EpiPen: What Accounts For The Spiraling Costs Of A Life-Saving Generic Medication?

IMG_7187I hold in my left hand an EpiPen, self-described as a “0.3 mg epinephrine auto-injector.” The EpiPen is a marvel of modern manufacturing. Take it out of its solid, clear,  plastic enclosure and you will notice instructions on how to use it in simple text and cartoons.

 

Basically, pull up the blue plastic piece at the top and you have activated it: now grasp the body and swing it down to your thigh , pushing the orange tip until it clicks, indicating the needle has emerged and injected life-saving epinephrine into the large muscle in your leg.IMG_7186

Epinephrine injections are the treatment of choice for severe allergic reactions. I have kept  EpiPens around me since my first episode of anaphylaxis after eating pecans as a child (see my post on nuts, legumes, drupes and mortality here) and can attest to how easy this is to use in treatment of an acute case of anaphylaxis.

About 12 years ago, when I lived in Louisville, Kentucky I was receiving allergy shots for chronic allergic rhinitis and conjunctivitis. One day I worked out after my shot and I suddenly began itching all over. Hives appeared on my chest and my face began swelling. I found it hard to breathe.

I was experiencing anaphylaxis, a severe, rapid and sometimes fatal allergic reaction that can occur after insect bites or stings, certain food consumption (I’ve had it to pecans, cashews, and  walnuts), and medications.

Fortunately, I had in my possession two EpiPens and even more fortunate they were  non-expired EpiPens. I quickly dressed, grabbed the EpiPens and had my then wife drive me to the closest ER.

After a few minutes I realized I was getting worse and opened up the first Epipen and jammed the needle into my thigh. I continued to get worse-my breathing became severely labored-and I grabbed the second EpiPen and repeated the thigh stabbing. Alas, the situation did not immediately improve and I made a command decision to stop at a fire station we were passing. There I was bundled into an ambulance, given IV steroids and oxygen and ultimately ended up in  an ER.

Epinephrine directly stimulates alpha and beta-receptors of the sympathetic nervous system and after the injections I felt like I had consumed 10 cups of coffee. My heart was racing, my blood pressure sky high and I was shaking uncontrollably. This is not a drug you want to take unless you desperately need it. In my case and thousands of others with anaphylaxis it is life-saving.

Consequently, I carry one with me at all times and as knowledge of food anaphylaxis and its treatment has spread in the last decade, Epipen sales and profits have exploded.

EpiPen Success: Marketing and Lobbying

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As this graph demonstrates, the annual sales increase in EpiPen for Mylan rose from 200 Million to over a billion driven by a combination of increased volume of sales and increased per device cost.

Last September,  Bloomberg published a story on the brilliant marketing of Mylan that turned EpiPen into a billion-dollar product. The Bloomberg article noted that the CEO of Mylan, Heather Bresch (who is the daughter of Democratic Senator Joe Manchin of West Virginia)  “turned to Washington for help”:

In 2010 new federal guidelines said patients who had severe allergic reactions should be prescribed two epinephrine doses, and soon after Mylan stopped selling single pens in favor of twin-packs. At the time, 35 percent of prescriptions were for single EpiPens. The U.S. Food and Drug Administration had changed label rules to allow the devices to be marketed to anyone at risk, rather than only those who’d already had an anaphylaxis reaction. “Those were both big events that we’ve started to capitalize on,” Bresch said in October 2011.

In 2013, the year following the widely publicized death of a 7-year-old girl at a school in Virginia after an allergic reaction to peanuts, Congress passed legislation encouraging states to have epinephrine devices on hand in schools. Now 47 states require or encourage schools to stock the devices.

Recent Furor Over High EpiPen Prices

In the last few days, the rising cost of EpiPens has become front page news. Although the active ingredient, epinephrine, is generic and cheap, and the basic delivery system has been around for decades,  Mylan, the company that purchased the rights to EpiPen in 2007 has increased its price from 57$ per injector to 600$ for 2 injectors.

Lack of generic competition to the EpiPen  is the primary reason that the price could be raised so much and also explains in many circumstances why drug costs are high in the US.

The US has long spent more on prescription medication than other IMG_7188countries. In 2013 per capita US spending on rx drugs was $858 compared to $400 for 19 industrialized anations.

Examples of markedly higher prices in the US are the statin drug crestor (216$/month for 10 mg in US versus $46 in France) and the asthma inhaler Advair ($216 US versus $20 in France.)

A recent article in JAMA analyzed the sources of the high prices in the US and concluded it is due to the fact that “unlike nearly every other advanced nation, the US health care system allows manufacturers to set their own price for a given product. In contrast, in countries with national health insurance systems, a delegated body negotiates drug prices or rejects coverage of products if the price demanded by the manufacture is excessive in light of the benefit provided.”

The ability of drug companies in the US to maintain high prices, the article points out, is due to 2 market forces: protection from competition and negotiating power.

Interestingly, last year , Mylan moved its corporate address overseas to lower its U.S. taxes in a transaction known as an inversion and is now incorporated in the Netherlands,

Bresch, the Mylan CEO is quoted as saying “We do subsidize the rest of the world… and as a country we’ve made a conscious decision to do that,” Bresch said. “And I think the world’s a better place for it.

Perhaps it would be better if the US, instead of having Congress rush into action and investigations when certain drug costs become worthy of news articles and public shaming, had a system in place like most other industrialized nations, that monitored and regulated drug costs.

Under such a system, life-saving medications like the EpiPen would not arbitrarily quadruple in price.

Anaphylactically Yours,

-ACP

 

 

 

Atrial Fibrillation Ablation: Time For A Team Approach?

For many proceduralists in medicine and surgery, there is a tendency to overestimate the value and underestimate the risk of the intervention that they perform. This factor, plus the current medical reimbursement system in the US, which rewards physicians primarily on the quantity of services performed rather than the quality of care, fosters a strong incentive for proceduralists to perform their procedures early and often.

It is rare for a proceduralist to publicly advocate a cautious and circumspect approach to their procedure; the usual public expressions are highly enthusiastic endorsements intended for marketing and increasing volume.

In this regard, it is particularly refreshing to read the thoughts today of a clinical electrophysiologist, whose bread and butter partially consists of doing ablations of atrial fibrillation (AF.)

John Mandrola (who writes a great blog at DrjohnM.org and reports for theheart.org) has written an excellent summary of the things that patients should consider prior to getting an AF ablation which I shall reblog below.

Mandrola asks us to consider whether the decision for AF ablation should be made by a team rather than by the proceduralist who stands to benefit from performing the ablation.

I’ve emphasized some points from his post:

-AF ablation is a multi-hour procedure that requires general anesthesia. Up to 80 burns are made in the left atrium, some close to the esophagus and phrenic nerve. There are significant risks to the procedure. The honest long-term success rate barely tops 50%.

-Many patients have to undergo a second procedure, or even third or fourth procedures.

-Some questions an AF team might ask:

  • Have you checked the patient for sleep apnea?

  • Have you asked him to reduce his alcohol intake or weight?

  • Will the AF resolve after the stress of a divorce has worn off?

  • Does the patient know there’s not a shred of evidence that AF ablation reduces stroke or death rates?

 

-Does the patient know that AF is not deadly heart disease? In other words, has fear been sufficiently extracted from the decision?

I, not infrequently, refer appropriate patients to excellent and thoughtful electrophysiologists for a discussion of the pros and cons of ablation and consideration of its performance .  Before sending them, I try to act like the “team” that Mandrola envisions and review the risks and benefits along with alternative approaches.

Below is John’s post in its entirety:

A patient presents with atrial fibrillation (AF) and a rapid rate. He doesn’t know he is in AF; all he knows is that he is short of breath and weak.

The doctors do the normal stuff. He is treated with drugs to slow the rate and undergoes cardioversion. During the hospital stay, he receives a stress test and an implantable loop recorder.

He goes home on a couple of medications. The expensive implanted monitor shows rare episodes of short-lived AF, less than 1% of the time. The patient feels great.

But here’s the kicker: his doctor recommends an AF ablation.

This is nuts. The man has had one episode of AF. He has no underlying heart disease. And he feels well while taking only basic meds. There’s been no discussion of weight loss, exercise, alcohol reduction, or sleep evaluation.

I don’t know how often this happens in the real world, but I suspect that it’s happening more and more. The number of doctors trained in electrophysiology have increased. And, trainees in academic centers spend most of their time mastering the AF ablation procedure.

The Dartmouth Atlas of Healthcare group have shown cardiology to be a supply-sensitive service. Meaning, the more cardiologists there are in an area, the more procedures get done. This build-it-and-they-will-come problem dogs much of US healthcare, not only cardiology. Think MRI and CT centers.

Might a solution to the overuse of AF ablation be a multi-disciplinary heart team?

We already do this for some heart valve surgeries, specifically, transaortic valve replacement (TAVR).

AF ablation is a multi-hour procedure that requires general anesthesia. Up to 80 burns are made in the left atrium, some close to the esophagus and phrenic nerve. There are significant risks to the procedure. The honest long-term success rate barely tops 50%. (Success rates depend somewhat on the type of AF.)

Then there are the repeat procedures. Many patients have to undergo a second procedure, or even third or fourth procedures. (All at many thousands of dollars per case.)

If doctors recommending the procedure had to present the patient to a team of peers, there may be more discussion about the sobering realities of AF care. Questions could arise:

  • Have you checked the patient for sleep apnea?
  • Have you asked him to reduce his alcohol intake or weight?
  • Will the AF resolve after the stress of a divorce has worn off?
  • Does the patient know there’s not a shred of evidence that AF ablation reduces stroke or death rates?
  • Does the patient know that AF is not deadly heart disease? In other words, has fear been sufficiently extracted from the decision?

I recognize that not every decision in medicine should be made by committee. AF ablation, however, might fit some sort of internal review.

The European Heart Journal just published a terrific review on the treatment of persistent AF. In this paper, the treatment of risk factors gets strong mention–as does the sobering results of AF ablation in more advanced forms of AF, and the vast uncertainty surrounding treatment approaches.

I’m not against AF ablation; I perform the procedure often. But after I’m sure all other aspects of atrial-health have been addressed, and the patient is fully informed. It’s a huge mistake to equate AF ablation with ablation of other focal (emphasis on focal) rhythm problems, like supraventricular tachycardia.

I’d have no trouble justifying my AF ablation procedures to a heart team.

JMM

Do You Know What’s On Garry Shandling’s And Your Parent’s Death Certificate?

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Better Call Saul’s Bob Odenkirk and Kathy Griffin “hanging” with an apparently healthy Larry Sanders on March 20. These two appeared on Shandling’s brilliant Larry Sanders TV show.

When someone who had appeared to be healthy dies suddenly, it is often assumed that he/she died of “a massive heart attack.” Certainly, this was the case in the recent unexpected sudden death of Garry Shandling, the actor and comedian.  Shandling, aged 66, died March 24 of this year.

ET online reported:

“His publicist Alan Nierob told the ET that Shandling had no history of heart problems, but that doctors believe he died as the result of a heart attack.”

Although a heart attack resulting in ventricular fibrillation is the most common cause of a sudden, unexpected death in individuals over the age of 40, it is not the only one.

In fact, People  magazine reported that Sanders experienced shortness of breath and pain in his legs just a day before his death, and that he spoke to a doctor friend about his symptoms, who stopped by that night to check on him,

Shortness of breath and pain in the legs raise the possibility of a clot or DVT in the leg, which can break loose and embolize into the pulmonary arteries. Such a pulmonary embolism, if massive, can result in swift and sudden death.

The LA Coroner’s office could not get Sanders’ physician to sign his death certificate and the cause of death has still apparently not been determined, pending toxicology testing which typically takes 6 weeks.

What’s On Your Parent’s Death Certificate

More important than what is on Garry Shandling’s death certificate is what is on your parent’s death certificate, and whether it is accurate. If one of your parents died prematurely and suddenly, it is  important to know with precision what caused it. If the cause was an heritable cardiovascular condition, hopefully, appropriate testing can determine if you have that condition, and steps can be taken to prevent your premature demise.

Examples of inherited cardiovascular conditions (in addition to heart attack (myocardial infarction) or pulmonary embolism) that can cause sudden and unexpected death include aortic aneurysm dissection, hypertrophic cardiomyopathy, arrhythmogenic right ventricular dysplasis, and long QT syndrome.

Unfortunately I find that, at least in my patients, uncertainty about the cause of death of one’s parents is the norm.

Many of my patients, for example, tell me one of their parents died of a “massive heart attack” and they assume that they are at increased risk of the same fate. When I press for details, typically no autopsy was performed.  Mom or dad may have been found dead at home, or they may have suddenly keeled over but not survived to make it to the hospital for a definitive diagnosis.

Without an autopsy in such circumstances, it is not possible to be sure of the cause of death.

Even if you have a cause of death listed on your parent’s death certificate, there is no guarantee that it is accurate.  The doctor that filled it out, without an autopsy in many circumstances, is just speculating on the cause based on what he/she knew about prior medical conditions and the circumstances surrounding the death.

I was recently asked to fill out the death certificate of an elderly patient of mine who had atrial fibrillation and congestive heart failure and was living in a nursing home.

One night she was noted by the staff to be very short of breath and was taken to a local  emergency room where she was pronounced dead.

Based on the information available to me, I had no idea what caused her death. Although she had quite signifiant cardiac problems, when I last saw her she was stable and I have numerous patients with the same conditions who live for decades.

I filled out the death certificate, listing all of her conditions, and entered in that the cause of death was unknown.

Although the CDC guide for physicians filling out death certificates clearly states that this is acceptable, I was subsequently informed that the funeral home did not accept unknown cause of death and that they had found another doctor to fill in a cause  of death.

I guarantee you, whatever he put on as the cause of death was total speculation.

Jerry Seinfeld was good friends with Garry Shandling and, oddly enough, not too long ago, featured him in an episode of his internet series “Comedians in Cars Getting Coffee” entitled “It’s Great That Garry Shandling Is Still Alive.

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Shandling mentions “I had hyperparathyroidism,” making a joke that “the symptoms are so much like being an older Jewish man, no one noticed!”

James Fallows, the excellent The Atlantic writer, highlights his own experience with hyperparathyroidism (a disease that leads to high calcium levels and is easily treated with surgery), in a recent Atlantic article. The subtitle of this article, “a rare and under-publicized condition that can sometimes be fatal,” suggests that hyperhyperparathyroidism might have led to Shandling’s death.

I don’t think this is likely because Shandling suggests that the disease is in the past tense (i.e. he has already had the surgery), and sudden death from hyperparathyroidism would be extremely unlikely.

Fortunately, Shandling is getting a full examination and autopsy to fully determine the cause of his death. If he has offspring, this will be extremely helpful to them in understanding what medical conditions they can expect later in life.

If he was not a celebrity, his death, like many of your parents’, most likely would have been ascribed to a “massive heart attack.”

 

 

Getting To The Heart Of Father’s Day

The skeptical cardiologist received an email from the folks at AliveCor a few days ago with the subject line:

Dad’s heart matters – Kardia Mobile for Dad will give you peace of mind and make Dad happy

The email contains this image of an older well-dressed man (withScreen Shot 2016-06-18 at 9.03.26 AM lots of bling) standing in a beautiful meadow near the ocean. The man has decided to turn his back on the ocean and check his heart rhythm using the AliveCor/Kardia (AliveCor has changed the name of its ECG devices to Kardia) mobile ECG. This man is a happy dad! (Unless his heart rhythm is interpreted as atrial fibrillation. Then the beach walk is ruined.)

The email asks the question “What if Dad’s heart really was an open book?”

Uhh, he’d be dead? Clearly books don’t function well at pumping 5 or 6 liters of blood through the cardiovascular system every minute whether they are open or closed. Perhaps  the question is using either  the heart or an open book as a metaphor?

The advertisement goes on to suggest that I get my dad an AliveCor device for father’s day  “So you always know what his heart is thinking.”

I believe this is the marketing person’s attempt to extend the metaphor of the open book, i.e., you know exactly what dad’s brain is thinking, now you can extend this knowledge to his heart.  The metaphor of the heart “thinking” is quite poor but poor metaphors are the norm today.

Bad metaphors and bad writing abound on father’s day because 90 million greeting cards are purchased and given as (according to the Greeting Card Association)  “a meaningful expression of personal affection for another person.” Despite the increasing use of Facebook and its ilk to transmit emotions, the Greeting Card Association assures us that “The tradition of giving greeting cards … is still being deeply ingrained in today’s youth, and this tradition will likely continue as they become adults and become responsible for managing their own important relationships.

Mobile Ecg Monitor As A Father’s Day Gift

I have to say that despite the horror of the writing in this email advertisement it got me thinking about getting my father a Kardia device. I’ve suggested  previously that  an AliveCor device would make a good gift for Christmas for a loved one who has intermittent unexplained palpitations or atrial fibrillation but had not considered this for my dad.

For one thing he does not possess a smart phone which is required to  make the Kardia device functional. For another, he doesn’t have atrial fibrillation (that we know of. Perhaps if I knew what his heart was thinking we would find out that it likes to fibrillate late at night,)

Perhaps it’s time to upgrade my Dad to an iPhone I began thinking.

But wait! He has an iPad mini (that he seems to only use for FaceTime conversations.)

Further research reveals that Kardia is not only compatible with iPhone and Android smartphones but apparently iPads and IPod Touch.Screen Shot 2016-06-19 at 8.04.27 AM

Taking Care of Dad’s Heart

What about the rest of the slick advertising copy in my email?

And now you can know the way to help take care of it. Kardia gives Dad a medical-grade EKG in only 30 seconds. It even gives him expert analysis and tracking, with reports getting shared directly with his physician

This part is pretty clear and correct. I use Kardia daily in my office to record patient’s heart rhythm and I have a dozen patients now who make recordings outside of the office. They can have their recordings read by a random cardiologist for a fee or establish a link with me as their provider and I can review them through my account for free.

 Is It The First Father’s Day Gift That Leads To More Father’s Days?

The ad ends with the remarkably brazen statement that “It’s the first Father’s Day gift that leads to more Father’s Days.”

While I find the device more helpful in many instances than current expensive and intrusive long term monitoring devices for detecting and monitoring atrial fibrillation and other abnormal heart rhythms, it is a huge leap to suggest that this translates somehow into a longer life span.

To AliveCor’s credit, despite such ridiculous marketing drivel , studies presented at the recent Heart Rhythm Society Scientific Meetings suggest:

  • Kardia Mobile Superior to Conventional Monitoring: Researchers at the Leeds General Infirmary found that the AliveCor monitor is superior to conventional Holter monitoring in patients with palpitations, providing a higher diagnostic yield, more detected arrhythmias, with a similar workload.

  • Kardia Mobile Leads to Improved Patient Compliance:Researchers at the University of Buffalo found that AliveCor provides a diagnostic yield comparable to a 30-day ambulatory looping event monitor and that the smartphone-based ECG monitor can be used as a first approach for the diagnosis of palpitations.

  • Kardia Mobile provided more information resulting in changes in arrhythmia patient management than traditional external event recorders in a study from researchers at the University of Miami.

  • AliveCor’s AF algorithm was reported to be superior by researchers at Arizona State University to the patient’s own ability to detect AF via symptoms.

    But even if these studies make it to publication they don’t suggest the device provides any improved longevity. In fact, such data, do not exist for any monitoring device.

Happy Father’s Day, Dad! Don’t be surprised when we FaceTime later today that I’ve found another use for your iPad.

Paternally Yours,

-ACP

N.B. Clearly I receive no consulting, speaking or P.R. writing fees of any kind from AliveCor. Nor do they provide me with any free devices. What’s more, when I lose one of their devices they don’t replace it.  I am totally free of any conflict of interest.

 

Snake Oil Du Jour: Turmeric

Part I of the skeptical cardiologist’s intermittent efforts at exposing the dark underbelly of the “superfood” snake oil parade deals with turmeric.

This key ingredienet of curry, has been seized upon by the useless and dangerous supplement/vitamin/nutraceutical industry recently and a patient asked me if he should take it.

A Google search yields overblown titles such as

-The amazing health benefits of turmeric  (MNN.com, a bogus website)

-6 Health benefits of Turmeric (Huffington Post, the health portion of which is full of hucksters)

-10 Proven Health Benefits of Turmeric and Curcumin (authoritynutrition.com, a bogus nutrition website)

-7 Powerful Turmeric Health Benefits and Side Effects (DrAxe.com, a bogus health website)

As I started researching turmeric I came across an outstanding summary of the topic on science-based medicine by Harriet Hall. I stopped the research and decided I would just put a link to that blog post on my site but never get around to it.

Today, however, another patient told me he was taking turmeric.

Consequently, I’m posting Harriet Hall’s article below in its entirety.

Turmeric: Tasty in Curry, Questionable as Medicine « Science-Based Medicine.

turmericA correspondent asked me to look into the science behind the health claims for turmeric. He had encountered medical professionals “trying to pass turmeric as some sort of magical herb to cure us from the ‘post-industrial chemical apocalypse.’” It is recommended by the usual promoters of CAM: Oz, Weil, Mercola, and the Health Ranger (who conveniently sells his own superior product, Turmeric Gold liquid extract for $17 an ounce).

Turmeric (Cucurma longa) is a plant in the ginger family that is native to southeast India. It is also known as curcumin. The rhizomes are ground into an orange-yellow powder that is used as a spice in Indian cuisine. It has traditionally been used in folk medicine for various indications; and it has now become popular in alternative medicine circles, where it is claimed to be effective in treating a broad spectrum of diseases including cancer, Alzheimer’s, arthritis, and diabetes. One website claims science has proven it to be as effective as 14 drugs, including statins like Lipitor, corticosteroids, antidepressants like Prozac, anti-inflammatories like aspirin and ibuprofen, the chemotherapy drug oxaliplatin, and the diabetes drug metformin. I wish those claims were true, because turmeric is far less expensive and probably much safer than prescription drugs. It clearly has some interesting properties, but the claims go far beyond the actual evidence.

The Natural Medicines Comprehensive Database has reviewed all the available scientific studies and has concluded that it is “Likely Safe,” “Possibly Effective” for dyspepsia and osteoarthritis, and “Insufficient Reliable Evidence” to rate effectiveness for other indications, such as Alzheimer’s, anterior uveitis, colorectal cancer, rheumatoid arthritis, and skin cancer.

Mechanism of action

The “14 drugs” website says turmeric is one of the most thoroughly researched plants ever, with 5,600 peer-reviewed studies, 175 distinct beneficial physiological effects, and 600 potential preventive and therapeutic applications. They provide a database of 1,585 hyperlinks to turmeric abstracts. Naturally I can’t read all of them, but a sampling indicates that they are almost entirely animal and in vitro studies. The NMCD has conveniently provided a list of the most pertinent studies.

The pertinent preclinical studies, in animal models and in vitro, indicate that curcumin has anti-inflammatory properties; can induce apoptosis in cancer cells and may inhibit angiogenesis; has antithrombotic effects; can decrease the amyloid plaque associated with Alzheimer’s; has some activity against bacteria, Leishmania, HIV; etc. These effects sound promising, but animal studies and in vitro studies may not be applicable to humans. As Rose Shapiro pointed out in her book Suckers, you can kill cancer cells in a Petri dish with a flame thrower or bleach. Preclinical studies must always be followed by clinical studies in humans before we can make any recommendations to patients.

Preliminary clinical research

There are preliminary pilot studies in humans suggesting that:

Clinical research on turmeric is being funded by the National Center for Complementary and Alternative Medicine (NCCAM), but the NCCAM website is not very encouraging. Under the section What the Science Says, it reads:

  • There is little reliable evidence to support the use of turmeric for any health condition because few clinical trials have been conducted.
  • Preliminary findings from animal and other laboratory studies suggest that a chemical found in turmeric—called curcumin—may have anti-inflammatory, anticancer, and antioxidant properties, but these findings have not been confirmed in people.
  • NCCAM-funded investigators have studied the active chemicals in turmeric and their effects—particularly anti-inflammatory effects—in human cells to better understand how turmeric might be used for health purposes. NCCAM is also funding basic research studies on the potential role of turmeric in preventing acute respiratory distress syndrome, liver cancer, and post-menopausal osteoporosis.

Side effects

Turmeric is generally considered safe, but high doses have caused indigestion, nausea, vomiting, reflux, diarrhea, liver problems, and worsening of gallbladder disease. The NMCD warns that it may interact with anticoagulants and antiplatelet drugs to increase the risk of bleeding, that it should be used with caution in patients with gallstones or gallbladder disease and in patients with gastroesophageal reflux disease, and that it should be discontinued at least 2 weeks before elective surgery. Purchasers of supplements are not given that information.

Conclusion

The “14 drugs” website recommends that everyone:

use certified organic (non-irradiated) turmeric in lower culinary doses on a daily basis so that heroic doses won’t be necessary later in life after a serious disease sets in.

There is no evidence to support any part of that recommendation. And the scientific evidence for turmeric is insufficient to incorporate it into medical practice. As with so many supplements, the hype has gone way beyond the actual evidence. There are some promising hints that it may be useful, but there are plenty of promising hints that lots of other things “may” be useful too. Since I have no rational basis for choosing one over another, I see no reason to jump on the turmeric bandwagon. On the other hand, I see no compelling reason to advise people not to use it, as long as they understand the state of the evidence well enough to provide informed consent and know that they are essentially guinea pigs in an uncontrolled experiment that makes no attempt to collect data. I will keep an open mind and stay tuned for further evidence in the form of well-designed clinical studies in humans.

So, the bottom line on turmeric, our “snake-oil du jour” is

-there is nothing to support its use for any health condition

-potential dangerous side effects

-interacts with legitimate prescription meds

-crucial ingredient in curry

My advice-DONT”T TAKE IT!

Gostephencurryily yours,

-ACP

Salt Talks Two

The skeptical cardiologist found himself reading a cookbook the other day, something he heretofore had avoided. Cookbooks somehow seem archaic and, I presumed, exclusively the domain of the women in my life.  My mother had loads of them, hiding their food-stained bindings behind a cabinet door in my childhood kitchen. Whereas I can stare longingly at all manner of books on  bookstore shelves, I scrupulously avoid the cooking section, finding nothing that intrigues or attracts me in their heavily illustrated contents.

The eternal fiancee’ of the skeptical cardiologist (EFOSC), I believe, had requested I find the recipes for several dishes we (more accurately, she) could prepare the next week and had headed off to Whole Foods or Nordstrom Rack or Pier 1 (all of which, strangely and conveniently sit side by side).

IMG_6880 copyAfter receiving directions on where these mysterious tomes resided, I grabbed the cookbook that looked the most interesting: Ruhlman’s TWENTY: 20 Techniques, 100 Recipes, A Cook’s Manifesto. Instead of searching for recipes I ended up being distracted by Chapter 2: Salt: Your Most Important Tool.

In Chapter 2, Ruhlman makes the bold statement that “if you don’t have a preexisting problem with high blood pressure and if you eat natural foods-foods that aren’t heavily processed-you can salt your food to whatever level tastes good to you without worrying about health concerns.”

As I’ve written previously, I agree with him, and a recent article published in The Lancet casts further doubt on recommendations for the general population to limit sodium consumption drastically.

In the Lancet article, the authors did a pooled analysis of four large prospective studies involving 133118 patients in 49 countries. They studied the relationship between salt consumption, measured by 24 hour urine excretion of sodium (because what goes in must come out) and the incidence of cardiovascular disease and death over about 4 years.

The findings:

  1. Patients without hypertension who excreted more than 7 grams/day of sodium were no more likely to have cardiovascular disease or death than those excreting  4-5 grams/day.
  2. In fact, in both normotensive and hypertensive groups, sodium excretion of < 3 g/day was associated with a significantly (26% higher in normotensives, 34% in hypertensives) increased risk of cardiovascular disease and death.
  3. The only group that would appear to benefit from lower sodium consumption was the hypertensive group which excreted 7 g/day of sodium and when compared to the hypertensive group that excreted 4-5 g/day of sodium had a 23% higher risk of CV death and disease.

If we have to worry about anything with salt consumption, this study (and others) suggests that it is consuming too little salt.

The only group that need worry about too much salt consumption is those who have hypertension and who consume a really large amount of salt.  Since the average American Average consumes 3.4 grams per day of salt, very few of us are consuming over 7 g/day.  Despite this, The American Heart Association continues to stick by its totally unjustified recommendation that sodium levels be no higher than 1,500 mg/day, and other organizations recommend sodium levels below 2,300 mg/day.

What Kind of Salt Should We Consume

Ruhlman recommends coarse kosher salt, preferably Diamond Crystal or, if that’s not available, Morton’s.

Why? Because “salt is best measured with your fingers and eyes, not with measuring spoons.”

“Coarse salt is easier to hold and easier to control than fine salt.”

He feels that salting is an inexact skill and one should always salt to taste.

“When  recipe includes a precise measure of salt, a teaspoon, say, this is only a general reference, or an order of magnitude–a teaspoon, not a tablespoon. You may need to add more. How do you know? Taste the food.”

IMG_6874
The skeptical cardiologist’s frittata.

These words were music to my ears as I am an advocate of serendipity, chaos and creativeness in the kitchen.  When I make a frittata, as I did this morning, I measure nothing precisely; not the butter and olive oil used to sauté, the bell peppers, onions and garlic; not the milk mixed with the eggs; not the cheese sprinkled on top; not the time spent in the oven or even the heat; and most assuredly, not the salt and pepper.

IMG_6876At the end of the frittata creation process I took a bite. It was delicious but it needed something: a touch more salt. I sprinkled some David’s kosher salt on top and tried again, Perfection!

Although I have hypertension, I know (see discussion here) that my salt consumption is way below 7 grams/day and, if anything, based on the most recent studies, I should be worrying about too little sodium in my diet.

saltatorily yours,

-ACP

PS>

As I outlined in one of my previous posts on salt, here is what I tell my patients:

  • Spend a day or two accurately tracking your consumption of salt to educate yourself. I found this app to be really helpful. I’ll expand on this in a future post.
  • Recognize that not everybody needs to follow a low salt diet. If your blood pressure is not elevated and you have no heart failure you don’t need to change your salt consumption.
  • If your blood pressure is on the low side and especially if you get periodic dizzy spells, often associated with standing quickly liberalize your salt intake, you will feel better.
  • If you have high blood pressure, you are the best judge of how salt effects your blood pressure. In the example I gave in a previous post, my patient realized that all the salt he was sprinkling on his tomatoes was the major factor causing his blood pressure to spike.
  • The kidneys do a great job of balancing sodium intake and sodium excretion if they are working normally. If you have kidney dysfunction you will  be more sensitive to the effects of salt consumption on your blood pressure and fluid retention.
  • If you are following a Mediterranean diet with plenty of fresh fruits and vegetables you are going to be in the ideal range for both potassium and sodium consumption.

Does Pravastatin Lower Your Risk of Diabetes?: The Joys of Continuing Education From Patients

One of the amazing perquisites of being a doctor is the opportunity to talk to a wide diversity of individuals with fascinating backgrounds and interests. I’ve always had some appreciation of this during my office interactions, but with age and ripening, I have come to relish and savor these conversations.

The skeptical cardiologist learns something from virtually every patient visit.  On a recent office day, I received patient pearls on topics ranging from Viking River cruises in Germany, to the method by which Express Scripts squeezes money from Walgreens and drug manufacturers, to certain novels of T. Coraghessan Boyle not centered on the maniacal vegetarian John Harvey Kellogg.

Not uncommonly, I’ll learn something about medicine or cardiology if I listen closely to my patients and keep an open mind.

I saw a 69 year old woman (we’ll call her Donna) the other day who had advanced plaque in her coronary arteries and with whom I had  initiated a discussion on the pros and cons of taking a statin drug to lower her risk of heart attack and stroke. This was not the first time we had talked about this topic; in previous visits she had shared with me her great fear of statin side effects and her desire to modify risk by dietary modification. On this visit, she came prepared with more research she had done on statins, and told me she was concerned about an increased  risk of diabetes with statin drugs.

I gave her my standard spiel:  statins, especially more potent ones like rosuvastatin and atorvastatin, appear to increase the risk of diabetes by 10-20%, however, this is offset by the benefits of statins, especially in someone with significant atherosclerosis, in reducing heart attack and stroke.

Donna then told me that she had read that pravastatin lowers the risk of diabetes. I hadn’t heard this (or more likely this slipped out of my ever-shrinking cerebral database) previously. Ten years ago, in the era before routine use of electronic health records (EHR), I would have had to just admit my ignorance and promise to look into that claim later (something that would not consistently happen due to time constraints and forgetfulness).  However, now I enter the patient exam room with my MacBook Air, primarily to access the patient’s EHR and look at old notes, cardiac tests etc.

Increasingly I also use the Mac to quickly look up information about a topic the patient has brought to my attention – either double checking what I believe to be true or researching claims I am unfamiliar with.

Often, the topic raised is the “snake oil du jour” (for example, is turmeric a cardiovascular panacea?), but in this case and many others, it is a relevant question about the nuances of disease or my proposed treatment.

A quick search (20 seconds) pulled up a 2009 meta-analysis of randomized trials of statins and the risk of diabetes. Sure enough, one of these trials (the West of Scotland Coronary Prevention Study) actually showed that patients treated with 40 mg of  pravastatin had a 30% lower risk of developing diabetes.  Four studies showed no effect of statins on risk of developing diabetes and only one, the JUPITER trial utilizing rosuvastatin (Crestor), showed a slight increase.

For some patients like Donna, a higher risk of diabetes may be a deal breaker for taking a life-saving medication. Although I can confidently tell her that the benefits outweigh the risks, if she has a specific fear of diabetes, perhaps related to a family member who had horrific complications of the disease, she could easily decline to take statins.

In Donna’s case, this new information about pravastatin, confirmed by the wonders of Google and a fast WiFi connection led to her giving statins (in the form of pravastatin) a chance.

I’ll remember this patient-triggered drop of wisdom for future discussions with patients whose  grave fear of diabetes makes them balk at taking statins.

Corasonically Yours,

-ACP

 

 

 

 

 

 

west of scotland

http://care.diabetesjournals.org/content/32/10/1941.full

Coconut Oil: Greasing the Skids to Wellville or Clogging the Arteries To the Heart

While the skeptical cardiologist was wandering around in ketoland, he acquired a large jar of extra virgin coconut oil for the purpose of boosting his fat consumption. He stirred spoonfuls of the solid waxy substance into his coffee and applied it to various and sundry skin rashes.

Coconut oil (CO) is a microcosm of the dietary confusion present in the U.S. On one hand a CO Google search yields a plethora of glowing testimonials to diverse benefits: Wellness Mama lists “101 Uses for Coconut Oil,” Authority Nutrition lists “10 Proven Health Benefits.”

On the other hand, the  American Heart Association (AHA) and the USDA’s Dietary Guidelines For Americans warn us to avoid consuming coconut oil  because it contains about 90% saturated fat (SFA) which is a higher percentage than butter (about 64% saturated fat), beef fat (40%), or even lard (also 40%) and thus contributes to heart disease.

In many respects, the vilification of coconut oil by federal dietary guidelines and the AHA resembles the inappropriate attack on dairy fat and is emblematic of the whole misguided war on dietary fat.

The problem with this simplistic message is that the kind of saturated fat in CO differs markedly from both dairy SFAs and beef SFAs and, like dairy fat, appears to have a beneficial effect on blood lipids, weight, and cardiovascular health.

Misguided Dietary Fat Recommendations

The AHA guidelines, for example, recommend cooking oils that have less saturated fat such as canola and corn oil. They advise, in general, to “choose oils with less than 4 grams of saturated fat per tablespoon.”

Screen Shot 2016-05-07 at 12.28.40 PMCanola and corn oil, the products of extensive factory processing techniques, contain mostly mono or polyunsaturated fats which have been deemed “heart-healthy” on the flimsiest of evidence.

The most recent data we have on replacing saturated fat in the diet with polyunsaturated fat comes from the Minnesota Coronary Experiment performed from 1968 to 1973, but published last month in the BMJ, (don’t get me started on why these data were “buried” for decades).

Data from this study, which substituted liquid corn in place of the usual hospital cooking fats, and corn oil margarine in place of butter and added corn oil to numerous food items, showed no overall benefit in reducing mortality. In fact, individuals over age 65 were more likely to die from cardiovascular disease if they got the corn oil diet.

Very Brief (But Seemingly Unavoidable) Digression Into Organic Chemistry Featuring Obscure But Intriguing Chemical Names and Numbers to 5.0 Significant Digits

Saturated fats are divided into various types based on the number of carbon atoms in the molecule. Depending on length, they differ markedly in their metabolism, absorption and effects on lipid profiles.

The major SFA in coconut oil, lauric acid, has a 12 carbon chain and is thus considered a medium chain fatty acid (MCFA). Take a look at the complex mixture of saturated fatty acids present in virgin coconut oil and note lauric acid (green) and palmitic acid (red):

Fatty acid profile Concentration (%)
C6 Caproic 2.215
C8 Caprylic 12.984
C10 Capric 6.806
C11 Undecanoic 0.028
C12 Lauric 47.280
C13 Tridecanoic 0.030
C14 Myristic 15.803
C15 Pentadecanoic 0.006
C16 Palmitic 6.688
C16 : 1 Heptadecanoic 0.011
C17 Stearic 0.011
C18 Oleic 1.481
C18 : 1n9c Elaidic 5.073
C18 : 1n9t Linoleic 0.231
C18 :  2n6c Linolelaidic 1.168
C18 : 2n6t γ-Linolenic 0.045
C18 : 3n6g α-Linolenic 0.007
C18 : 3n3a Arachidic 0.013
C20 Cis-11-Eicosenoic 0.039
C20 : 1n9 Behenic 0.039
C22 Cis-13,16-Docisadienoic 0.006
C24 Lignoceric 0.020

Palmitic acid, a long chain FA with 16 carbon atoms, makes  up only  7% of coconut oil, but is the major SFA in dairy and beef fat. When consumed in isolation, it raises the LDL or bad cholesterol and the ration of LDL to HDL, and thus has been labeled as unhealthy. Of course, as pointed out here we don’t consume either palmitic acid or lauric acid in isolation; we consume them in the complex milieu of other fats, antioxidants, proteins and carbohydrates that we call food.

Medium chain fatty acids, and especially lauric acid, do a really good job of raising the good HDL cholesterol and lowering the ratio of LDL to HDL, changes which should boost heart health.

Detailed Explanation of Differential Long and Medium Chain Fatty Acid Absorption and Metabolism (Feel Free to Skip)

Looking closely at the metabolism of MCSFAs we find:

” MCFAs are rapidly absorbed in the intestines even without catalyzation by the pancreatic lipase enzyme. LCFAs, on the other hand, required pancreatic lipase for absorption. They are carried by the lymph to the systemic circulation in chylomicrons and eventually reach the liver where they either undergo beta oxidation, biosynthesis to cholesterol, or are repackaged as triglycerides. MCFAs are carried by the portal vein to the liver where they are rapidly oxidized to energy. Unlike LCFAs, MCFAs do not enter the cholesterol cycle and they are not deposited in fat depots.”

Benefits of Coconut Oil, Cardiovascular and Otherwise

If you’d like to read a lot of hype and mumbo-jumbo about the benefits of coconut oil, I suggest you start at coconutoil.com and take a look at this graphic:Coconut-Oil-Health-Benefits

 

After a little reading, you will be ready to smear coconut oil all over your body and consume heaping spoonfuls thrice daily.

pastedgraphic-3_custom-0c04b15858d6b64ecbb597e1a17940ae72e34449-s400-c85
August Engelhardt stands underneath a palm tree with Berlin concert pianist Max Lützow at his feet. Lützow went to Kabakon to join Engelhardt’s sun-worshipping cocovore cult, The Order of the Sun. He died there, as did several other followers.

Be careful, though, you may end up like German nudist August Englehard who believed “that since the coconut grew high up in the tree, closest to God and closest to the sun, it was godlike, And since it had hair and looked like a human head, he thought it came closest to being a man. According to his rather crackpot theory, to be a cocovore was to be a theophage — or eater of God.”

My favorite article on the potentially atherogenic effects of coconut oil is entitled “Atherogenic of Not? (What therefore causes atherosclerosis?)  published in the Philippine Journal of Cardiology in 2003:
Screen Shot 2016-05-07 at 12.07.41 PM
The author, a prominent Phillipino cardiologist inserted the Phillipines (note my big red arrow) data into the famous Ancel Keys graph which plots heart disease mortality rate versus percent calories from fat.

The data point of the Phillipines, where coconut oil is the predominant cooking oil, totally disrupts the relationship between dietary fat and heart disease.

Of course, scientists now know that these kinds of correlations prove nothing, but they were the basis for guiding Americans to low fat, high carbohydrate manufactured monstrosities.

Coconut Oil: The Bottom Line

After all is said and done, it would appear that coconut oil, despite coming from a vegetable, resembles dairy fat in many ways.

It is more likely than not that coconut oil, like dairy fat, reduces your chances of obesity and heart disease, especially when compared to the typical American diet of highly processed and high carbohydrate foods.

Although containing lots of saturated fat, the SFAs in coconut oil are drastically different from other dietary sources of SFA.  The medium chain fatty acids like lauric acid which make up the coconut are absorbed and metabolized differently from long chain fatty acids found in animal fat.

The only explanation for dietary guidelines advising against coconut oil and dairy fat is the need to stay “on message” and simplify food choices for consumers, thus continuing the vilification of all saturated fats.

Substituting corn oil (or other vegetable oils with lots of linoleic acid) for foods containing saturated fats does not lower risk of heart disease and may promote atherosclerotic outcomes like heart attack and stroke.

I doubt that few if any of the miraculous  CO benefits hyped at coconutoil.com and elsewhere are real but if it helps your skin or your scalp, your digestion or your taste buds, feel free to consume ad lib and don’t worry about any adverse effects on your coronary arteries or your heart.

Cocovorically Yours,

-ACP

For those seeking more information.

This graph is from the BMJ paper which also included a meta-analysis of all randomized studies substituting linoleic acid for saturated fat.  The data do not favor substituting corn oil for saturated fat

F7.large

 

 

 

Here is a primer on SFA sources and effects on cholesterol from a recent review on dairy fat and cardiovascular disease.

/After absorption, the predominant dairy SFA palmitic acid (C16:0), but also myristic acid (C14:0) and lauric acid (C12:0) are preferentially directed to TG formation rather than to phospholipid acylation. These three long-chain fatty acids raise total cholesterol, but their effects on LDL:HDL ratios are different. Palmitic acid is the major SFA in the diet and also in milk fat with a content of about 30%. Palmitic acid raises the LDL cholesterol more than it raises HDL cholesterol (27). Myristic acid represents 11% of the dairy fatty acids and increase total cholesterol as much as palmitic acid, but does not affect total cholesterol:HDL ratio (128). Lauric acid is the most potent fatty acid in raising plasma total cholesterol, but dairy content is only 3.3%. The increase in HDL cholesterol induced by lauric acid is higher than the increase in LDL and thus the total cholesterol:HDL ratio was decreased when lauric acid was used to replace carbohydrates (1). Stearic acid represents 12% of the dairy fatty acids and improves the plasma cholesterol profile by decreasing total/HDL cholesterol ratio compared to other SFAs. But compared to polyunsaturated fatty acids (PUFA), stearic acid increases LDL and decreases HDL and increase total/ HDL ratio. (29). Other SFAs are short- and medium-chain length and are mainly considered to be cholesterol neutral. At a certain amount of SFA intake, an increase in both LDL and HDL cholesterol can be seen, especially if the intake of unsaturated fatty acids is low (3031). In a recent meta-analysis of prospective epidemiological studies, intake of SFA and risk of CVD was studied (32). Six studies found a significant positive association between SFA intake and CVD, and 10 studies found no significant association.

For Whom The Ketosis Tolls

The skeptical cardiologist has gotten a lot of comments in the last week on both his “farewell to ketosis” post and a mysterious post consisting of simply “Br.”

On some level I feel like I’ve let down the low carb, high fat community by exiting ketoland prematurely. Certainly, the many ketophiles who pointed out the error of my path in ketoland have made excellent points.

One commenter wrote that side effects:

“can be mitigated or eliminated entirely by dramatically increasing your sodium intake (blasphemy, I know!), and decreasing your blood pressure medication (fun fact — that is one of the benefits of keto — normalizing things like blood pressure)”

Having read Atkins and other LCHF writers (including Peter Attia) pretty closely, I was aware of this and doubled or tripled my salt intake. I was dissolving salt into water and drinking multiple cups per day.  Also, if you read my posts on salt consumption, you’ll see that I don’t advocate across the board cuts in dietary salt, and thus I  commit dietary blasphemy with regularity.

In fact, I’ve written, with respect to salt loss by tennis players and by my hypertensive patients during the summer, the following:

“These variations in salt loss in the context of large variations in cardiovascular physiology and blood pressure regulation between individuals is further support for abandoning the ultra-low salt limits suggested by the AHA and the USDA.”

Also, I think dietary blood pressure lowering is awesome and as I mentioned, I cut back on my blood pressure meds and monitored my blood pressure regularly.

In response to another good point from a commenter on my statement that, “after a week of having to analyze in detail the carb or net carb content of everything that I consumed, I realized this was not something I wanted to do long term,” I can only say, “mea culpa.”

It could be the program you were attempting to do, but you’re overthinking it. Avoiding heavily processed foods (like Atkins bars) and favoring fatty meat and non-starchy vegetables will get you at least 80% of the way there without even really trying.

If/when I do it again, I’ll have a pretty instinctual understanding of what to do. It’s possible that my reasons for exiting ketoland relate more to a desire to consume proscribed items like beer, cocktails and large amounts of parsnips.

Another comment was “Since you wouldn’t run your car’s engine at hard and heavy exertion while you are in the middle of rebuilding it, why so would you expect to be able to continue to perform exercise at previous levels while you are rebuilding your body’s internal engine? Also, why are the only resources you referenced in this journey woefully outdated?”

I wouldn’t say I was engaging in hard and heavy exertion during my week in ketoland; walking a couple of miles to and from a restaurant or riding my bike at a moderate pace plus weights was the extent of it.  Perhaps that was too much to ask of my aging car’s engine as I retooled it’s fuel.

As to the references being outdated: William Banting writing in the 1700s is not recent enough for you?

Seriously, I was primarily delving into what Robert Atkins had promulgated and I utilized his Diet Revolution book,  first published in 1972; but I also referenced recent writings of Peter Attia and Andreas Eenfeldt.

Speaking of outdated references published in 1972 (and in a blatant attempt to reestablish my low carb cred), I highly recommend Paul Yudkin’s “Pure, White and Deadly.”  Yudkin, a British physician and nutritionist, concluded that increased sugar consumption was the major dietary cause of heart disease. Unfortunately, this scientific concept went up against the great and powerful Ancel Keys and the (now increasingly discredited) concept that dietary fat causes heart disease.

As Robert Lustig wrote in his introduction to the 2012 edition:

“The Pharisees of this nutritional holy war declared Keys the victor, Yudkin a heretic and a zealot, threw the now discredited Yudkin under the proverbial bus, and relegated his pivotal work to the dustbin of history, as this book went out of print and virtually disappeared from the scene. The propaganda of “low-fat” as the treatment for heart disease was perpetuated for the next thirty years. And the cluster of diseases (obesity, diabetes, hypertension, lipid problems, heart disease) collectively termed the “metabolic syndrome” increased in a parabolic fashion under the canopy of the sugar industry and their propaganda machine.
But good ideas die hard. Larger studies started to demonstrate that serum triglyceride levels correlated with heart disease, with sugar consumption being the primary driver. And there wasn’t one type of LDL, there were two: large buoyant LDL, driven by dietary fat, but which was neutral in terms of heart disease; and small dense LDL, driven by dietary carbohydrate, and which oxidizes quickly, driving atherosclerotic plaque formation (hardening of the arteries). The Atkins diet was now being taken seriously. Carbohydrates started to assume center stage in promoting metabolic disease, with sugar consumption implicated as the most notorious carbohydrate.”

The nutritional Holy Wars rage on. This omnivore, although an apostatic ketotic, genuflects before the wisdom of Yudkin.

UnPhariseeically Yours,

-ACP

Br

 

 

A Farewell to Ketosis: Banting, Dickens and The Roots of Atkins

The skeptical cardiologist spent an interesting week in ketoland, counting carbs, and turning ketostix purple,  but ultimately decided this was not a world he wanted to inhabit long term.

letter-on-corpulence-by-william-banting3During that week I paid 1.99$ to download William Banting’s “Letter on Corpulence”(available here for free.) Banting, writing in 1869, first popularized a low carb, high fat diet for obesity with this pamphlet. He starts it off with these words:

“OF all the parasites that affect humanity I do not know of, nor can I imagine, any more distressing than that of Obesity, and, having emerged from a very long probation in this affliction, I am desirous of circulating my humble knowledge and experience for the benefit of other sufferers, with an earnest hope that it may lead to the same comfort and happiness I now feel under the extraordinary change,—which might almost be termed miraculous had it not been accomplished by the most simple common-sense means.”

The pamphlet was enormously popular and sold over 60,000 copies. Banting donated his 225 £ of profit to various charities, including:

charles_dickens__2_
Charles Dickens, twice President of the Printer’s Pension Society and also did some writing. In the Pickwick Papers, he describes Joe, the Fat boy, who was perpetually falling asleep. Pickwickian Syndrome was the early medical term for what is now sleep apnea.

FatboyJoe“£ s.d.

To The Printers’ Pension Society, at the

Anniversary Dinner, in March, 1864,

per Chas. Dickens, Esq. .. .. 50 0 0″

 

 

In my last post, I closed with a paragraph  describing the benefits I had experienced of consuming a really high fat, very low carb diet: more energy, less sleep needed, asthma cured, wrinkled skin “melting away. This was supposed to be a humorous parody of how enthusiastic supporters of fad diets feel after they have jettisoned their bad eating habits but apparently most readers, unaware of my dry sense of humor (or perhaps not familiar with David Cronenberg’s The Fly) took this seriously.

Certainly, if I had felt significantly better on the Atkins diet I, like William Banting,  would still be on it. Alas, if anything, I felt worse.

My sleep was unaffected. Unllike, Robert Atkins, who noted his sleep requirements went from 8 hours a night to 5 hours a night, my sleep patterns were unchanged.

Energy levels in the morning were good but periodically in the afternoon, especially after even minor exertion but particularly after an intense workout, I would feel uncharacteristically exhausted.

Although my weight dropped 3-4 pounds this is typically what happens if I cut out alcohol from my diet for a week so it’s hard to say what the independent role of the extremely low carb intake and ketosis was.

My blood pressure dropped during the week and I had to cut back on my blood pressure medications to avoid dizziness. There were too many other variables occurring simultaneously that week (weight loss, lack of alcohol consumption) to know if this was independently associated with the ketogenic diet, however.

To be fair, supporters of ketogenic/Atkins diets warn us that during  the initial weeks, we may feel worse, experiencing the so-called “low carb flu.” To fully test it I should have stayed on it for 3-6 weeks and entered a maintenance phase in which I could have consumed more carbohydrates.

However, after a week of having to analyze in detail the carb or net carb content of everything that I consumed, I realized this was not something I wanted to do long term.

For the significantly obese like William Banting who  struggle to achieve weight loss the ketogenic/Atkins diet is likely to be a much better experience than for someone like me who is not overweight. Banting’s diet prior  to his “miraculous change” consisted primarily of bread, milk and beer and it is likely that cutting out the bread and beer alone would have had a dramatic effect on his weight and well-being.

My adventure in ketoland inspired me to update my dietary recommendations , the pdf of which is here (What Diet Is Best For Heart Health).

It would nice if we had some sort of genetic test that would tell us what diet is perfect for us. Unfortunately, until that is developed, trial and error is the only viable approach. Some, like William Banting, Robert Atkins and the  lady at zerocarbizen.org will thrive on very low carbs whereas others, like Dean Ornish and Nathan Pritikin prosper on a very low fat diet.

Most individuals will be served best by a diet of real, minimally processed food with lots of different vegetables growing both above and below ground and eaten in moderation.

Unbantingly Yours

-ACP

N.B. Here, in a nutshell, in Banting’s own words ,is the essence of the Banting diet:

“I never eat bread unless it is stale, cut thin, and well. toasted. I very seldom take any butter, certainly not a pound in a year. I seldom take milk (though that called so, in London, is probably misnamed), and I am quite sure that I do not drink a gallon of it in the whole year. I occasionally eat a potato with my dinner, possibly to the extent of 1 lb. per week. I spoke of sherry as very admissible, and I am glad of this opportunity to say, that I have since discovered it promoted acidity. Perhaps the best sherry I could procure was not the very best, but I found weak light claret, or brandy, gin, and whisky, with water, suited me better; and I have been led to believe that fruit, however ripe, does not suit me so well taken raw as when cooked, without sugar. I find that vegetables of all kinds, grown above ground, ripened to maturity and well boiled, are admirable; but I avoid all roots, as carrot, turnip, parsnip, and beet. ”

Excerpt From: William Banting. “Letter On Corpulence.” Foster, 2014. iBooks. https://itun.es/us/fOKP3.l

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

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