

-ACP

 

 

 

Raw Almonds From The Gas Chamber or: A PPO Most Investors Should Avoid

In my previous post highlighting the marketing hype, silliness, and duplicity surrounding Kind bars, I revealed that the skeptical cardiologist would soon begin issuing bags of special stroke-busting  nuts to his patients.

I solicited a catchy name for the sacks.

One reader suggested:

“The Snack” or “Snack?” No one will forget that name.. In the center of a small heart shape on the front of the package will be shown the type of nuts (either written or better as a picture.. )

Another:

How about “Pearson’s Health Nuts?” It could refer to both the nuts and the eaters.

Another:

“Nuts About Nuts!”

The logo is a kindly cardiologist, in a lab coat, peering over the top of his glasses, with a stethoscope draped around his shoulders.

Another

Call it Pearson’s delight!!! I always keep a bag of nuts mixed with raisins, m&ms, almonds and cashews. Have done this for last 3 years. But some times I over eat them. But better than junk food..hope this is ok

(Raisins and M & Ms are right out! Too much sugar)

I’ve created a poll that I would appreciate your voting on. I can guarantee this will be less controversial than the Presidential election.

Raw Almonds: Straight From Fumigation

While exploring where to obtain the best walnuts, almonds, and hazelnuts for these “yet to be named” snacks, I discovered that the vast majority of almonds consumed in the US have been pasteurized by fumigation with an organic chemical called propylene oxide (PPO).

Because of two salmonella outbreaks involving almonds from California, the FDA mandated in 2007 that all California almonds had to be pasteurized either by a steam process or by PPO. Since the PPO process is cheaper, the vast majority of non-organic almonds have been sprayed with PPO. Both PPO sprayed and steamed almonds are marketed as “raw.”

Although I’m not fanatical about choosing organic (with the exception of dairy) I really don’t like the idea of eating things that have been sprayed with PPO.  PPO is primarily used to make polyurethane plastics. The CDC says:

“propylene oxide is a direct-acting carcinogen”

Several online sources state that PPO has been banned in “Canada, Mexico, and the European Union” including this Almond fact sheet from cornucopia.org

https://www.cornucopia.org/almond/Almond_Fact_Sheet.pdf

but it’s more accurate to say that these countries have not approved PPO fumigation.

Consequently, I’m getting my almonds from nutsinbulk.com. They are selling almonds from Spain, grown organically, and they promise there will be no PPO consumed.

Once my nuts arrive and I get them in appropriate sacks with appropriate labels, I’ll start handing them out to my patients.

If anyone has advice on creating such labels and sacks feel free to comment below.

Amandinely Yours

-ACP

P.S. Here’s what the CDC says about PPO

Studies in animals have demonstrated that propylene oxide is a direct-acting carcinogen. B6C3F1 mice exposed by inhalation to propylene oxide developed hemangiomas and hemangiosarcomas of the nasal mucosa. F344/N rats exposed to propylene oxide in air developed papillary adenomas of the nasal epithelium. Degeneration of the olfactory epithelium and hyperplasia of the respiratory epithelium were induced in the nasal cavities of Wistar rats exposed to propylene oxide by inhalation. Squamous cell carcinomas of the forestomach developed in rats administered propylene oxide by gavage. Although epidemiologic data are not available from workers exposed to propylene oxide, the findings of cancer and other tumors in both rats and mice treated with propylene oxide meet the criteria established in the Occupational Safety and Health Administration Cancer Policy [Title 29 of the Code of Federal Regulations, Section 1990.112] for regarding propylene oxide as a potential occupational carcinogen. The National Institute for Occupational Safety and Health therefore recommends that occupational exposures to propylene oxide be reduced to the lowest feasible concentration.

Choosing A “Healthy” and “Natural” Snack: Kind Bars Versus Simple Stroke-Busting Nuts

The eternal fiancee’ of the skeptical cardiologist (EFOSC) deserves serious kudos for (among myriad other things) challenging his conventional ideas about heart-healthy food and serving as his dietary muse.

However, the EFOSC seems to have a weakness for what I would consider a highly processed, sugared up, over-priced piece of marketing hype—Kind Bars.

I asked the EFOSC recently why she was so enamored of Kind Bars and she told me “I like that they are convenient, you can find them anywhere, they are not expensive and they taste good and they are low in sugar and they are 100 times better than all the other snack bars on the market that are expensive and have tons of sugar and chemicals and disgusting things in them:

She also points out that for frequent business travelers, the bars are more convenient (and often cheaper) than buying  a bag of nuts in an airport kiosk.

She is not alone.

The Booming “Healthy and Natural” Snack Bar Business

The “healthy” snack bar business has been booming lately.

The WSJ points out

“Bar makers are opening the floodgates on nuts, dried meats, cricket flour and other nutrient and protein-rich ingredients to compete for consumers and command top dollar. Many of these ingredients cost more than those found in a traditional cookie—and as sources of protein, ounce for ounce, some of them cost more than a steak.There are 1,012 nutrition bars on the market now, compared with just 226 a decade ago, according to a tally by Valient Market Research in Philadelphia.”

Consumers, attracted by convenience and a desire for “healthy and natural” food are paying more for snacks like Kind bars which have high profit margins.

“The average bar costs about two dollars, up from just one dollar 10 years ago, a sign of how much more consumers are willing to pay, or “diminishing price sensitivity,” as Valient founder Scott Upham calls it. “The cost of ingredients makes up only 25% of the price, and profit margins for bars tend to hover as high as 40% to 50%, compared with only 20% to 30% for most other packaged foods, says Mr. Upham.”

Stores love them because “they are individually wrapped and have a long shelf life, yet they are popular and turn over fast.”

Are Kind Bars And Their Ilk Healthy?

Interestingly, about a year ago, the FDA issued a “warning letter” to Kind asking the company to remove the term “healthy” from its product labels.

Violation 1a. of that letter fingers Kind Fruit & Nut Almond & Apricot for having 3.5 grams of saturated fat per 40 grams of food (the so-called Reference Amount customarily consumed or RACC) which is more than the 1 gram of saturated fat per RACC allowed if is one is going to describe one’s food as healthy.

This is clearly a ridiculous and out-dated requirement: saturated fats are a diverse category of nutrients, some of which are likely very healthy (see my posts on dairy fat or coconut oil). According to these criteria, foods that are clearly very healthy such as avocados, salmon and nuts, cannot be labeled as healthy.

Kind fought back and challenged the FDA and the FDA backed down.

According to the WSJ:

“The FDA said in a statement to The Wall Street Journal that in light of evolving nutrition research and other forthcoming food-labeling rules, “we believe now is an opportune time to re-evaluate regulations concerning nutrient content claims, generally, including the term ‘healthy.’”

However, I don’t think Kind bars are necessarily a healthy good food choice. I think people buy them because they have been slickly marketed as “healthy” and “natural.”

As Marion Nestle points out, when it comes to food labels, “healthy” and “natural” are marketing terms.  Their purpose is to sell food products.

kin-17113-4
Is this the most annoying advertising blather in existence? Is the EFOSC a KINDAHOLIC with an uncontrollable love for KIND and spreading kindness?

The ingredients in the almond and apricot Kind bar are: Almonds, coconut, honeynon GMO glucose, apricots, apple juice, crisp rice, vegetable glycerine, chicory root fiber, soy lecithin, citrus pectin, natural apricot flavor.

Nutrition: 180 calories, 10 g fat (3.5 g saturated fat), 25 mg sodium, 23 g carbs, 3 g fiber, 13 g sugar, 3 g protein

Basically, the healthy part of this Kind Bar is almonds and coconut, which you could purchase for a hell of a lot less than what you are paying for this processed junk.

Also, please note that it doesn’t contain any actual apricots, merely “apricot flavor.”

Also, note that the third ingredient is honey and the fourth is non GMO glucose. What on earth is non GMO glucose? Do we really care whether the added sugar you are pumping into your crappy bars is GMO or non GMO?

Some Kind bars are clearly no healthier than a typical Payday candy bar:

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Is a KIND bar any healthier than these Halloween treats? Is that Jenny in the background, Dr. Pearson’s marvelous medical assistant?

IAs Crains  writes:

“the packaging of the dark chocolate cherry cashew bar advertises the word “Antioxidants.” In other words, the bar isn’t promoted as being low in sugar, so it’s a fair choice to compare with a PayDay.
The Kind bar has 9 grams of fat—1 gram less than PayDay’s bar. The sugar count, at 14 grams, is 2 grams less than PayDay. So far, so good. But this particular Kind product has a total carbohydrate count 1 gram higher than PayDay, and 1 fewer grams of protein. The bar has 2.5 grams of dietary fiber, a fraction more than PayDay.”

The Kind PR machine responds thusly:

“It is not at all a fair comparison to equate KIND’s Dark Chocolate Cherry Cashew bar to a Pay Day,” a company spokesman said. “This completely ignores the nutrient-rich ingredients that are in a KIND bar, not to mention the exponentially lower level of sodium.”

You can buy 24 Payday bars at Sam’s Club for $14, about 61 cents a bar.

To be fair to the EFOSC, she usually only eats Kind bars that have about 5 grams of sugar.

Preventing Stroke and Heart Attack with 30g of “Mixed Nuts” Daily

In a previous post (Nuts, Legumes, Drupes and Mortality)  I summarized the evidence IMG_3593supporting the cardiovascular benefits of consuming various kinds of nuts.

The PREDIMED trial, in particular, showed a remarkable benefit in reducing heart attacks and strokes when patients ate a Mediterranean diet supplemented with 30g mixed nuts per day (15g walnuts, 7.5g almonds and 7.5g hazelnuts). Walnuts and almonds are actually drupes, but hazelnuts are true nuts.

The  Mediterranean diet, including nuts, reduced the risk of cardiovascular diseases (myocardial infarction, stroke or cardiovascular death) by 30% and specifically reduced the risk of stroke by 49% when compared to a reference diet consisting of advice on a low-fat diet (American Heart Association guidelines). The Mediterranean diet enriched with extra-virgin olive oil also reduced the risk of cardiovascular diseases by 30%.

You can buy 454 grams of walnuts or hazelnuts for $14 , and 454 grams of almonds for $10. Thus, for 46 cents for the walnuts, 23 cents for the hazelnuts and 16 cents for the almonds (total 85 cents) you can recreate the snack that the Spaniards ate in PREDIMED.

This compares to Kind bars which retail anywhere from $1.99 to $3.50.

The PREDIMED investigators explain why they chose these specific nuts:

“WALNUTS. Walnuts differ from other nuts in that they are very rich in omega 6 and omega 3 type unsaturated fats. Moreover, the antioxidants they contain are among the most powerful in the plant world. It should be mentioned that, like omega 3 in fish, nut fats possess important beneficial properties for general health and the heart in particular.

ALMONDS. Almonds form part of many traditional desserts and sweets of Arabic origin, such as nougat. Currently, Spain is the second largest producer and consumer of almonds in the world, after the United States. As with hazelnuts and olive oil, almonds are rich in oleic acid. They differ from other nuts in that they contain more fibre, vitamin E, calcium and magnesium.

HAZELNUTS. Hazelnuts, another widely consumed nut in Spain, are very rich in oleic acid. Furthermore, they are nuts that provide a large amount of folic acid, a vitamin very important for regulating the metabolism, a lack of which can lead to thrombosis and an acceleration of degenerative processes such as arteriosclerosis and senile dementia.”

Unfortunately, I can eat neither hazelnuts nor walnuts (tree nut allergy), but I’ve decided to create for my patients little baggies filled with 30 grams of the magical PREDIMED nut mixture. I’ll give these out during office visits as I explain the glories of the Mediterranean diet (I’ll try to forbear elaborating to them the difference between drupes and nuts).

I need a catchy name for these bags-“Pearson’s PREDIMED bags” or “Stroke-busting nuts?”

If any reader or patient has a suggestion, please add it to the comments.

If I choose your suggestion, I’ll provide you with 10 bags of nuts and oodles of glory!

Hopefully, once I start creating the nut bags, the EFOSC will begin to eschew the faux healthiness of Kind bars and embrace the natural and unmarketed goodness of drupes and nuts.

Kindly Yours

-ACP

Somes notes:

A drupe is a type of fruit in which an outer fleshy part surrounds a shell (what we sometimes call a pit) with a seed inside.  Some examples of drupes are peaches, plums, and cherries—but walnuts, almonds, and pecans are also drupes. They’re just drupes in which we eat the seed inside the pit instead of the fruit!

In PREDIMED:

“Every 3 months a supply of 1,350-g walnuts (®California Walnut Commission, Sacramento, Cal), 675-g almonds (®Borges SA, Reus, Spain), and 675 g hazelnuts (®La Morella Nuts, Reus, Spain) is provided to each participant assigned to the MeDiet+Nuts group.”

 

Two Three Letter Words For Saving Lives: CPR and AED

Every two years the skeptical cardiologist has to get recertified in Basic Life Support for medical personnel. This involves a review of what, the American Heart Association has decided, are important changes in guidelines for Emergency Cardiac Care and cardiopulmonary resuscitation (CPR).

I highly recommend all of you undergo such training. Although the survival rate of patients with “out of hospital cardiac arrests” is very low, your appropriate actions could be crucial in saving the life of a stranger or a loved one.

About a year ago one of my patients suddenly, and without any warning symptoms, collapsed at work. Fortunately for him, a co-worker had undergone CPR training and initiated chest compressions right away. When paramedics arrived 15 minutes later he was defibrillated from ventricular fibrillation and taken to a nearby hospital.

Our best information on cardiac arrest suggests that without CPR, irreversible brain damage (due to lack of oxygen) develops in about four minutes after the heart stops beating. Even with good CPR, the longer the time interval from arrest to defibrillation, the less likely the patient is to survive with good brain function.

Thus, the two keys to helping someone who drops dead next to you are beginning effective CPR (and compression only is OK) and defibrillating a fibrillating heart as soon as possible.

My patient was comatose on arrival to the hospital and was put into a hypothermic state, a process which has been shown to improve neurological outcome in cardiac arrest victims. Doctors informed his wife that they thought his prognosis was bad-less than 5% chance of surviving with intact brain function.  After three days he awoke from his coma and was transferred to my hospital.

I visited him in the ICU and other than a sore chest and an inability to remember the events surrounding his cardiac arrest, he was mentally normal and felt great. He continues to do very well to this day, but without the bystander CPR that he received (followed by the defibrillation) he would be one of the 350,000 who die of cardiac arrest in the US each year.

If the co-worker had not initiated CPR for the many minutes it took for EMRs to arrive, my patient’s brain would have been dying from lack of oxygen and it is most likely he would have suffered severe encephalopathy or brain death.

Recognizing Cardiac Arrest

Recognizing when someone needs CPR is a critical first step in the chain of events that can improve survival in cardiac arrest.

You are looking for two things before starting CPR:

  1. Unresponsiveness. The victim  does not move and does not respond at all to either verbal or physical stimulation.
  2. Breathing is absent or atonal (meaning ineffective , intermittent gasps).

Agonal respirations have also been described as “snoring, snorting, gurgling, or moaning or as barely, labored, noisy, or heavy breathing.”  Studies have shown that agonal respirations are common in the early minutes after cardiac arrest and are associated with good outcomes.

Two Steps To Save A Life

The two key components of resuscitation are CPR and defibrillation.

Performing these steps is simple and straightforward.

The earlier they are started, the more likely the victim is to survive.

If someone collapses near you and they are unresponsive and not breathing, they need CPR and an AED. Call for help as you are starting CPR.

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Cardiopulmonary Resuscitation (CPR)

CPR consists of repeated compressions of a victim’s chest.

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I came across this machine recently. You can learn and practice hands-only CPR using it.

Everyone has seen dramatizations of CPR and it is quite simple to do even without training. Basically, you want to “push hard and fast in the center of the chest.”

CPR training undergoes some tweaking over time as more scientific data is obtained but the fundamentals remain the same. The changes that the AHA is emphasizing in their current CPR courses are:

-depress the chest at least 2 inches

-depress the chest 100-120 times per minuCPR-Certificationte (as opposed to just >100 time per minute).

Of note, the recommended sequence has changed from A, B, C, to C, A, B. Compressions right away followed by assessment of airway and then mouth-to-mouth breathing.  In fact, because compressions without breaths have been shown to be as effective as with breaths, if you are uncomfortable giving breaths, recommendations now are to just do CPR.

 

Initiating CPR and calling 911 are the greatest initial things you can do for the person who collapses next to you.

However, the earlier you can defibrillate that person from ventricular fibrillation, the better their chance of survival.

Ambulatory electronic defibrillators or AEDS , if available, are very easy to use devices that can shorten the time to defibrillation and are the second key to successful resuscitation of cardiac arrest victims in the community.

I’ll talk about using them in a subsequent post.

antimortatorially yours

-ACP

 

Unbiased, evidence-based discussion of the effects of diet, drugs, and procedures on heart disease

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