Is Chocolate Good For The Heart?

While in Paris recently,  allegedly researching the French Paradox, the skeptical cardiologist and his Eternal Fiancee’ participated in a Food Tour (Paris By Mouth).  Along with 2 other American couples, we were guided and educated by a Parisian food/wine expert as we wandered from one small shop to another in the St. Germain district of the Left Bank.

We collected the perfect Baguette Monge from Eric Kayser, delicious rillettes, terrine, and saucisson from Charcuterie Saint Germain, amazing cheese from Fromager Laurent Dubois, delightful  pastries from Un Dimanche a Paris, and unique and delicious chocolate from Patrick Roger.

The tour ended at La Cave du Senat wine shop, where we descended into a stone cellar and tasted all of the delicious foods while drinking wonderful wines.

The French Paradox refers to the fact that the French are among the world’s highest consumers of saturated fat, but have among the world’s lowest rates of cardiovascular disease. For those nutritional experts still obsessed with the dangers of all saturated fats, this poses a conundrum.

Cheese And The French Paradox

France consumes more cheese (27 kg per person per year) than any other country in the world (the US only consumes 16 kg per capita). Unlike Americans who have embraced low fat or skim versions of cheese, the French predominantly consume full fat cheese.

I wrote In Defense of Real Cheese  in 2014 and extolled the heart-healthy virtues of eating full fat , non factory-processed cheese.

Perhaps the French are protected against heart disease by their high consumption and love of real cheese ?

Chocolate And The French Paradox

Whereas cheese contains saturated fat and has been unfairly stigmatized as unhealthy, chocolate, similarly with high saturated fat content, seems to have been coronated as the king of food that is yummy but paradoxically is also heart healthy.

Could chocolate be the enigmatic protector of the hearts of the French?

Back on Boulevard Saint-Germain we entered the shop of Patrick Roger, who won the coveted Meilleur Ouvrier de France, in the craft of chocolate in 2000. The MOF is France’s way of recognizing the best artisans in various fields and occurs every 4 years. The standards are so high that in 2015 none of the 9 chocolatier competitors were felt to merit receiving the award.

The French clearly take their chocolate seriously but they don’t top the international charts at per capita consumption.

The Swiss consume 20 pounds of chocolate per year, whereas the French and US are tied for 9th, consuming 9.3 and 9.5 lbs. (Infographic from Forbes

 

 

Chocolate And The Heart

I’ve been meaning to write a post on chocolate and the heart since my encounter with high end chocolatiers in Paris and Bruges, and especially since May when there was much fanfare over a Danish study showing less atrial fbrillation in high chocolate consumers.

A NYTimes piece stimulated by the Danish study and entitled “Why Chocolate May Be Good For The Heart” typified the media headlines  and summarized the study thusly:

Scientists tracked diet and health in 55,502 men and women ages 50 to 64. They used a well-validated 192-item food-frequency questionnaire to determine chocolate consumption.

After controlling for total calorie intake, smoking, alcohol consumption, body mass index and other factors, they found that compared with people who ate no chocolate, those who had one to three one-ounce servings a month had a 10 percent reduced relative risk for atrial fibrillation, those who ate one serving a week had a 17 percent reduced risk, and those who ate two to six a week had a 20 percent reduced risk.

Previous large, well done observational studies also show that high chocolate consumption compared to no consumption is associated with a lower risk of cardiovascular disease.

Of course these being observational studies with only weak (but significant) associations, we cannot conclude that chocolate consumption actually  lowers the risk of developing afib or cardiovascular disease (causation.)

My favorite graph to hammer home this point is below and plots how much each country consumes in chocolate, versus the number of nobel laureates.

 

 

 

 

 

 

 

 

 

There is a good correlation here (Pearson’s (no relation unfortunately) correlation coefficient or r value) which is highly significant (p value <.0001). But does anyone seriously think a country can boost its Nobel Laureate production by promoting chocolate consumption?

The authors of the Danish afib trial, admit the possibility of residual or unmeasured confounding variables as a limitation in their discussion:

Although we had extensive data on diet, lifestyle and comorbidities, we cannot preclude the possibility of residual or unmeasured confounding. For instance, data were not available on renal disease and sleep apnoea. However, after adjusting for age, smoking status and other potential confounders, the association was somewhat attenuated but remained statistically significant.

Most chocolate authorities proclaim the health  benefits of dark chocolate over milk chocolate but in this Danish study:

We did not have information on the type of chocolate or cocoa concentration. However, most of the chocolate consumed in Denmark is milk chocolate. In the European Union, milk chocolate must contain a minimum of 30% cocoa solids and dark chocolate must contain a minimum of 43% cocoa solids; the corresponding proportions in the USA are 10% and 35%.16 Despite the fact that most of the chocolate consumed in our sample probably contained relatively low concentrations of the potentially protective ingredients, we still observed a robust statistically significant association, suggesting that our findings may underestimate the protective effects of dark chocolate.

Despite the fact that the participants in the Danish AFib study were likely mostly consuming  milk chocolate rather than dark chocolate,  the lead author of the study has been quoted as saying “dark chocolate with higher cocoa content is better… because it is the cocoa, not the milk and sugar, that provides the benefit.”

The Chocolate-Industrial -Research Complex

Julia Volluz, in a nicely written piece at Vox  entitled “Dark chocolate is now a health food. Here’s how that happened.” describes how “over the past 30 years, food companies like Nestlé, Mars, Barry Callebaut, and Hershey’s— among the world’s biggest producers of chocolate — have poured millions of dollars into scientific studies and research grants that support cocoa science.”

Here at Vox, we examined 100 Mars-funded health studies, and found they overwhelmingly drew glowing conclusions about cocoa and chocolate — promoting everything from chocolate’s heart health benefits to cocoa’s ability to fight disease. This research — and the media hype it inevitably attracts — has yielded a clear shift in the public perception of the products.

“Mars and [other chocolate companies] made a conscious decision to invest in science to transform the image of their product from a treat to a health food,” said New York University nutrition researcher Marion Nestle (no relation to the chocolate maker). “You can now sit there with your [chocolate bar] and say I’m getting my flavonoids.”

Flavonols and Blood Pressure

Dark chocolate and cocoa products are rich in chemical compounds called flavanols. Flavanols have attracted interest as they might help to reduce blood pressure, a known risk factor for cardiovascular disease. The blood pressure-lowering properties of flavanols are thought to be related to widening of the blood vessels, caused by nitric oxide.

The latest Cochrane Review on this topic commented on the poor quality of the studies involved:

Studies were short, mostly between two and12 weeks, with only one of 18 weeks. The studies involved 1804 mainly healthy adults. They provided participants with 30 to 1218 mg of flavanols (average of 670 mg) in 1.4 to 105 grams of cocoa products per day in the active intervention group. Seven of the studies were funded by companies with a commercial interest in their results, and the reported effect was slightly larger in these studies, indicating possible bias.

This graph from Volluz’s Vox article demonstrates how much chocolate you would need to consume to get the average amount of flavanols that participants in these studies received:

The Cochrane review felt there was

moderate-quality evidence that flavanol-rich chocolate and cocoa products cause a small (2 mmHg) blood pressure-lowering effect in mainly healthy adults in the short term.

Thus, for a very small drop in blood pressure you would have to make chocolate the main source of calories in your daily diet.

Consuming such large amounts of chocolate, even dark chocolate, would drastically increase your sugar consumption.

Further weakening any conclusions on the benefit of chocolate are that these are very short-term studies with markedly different baseline BPs, ages, and large variations in flavanol dosage.

Is Your Chocolate Produced By Slaves?

After reading the Danish AFib article, I purchased several bars of Tony’s Chocolonely chocolate that caught my eye at the Whole Foods checkout counter. The bars had interesting wrappers and on the inside of the wrapper I discovered that Tony’s Chocolonely’s claim to fame is that it is “slave-free.”

Per Wikipedia:

Tony’s Chocolonely is a Dutch confectionery company focused on producing and selling chocolate closely following fair trade practices, strongly opposing slavery and child labour by partnering with trading companies in Ghana and Ivory Coast to buy cocoa beans directly from the farmers, providing them with a fair price for their product and combating exploitation.

The slogan of the company is: “Crazy about chocolate, serious about people“.

I was previously unaware of the problem of child slavery and cocoa production. If you’d like to read more about it start here.

The Tony’s Chocoloney was so tasty I ended up consuming vast quantities of it at the end of the day and it disappeared rapidly. Currently the skeptical cardiologist’s house is chocolate free.

Should Chocolate Be Considered A Super Food or A Slave Food?

I can’t recommend chocolate to my patients as a treatment for high blood pressure or to reduce their risk of heart attack or stroke on the basis of the flimsy evidence available.

If you like chocolate, the evidence suggests no adverse effects of consuming it on a regular basis.

As far as flavanols obtained from cocoa and their benefits for cardiovascular disease, I eagerly awaiit the result of the ongoing Cocoa Supplement and Multivitamin Outcomes Study (COSMOS), a randomized trial looking at whether daily supplements of cocoa extract and/or a standard multivitamin reduces the risk of developing cardiovascular disease and cancer.

Patients and readers should recognize that there is an ongoing research/media campaign by Big Chocolate to convince them that chocolate is a SuperFood which can also be a dessert.

Flavanoidly Yours,

-ACP

Most Echocardiograms Done In the UK Are Free But Not Read By Cardiologists

In the course of researching a previous post on the cost of an echocardiogram, the skeptical cardiologist discovered a website in the UK ((HeartScan)) that offered a “private” echo at a cost of around $400.

Subsequently,  Antoinette Kenny, the creator of HeartScan, was kind enough to answer some questions I had about echocardiography in the UK.

 

From the HeartScan website. I presume this is Dr. Kenny, herself, performing an echocardiogram on a patient.

 

First she provided me with some background on her career. (Green text below from Dr. Kenny)

As you will know from HeartScan’s website (redesign of which is almost complete and will be launched next month) I am a cardiologist in the UK. I am still a fulltime NHS (UK’s public health service) cardiologist at one of the leading heart centres in the UK, the Freeman Hospital, Newcastle upon Tyne. I am Head of the Regional Echocardiography Department there providing TTE, TEE, stress echo, 3D etc. My career has also been heavily involved with the British Society of Echocardiography (BSE) which is affiliated with British Cardiovascular Society and promotes standards of practice for echocardiography in the UK including accreditation programmes for individuals and departments/private services.

Dr. Kenny is clearly well-trained and dedicated to providing high quality echocardiography.

And according to  HeartScan’s FAQs

At HeartScan you are secure in the knowledge that your Echo will be performed to the highest standards laid down by the British Society of Echocardiography. HeartScan is to date the only private provider in the UK to be awarded British Society of Echocardiography Departmental Advanced Accreditation.

Are Echos Free In The Uk?

You are correct, echocardiograms are free of charge through the NHS in the UK. However, there are waiting times involved for elective referrals and typically patients may have to wait for 6-12 weeks or longer in some geographical areas.  So some patients will chose to have their echocardiogram privately and self-fund.  Other patients are covered by health care insurance and will have their echo reimbursed by their health insurance provider

It would be unusual for someone to wait for more than 1-2 weeks for an echocardiogram in the US. I suspect the longer UK waiting time does not cause worse outcomes.

Hopefully, patients presenting with some conditions (acute heart failure  comes to mind)  are moved up in the queue.

How Does Dr. Kenny Determine What To Charge For Her Private Echocardiograms?

My services are very competitively priced and I chose this price point to be competitive with other private echo services but also add value to the patient in that the echo is reported by a cardiologist who is an echo specialist.  Other local private hospitals provide an echo privately at a higher cost (approx. £380-480 for a sonographer reported echo).

So £295 is the cost of what I believe is a very high quality echo with a high quality  report.  I guess I have tried to make private echo reported by an echocardiologist as available as I can.  Whilst we are a small clinic I do get patients who travel great distances for an echo as they tell me they trust the service (as they know it’s reported by a specialist) and find the pricing better than they can attain locally.

A Marked Difference In The Practice of Echocardiography Between In The US Compared To The UK

One of the main differences between the UK and US I think is that imaging cardiologists are very much in the minority here so that in a smaller hospital there may be no cardiologist who has echo expertise.  Therefore the Echo service is almost completely physiologist delivered.  In larger teaching hospitals over the last decade or so there has been an increased awareness of the importance of imaging and thus an increased training and appointment of imaging cardiologists.  However numbers are small in relation to the service load. For instance in my unit we perform almost 18,000 TTEs annually but there are only 1.5 Echo consultants (and we both do general cardiology also).  So the TTE service is physiologist reported with myself and my colleague running ongoing education and  QA programmes for the physiologists.  We only report a small percentage of TTE cases that are flagged up by the physiologists but we perform the TOE (TEE!) and DSE’s etc. Echo is a relatively small sub-specialty in the UK so echo cardiologists tend to know each other and lecture on each other’s teaching courses etc. But there are many hospitals with no cardiologist echo expertise.

I was amazed by this. In the US, sonographers record the examination and make measurements. In some (typically academic) centers the sonographers create a preliminary reports, however, an echo trained physician signs off on all reports.

I was curious what training and reimbursement these physiologists receive  as they doing, in essence,  what a cardiologist does in the US.

Salary and Training of Physiologists in UK

Yes, our cardiac physiologists have considerable responsibility!

Their training is changing with a programme of ” modernising scientific careers” that’s underway but I will send you on info regarding their training. In essence the previous model was to complete a university course and then train in the hospital in various disciplines. For those in cardiology they train in the cath lab, cardiac rhythm management and Echo so have a very broad base before then specialising in Echo ( or cardiac rhythm etc).

Salaries depend on experience and seniority but the salary for a cardiac physiologist who has attained BSE accreditation and reports independently is up to £42,000 a year.

I’m fascinated by this fundamental difference in the way echocardiography happens in the US versus the UK. I wonder how it impacts either clinical outcomes or the cost of medical care in the two countries.

I’ll be posting information on the training that UK physiologists go through in the near future.

I welcome comments from any UK readers on their experience with private or NHS echocardiograms, either good or bad.

I remain Anglophilically yours,

-ACP

 

N.B.  For your further edification, I’ve copied Dr. Kenny’s About Page from the HeartScan web page.

Perhaps Dr. Kenny can tell us what all those initials after her name mean.

About Dr Kenny

Dr. Antoinette Kenny, Director of HeartScan Ltd.
MB BCh BAO MD FRCP FRCPI

Dr. Antoinette Kenny is a full time Consultant Cardiologist and Specialist in Echocardiography (ultrasound heart scans) at the Regional Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne.  She is also an expert in cardiac screening for individuals involved in sport.

Dr. Kenny qualified in medicine in Dublin in 1983 and trained in clinical cardiology at St. James’s Hospital Dublin and Papworth Hospital Cambridge. She was awarded the Grimshaw-Parkinson  Fellowship from Cambridge University for her research towards an MD thesis in echocardiography at Papworth Hospital. She was made a Fellow of the Royal College of Physicians, London, in 1998 and of the Royal College of Physicians, Ireland, in 1999.

Following her clinical cardiology training and MD thesis she was appointed Fellow in Echocardiography at the Oregon Health Sciences University, Portland, Oregon, USA.  There she undertook training in advanced echocardiography, including three-dimensional echo techniques, with Professor David Sahn the internationally renowned specialist in echocardiography. In 1993, at the relatively young age of 33, she was appointed Consultant Cardiologist and Clinical Head of Echocardiography at The Regional Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne.  At that time only 19 (<5%) of consultant cardiologists in the UK were female and an even smaller percentage of cardiologists had achieved consultant status by the age of 33, facts which serve to highlight Dr. Kenny’s postgraduate career achievements.  (Source Royal College of Physicians Census).

Echo experience:
As Clinical Head of Echocardiography at Freeman Hospital for over 20 years, Dr. Kenny has gained a vast experience in assessing patients with heart failure, valve disorders and inherited cardiomyopathies.  Her expertise includes evaluation and selection of patients for advanced valve replacement techniques such as TAVI (transcutaneous aortic valve implantation) and minimally invasive surgery.  She is a member of the Specialist Heart Valve Team at Freeman Hospital providing specialist echocardiographic expertise for the selection of patients for valve surgery.

Sports Cardiology experience:
Dr. Kenny is also a cardiology adviser to the Football Association (FA) and a member of the FA cardiology consensus panel producing guidelines for cardiac screening.  She has performed cardiac screening for the Football Association since this programme was introduced for young footballers in 1996.

Dr Kenny has also been involved with investigation and heart screening in premiership football players for the last decade and provides heart screening for Newcastle United FC, Sunderland AFC and Middlesbrough FC, including their first team players. Dr. Kenny has particular expertise in distinguishing between the normal changes produced by athletic training (athlete’s heart) that could be misinterpreted as abnormalities and abnormal cardiac conditions that can pose a serious health risk.

Achievements:
Dr Kenny holds full accreditation with the British Society of Echocardiography, the national benchmark of quality in performing and interpreting Echo scans.  As an elected council member of the British Society of Echocardiography she has been involved with standards and quality in delivery of national Echo services.  She also held the post of Chairman of the Scientific and Research Committee of the British Society of Echocardiography with responsibility for organisation of the annual meeting and educational sessions.

She is co-author of a well received textbook of echocardiography which has been translated into other languages. Dr. Kenny is also a leader in education in echocardiography, co-directing a national Echo course and invited to lecture at both national and international Echo conferences.

Dr. Kenny has developed and led research studies in advanced applications of echocardiography over the last two decades and has published widely in peer reviews journals.

What Is Behind The Significant Changes In AliveCor’s Kardia Mobile ECG App?

The Skeptical Cardiologist is a strong proponent of empowering patients with atrial fibrillation by utilizing personal cardiac rhythm devices such as Afib Alert or AliveCor’s Kardia.

I’ve written about my experiences with the initial versions of the Kardia mobile ECG device and the service it provides here and here.

I have been monitoring dozens of my afib patients using AliveCor’s Physician Dashboard.

Recently AliveCor changed fundamentally the way their app works such that for new users much of the functionality I described in my previous posts now requires subscribing to their Premium service which costs $9.99 per month or $99 per year.

What Has Changed With The Kardia App

The Kardia device which works with both iOs and Android smart
phones is unchanged and still generates a “medical-grade” single lead rhythm strips which appears within the Kardia app.

Screenshot from AliveCor’s website showing the Kardia recording device being utilized with the obtained  typical ECG recording displayed on the smartphone app.

 

 

The app still is reasonably accurate at identifying atrial fibrillation or normal heart rhythms and offers a fee-based service for interpretation of unclassified ECGs.

However, for new purchasers of Kardia,  the capability to access, email or print prior ECG recordings has gone away. Prior to March of this year, Kardia users could access prior ECG tracings which were stored in the cloud  by touching the “Journal” button on the app. These older tracings could be emailed and they were available through the cloud for a physician like myself to review at any time.

Now new Kardia purchasers will find that when they make an ECG recording they have the option to email a PDF of the ECG but once they hit the DONE button it is gone and is not stored anywhere.

For my patients purchasing after March, 2017 this means that unless they  purchase Kardia Premium service I will not be able to view their ECG recordings online.

An AliveCor account executive summarized for me the changes as follows:

We added a significant number of features over the past year and a half, and grandfathered all users on March 16th, 2017. New users now have the option to download and use Kardia for free, but the premium services are $9.99/mo or $99/year. Kardia Premium allows unlimited storage and history of their EKGs, summary reports with longitudinal data, blood pressure monitoring and tracking weight and medication.

Why Journal Functionality Is Important

If you purchased your AliveCor/Kardia device prior to March 16th, 2017 ago the journal  functionality still works. Let’s call such customers “Journal Grandfathered”.

This Journal functionality is important in a number of ways:

  1. My Journal Grandfathered patients can bring their phones with them during an office visit and we can review all of their ECG tracings.
  2. Journal gGandfathered Kardia users can email their old tracings to their physicians or to anyone they wish (even the skeptical cardiologist!). They can also print them out and save PDFs of the tracings.
  3. I  can view through my online physician account all of my Journal Grandfathered patients. This means any time a patient of mine makes a recording that is unclassified or suggests atrial fibrillation I can be notified and immediately view it online.

This fundamental change took place as AliveCor attempts to convince  purchasers of the Kardia device to use their Premium service.

Why AliveCor Changed The Kardia App Function

Dr. David Albert, inventor and  cardiologist and the founder of AliveCor was kind enough to talk with me about this change.

He indicates that of the 150,000 AliveCor users, 10,000 are now using the Kardia Premium service. About 20% of new users elect Kardia Premium.

Prior to the change all AliveCor users had their old ECG recordings stored in the cloud in a HIPPA compliant fashion. This free service was costing AliveCor quite a bit and the company felt it was best to switch to a subscription service to provide this secure cloud storage.

With the change to the (relatively inexpensive)  subscription service, patients will get additional features. As the AliveCor account executive described:

Kardia Premium allows unlimited storage and history of their EKGs, summary reports with longitudinal data, blood pressure monitoring and tracking weight and medication.

 

 

I’ve looked at the Premium service and it seems quite useful when combined with a connected physician utilizing Kardia Pro.  I’ll evaluate the Premium service and the physician Kardia Pro service  further and write a full post on its features in the near future.

If you are not grandfathered and want to stick with the Basic Kardia service you still have an immensely useful and  inexpensive device which allows personal detection of your cardiac rhythm. Just remember to email yourself the ECG recording you just made before you hit DONE.

Nonarrhythmically Yours,

-ACP

Are Physicians Influenced By Pharmaceutical Gifts?

The Skeptical Cardiologist stopped giving talks for pharmaceutical companies 5 years ago and stopped accepting lunches from pharmaceutical reps because he wanted to be certain that he was not being influenced by them in his writing or patient care.

I made an exception 6 months ago and consumed panang curry provided by a pharmaceutical representative who was promoting the blood thinner Pradaxa.

He enthusiastically extolled the virtues of Pradaxa throughout the lunch and made some excellent points supporting the use of the drug. Shortly thereafter, when I was considering which of the newer blood thinners to prescribe for a patient , Pradaxa was foremost in my mind.

The scientific data that Boehringer Ingelheim wanted me to be aware of entered the crowded marketplace of ideas in my head that day but I prefer the data that enters my consciousness come from unbiased sources.

A new study from Georgetown University, published in PLOS One provides support for physicians eschewing pharmaceutical gifts.

The authors point out in their introduction that gifts are important:

Gifts, no matter their size, have a powerful effect on human relationships. Reciprocity is a strong guiding principle of human interaction. Even gifts of small value, such as “modest” industry-sponsored lunches, may foster a subconscious obligation to reciprocate through changes in prescribing practices. DeJong et al has shown that a meal with a value of less than $20 can increase the prescribing of branded statins, beta-blockers, ACE inhibitors, and antidepressants.

The study found:

Physicians who received small gifts (less than $500 annually) had more expensive claims ($114 vs. $85) and more branded claims (30.3% vs. 25.7%) than physicians who received no gifts. Those receiving large gifts (greater than $500 annually) had the highest average costs per claim ($189) and branded claims (39.9%) than other groups. All differences were statistically significant (p<0.05).

The conclusions of the study:

Gifts from pharmaceutical companies are associated with more prescriptions per patient, more costly prescriptions, and a higher proportion of branded prescriptions with variation across specialties. Gifts of any size had an effect and larger gifts elicited a larger impact on prescribing behaviors. Our study confirms and expands on previous work showing that industry gifts are associated with more expensive prescriptions and more branded prescriptions. Industry gifts influence prescribing behavior, may have adverse public health implications, and should be banned

Michael Joyce has written a detailed and insightful analysis of this paper at the excellent website, HealthNewsReview.org.

He points out the limitations of this and all observational studies:

Although the study cannot definitively establish cause-and-effect between a provider receiving such gifts and any subsequent upturn in their prescribing, it does make a significant contribution to a growing body of literature documenting how drug company largesse is clearly linked — either consciously or otherwise — to the way in which health care providers prescribe.

And the article quotes Daniel Goldberg, an expert on bioethics:

“First, in situations when the evidence is imperfect, and the decisions are subtle, as is so often true in medicine. In these ambiguous situations the evidence clearly suggests that gifts can sway doctors in one direction, even if there’s no evidence to support that as the best decision. Second, it frames decisions in pharmaceutical terms, even when there may be other options — proven to be better — that have nothing to do with drugs.

Drugs are just one tool. But we have ‘pharmaceuticalized’ health care to a point where many patients are conditioned to equate health with access to drugs.”

Since I consumed the panang curry, I’ve gone back to bringing in my own lunch. Thus, my lunch/breakfast typically consists of Trader’s Point full fat plain yogurt with lots of blueberries and raspberries, and perhaps some ground up flaxseed and/or almonds (although today I’ll be bringing in leftover-meatloaf and roasted root vegetables.)

It’s not as tantalizing as the curry, but it leaves my crowded brain free to ponder the multitude of unbiased data from scientific papers, rather than the talking points a pharmaceutical representative would prefer I ponder.

The end result, I hope, is unbiased blogging and prescribing-better information for readers and better care for patients.

-ACP

 

Why Did I Go Into Atrial Fibrillation?

The skeptical cardiologist is asked this  question or  variations of it (such as  what caused me to go out of rhythm?) on a daily basis.

Most patients would like to have a reason for why their atria suddenly decided to fibrillate.  It’s understandable. If they could identify the reason perhaps they could stop it from happening again.

There are two variations on this question:

For the patient who has just been diagnosed with afib the question is really “what is the underlying reason for me developing this condition?”

For the patient who has had afib for a while and it comes and goes seemingly randomly the question is “what caused the afib at this time? i.e. what triggers my episodes?”

For most patients, there is no straighforward and simple answer to either one of these questions

The Underlying Cause of Atrial Fibrillation

My stock response to this first question goes like this:

“Atrial fibrillation is associated with getting older and having high blood pressure. 10 % of individual >/= 80 years have atrial fibrillation. 90% of patients with afib have hypertension.

Aging and hypertension may increase scarring or damage in the left atrium or pulmonary veins that drain into the left atrium setting up abnormal electrical signals.

There are some specific things that cause afib and we will be doing a complete history and physical and some testing to check for the most common. We’ll check you for thyroid or electrolyte abnormalities and we will do an echocardiogram to look for any structural problems with your heart.

If we do find a treatable cause such as hyperthyroidism or a cardiac valve problem we will fix that and the afib may go away, however chances are we won’t find a specific reason why you developed atrial fibrillation.

Finally, and possibly most importantly, let’s take a close look at your lifestyle. Are you overweight? If so, losing 10% of your body weight will substantially lower your risk of recurrent atrial fibrillation. Let’s get you exercising regularly and eating a healthy diet, Make sure your sleep is optimized and your stress minimized.”

If you’d like a more sophisticated look into what causes afib take a look at this graphic from a recent paper.

Current theory has it that factors that we know are associated with atrial fibrillation  including obesity, hypertension and sleep apnea cause atrial structural abnormalities or remodeling which then create various atrial electrical abnormalities.

 

Exhaustive List of Causes

If you’d like an exhaustive list of factors associated with atrial fibrillation, you can memorize the acronym P.I.R.A.T.E.S. which is sometimes used by medical students to remember the causes of atrial fibrillation which include:

  • Pulmonary disease (COPD, PE)/Phaeochromocytoma
  • Ischemia (ACS)
  • Rheumatic heart disease (mitral stenosis)
  • Anemia (high output failure/tachycardia)/Atrial myxoma/Acid-base disturbance
  • Thyrotoxicosis (tachycardia)
  • Ethanol/Endocarditis/Electrolyte disturbance (hypokalaemia, hypomagnesaemia)/Elevated BP
  • Sepsis/Sick Sinus Syndrome/Sympathomimetics (Drugs)

And here’s a cute  mnemonic from the Family Practice Notebook using ATRIAL FIB itself (although you have to use the ph of pheochromocytoma to make the f of fib)

  1. Alcohol Abuse
  2. Thyroid Disease
  3. Rheumatic Heart Disease
  4. Ischemic Heart Disease
  5. Atrial Myxoma
  6. Lung (Pulmonary Embolism, Emphysema)
  7. Pheochromocytoma
  8. Idiopathic
  9. Blood Pressure (Hypertension)

Both of these mnemonics are a little outdated. For example, rheumatic mitral stenosis is quite rare as a cause of afib in the US but  degenerative and functional mitral regurgitation is a common cause.

Ischemic heart disease (aka coronary heart disease) isn’t felt to cause atrial fibrillation unless it results in a myocardial infarction and subsequent heart failure. Way too many cardiac catheterizations are performed on patients who present with atrial fibrillation by doctors who don’t know this.

Congenital heart defects (not mentioned in either mnemonic) especially atrial septal defects often are associated with afib

There may be case reports of pheochromocytoma (a catecholamine-secreting neuroendocrine tumor) causing afib but they are few and far between.

Finally, genetics clearly play a role in the younger patient with afib without any known risk factors. One of my patients and his twin brother both developed symptomatic afib in their 40s.

In The Chronic Afibber What Triggers An Episode?

Alas, for most afibbers we won’t identify specific reasons why you go in and out of afib although there are some triggers you should definitely avoid such as excessive alcohol.

Some of the “causes” listed in the mnemonic are acute triggers of afib episodes.

For example low potassium or magnesium (typically induced by diuretics, diarrhea or vomiting) can bring on episodes .(See my discussion on potassium and PVCS here-much of it is relevant to afib.)

And I  have definitely seen patients go  into atrial fibrillation who have acute pulmonary problems such as pneumonia, pulmonary embolism or exacerbation of COPD.  In these cases, it is felt that the lung process raises pressure in the pulmonary arteries thereby  putting strain on the right heart leading to higher right atrial pressures.

Sleep apnea is associated with afib and I have had a few cases where after identifying that a patient’s  afib always began during sleep we were able to substantially lower episodes by treatment of sleep apnea.

Pericarditis with inflammation adjacent to the left atrium not uncommonly causes  afib. This is the likely mechanism for the afib that occurs frequently after cardiac surgery. Since pericarditis may never recur (especially in the cardiac surgery patient) we think the risk of afib recurring is low in these patients.

Anything that raises stress and stimulates the sympathomimetic nervous system can be a trigger. For example, a young and otherwise healthy patient of mine went into afib after encountering a car in flames along the side of the road. We found that beta-blockers (which block the sympathetic nervous system) helped prevent her episodes.

Some patients have odd but reproducible triggers. One of my patients routinely went into afib when he ate ice cream. I had a simple , very effective treatment plan for him.

Caffeine and Chocolate

Many afibbers have been told to avoid caffeine but a recent study of 34,000 women found that there was no increased risk of afib with increasing caffeine content and no sign that any of the individual contributors to caffeine in the diet (coffee, tea, cola, and chocolate) were more likely to cause afib.

Higher chocolate consumption, in fact, has recently been linked to a lower rate of afib. An observational  study of 55 thousand Danish men and women found that those who consumed 2 to 6 servings per week of 1 oz (30 grams) of chocolate had a 20% lower rate of clinically apparent afib.

Alcohol and Atrial Fibrillation

Binge drinking has long been known to cause acute atrial fibrillation.

However, it appears that even light to moderate chronic alcohol consumption increases the risk of going into atrial fibrillation.

This graphic from an excellent recent review of the topic gives the potential mechanisms:

The review concludes that although light to moderate alcohol consumption lowers your risk of dying, any alcohol consumption increases your risk of afib.

This graph shows the relationship between dying from heart disease (red line) and risk of going into afib (blue line) and amount of alcohol consumed.

Looking at the 15 drinks per week point on the x-axis (about 2 drinks per day) we see that your CV mortality is reduced by 20% whereas your risk of afib has increased by 20%.

A better point on the x-axis is 7 (1 drink per day) which has a 25% lower CV mortality but only a 10% higher risk of afib.

Whatever caused you to go into afib the good news is that with lifestyle changes and the care of a good cardiologist chances are excellent that you can live a normal, happy, healthy , long and active life.

Etiologically Yours,

ACP

 

How Much Does or Should An Echocardiogram Cost?

One might assume the skeptical cardiologist has a quick and accurate answer to this question given that he has spent a very large amount of his career either researching, teaching or interpreting echocardiograms.

Surprisingly, however, it turns out to be extremely difficult to come up with a good response.

An echocardiogram is an ultrasound test that tells us very precisely what is going on with the heart muscle and valves. I’ve written previously here and here on how important they are in cardiology, and how they can be botched.

As in the  example of a severely leaking aortic valve  below, we get information on the structure of the heart (in grey scale) and   on  blood flow (color Doppler). This type of information is invaluable in assessing cardiac patients.

In the last week I’ve had 2 patients call the office indicating that even with insurance coverage, their out of pocket costs for an echocardiogram were unacceptably high – almost a thousand dollars.

Wide Variations In Equipment, Recording and Interpretation Expertise For Echocardiograms

A small, handheld ultrasound machine that performs the basics of echocardiography can now be purchased for 5 to 10K. More sophisticated systems with more elaborate capabilities cost up to 200K. In my echo lab the machines are typically replaced about every 5 years, but in smaller, more cost sensitive labs they can be used for decades.

An echo test typically takes up to an hour, and a sonographer performs up to 8-10 tests per day. At facilities trying to maximize profit, tests are shortened and sonographers might perform 20 per day.

In the U.S., echos are performed by sonographers who have trained for several years (specifically in the field of ultrasound evaluation of the heart) and earn on average around 30$ per hour, however, Medicare and third party payors usually don’t require any sonographer certification for echo reimbursement.

Physicians who read echocardiograms vary from having rudimentary training to having spent years of extra training in echocardiography, and gaining board certification documenting their expertise.

Interpretation of a normal echocardiogram takes less than 10 minutes, whereas a complicated valvular or congenital examination requiring comparison to previous studies, review of clinical records and other imaging modalities, could take more than an hour.

Given these wide parameters, estimating what one should charge for the technical or physician portions of the average echo is challenging.

Wildly Differing Charges For Echocardiograms

Elizabeth Rosental wrote an excellent piece for the NY Times in 2014 in which she described the striking discrepancy between 2 echos a man underwent at 2 different locations:

Len Charlap, a retired math professor, has had two outpatient echocardiograms in the past three years that scanned the valves of his heart. The first, performed by a technician at a community hospital near his home here in central New Jersey, lasted less than 30 minutes. The next, at a premier academic medical center in Boston, took three times as long and involved a cardiologist.

And yet, when he saw the charges, the numbers seemed backward: The community hospital had charged about $5,500, while the Harvard teaching hospital had billed $1,400 for the much more elaborate test. “Why would that be?” Mr. Charlap asked. “It really bothered me.”

Testing has become to the United States’ medical system what liquor is to the hospitality industry: a profit center with large and often arbitrary markups”

This graph shows the marked variation across the US in price of an echo.  In all the examples, however, what the hospitals were paid was around 400$ which is the amount that CMS pays for the complete echo CPT code 93306.

Costs Outside the US

At the Primus Super Specialty Hospital in New Delhi, India, apparently you can get an echocardiogram for $50.

This site looks at prices for private echos across the UK. The cheapest is in Bridgend in Wales (where suicide is rampant) at 175 pounds. You can get an echo for 300 pounds at the Orwell clinic (where their motto is “War is peace. Freedom is slavery. Ignorance is strength.”)

At one private  UK clinic, you can have your echo read by Dr. Antoinette Kenny, who appears extremely well qualified  for the task.

“In 1993, at the relatively young age of 33, she was appointed Consultant Cardiologist and Clinical Head of Echocardiography at The Regional Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne.  At that time only 19 (<5%) of consultant cardiologists in the UK were female and an even smaller percentage of cardiologists had achieved consultant status by the age of 33, facts which serve to highlight Dr. Kenny’s postgraduate career achievements.”

Whereas I would not be interested in getting an echo done in India or Mexico, I would definitely have one done in Dr. Kenny’s center if I lived nearby.

Self Pay Cost

My hospital, like most, will write off the costs of an echo for indigent patients. I will read the tests on such patients pro bono (although doctors never use that term because we feel it makes us sound to lawyeresque).

The hospital also has a price it charges for those patients who are not indigent, but who have excessively high deductibles or co-pays with their insurance. In some cases this “self-pay” charge is significantly less than what the patient would pay with their insurance.

Paying out of the pocket for the echocardiogram may also make sense if the patient and/or physician really thinks the test is warranted, but the patient’s insurance deems it unncessary.

If you find yourself in a situation where a needed echocardiogram performed at your ordering doctor’s preferred facility is prohibitively high, it makes sense to look around for a more affordable option.

However, I must advise readers to be very cautious. In the NY Times example, the hospital charges for Mr. Charlap seemed inversely proportional to the quality of the echo he received.

This is not necessarily the case for a self pay echo. It is more likely that a cheap upfront out-of-pocket cost quote in a doctor’s office or a screening company reflects cheap equipment with minimal commitment to quality and brevity of exam and interpretation time.

I have encountered numerous examples of this in my own practice.

One of my patients who has undergone surgical repair of her mitral valve decided to get an echocardiogram as part of a LifeLine screening (see here and here for all the downsides of such screenings).

The report failed to note that my patient had a bicuspid aortic valve and an enlarged thoracic aorta.  These are extremely significant findings with potentially life threatening implications if missed.

If a high quality echo recording and interpretation is indicated for you make sure that the equipment, technician and physician reader involved in your case are up to the task.

Ultrasonically Yours,

-ACP

What Is the Significance Of A Spot On The Lung? The Three-eyed Radiologist On Incidental Pulmonary Nodules

The Three-eyed Radiologist (TR) has been asked by The Skeptical Cardiologist (SC) to discuss the epidemic of incidental pulmonary nodules that are found on routine cardiac diagnostic studies including coronary calcium CTs, coronary CTAs, and myocardial perfusion scans (using CT for attenuation correction), not to mention a whole host of other CT (computed tomography or “CAT”) scans and x-ray exams performed for many reasons that have nothing to do with inspecting lungs for pulmonary nodules. The TR will herein anticipate and answer common questions that might be asked by the SC audience.

  1. What is a pulmonary nodule (and why should I care)?

A pulmonary nodule is a nonspecific “spot” or lesion or density seen in the lung (1). It could be nothing. It could indicate lung cancer, and that is why you should care. Larger nodules, say 8 mm or larger (bigger than one-third of an inch), are of greater concern than smaller ones, but size alone is not an indicator of malignancy or benignity.

An incidental pulmonary nodule (inside red circle) discovered on a CT scan of the chest which was done in conjunction with a nuclear stress test.

A nodule may initially appear to be benign but upon further investigation be malignant—or vice versa. It could be a scar. It could indicate an old infection of no consequence. It could indicate an active infection or inflammation.

Again, it is a nonspecific finding that requires further thought, analysis and maybe additional testing.

2. Okay, you scared me by mentioning cancer. What should I do about a pulmonary nodule?

In many instances, the nodule can be dismissed if it has characteristic imaging features of a granuloma (calcium) or hamartome (fat) or if it can be shown to be stable over time (at least two years in many typical nodules). In most other cases, the nodule will require a follow up scan or two, and occasionally a PET scan and or a consultation with a lung doctor (a pulmonologist). Less frequently, the nodule will need a biopsy or to be removed, especially if it is likely or proven to represent cancer.

3. How common are pulmonary nodules?

Very common. In fact, last week the TR’s own 85 year old father texted him to tell him about the incidental pulmonary nodule discovered in the right lung when he was having a CT scan of the kidneys for blood in the urine.

The TR spends a good deal of his work day following pulmonary nodules with serial chest CT scans and discovers them regularly, too. The American Thoracic Society estimates that as many as one half of all people getting an x-ray or CT scan that includes part of the lungs has a pulmonary nodule (1). The TR’s experience is that the number is quite a bit lower in actual practice.

4. I have a pulmonary nodule. What should I do about it?

First, do not panic. Much of the time, this amounts to very little.

There are evidence-based consensus recommendations called, The Fleischner Society Guidelines (2), created with input from leading chest radiologists, pulmonologists, and chest surgeons, to advise the doctor and patient to manage these incidental lung nodules. It was updated in early 2017, and the new guidelines represent the state-of-the-art for handling this medically common scenario.

Based on the size and appearance, there are standardized work up and follow up protocols. The TR was positively pleased to see that the new recommendations are much less aggressive than the early version, previously requiring more frequent workup and monitoring for minuscule nodules that never seemed to amount for much. As the TR ages, his visual acuity for small things is naturally declining, and he is thrilled that the tiniest nodules can now usually be ignored.

5. While I have you here, TR, what’s the deal with lung cancer screening?

Lung cancer screening is a newer test, using low dose CT scans, for the early detection of lung cancer in a subset of people with a history of smoking (3). It was graded “B”, by the USPSTF, for its life saving potential (for comparison, screening mammography gets a “C” grade) and is offered to Medicare and commercial insurance patients who qualify, based mostly on age and smoking history. The CT scans are used to detect and follow the same nodules discussed above. If you are a smoker or former smoker, consider a discussion with your doctor as to whether or not lung cancer screening might benefit you.

6. Thank you, TR. What can I do to repay you for this useful information?

Do not tell the SC, but the TR loves salted caramel gelato and will accept gelato donations.

1) https://www.thoracic.org/patients/patient-resources/resources/lung-nodules-online.pdf

2) http://pubs.rsna.org/doi/pdf/10.1148/radiol.2017161659

3)https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/lung-cancer-screening

N.B. The Three-eyed Radiologist is Robert Kanterman, MD, a radiology colleague at St. Luke’s Hospital in Chesterfield, MO. He can be followed on Twitter @3EyeRadiologist

 

Why Doesn’t The USA Have Graphic Warning Labels On Cigarette Packs Like The Netherlands?

While strolling the delightful (and typically debris-free) streets of Haarlem in The Netherlands the skeptical cardiologist espied an unusual cigarette pack on the ground.

In comparison to the typical American cigarette pack I noted a very prominent and disgusting picture of a leg which had been ravaged by peripheral artery disease.

The large print translates “smoking clogs your arteries.”

This is one of many potential warnings on Dutch cigarette packs. My favorite is

Roken kan leiden tot een langzame, pijnlijke dood

(Smoking can lead to a slow, painful death)

Perhaps, if such warning had been on American cigarette packs in the 1990s my mother would have been able to walk without severe pain in her legs (claudication) from the severe blockages caused by her decades of cigarette smoking.

When cigarette smoking patients tell me that “you have to die from something” I tell them that although they are greatly increasing their chance of dying from lung and cardiac disease, the smoking may not kill them but  leave them miserable and unable to walk or breath.

Experts on tobacco control note that these large, graphic and direct warnings are much more effective than the first small boxed warnings:

After the implementation of the first warning labels in 1966, the FTC’s 1981 report concluded that the original warning labels were not novel, overexposed and too abstract to remember and be personally relevant.46 Warning labels, like advertisements, wear out over time.47 Written warning labels wear out faster than graphic ones.48,49 In response, Congress passed a law mandating four rotating warnings. Studies on them began appearing in the late 1980s, demonstrating that several years after the implementation, those written labels on cigarette packs were also not noticed and not remembered by smokers and adolescents.5053 Since then, the diffusion and evolution of tobacco warning labels have been propelled by observational and experimental studies showing the effectiveness of large graphic warning labels in informing consumers about the health harms of smoking and reducing their smoking behavior.45,54

Here’s how Australia’s warnings have evolved

autralia-cigarette.jpg

 

 

 

 

 

 

 

In 2011 the US Congress passed legislation moving America towards such effective graphic warnings:

However, the law was challenged by Big Tobacco and has never been enacted. From the FDA site:

The Family Smoking Prevention and Tobacco Control Act requires the FDA to include new warning labels on cigarette packages and in cigarette advertisements. On June 22, 2011, the FDA published a final rule requiring color graphics depicting the negative health consequences of smoking to accompany the nine new textual warning statements. However, the final rule was challenged in court by several tobacco companies, and on Aug. 24, 2012, the United States Court of Appeals for the District of Columbia Circuit vacated the rule on First Amendment grounds and remanded the matter to the agency.[1] On Dec. 5, 2012, the Court denied the government’s petition for panel rehearing and rehearing en banc. In 2013, the government decided not to seek further review of the court’s ruling.

The FDA has been undertaking research related to graphic health warnings since that time.

[1] R.J. Reynolds Tobacco Co., et al., v. Food & Drug Administration, et al., 696 F.3d 1205 (D.C. Cir. 2012)

What Other Countries Are Doing

According to a Canadian Cancer Society report from late 2016,

More than 100 countries/jurisdictions worldwide have now required pictorial warnings, with fully 105 countries/jurisdictions having done so. This represents a landmark global public health achievement.

Increasingly, the United States stands alone, because of a constitutional doctrine privileging commercial speech above public health.

Here are the countries requiring pictorial warnings courtesy of that Canadian Cancer Society report.

And some of their warning pictures:

And this a picture that FDA would have required:

 

Skeptically Yours,

-AcP

Is September Really National Atrial Fibrillation Awareness Month (And Why Does It Matter?)

The skeptical cardiologist received an email from a woman telling him that September is atrial fibrillation awareness month and offering me the free use of an infographic given that I

“care deeply about helping people living with AF.”

Well, I do care about deeply about people living with atrial fibrillation and pretty much all cardiac diseases  (except perhaps Schuckenbuss syndrome.)

That’s the major reason I write this blog. I’ve written a lot about Afib and have a lot more i want to write (I really want to write about antiarrhythmic drugs, i.e. drugs that maintain you in normal sinus rhythm.)

But I don’t find it particularly helpful to assign a disease to a month or a day so my posts on atrial fibrillation come out randomly dependent on the mysterious machinations of my messy mind.

It turns out that September, 2009 was declared National Atrial Fibrillation Awareness Month (NAFAM) by Senate Resolution 262 although Stop Afib.org wants us to believe September is eternally NAFAM.

However, the email prompted me to better organize my atrial fibrillation and stroke page (now containing all that I have written on the subjects) which I have copied below.

Posts on Diagnosing Atrial fibrillation

Take your pulse and prevent a stroke

TIAs and silent atrial fibrillation. Sometimes strokes present in unusual ways, like the inability to differentiated a spade from a diamond when playing bridge and afib is often the cause.

Estimating Stroke Risk in Patients With Atrial Fibrillation You can estimate your stroke risk using an app that utilizes the CHAD2DS2-VASc score. I prefer to call the Lip score.

Posts About Using Personal Devices To Diagnose Atrial Fibrillation

Two That Work Reasonably Well

AliveCor

Using a Smart Phone Device and App To Monitor Your Pulse for Atrial Fibrillation (AliveCor)

AliveCor Is Now Kardia and It Works Well At Identifying Atrial Fibrillation At Home And In Office

AliveCor Successes and Failures.

Sustained Atrial Fibrillation or Not: The Vagaries and Inaccuracies of AliveCor/Kardia and Computer Interpretation of ECG Rhythm

AfibAlert

How Well Does The AfibAlert Remote Hand-Held Automatic ECG Device Work For Detection of Atrial Fibrillation?

AfibAlert Versus AliveCor/Kardia: Which Mobile ECG Device Is Best At Accurately Identifying Atrial Fibrillation?

And One of Several Devices To Avoid: AF Detect

Do NOT Rely on AF Detect Smartphone App To Diagnose Atrial fibrillation

Posts About Treatment Of Atrial Fibrillation

        Lifestyle Changes

How Obesity Causes Atrial Fibrillation in FatSheep and How Losing Weight helps prevent afib from coming back.

Drug Therapy: Rate Control and Anticoagulation

Foxglove Equipoise. When William Withering began treating patients suffering from dropsy in 1775 with various preparations of the foxglove plant he wasn’t sure if he would help or hurt them. After 240 years of treatment, we are still unsure if the drug obtained from foxglove is useful.

Should Digoxin Still Be Used in Atrial Fibrillation? Recent studies suggest that we should not.

Why Does the TV Tell Me Xarelto Is A BAD Drug? Anticoagulant drugs that prevent the bad clots that cause stroke also increase bleeding risk. A bleeding complication is not a valid reason to sue the manufacturer.  The lawsuit are strictly a money-making tactic for sleazy lawyers.

Cardioversion and Ablation

Cardioversion: How Many Times Can You Shock The Heart?

Ablation: Cautionary Words From Dr. John Mandrola and The Wisdom of a Team Approach

Miscellaneous Topics

What Happens If You Go Into Atrial Fibrillation On A Cruise?

Infographics

Are infographics really helpful? Someone should do a study on that. Perhaps we could use the money we spend on infographics in atrial fibrillation to research whether the left atrial appendage should be excised at the drop of a hat.

Here’s the infographic (because everyone loves an infographic!)

The first part lays out the problem of AF with patriotic bunting.

The second part uses the annoying numerical infographic approach.

 

 

 

 

 

 

 

The third part explains why I got the email. A product is being promoted. The woman who sent me the email works for MyTherapyApp.

 

 

 

Eagerly Awaiting Schuckenbuss Syndrome Day,

-ACP

 

 

 

The Harvard T.H. Chan School of Public Health Now Recommends Full Fat Dairy For Your Kid’s Lunch Boxes

The skeptical cardiologist became overjoyed while reading an email from The Harvard T.H. Chan School of Public Health (THTHCSPH) which outlined  their recommendations for packing kids‘ lunch boxes.:

The Kid’s Healthy Eating Plate was created as a fun and easy guide to encourage children to eat well and keep moving. The plate guidelines emphasize variety and quality in food choices.

The majority of the recommendations were pretty straightforward and mainstream:

The formula is simple: Fill half your plate (or lunch box) with colorful fruits or vegetables(aim for two to three different types). Fill about one-quarter with whole grains like whole grain pasta, brown rice, or quinoa, and the remaining quarter with healthy proteinslike beans, nuts, fish or chicken. Healthy fatsand a small amount of dairy (if desired) round out a tasty meal that will fuel an active, healthy lifestyle.

What caught my attention was the comment about dairy.

The dreaded words skim or low-fat did not appear in the sentence!

It would appear that a highly respect and mainstream source of nutritional advice is not making the typical (and scientifically unsupported ) recommendation to consume low fat or skim dairy products!

Indeed, if we look at their expanded comments on dairy they read:

Incorporating dairy (if desired). For example: unflavored milk, plain Greek yogurt, small amounts of cheese like cottage cheese, and string cheese.

No mention of fat content. Zip. Zero. To me, if you don’t put non fat low fat or skim next to the word diary it implies full fat.

Following their yogurt link we find no reference to preferentially consuming low fat yogurt despite the fact that the vast majority of yogurt sold in the US has been processed to remove healthy dairy fat, something the THCHSPH must be painfully aware of. (My wonderful MA Jenny’s husband, Frank, until very recently was unable to find full fat yogurt at Schnuck’s.)

As I pointed out here, a huge scam was foisted on Americans when allegedly healthy non fat yogurt filled with added sugar began to be promoted as a healthy treat.

It is almost  as if the THTHCSPH  has become agnostic about dairy fat and therefore is trying not to make recommendations.

Elsewhere on the THTHCSPH site however the old unwarranted advice  to avoid dairy fat rears its ugly head. On a page devoted to calcium we read:

Many dairy products are high in saturated fats and a high saturated fat intake is a risk factor for heart disease”

Then this interesting (and ?ironic) observation:

And while it’s true that most dairy products are now available in fat-reduced or nonfat options, the saturated fat that’s removed from dairy products is inevitably consumed by someone, often in the form of premium ice cream, butter, or baked goods.

Strangely, it’s often the same people who purchase these higher fat products who also purchase the low-fat dairy products, so it’s not clear that they’re making great strides in cutting back on their saturated fat consumption.

The THTHCSPH seems conflicted, as well they should. They want to keep up the nutritional party line that they have been spouting for 30 years that all saturated fats are bad but they now realize that supporting non fat dairy products has likely worsened rather than improved the diet of millions of Americans.

Galactosely Yours,

-ACP

N.B. The overall Kid’s healthy eating plate is not likely to be a favorite of kids  and I disagree with some aspects of it.

Namely, I think it is fine to have red meat and processed meats in moderation and I wouldn’t push the pasta, rice, and bread.

 

 

 

 

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

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