How To Spot a Quack Health Site: Red Flag #1, Primary Goal Is Selling Supplements

During the process of compiling the Cardiology Quackery Hall of Shame, the skeptical cardiologist has recognized that the #1 red flag of quackery is the constant promotion of useless supplements.

Such supplements typically:

-consist of “natural” ingredients

-are a proprietary blend of ingredients or a uniquely prepared single ingredient, and are only available through the quack

screen-shot-2017-01-15-at-11-11-44-am
And you thought Vital Red referred to Putin! *Individual results will vary according to the strength of the placebo effect

-have thousands of individuals who have had dramatic improvement on the supplement and enthusiastically record their testimonial to its power

-have no scientific support of efficacy or safety

-despite the lack of scientific data, the quack is able to list a series of seemingly valid supportive “studies”

-aren’t checked by the FDA

-apparently cure everything from heart disease to lassitude

I received an email today purportedly from a reader complimenting me on my post on the lack of science behind Dr. Esselstyn’s plant-based diet. The writer thought I would be interested in the work of a Dr. Gundry.

I clicked on the one of the numerous links that were provided andscreen-shot-2017-01-15-at-10-59-10-am based on the appearance of the home page of Dr. Gundry’s website, I feel confident that he is a quack.

Yes, there it is. Red Flag #1: an immediate and aggressive attempt to sell lots of useless supplements.

I didn’t spend a lot of time perusing Gundry’s website, but I read enough to enter him into my contest for America’s Greatest Quack Cardiologist.

Sadly, Dr. Gundry used to be a well-respected cardiac surgeon.screen-shot-2017-01-15-at-11-12-06-am (what is it about cardiac surgery that makes so many turn to quackery?)

Gundry’s life story is typical of the physician who has given up actually helping patients with real medicine and resorted to shilling untested snake oil to gullible people.

“I left my former position at California’s Loma Linda University Medical Center, and founded The Center for Restorative Medicine. I have spent the last 14 years studying the human microbiome – and developing the principles of Holobiotics that have since changed the lives of countless men and women.”

Need I mention that “holobiotics” is (?are) not real.

If any readers have more candidates to nominate for the soon-to-be-announced honor of America’s #1 Quack Cardiologist please forward their names to me.

Bonohibotically Yours,

-ACP

After writing this, I googled “red flag of quackery” images in the foolish hope that I might find a useable image. Lo and behold the image I featured in this post turned up courtesy of sci-ence.org. Here it is in all its glory, courtesy of Maki

2012-01-09-redflags2-682x1024

 

 

Are You On The Fence About Taking A Statin Drug?

The father of the eternal fiancee’ of the skeptical cardiologist (FOEFOSC, let’s call him “Geo”) is a typical 61 year old white male. A year ago his primary care physician informed him that he needed to start taking a statin drug because his cholesterol was high. The note accompanying this recommendation also stated “work harder on diet and exercise to get LDL<130.”  No particulars on how to change his current diet and exercise program were provided.

Neither of Geo’s parents and none of his siblings have had heart problems at an early age and Geo is very active without any symptoms. His diet is reasonably free of processed food and added sugar, he is not overweight and his blood pressures are fine. Due to concern about side effects he had read about on the internet and because he doesn’t like taking medications , Geo balked at taking the recommended statin,

Reluctance to start a new and likely life-long drug is understandable especially when combined with a constant stream of internet-based bashing of statins.

My advice was sought and I suggested a few things that would be helpful in making a more informed decision:

-Calculate Geo’s 10 year risk of heart attack and stroke using the ACC ASCVD Risk estimator app.

-Assess for early or advanced build-up of atherosclerotic or fatty plaque in the carotid arteries (vascular ultrasound) and coronary arteries (coronary calcium scan).

As I’ve pointed out before (here), the vast majority of men over the age of 60 move into a 10 year risk category >7.5%, no matter how great their lifestyle is, and Geo was no exception with a risk of 8.4%. His total cholesterol was 249, LDL (bad) 154, HDL (good) 72 and triglycerides 116.

The vascular ultrasound showed below normal carotid thickness and no plaque and his coronary calcium score was 18,  putting him at the 63rd  percentile. This is slightly higher than average white men his age.

When Geo presented these findings to his PCP, he seemed unaware of the ASCVD risk estimator (recommended by AHA/ACC guidelines first published in 2013), which no longer suggests LDL levels as goals. His PCP also seemed miffed that he had gotten the coronary calcium scan. Geo felt like the PCP’s attitude was “shut up and do what I tell you.”

Geo’s PCP’s approach exemplifies a not-uncommon traditional doctor-patient relationship, but a better approach is shared decision-making (see here). Geo, like many patients, welcomes more information on the risks and benefits of any recommended treatment so that he can participate in deciding the best course of action.

I steer patients who want more complete information towards my  evidence-based blog posts on statins (see here for discussion on statin side effects and here for statin benefits beyond cholesterol lowering.)

By giving patients more information on the risks, side effects, and benefits of the statin drugs along with a better understanding of their overall risk of heart disease and stroke, we can hopefully move more patients “off the fence” and onto the most appropriate treatment.

Stay tuned to find out what The Skeptical Cardiologist Recommended for Geo.

Decisively Yours

-ACP

For more discussion on the value of coronary artery calcification (CAC) and the value of statin in lower risk patients see this recent paper entitled “Refining Statin Prescribing in Lower-Risk Individuals: Informing Risk/Benefit Decisions”(PDF refining-statin-prescribing-in-lower-risk-individuals-informing-riskbenefit-decisions)

If you’d like to read the recently published recommendations of the US Preventive Services Task Force on statins for primary prevention of cardiovascular disease see here. Importantly this panel of unbiased experts concluded that statin therapy significantly reduced overall mortality and cardiovascular mortality. In addition, the review found no increased risk of diabetes overall with statin therapy. The only trial that identified an increased risk was using high intensity statin therapy (Crestor (rosuvastatin) >20 mg).

And,  since the internet is jammed with people who believe statins robbed them of their brain power, I would advise noting that the writers concluded  “These findings are consistent with those from a recent systematic review of randomized trials and observational studies that found no adverse associations of statins with incidence of Alzheimer disease, dementia, or decreased scores on tests of cognitive performance.”

 

 

Female Frenchmen Flagrantly Flock To Franklin

Traffic on The Skeptical Cardiologist doubled from 2015 to 2016 despite a significant drop in output in the middle of the year. WordPress provides  its bloggers with statistics on visits and views that are disturbingly  addictive.  For example, people from 160 different countries viewed my blog in 2016 including one from Reunion,  a country with which I was totally unfamiliar. See if you can spot it in this map of EU Oversease Countries and Territories.

eu_oct_and_omr_map_en

After reading  about this tropical island in the Indian Ocean, I’m pondering flying there to frolic on its unique beaches and search for the one Reunion inhabitant who clicked on my blog.

I suspect this Reunionista was directed to my site as were hundreds of Frenchmen (although potentially sexist, the term is gender neutral) one day  in November by this link to my post on examining the heart of Franklin Delano Roosevelt.

screen-shot-2016-12-31-at-8-30-31-am

I have no idea why but if any of my French speaking/reading readers cares to enlighten me I will be eternally grateful. And if any female Frenchmen read this let me know if Samuel Johnson was correct when he said  “A Frenchman must be always talking, whether he knows anything of the matter or not; an Englishman is content to say nothing when he has nothing to say.”

Bonsoir

-ACP

What Does The Death of Robert Atkins Tell Us About the Atkins Diet?

In the spring of 2003 at the age of 72 years, Robert Atkins, the cardiologist and  controversial promoter of high fat diets for weight loss, fell  on the sidewalk in front of his Atkins Center for Complementary Medicine in Manhattan.  He lost his footing on a patch of ice, slipped and banged his head on the pavement.  At the time of his fall his book ”Dr. Atkins’ New Diet Revolution” lead the NY times paper-back best seller list.

He was taken to nearby Cornell Medical Center where a clot was evacuated from his brain. Thereafter he lapsed into a coma and he spent 9 days in the ICU, expiring on April 17, 2003.

screen-shot-2016-11-27-at-8-44-55-amThe cause of death was determined by the New York Medical Examiner to be “blunt injury of head with epidural hematoma.”

An epidural hematoma is a collection of blood between the skull and the tough outer lining of the brain (the dura) which can occur with blunt trauma to the head which results in laceration of the arteries in this area. It is a not  uncommon cause of death in trauma . Actress Natasha Richardson (skiing, see below)  died from this. Nothing about the manner in which Robert Atkins died would suggest that he was a victim of his own diet any more than  Natasha Richardson was.

However, within the year a campaign of misinformation and deception spear-headed by  evangelistic vegans would try to paint the picture that Atkins died as a direct result of what they perceived as a horribly dangerous diet.

Michael Bloomberg, then New York major,  was quoted as saying

“I don’t believe that bullshit that [Atkins] dropped dead slipping on the sidewalk.”

According to the Smoking Gun:

“The 61-year-old billionaire added that Atkins was “fat” and served “inedible” food at his Hamptons home when Bloomberg visited. The mayor’s inference, of course, was that Atkins was actually felled by his meat-heavy diet, that his arteries were clogged with beef drippings. “

Enter The Vegans

Richard Fleming, a physician promoting prevention of cardiovascular disease through vegetarianism and with close ties to an organization  called Physicians Committe for Responsible Medicine (PCRM) sent a letter to the NY Medical Examiner requesting a copy of the full medical examination of Atkins. The NYME office  should have only issued copies of this report to physicians involved in the care of Atkins or next of kin but mistakenly complied with this request.  Fleming, who would subsequently publish his own low fat diet book, conveniently gave the report to PCRM which is directed by animal rights and vegan physicians.

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From the front page of pcrm.org. The two major concerns of the group are converting everyone to veganism and animal rights.

Neal Barnard, the President of PCRM, in an incredibly unethical move sent the letter to the Wall Street Journal with the hope that the information would destroy the popularity of the Atkins diet, a diet he clearly despises..  Barnard said the group decided to publicize the report because Atkins’ “health history was used to promote his terribly unhealthy eating plan..” The WSJ subsequently published an article summarizing the findings.

To this day, advocates of vegetarianism and low fat diets, distort the findings of Atkins’ Medical Examination in order to depict high fat diets like his as dangerous and portray Atkins as a victim of his own diet.

To scientists and thoughtful, unbiased physicians it is manifestly apparent that you cannot base decisions on what diet plan is healthy or effective for weight loss on the outcome of one patient. It doesn’t matter how famous that one person is or whether he/she originated and meticulously followed the diet. It is a ludicrous concept.

Would you base your decision to engage in running  based on the death of Jim Fixx?  Fixx  did much to popularize the sport of running and the concept of jogging as a source of health benefit and weight loss. He died while jogging, in fact. An autopsy concluded that he died of a massive heart attack and found advanced atherosclerosis (blockage) of the arteries to his heart.

Fixx inherited his predisposition to heart disease and couldn’t run himself out of it. Multiple studies over the years have documented the benefit of regular aerobic exercise like running on longevity and cardiovascular risk.

Would you based your decision to engage in  a very low fat diet based on how Nathan Pritikin died?  Pritikin authored an extremely popular book emphasizing eliminating fat from the diet but developed leukemia and slashed his wrists,  committing suicide at the age of 69 years. Would vegetarians accept the premise that their preferred diet results in leukemia or suicidal depression based on Pritikin’s death?

The Distortion of Atkins Death

The NYME report lists Atkins weight at autopsy as 258 pounds. Low-fat zealots seized on this fact as indicating that Atkins was screen-shot-2016-12-17-at-5-32-56-ammorbidly obese throughout his life.  For example, a  you-tube video of an audio interview of Atkinas online posted by “plant-based coach”  has this obviously photoshopped head of Atkins put on the body of a morbidly obese man. Atkins actually weight around 200 pounds through most of his life and a hospital note on admission showed him weighing 195 pounds. A substantial weight gain of 63 pounds occurred in the 9 days after his admission due to the accumulation of fluid volume and swelling which is not uncommon in the critically ill.

screen-shot-2016-11-27-at-8-42-59-amscreen-shot-2016-11-27-at-8-42-39-am

No autopsy was performed on Atkins but the NYME wrote on the document that he had “h/o of MI, CHF, HTN.”

MI is the acronym for a myocardial infarction or heart attack. As far as we can tell without access to full medical records, Atkins never had an MI. He did have a cardiac arrest in 2002. While most cardiac arrests are due to a cardiac arrhythmia secondary to an MI they can also occur in patients who have a cardiomyopathy or weakness in the heart muscle from causes other than MI. In fact, USA Today reported that Stuart Trager, MD,  chairman of the Atkins Physicians Council in New York, indicated that Atkins was diagnosed with a cardiomyopathy at the time of his cardiac arrest and that it was not felt to be due to blocked coronary arteries/MI. Cardiomyopathy can be caused by viral infections or nonspecific inflammation of the heart muscle and would have nothing to do with diet.

Trager also stated that Atkins, as a result of the cardiomyopathy, had developed heart failure (CHF) and the pumping ability of his heart (ejection fraction )had dropped to 15 to 20%. While CHF can be due to heart attacks causing heart weakness in Atkins case it appears it was unrelated to fatty blockage of the coronary arteries causing MI and therefore not related in any way to his diet.

What Does Atkins Death Tell Us About His Diet 

The information about Atkins death tells us nothing about the effectiveness or dangers of his diet.  In one individual it is entirely likely that a genetic predisposition to cancer or heart disease overwhelms whatever beneficial effects the individual’s lifestyle may have had. Thus, we should never rely on the appearance or the longevity of  the primary promoter of a diet for the diet’s effectiveness.

The evangelists of low-fat, vegan or vegetarian diets like PCRM have shamelessly promoted misinformation about Atkins death to dismiss high fat diets and promote their own agenda. If their diets are truly superior it should be possible to utilize facts and science to promote them rather than a sensationalistic, distorted focus on the body of one man who slipped on the ice and fell to his death.

Epidurally Yours

-ACP

Addendum: Earlier versions of this post cited  MLB pitcher Brandon McCarthy as a victim of a fast ball to the head causing epicardial hematoma. I was corrected by astute reader Fred N who pointed out that McCarthy is still pitching for the Dodgers and was hit by a line drive (off the bat of Erick Aybar). McCarthy had emergency surgery for the epicardial hematoma in 2012. His diet had nothing to do with the epicardial hematoma.

N.B. Natasha Richardson fell while taking beginner skin lessons at a Canadian Ski resort. According to a release from the resort:

Natasha Richardson fell in a beginners trail while taking a ski lesson at Station Mont Tremblant,” the statement said. “She was accompanied by an experienced ski instructor who immediately called the ski patrol. She did not show any visible sign of injury but the ski patrol followed strict procedures and brought her back to the bottom of the slope and insisted she should see a doctor.

“As an additional precautionary measure, the ski instructor as well as the ski patrol accompanied Mrs. Richardson to her hotel,” the statement continued. “They again recommended she should be seen by a doctor. The ski instructor stayed with her at her hotel. Approximately an hour after the incident Mrs. Richardson was not feeling good. An ambulance was called and Mrs. Richardson was brought to the Centre Hospitalier Laurentien in Ste-Agathe and was later transferred to Hôpital du Sacre-Coeur.”

A spokesperson for the resort noted Richardson was not wearing a helmet while skiing and didn’t collide with anything when she fell. Thursday, in the wake of her death, Quebec officials said they are considering making helmets mandatory on ski slopes, according to The Associated Press.”

The last time I skied I found myself falling and banging my head an extraordinary amount. If I ever ski again (in contrast to my resistance to bike helmets) I plan to wear a helmet.

 

What Can America Learn From Australian Gun Laws?

In April of 1996, a 28-year old man murdered 35 people in Tasmania primarily utilizing a Colt AR-15 rifle (a lightweight, 5.56×45mm, magazine-fed, air-cooled semi-automatic rifle with a rotating bolt and a direct impingement gas-operation system.)

This event led to public outcry in Australia and  bipartisan passage of a comprehensive set of gun regulation laws (the National Firearms Agreement (NFA)).

In the 20 years since the law was put into place (1997-2016), there has not been a single fatal mass shooting in Australia.

In the 17 years prior to the NFA enactment 13 mass fatal shootings (defined as ≥5 victims, not including the perpetrator) occurred in Australia.

An analysis of this process was recently published in JAMA.

Australia’s 1996 NFA mandated:

  • the ban and buy-back of semiautomatic long guns.
  • licensing of all firearm owners and registration of firearms.
  • that  persons seeking firearm licenses  must document a “genuine need,” have no convictions for violent crimes within the past 5 years, have no restraining orders for violence, demonstrate good moral character, and pass a gun safety test.
  •  uniform standards for securing firearms to prevent theft or misuse, record-keeping for fire arms transfers, purchase permits, and minimum waiting periods of 28 days.
 I agree with the comments in an accompanying editorial written by Daniel Webster of the John Hopkins School of Public Health, Center for Gun Policy and Research(:gun-regulation.)

Research evidence should inform the way forward to advance the most effective policies to reduce violence. However, research alone will not be enough. Australian citizens, professional organizations, and academic researchers all played productive roles in developing and promoting evidence-informed policies and demanding that their lawmakers adopt measures to prevent the loss of life and terror of gun violence. Citizens in the United States should follow their lead.

-ACP

N.B. Of the 46 mass shooting since 2004, 14 featured assault rifles, including Newtown, Aurora, Orlando and San Bernardino. Apparently there are 10 million AR-15 type rifles in private hands in the USA and as Vox has pointed out

“the AR-15 is caught in a cycle. The more it’s used in high-profile mass shooting cases, the more people want to ban it. The more people want to ban it, the more AR-15s are sold. And the more AR-15s are sold, the harder it becomes to create a ban that would be able to stop the next tragedy.”

For more on assault-style rifles you can view this Washington Post video created after the Orlando shootings.
//www.washingtonpost.com/video/c/embed/28d02e8e-3118-11e6-ab9d-1da2b0f24f93

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.

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

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