A Call To Reconsider The Heimlich Experiment: Let’s Scientifically Determine The Best Approach To Choking Victims

What should you do if you encounter someone choking on food?

If you ask someone on an American street  the likely answer will be to “perform a Heimlich maneuver.”

This is understandable because we frequently hear of celebrities performing or having performed on them a Heimlich maneuver and saving or being saved from choking to death. In addition, we have  descriptions of individuals relating their own stories of lives saved.

For example, in May of 2016, 96-year-old Dr. Henry Heimlich, widely credited as the inventor of the eponymous abdominal thrust procedure, made headlines around the world when he reportedly performed it on a fellow retirement home resident in Cincinnati.

Surprisingly, despite the widespread belief that the Heimlich maneuver is the scientifically-affirmed treatment of choice for choking victims, there is only anecdotal evidence for its effectiveness as well as its dangers and there is no scientific consensus on the best approach to a person who is choking or has foreign body airway obstruction (FBAO).

The Origins of The Heimlich maneuver

In 1972,  Heimlich writes in his autobiography “Heimlich’s Maneuvers“,  he came across a NY Times article  which revealed that the sixth leading cause of accidental deaths in the
US  was  choking on a foreign body, usually food ,and that 3900 individuals were dying from foreign body airway obstruction (FBAO) a year.

 

The typical scenario for these deaths was first described  in a 1963 JAMA report on 9 patients who suddenly collapsed at a dinner table and were subsequently pronounced dead on arrival to the emergency room. Death had been attributed to coronary artery disease but  at autopsy these victims were found  to have food obstructing their airways  (4 by steak, 2 by beef, one by ham and one by kippered herring). The author termed these sudden deaths in resturants “The Cafe’ Coronary.”

In 1972 there was no consensus on how to treat victims of the Cafe’ Coronary and Heimlich noted that the three options were

  1. Inserting a large-caliber hypodermic needle into the trachea or performing a tracheotomy
  2. Utilizing an instrument designed to remove the object from the throat
  3. Slapping choking victims on the back.

Noting the risks of option one, the impracticality of option two and the lack of scientific evidence to support option 3,  Heimlich pondered a better approach, one that would utilize the residual air in the victim’s lungs to forcefully expel the lethal food bolus “like the cork from a Champagne bottle.”

Pop Goes The Cafe’ Coronary

Heimlich first described his  namesake maneuver in an article in Emergency Medicine in June of1974 entitled “Pop Goes The Cafe Coronary.”

Standing behind the victim the rescuer puts both arms around him just above the belt line, allowing head, arms and upper torso to hang forward. Then, grasping his own right wrist with his left hand, the rescuer rapidly and strongly presses into the victim’ abdomen, forcing the diaphragm upward, compressing the lungs and expelling the obstructing bolus

Heimlich states in the 1974 article that the procedure was adapted from “experimental work “with four 38-pound beagles.

Although admitting that these results might not be duplicated in humans, he indicates that “there is certainly no risk in recommending that the procedure be tried in actual cafe’ coronary emergencies.”

“then, as experiences are reported, the method can be evaluated.”

Shockingly, Heimlich, in this article (subsequently picked up and promoted by the lay press) proposed to  all Americans that they begin an experiment on helpless choking victims to see if his newly developed idea was of any benefit.

He requests in the last lines of this monumental communication that Americans help him gather information from the experiment.

“Should you use, or learn of anyone else using, the Heimlich method by the way, please report the results either to EM or me.”

Flimsy Experimental Basis For Heimlich

Four 38 pound beagles-The experimental work supporting an unsupervised, unregulated national experiment on choking victims!

Below is the sum total of the description Heimlich provides for his experiments:

After being given an intravenous anesthetic, each dog was “strangled” with a size 32 cuffed endotracheal tube inserted into the larynx. After the cuff was distended to create total obstruction of the trachea, the animal went into immediate respiratory distress as evidenced by spasmodic, paradoxical respiratory movements of the chest and diaphragm. At this point, with a sudden thrust. I pressed the palm of my hand deeply and firmly into the abdomen of the animal a short distance below the rib cage, thereby pushing upward on the diaphragm. The endotracheal tube popped out of the trachea and, after several labored respirations, the animal began to breathe normally. This procedure was even more effective when the other hand maintained constant pressure on the lower abdomen directing almost all the pressure toward the diaphragm.

We repeated the experiment more than 20 times on each animal with the same excellent results When a bolus of raw hamburger was substituted for the endotracheal tube, it, too, was ejected by the same procedure, always after one or two compressions.

This “experimental work” seems to have been sloppily done and would not have passed muster through a legitimate current day peer-reviewed scientific journal. It seems more like the observations of an 18th century  scientist than a 20th century one.

Here are a few of the red flags I see that suggest either these experiments weren’t really done or that they need to be repeated with better documentation or by an investigator who is unbiased as to the outcome.

  • The beagles are all exactly the same size
  • There are no measurements recorded. Of any kind.
  • Important data was not recorded: What anesthetic was utilized? What was the position of the animals? How long between experiments?. How many “more than 20 times” were the animals choked.? How big was the hamburger bolus?

Flimsy Experimental Work Embellished And Republished

A year later Heimlich was  apparently emboldened by reports of the successful application of his now namesake maneuver and his “special communication” ,published in JAMA, in October of 1975 reiterated his previous publication with a near identical description of the experiments on the four 38 pound beagles.

He added some more details to these experiments. For example, we learn the beagles were anesthetized, with thiamyial sodium given intravenously.

And he embellishes the method for choking the dogs

A cuffed, No. 32 endotracheal tube, the lumen plugged by a rubber stopper, was inserted under direct vision through the mouth into the larynx. The cuff was distended with 3 to 4 ml of air, causing total obstruction of the trachea, simulating a bolus of food caught in the human larynx. The animal immediately went into respiratory distress, as evidenced by spasmodic paradoxical respiratory move- ments of the chest and diaphragm.

At first, the rib cage was manually compressed in an attempt to increase the intrapulmonary pressure and expel the bolus. This procedure was unsuccessful. It was later realized that the compressibility of the lungs by this technique was inadequate due to the rigidity of the chest wall. Furthermore, any increase in intrapleural pressure would be dissipated by depressing the diaphragm.

Apparently realizing that he needed to provide some evidence that his abdominal thrusts were superior to chest compression He added to  his experimental description the following:

At first, the rib cage was manually compressed in an attempt to increase the intrapulmonary pressure and expel the bolus. This procedure was unsuccessful.

And adds a gratuitous explanation for the failure of the chest compression:

It was later realized that the compressibility of the lungs by this technique was inadequate due to the rigidity of the chest wall. Furthermore, any increase in intrapleural pressure would be dissipated by depressing the diaphragm.

Subsequently, I pressed the palm of my hand deeply and firmly upward into the abdomen of the animal a short dis- tance below the rib cage, thereby pushing against the dia- phragm. The endotracheal tube (bolus) popped out of the trachea.

Interestingly, there is no published, peer-reviewed paper verifying the research that Heimlich claims to have done in developing this procedure. And according to his son, Peter M. Heimlich, his father’s archives at a University of Cincinnati medical library include no documentation of the research on the beagles.

 

The Chest Thrust (Guildner Maneuver): A Superior Approach?

Two years later, Charles W. Guildner, an Everett, Washington anesthesiologist and American Heart Association (AHA) consultant, published the results of experiments he performed on six human volunteers which concluded that chest thrusts were  superior to abdominal thrusts in generating air flow out of the trachea and presumably more effective at clearing foreign bodies obstructing the airway of choking victims. Guildner’s results are supported by  a study by Audun Langhelle of Oslo, Norway, published in 2000 by the journal Resuscitation.

Langhelle compared peak airway pressure with standard chest compressions versus Heimlich maneuvers done by emergency physicians in cadavers with simulated complete airway obstruction in a randomized crossover design.  Mean peak airway pressure was significantly lower with the Heimlich maneuver than with the chest compressions.

Heimlich Markets and Bullies To Gain Prominence For His Maneuver 

Prior to 1976, the guidelines of the AHA and the American Red Cross (ARC)  recommended back blows as the best treatment for responding to a conscious choking victim. After a 1976 National Academy of Science conference on emergency airway management (at which Heimlich was an invited participant), both organizations adopted the following recommendations:

  1. Back blows (4)
  2. Manual thrust (4)
  3. If ineffective repeat back blows and manual thrusts until they are effective or until the victim becomes unresponsive.
Host Johnny Carson demonstrates the Heimlich maneuver on actress Angie Dickenson while Dr. Henry Heimlich watches on April 4, 1979..

For Heimlich, having his maneuver incorporated in US first aid guideliness only two years after he introduced it wasn’t enough. He then embarked on a ten-year media campaign he called “back blows are death blows” in which he accused the AHA and ARC of putting lives at risk because they continued to recommend that treatment.

In 1986, with support from Dr. C. Everett Koop, U.S. Surgeon General under President Ronald Reagan, Heimlich got his way. The AHA removed backblows from its guidelines and endorsed the Heimlich maneuver as the sole approach to the choking victim. The ARC followed suit.

Heimlich’s typical rhetoric on this issue can be found in a July, 1988 NY Times editorial where he extensively quotes Koop’s condemnation of back blows and states:

“The organizations and journals responsible for disseminating this medical error should advise Americans that the back slap, taught for more than a decade as a treatment for choking, causes death.”

Review Of The Literature Finds Abdominal Thrusts and Chest Compressions Equivalent

In 2005, the American Red Cross, after reviewing the scientific literature concluded that back blows, abdominal thrusts, and chest thrusts were equally effective for FBAO.

As a result, the ARC’s 2005 Guidelines for Emergency Care and Education essentially returned to their 1976-1985 recommndation to treat conscious, choking children and adults, now called “the five and five”: first perform 5 back blows; if that fails to remove the obstruction, proceed with 5 abdominal thrusts. If necessary, repeat the cycle.”

Heimlich, ever vigilant of the primacy of his maneuver, condemned this to the Cincinnati Enquirer in a 2013 interview.

Those recommendations “horrify” Heimlich. “There has never been any research saying the back slap saves lives,” he said. “We know the Heimlich maneuver works. So it comes down to a matter of life or death.”

Richard Bradley, MD writing in defense of this change on the Red Cross blog  in 2013 wrote:

A review of the scientific literature suggested that back blows, abdominal thrusts and chest compressions are equally effective. Additionally, the use of more than one method can be more effective to dislodge an object. These findings are consistent with those of international resuscitation societies.

The Red Cross certainly isn’t discounting the use of abdominal thrusts. But we include back blows, abdominal thrusts and chest compressions in our training because there is no clear scientific evidence to say that one technique is more effective than the others when treating a choking victim.

. “Additionally, the use of more than one method can be more effective to dislodge an object. These findings are consistent with those of international resuscitation societies.”

The AHA ‘s 2005  Adult Basic Life Support guidelines were published in Circulation recognizing that there was insufficient evidence to promote the Heimlich maneuver (like the ARC, now referring to it by the generic abdominal thrust) over back slaps or chest thrust

Chest thrusts, back blows/slaps, or abdominal thrusts are effective for relieving FBAO (Foreign Body Airway Obstruction) in conscious adults and children >1 year of age, although injuries have been reported with the abdominal thrust. There is insufficient evidence to determine which should be used first. These techniques should be applied in rapid sequence until the obstruction is relieved; more than one technique may be needed. Unconscious victims should receive CPR. The finger sweep should be used in the unconscious patient with an obstructed airway only if solid material is visible in the airway. There is insufficient evidence for a treatment recommendation for an obese or pregnant patient with FBAO.

Interestingly, the switch in recommendations and the change in terminology were likely influenced by Dr. Heimlich’s son investigative blogger Peter M. Heimlich,  Research by Peter and his wife  Karen M. Shulman has  resulted in scores of exposes  in the lay press about what they term Dr. Heimlich’s “wide-ranging unseen history of fraud,” and is documented on their website: http://medfraud.info

The AHA Goes Back To The Heimlich

In 2010, the AHA guidelines revisited foreign body airway obstruction (FBAO) and gave the abdominal thrust priority again “for simplicity in training.”:

Although chest thrusts, back slaps, and abdominal thrusts are feasible and effective for relieving severe FBAO in conscious (responsive) adults and children ≥1 year of age, for simplicity in training it is recommended that abdominal thrusts be applied in rapid sequence until the obstruction is relieved. If abdominal thrusts are not effective, the rescuer may consider chest thrusts. It is important to note that abdominal thrusts are not recommended for infants <1 year of age because thrusts may cause injuries.

The 2015 AHA guidelines did not update  the 2010 FBAO recommendations

Scientific Support For The Heimlich

An abstract presented at the 2012 AHA meetings reviewed the scientific literature to answer the question:

For adults, either conscious or unconscious, with obstructed airway, does any specific resuscitation techniques compared to currently recommended techniques, lead to different outcomes?”

This review found only two studies provided significant evidence to support recommendations

  1. one fair quality LOE 3b study suggests that peak airway pressures developed by chest compressions are significantly higher than the pressure from abdominal thrusts
  2. 2. one poor quality LOE 4 study suggests that for conscious adults with an obstructed airway, abdominal thrusts generate higher peak airway pressures when delivered when the victim is supine as compared to seated and that back blows do not generate any significant change in airway pressure.

The final conclusion of this review:

Clearly, there is a dearth of evidence to support basic life support treatment guidelines for this important problem.

 

Choking Treatment Recommendation in Australia/New Zealand/UK

In the resuscitation guidelines of medical organizations in Australia and New Zealand, the Heimlich maneuver is warned against as unproven and  to be avoided due to “life-threatening complications” associated with its use. Instead, first aid authorities in those countries recommend first performing a series of backblows followed by, if necessary, a series of chest thrusts, the treatment studied by Guildner (1976) and Langhelle (2000).

The Resucitation Council of the United Kingdom recommends the following for choking victims:

  1. Encourage to cough
  2. Give back blows (up to 5). Support the chest with one hand and lean the victim well forwards so that when the obstructing object is dislodged it comes out of the mouth rather than goes further down the airway.Give five sharp blows between the shoulder blades with the heel of your other hand
  3. Give abdominal thrusts.

Heimlich Maneuver: Time For A Reconsideration 

Thus, it is clear the Heimlich maneuver was recommended by Henry Heimlich for general usage without any human clinical studies to support its safety and efficacy. With Heimlich’s aggressive promoting of the technique it became the recommended way to treat choking conscious individuals despite experimental evidence showing it inferior to chest thrusts and no controlled human trials to support its safety and effectiveness.

Australia and New Zealand, countries free of Heimlich’s influence, do not recommend the Heimlich maneuver for choking victims.

It is entirely possible that chest thrusts are a safer and more effective maneuver for removing foreign bodies from choking victims. Since Dr. Heimlich died in December, 2016 perhaps the organizations that teach CPR can reevaluate their recommendations in this area without fear of public shaming or retribution.

Given the uncertainty in the treatment of choking victims and the number of deaths a national trial comparing chest thrusts versus abdominal thrusts as the initial procedure should be initiated as soon as possible.

Skeptically Yours,

-ACP

N.B. In Part Two of this analysis of the Heimlich maneuver we will review the evidence of the harm the Heimlich maneuvers have done over the years.

Apple AirPods Are Absolutely Awesome!

The skeptical cardiologist  began using Apple products during his cardiology fellowship in 1984.  My first research was done on an Apple II and my first personal computer was an original Mac.

These days I am unabashedly and totally immersed in Apple stuff which I use at work, at home, on vacation and while exercising.

In the last year I have fallen in love with Apple AirPods.

Mauricio Pesce/Flikr

I use these bluetooth earphones for listening to music and podcasts and telephone conversations and I like them far better than anything I have previously stuck in or around my ears.

Apple AirPods are amazing.

Here are  a few things off the top of my head that I find amazing about them…

  1. They come in an incredibly slick little white case that serves as storage and charging dock and looks like a container of dental floss. You literally never run out of juice if you put your earphones back in the case when you are done and charge it occasionally.
  2. Pairing with my iPhone and my various Macs is a breeze. Once paired the device automatically plays music through the AirPods if they are in your ears and nearby.
  3. They sense when they are in your ears, give you a tone that they are working and start playing from your paired device on their own.
  4. If you double tap on one of them you can have it advance to next song, bring up Siri, or  stop playing.
  5. If you bring up Siri you can give complex commands like call the Eternal Fiancée or remind me  to bring in Jen’s new shoes package on the porch.
  6. They are so comfortable you don’t notice you are wearing them.
  7. What about appearance you may ask?
    The eternal fiancee’ with q-tip in right ear

    Well, when I first started wearing them the Eternal Fiancée made fun of me because, she said, it  looked like I had  q-tips in my ears. Four months later she borrowed mine to go on a run and decided to order her own the next day

  8. What about the sound you may ask? I think the sound is awesome. I’m a musician and a music fanatic but don’t consider myself an audiophile. I find the sound quality on these little things perfect for my needs and equivalent to any headphones I have used.  I spend a lot of time while listening to songs picking out individual instruments and these are great for that.
  9. What if you forget and leave the AirPods out and they become almost fully discharged. Have no fear, within 10 minutes they are fully charged in the case and ready to go-amazing.
  10. They can survive a washing machine/dryer assault (see below).

AirPods: The Cons

Due to my tendency to lose various components of the AirPods the EF has marked hers with a red dot of  nail polish

There are some downsides…

-Because they are so small and unobtrusive I forget about them and lose them easily. You can actually use the Find My iPhone Apple feature to have them make a sound and track them down but a few months ago I misplaced one so badly I had to replace it.

–One quick visit to my local Apple Genius Bar and 69$ later I had a new right AirPod.

-Early on in my AirPods experience I left them in my running shorts pocket and they went through an entire washing and drying experience….. and after a several  hour  period of dormancy they worked perfectly well!

Can you tell the difference between the dental floss case and the Apple AirPods case?

-The case is so small and unobtrusive it is very easy to forget. I have left it on treadmills innumerable times. One time I left it on an airplane….Another visit to Apple required.

I am not alone in my love of the AirPods.

I came across this review on The Verge by Vlad Savov (“‘The Verge’s resident Bulgarian, headphone and mobile reviewer”)

But when I look at the limits of what’s possible today — in terms of miniaturization of audio and wireless components — I can’t see a better combination of price, features, and performance than what’s offered by the AirPods. The price is fair and the compromises are acceptable. I make it my job to review (and enjoy) super heavy and expensive headphones that do amazing things with music, recreating and illuminating every minute detail of a recording. That makes me extremely picky about any products I listen to, and the thing the AirPods share with the giant cans built by the likes of Audeze and Focal is that they convey the sense and intent of the music. And the reason I now reach for the AirPods even when I’m at home, the unique thing that delights all their users, is their unrivalled ease of use

AirPodsRulingly Yours,

-ACP

N.B.  The AirPods greatness at unobtrusively staying in your ear was initially thought to be a design flaw. This writer at Business Insider recently noted that

Most earbuds have gummy tips, which create a “seal” around the inside of your ear that’s important for two reasons. First, it creates an environment where outside sound can’t leak in, so you can listen to your music without being interrupted by outside noises, like a subway car or people walking on the street. Second, by creating that ideal environment, your music will actually sound better, especially lower bass frequencies.
The AirPods break that design rule. Instead of having gummy tips, they have a hard plastic shell, like Apple’s wired earbuds, the EarPods. They don’t create a tight seal, and sit on the inside of my ears instead of totally plugging them up. This design lets outside sound leak in, which is annoying, but it actually helps the AirPods stay in my ears.
Totally wireless earbuds rely on their seal for more than just audio quality. They actually need that tight seal to stay securely in your ears. Unfortunately, it doesn’t matter if I’m sitting, walking, or running — all of the gummy-tipped wireless earbuds I’ve tried fit into my ears nicely for a couple of minutes, then start loosening up.
Eventually, the seal the earbuds created breaks, and one or both of them fall out of my ears. Because the AirPods don’t have to maintain a seal, they’re the only totally wireless headphones I can reliably keep in my ears for more than a few minutes at a time.

Update On The Kardia Band Apple Watch Accessory: Accuracy In Atrial Fibrillation Pre and Post Cardioversion

As I described here, the Kardia Band (KB) is an FDA-approved Apple Watch accessory available to the general public without a prescription which records a high quality single-lead ECG.

I’ve been using mine now for a while and can confirm the ease and accuracy of the ECG recordings it makes. I find recordings made with my Apple Watch/Kardia Band are reliably high quality with minimal artifact (unless I’m running on a treadmill.)

Once the 30 second recording is completed, the Kardia app on the Apple Watch takes about 5 seconds to process the information using an AI algorithm and then makes a determination of normal sinus rhythm (NSR), atrial fibrillation or unclassified.

 

 

The New Study

A study published in the June JACC examined the accuracy of  Alivecor’s Kardia Band in detecting atrial fibrillation (AF.)

In the JACC study, investigators from the Cleveland Clinic studied  100 consecutive patients presenting for cardioversion from AF with recordings made before  and after the procedure. KB interpretations were compared to 12 lead ECGS read by electrophysiologists.

KB interpretations  identified AF with  93% sensitivity and 84% specificity. Of the total 169 recordings, 34% were unclassified due to short recordings, low-amplitude p waves, and baseline artifacts.

The authors concluded that the KB algorithm for AF detection, when it is supported by a physician review can reliably differentiate AF from NSR.

(Of note the lead author on this study is on the advisory board of Alivecor the maker of the KB and AliveCor (AliveCor, Mountain View, CA) provided the Kardia Band monitors which were connected to an Apple Watch and paired via Bluetooth to a smartphone device for utilization in the study. AliveCor was not involved in the design, implementation, data analysis, or manuscript preparation of the study.)

My Updated Kardia Experience

I have found the standard Kardia device to be immensely helpful in the management of my afib patients before and after cardioversions (see my prior description here). The paper mentions that 8% of these pre-cardioversion patients showed up for the procedure in normal sinus rhythm, noting that

For each of these patients, the automated KB algorithm did not erroneously identify AF, and the physician interpretation of the KB recording correctly confirmed SR in each case.

Needless to say, it is better to find out a cardioversion is not needed before the patient shows up for the procedure. I would estimate this happens about 5-10% of the time in my practice.

The Kardia device or the KB is also really helpful post cardioversion. If the patient makes daily recordings (which I can review on Kardia Pro online) h/she and I know exactly how long sinus rhythm persisted before reverting back to AF.

This is important information which impacts future management decisions.

Kardia Band Versus Standard Kardia Device

None of my patients have purchased the Kardia Band most likely due to the cost and the fact that they don’t have an Apple Watch. If you have an Apple Watch and want to monitor your heart rhythm I think the KB is a good choice. Otherwise, the original AliveCor mobile ECG device continues to do a fantastic job (in conjunction with Kardia Pro, see here).

The combination of Kardia and Kardia Pro has substantially reduced my use of expensive and annoying long term monitors in my AF population.

In my next update on the KB I will share a reader’s real world description of the pros and cons of the KB (with Smart Rhythm monitoring) in a patient post cardioversion for AF.

Skeptically Yours

-ACP

What’s The Best Treatment For Seasickness? Part I, What Won’t Work Well

While stocking up on key items for our Galapagos cruise, the eternal fiancée of the skeptical cardiologist (EFOSC) bought an item that set off the skeptical cardiologist’s (extremely sensitive) BS detector.

Once I began looking into the seasickness treatment options and science I soon realized that the vast majority of OTC medications, patches and devices offered are snake oil.

There is one highly effective treatment which requires a prescription, one possibly effective OTC treatment which will likely put you to sleep, and one very slightly effective treatment which will also likely put you to sleep.

First let’s look at the totally bogus patch Jen purchased.

It calls itself a “motion sickness patch.” It is manufactured in China. (Somebody should put a tariff on this junk!)

It also carries the allure of being natural which people (mistakenly) assume means free of side effects.

Since most people have heard of an effective motion sickness patch, they naturally assume that this is legitimate. 

It appears to be highly rated on Amazon with 80% of over a thousand reviewers giving it 4 or 5 stars. However, 10% of reviewers give it 1 star, usually commenting that the MQ patches were useless  and were purchased as they were cheaper than the prescription patch that worked for them before.

And it is no surprise that it doesn’t work for many because the ingredients would not be expected to have any effect on motion sickness.

The main Ingredient are listed as

safflowertall,gastrodia,tuber,sanchi,hairy datura flower,borneol,pinellia tuber,obtuseleaf cinnamon bark,frankincense,dahurian angelica root,etc.

Yes, in these patches you get the added bonus of “etc.” in the formulation!

In case you needed more explanation of how this works, check out the bizarre “working theory” of the mysterious ingredient’s efficacy:

Working theory
1. Adjust the control of the vagal nerve to gastrointestinal tract, inhibit the motility of the gastrointestinal, thus preventing nausea and vomiting.
2. By expanding the capillaries of the skin, to improve the microcirculation of body and increase the amount of oxygen to brain, thus comes to the effect of refreshing your brain.

All I can say about those who have experienced relief with this MQ nostrum is “the placebo force is strong with you!”

After reading the reviews for the MQ patch and  listening to an NPR story on paid Amazon product reviews  my faith in Amazon product reviews is at an all time low.

Similarly, most of the sites on the internet which promise to give you the top 10 products in a certain area I have found to be bogus. For example, the amazingly useless MQ motion sickness patch is ranked #5 on the “Best Reviews” Guide to Motion Sickness.

Bonine

The second product the EFOSC purchased online was the oddly-named Bonine.  Bonine is the brand name for meclizine, a first-generation antihistamine with anti-cholinergic properties which is often prescribed for benign positional vertigo.

There is not much evidence supporting meclizine for sea sickness but it is widely used owing to its accessibility and marketing. Like all first-generation antihistamines, it will make you drowsy. Before the second generation, non-sedating antihistamines were introduced, I would walk around in a zombie-like state when my allergies required an antihistamine.

Keep in mind you can get a prescription for 30 tablets of meclizine 25 mg for about 12$.

Acupressure

More evidence that the placebo force is particularly strong in the motion sickness world is the widespread marketing, sales and testimonials to “acupressure”  devices.

The EFOSC with her Sea Band. She likes to wear it because it is blue and white, her favorite colours.

The EFOSC suffers from car sickness and several years ago purchased something called the  Sea Band.

Wrist bands like the Sea Band claim to reduce nausea and other symptoms of seasickness through stimulation of the “P6/Neiguan” acupuncture point by applying acupressure or electrical acustimulation.

These work primarily through placebo effect and studies have shown a “sham” acupressure band works as well as a real one.

One fascinating study examined  a self-fulfilling prophecy (SFP) approach to combating seasickness:

the authors experimentally augmented the self-efficacy of naval cadets by telling them that they were unlikely to experience seasickness and that, if they did, it was unlikely to affect their performance at sea. Naval cadets (N = 25) in the Israel Defense Forces were randomly assigned to experimental and control conditions. At the end of a 5-day training cruise, experimental cadets reported less seasickness and were rated as better performers by naive training officers than were the control cadets

The EFOSC is gravely concerned about debilitating seasickness during our 8 days on the Samba. To maximize the placebo force in her I should have emphasized how well the Sea Band and the MQ patch work. Hopefully she won’t read this post.

In Part 2 of the Best Seasickness Treatment I’ll discuss transdermal scopolamine and dramamine, the treatments with the best evidence for efficacy, safety and tolerability.

I’ll also examine the evidence for ginger.

What’s been your experience with sea sickness and treatments for sea sickness?

Vertiginously Yours,

-ACP

Is A Canine Cardiomyopathy Being Created By Crazy Chow?

The eye of the  skeptical cardiologist was caught by an FDA alert issued recently:

FDA Investigating Potential Connection Between Diet and Cases of Canine Heart Disease

According to the alert:

reports of canine dilated cardiomyopathy (DCM) in dogs eating certain pet foods containing peas, lentils, other legume seeds, or potatoes as main ingredients. These reports are unusual because DCM is occurring in breeds not typically genetically prone to the disease.

What Is Dilated Cardiomyopathy?

Dilated cardiomyopathy refers to a disease of the heart muscle characterized by enlargement and global weakness of the main pumping chambers, the ventricles.

The image below is from the echocardiogram of a human with a severe dilated cardiomyopathy.

Humans with DCM experience weakness, shortness of breath and swelling in the legs due to heart failure. Severe cases of DCM are at risk for dying suddenly.

Cardiomyopathy Used To Be A Disease of Large Dogs

According to Lisa Freeman a veterinarian at the Cummings Veterinary Center at Tufts University

Heart disease is common in our companion animals, affecting 10-15% of all dogs and cats, with even higher rates in Cavalier King Charles Spaniels, Doberman Pinschers, and Boxer dogs.

Dilated Cardiomypathy in dogs

typically occurs in large- and giant-breeds, such as Doberman pinschers, Boxers, Irish Wolfhounds, and Great Danes, where it is thought to have a genetic component.

The FDA alert indicates that DCM

 is less common in small and medium breed dogs, except American and English Cocker Spaniels. However, the cases that have been reported to the FDA have included Golden and Labrador Retrievers, Whippets, a Shih Tzu, a Bulldog and Miniature Schnauzers, as well as mixed breeds

Is Doggy Dilated Disease Due To Demented Diets?

Writing last year, Dr. Freeman noted that

“In the last few years I’ve seen more cases of nutritional deficiencies due to people feeding unconventional diets, such as unbalanced home-prepared diets, raw diets, vegetarian diets, and boutique commercial pet foods.  The pet food industry is a competitive one, with more and more companies joining the market every year.  Marketing is a powerful tool for selling pet foods and has initiated and expanded fads, that are unsupported by nutritional science, including grain-free and exotic ingredient diets.  All this makes it difficult for pet owners to know what is truly the best food for their pet (as opposed to the one with the loudest or most attractive marketing).  Because of the thousands of diet choices, the creative and persuasive advertising, and the vocal opinions on the internet, pet owners aren’t able to know if the diets they’re feeding have nutritional deficiencies or toxicities – or could potentially even cause heart disease.

Purina has a whole line of grain-free wet and dry dog food under their Beyond label

Apparently, it has become trendy in the pet world (just like the human world) to vilify grains as in this article highlighting potential signs of doggy grain allergy at the dogbaker.com.

Freeman notes that grains are not felt to significantly contribute to pet diseases:

Many pet owners have, unfortunately, also bought into the grain-free myth.  The fact is that food allergies are very uncommon, so there’s no benefit of feeding pet foods containing exotic ingredients.  And while grains have been accused on the internet of causing nearly every disease known to dogs, grains do not contribute to any health problems and are used in pet food as a nutritious source of protein, vitamins, and minerals.

The FDA alert notes that in 4 cases of doggy DCM (3 of which were golden retrievers) taurine levels were low and with a change back to a normal diet and taurine supplementation the cardiomyopathy resolved. However, some reported cases had normal taurine levels.

Reconsider Your Dog’s Diet

To avoid doggy DCM, Dr. Freeman recommends

  • Reconsider your dog’s diet. If you’re feeding a boutique, grain-free, or exotic ingredient diets, I would reassess whether you could change to a diet with more typical ingredients made by a company with a long track record of producing good quality diets.  And do yourself a favor –  stop reading the ingredient list!  Although this is the most common way owners select their pets’ food, it is the least reliable way to do so.  And be careful about currently available pet food rating websites that rank pet foods either on opinion or on based on myths and subjective information. It’s important to use more objective criteria (e.g., research, nutritional expertise, quality control in judging a pet food). The best way to select what is really the best food for your pet is to ensure the manufacturer has excellent nutritional expertise and rigorous quality control standards (see our “Questions you should be asking about your pet’s food” post).
  • If you’re feeding your dog a boutique, grain-free, or exotic ingredient diet, watch for early signs of heart disease – weakness, slowing down, less able to exercise, short of breath, coughing, or fainting. Your veterinarian will listen for a heart murmur or abnormal heart rhythm and may do additional tests (or send you to see a veterinary cardiologist), such as x-rays, blood tests, electrocardiogram, or ultrasound of the heart (echocardiogram).

Anticardiomyopathically Yours,

-ACP

Where Are My Generics Medications Made? India, China, or the US?

With the recent recall of valsartan due to carcinogenic Chinese contaminants the issue of where one’s generic medication is manufactured has become more important.

I take two generics: ramipril for my hypertension and rosuvastatin for my cholesterol/atherosclerosis and I had no idea where they came from when I discussed the rise of generics manufactured in China recently.

Where Is My Ramipril Made?

I called my St. Lukes pharmacist, Robert, and asked him if he could give me information on the origin of these pills.

Robert told me that my 10 mg ramipril capsule was distributed by a company called West-Ward located in New Jersey.  West-Ward was an independent Columbus, Ohio company but was purchased in 2016 by a very large pharmaceutical company , Hikma, based in Aaman, Jordan. Now the Hikma web site indicates West-Ward is no more and is simply called Hikma in the US.

According to a 2017  Columbus article

Hikma Pharmaceuticals Plc projects it will end 2017 with about $2 billion revenue, about $600 million of which is from generic drugs made by its U.S. subsidiary West-Ward. In the spring, the company had projected $800 million in generics sales.

Customer service at Hikma informs me that my ramipril was made in their Columbus, Ohio plant.

Where Is My  Rosuvastatin Made?

My rosuvastatin (generic of Crestor) was made by Glenmark Pharmaceuticals which, per wikipedia

 is a pharmaceutical company headquartered in Mumbai, India that was founded in 1977 by Gracias Saldanha as a generic drug and active pharmaceutical ingredient manufacturer; he named the company after his two sons.

Glenmark received FDA approval to market their generic rosuvastatin in the US in July, 2016. and at that time had 115 products authorized for distribution in the US market and 61 drugs pending approval with the US FDA.

My rosuvastatin according to Robert was made in India although the Glenmark product catalog does not reveal this information.

Generic versus Brand Name

I’ve talked about Crestor/rosuvastatin a few times on this blog and the development of a generic version has been very helpful for many of my patients. Looking online today I see that generic rosuvastatin goes for about 10$ per month compared to 260$ for Crestor.

Is it worth paying an extra 250$ per month to get brand name Crestor if, let’s say it was manufactured in the US? For most people it isn’t. For one thing, there is no guarantee of where your brand name drug is manufactured.

Crestor used to be made in a factory in Bristol, UK but this was shut down in 2017 and now I can’t tell where Astra-Zeneca makes the stuff. Frankly, I’m surprised that they are selling any of the drug which used to account for 5 billion dollars of their annual sales.

So my cholesterol drug is made in India by an Indian company and my blood pressure drug is made in Columbus, Ohio by a Jordanian company.

I never realized how globalized the pharmaceutical industry has become. Hopefully, the FDA is doing a good job of monitoring the safety and quality of products we rely on for our wellbeing which are manufactured all over the globe.

Skeptically Yours,

-ACP

“Anthony, You Have One More Research Citation”: Social Networking For Researchers

The skeptical cardiologist joined ResearchGate recently. Per wikipedia:

ResearchGate is a social networking site for scientists and researchers[3] to share papers, ask and answer questions, and find collaborators.[4]According to a study by Nature and an article in Times Higher Education, it is the largest academic social network in terms of active users,[5][6] although other services have more registered users and more recent data suggests that almost as many academics have Google Scholar profiles.[7]

I published lots of research during my academic career in cardiology (1987-1996) and have written a few papers in the last few years while in clinical practice. Since I verified with ResearchGate the publications I was co-author on they regularly send me notifications when they find that my work has been referenced by another paper.

Screen Shot 2018-07-03 at 6.33.50 AM

I find such notifications fascinating on a number of levels. First, it reminds me of a topic that I was incredibly interested in to which I contributed meaningful information. This, in turn has me ponder the importance of my prior research and the current status of knowledge in the area.

I feel a strong compulsion to click on the “view citing research” button to see who cited me and why. Once on the ResearchGate site there are multiple things to further distract me from whatever I was doing previously, ranging from a statistical summary of my works read to a listing of papers that have been cited.

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You can imagine how addictive this site is for me. For example, that top citation about atrial septal aneurysm from nearly 30 years ago is the first paper to describe the relationship of atrial septal aneurysm described by transesophageal echocardiography and stroke, a relationship which has become even more significant since the approval of atrial septal occluder devices for treatment of stroke caused by PFO.

That citation of “systolic anterior motion of the mitral chordae tendineae” reminds me that nothing significant has been written in this area since my paper. I couldn’t figure out the significance of chordal SAM then and to this day nobody has.

Clicking on “view citation” takes me to a page which shows me the citing paper along with their stats on my paper. From there I can click on a link to the citing paper which was published in a curious journal entitled Cureus.

Sure enough my paper is reference #7 (Systolic anterior motion of the mitral chordae tendineae: prevalence and clinical and Doppler-echocardiographic features) and the authors are listed as:

Anthony C. Pearson, MD'Correspondence information about the author MD Anthony C. Pearson

Tomasz J. Pasierski, MD

David A. Orsinelli, MD

Department of Internal Medicine, Division of Cardiology, The Ohio State University Columbus, Ohio, USA
with the technical assistance of Peter Gray and Karen Huschart
Reading the list of my co-authors and contributors brings back fond memories of days spent in research collaboration and discussion. I ponder catching up with long-lost colleagues.
ResearchGate also tantalizes me by showing how many times my 96 research publications have been cited-8,594 times.
ResearchGate gives me a score. Mine is 39.78 and is apparently higher than 97.5% of ResearchGate members.
I have no clue what the RG score means but I am  really happy to have a high one.
Alas, I have added ResearchGate to the list of websites clamoring for my attention and my (really limited) time.
Skeptically Yours,
-ACP

Is Your Generic Medication Made In China and Is It Safe?

Last week the FDA recalled several versions of the generic blood pressure medication valsartan which were made in China and contained a carcinogen (see here.)

Since then I  have switched many patients from the bad valsartan to losartan or valsartan from presumably safe manufacturers.

It didn’t really occur to me that this could be just the tip of the iceberg until I received a reader comment which I will copy below.

As I thought about it, I realized that I have no idea where the generic ramipril I am taking is manufactured. It very well could be in China or India.

This recent article from The Epoch Times confirms that Americans are becoming more and more reliant on medications manufactured in China and that many researchers feel this poses a significant security threat.

The Food and Drug Administration (FDA) is inspecting only a small number of the Chinese companies that manufacture U.S. drugs, and those it does inspect are often found to have serious health violations. Meanwhile, the drugs that are making their way into the United States from China, either as finished products or as ingredients, are often falling far below U.S. safety standards. And some of these drugs are not being inspected at all.

The book, “China RX: Exposing the Risks of America’s Dependence on China for Medicine” by Rosemary Gibson and Janardan Prasad Singh,” details the problem.

It is very hard to find out how many US drugs come from China since drug companies don’t make their sources apparent. In addition, even if the drugs themselves aren’t manufactured in China, Gibson and Singh write

“China is the largest global supplier of the active ingredients and chemical building blocks needed to make many prescription drugs, over the counter products and vitamins.”

Below are the comments of my reader:


This is horrible. We have a problem in the U.S. It is the infiltration of Chinese generics. I had no idea that this generic was being supplied by a Chinese maker. In fact, the bottles I got said “SOLCO” which is based in New Jersey. Now I’m painfully aware that SOLCO Healthcare US which is based in New Jersey, is owned by Zhejiang Huahai Paarmaceutical based in China’s Zhejiang Province. So this is the Chinese company’s subsidiary distributing this drug in the U.S. China has a long history of selling tainted products in the U.S. Chinese drywall, lead-based paint on toys, tainted pet food, etc. Now it is important to understand that 85% of prescriptions filled in the U.S. are generic. And insurance companies will not pay for brand when generic is available. My valsartan was about $30 for 90 days. Diovan is $750. I get it. But when these companies cut corners and people are endangered, something is wrong. I will never ever take another generic drug without first finding out where the product comes from. I know this is not perfect, but it is something. I think the U.S. lawmakers need to do something to make this information more transparent. It baffles me as to how this drug could have been tainted with a highly toxic chemical for so many years (they now say 4 years). This chemical is known to cause liver damage and cancer. Apparently the manufacturer changed the way it made the active ingredient which created this poison by-product. And now who do we hold accountable? How do we get to the bottom of what went wrong, and how to prevent this going forward. We have no way to compel anything in China. All that said, thanks for your information here it is helpful. I worry that the losartan is made by the same company – I will surely investigate.


China is also flooding the American market with useless OTC medications. I realized this when I looked closely at this “motion sickness patch” which is highly rated on Amazon.

It has no active ingredient which could be realistically thought to treat motion sickness yet is featured on Amazon’s motion sickness treatment section and is favorably reviewed by over a thousand users.

 

Unfortunately, in the US now users of medications must be very aware of the source and quality of the products they put in their body. Generic prescription medications and OTC products are highly likely to be manufactured out of the US and with minimal oversight.

Skeptically Yours,

-ACP

Drinking From The Giant Tortoise Pericardium

In preparation  for our Voyage of the Samba in the Galapagos Islands I’ve been reading the chapter of Darwin’s Voyage of the Beagle that describes his 31 days in the archipelago.

Darwin felt the reptiles of the Galapagos  gave the “most striking character to the zoology ” of the islands. He spends considerable time in his diary describing the creatures for whom the Spaniards named the islands. the giant tortoises.

Giant Tortoises

A Galapagos giant tortoise  can weight up to 600 pounds and live up to 150 years. A distinct species of tortoise developed on each separate island, adapting to differing environments.

On Charles Island (now Floreana) Darwin encountered the slowly

Lonesome George was the last survivor of the abingdonii subspecies, which became extinct with his death on 24th June, 2012.

lumbering (4 miles per day) tortoises when they traveled to the central highlands to fill themselves with water.  Prior to encountering humans the tortoises had  had no natural predators and both the natives and the crews of whaling ships feasted on their easily obtained meat.

“the staple article of animal food is supplied by the tortoises. Their numbers have of course been greatly reduced in this island, but the people yet count on two days’ hunting giving them food for the rest of the week. It is said that formerly single vessels have taken away as many as seven hundred, and that the ship’s company of a frigate some years since brought down in one day two hundred tortoises to the beach.”

Natives savored both tortoise flesh and tortoise oil:

The flesh of this animal is largely employed, both fresh and salted; and a beautifully clear oil is prepared from the fat. When a tortoise is caught, the man makes a slit in the skin near its tail, so as to see inside its body, whether the fat under the dorsal plate is thick. If it is not, the animal is liberated and it is said to recover soon from this strange operation. In order to secure the tortoise, it is not sufficient to turn them”

Darwin also partook of tortoise:

“While staying in this upper region, we lived entirely upon tortoise-meat: the breast-plate roasted (as the Gauchos do carne con cuero), with the flesh on it, is very good; and the young tortoises make excellent soup; but otherwise the meat to my taste is indifferent.”

I’m pretty certain the passengers on the Samba will not be consuming any Giant tortoise meat this August but we will definitely encounter some of the surviving species on special farms and I will be listening for bellowing males:

During the breeding season, when the male and female are together, the male utters a hoarse roar or bellowing, which, it is said, can be heard at the distance of more than a hundred yards. The female never uses her voice, and the male only at these times; so that when the people hear this noise, they know that the two are together”

Perhaps I will be allowed to startle or ride a tortoise in the manner of Darwin:

“The inhabitants believe that these animals are absolutely deaf; certainly they do not overhear a person walking close behind them. I was always amused when overtaking one of these great monsters, as it was quietly pacing along, to see how suddenly, the instant I passed, it would draw in its head and legs, and uttering a deep hiss fall to the ground with a heavy sound, as if struck dead. I frequently got on their backs, and then giving a few raps on the hinder part of their shells, they would rise up and walk away; — but I found it very difficult to keep my balance.

Drinking FromThe Pericardium Of The Giant Tortoise

Finally, as this is a cardiology-oriented site I must take note of the following peculiar Darwinian observation:

“I believe it is well ascertained, that the bladder of the frog acts as a reservoir for the moisture necessary to its existence: such seems to be the case with the tortoise. For some time after a visit to the springs, their urinary bladders are distended with fluid, which is said gradually to decrease in volume, and to become less pure. The inhabitants, when walking in the lower district, and overcome with thirst, often take advantage of this circumstance, and drink the contents of the bladder if full: in one I saw killed, the fluid was quite limpid, and had only a very slightly bitter taste. The inhabitants, however, always first drink the water in the pericardium, which is described as being best.”

When I came across this description I was flabbergasted. Not at the inhabitants drinking tortoise urine (for indeed the tortoise does use his giant bladder as a water reservoir during times of drought) but at the Galapagoans drinking pericardial effusions.

The Pericardium

The pericardium is the sac around the heart. I am very familiar with the pericardium in humans as I look at it on every one of the  many echocardiograms I read.  Normally, it has only a very tiny bit of fluid in it, enough to lubricate the heart as it contracts and relaxes.

Thus, in a normal giant tortoise one would not expect more than an ounce of liquid in the pericardium-hardly worth butchering an ancient kind beast.

In the video below one can see a small to moderate sized pericardial effusion (the black crescent on the left of the heart) which corresponds to about 90 ml or 3 ounces.

I asked Jim Scharff, a cardiothoracic surgeon,who slices open the pericardium of humans on a daily basis what he typically encounters when the sac is opened. The question I texted him was:

“When you open the pericardium of someone without pericardial disease or effusion how much fluid do you typically encounter and what does it taste and look like?”

He responded  “Usually 15-20 mL of serous looking fluid. I have no idea what it tastes like but it does not have any odor.”

Serous means ” typically pale yellow and transparent” and limpid, Darwin’s term, means transparent and clear.

Some diseases cause inflammation of the pericardium (pericarditis) and with this fluid (pericardial effusion) can build up in the pericardial sac. Large pericardial effusions compress the heart, impeding blood from entering it, and can cause shock and death (tamponade).

Pericardial effusions due to inflammation typically are not limpid as they contain blood cells and protein from the inflammation of the pericardium.

Ultrasonic Explorations

If the inhabitants were sometimes encountering significant amounts of tasty, yet limpid fluid in the pericardial sac of the giant tortoises was this normal or did it indicate the turtles had pericardial disease?

I was unable to find any indication that giant tortoises suffer unduly from pericardial disease but I did encounter one study which utilized ultrasound to document a pericardial effusion in an 80 year old spur-thighed tortoise which was suffering from pneumonia.

Consequently, I’m looking into taking a portable ultrasound device to take with me to the Galapagos to examine the hearts of the giant tortoises and answer once and for all the mystery of the giant tortoise pericardial fluid.

Testudinally Yours,

-ACP

 

 

 

Three More Nails In The Omega-3 Supplement Coffin: Stop Taking Fish Oil Pills (The Complete Post)

If by now you are still taking fish oil supplements despite my last post on the topic I present three more reasons to stop wasting your money and destroying the ocean’s ecosystem.

The first nail: No Reason To Take Fish Oil Pills

A Cochrane review showing shows there is little or no effect of omega 3 supplements on our risk of experiencing heart disease, stroke or death.

This is the most extensive systematic assessment of effects of omega-3 fats on cardiovascular health to date. Moderate- and high-quality evidence suggests that increasing EPA and DHA has little or no effect on mortality or cardiovascular health (evidence mainly from supplement trials). Previous suggestions of benefits from EPA and DHA supplements appear to spring from trials with higher risk of bias. Low-quality evidence suggests ALA may slightly reduce CVD event risk, CHD mortality and arrhythmia.

Second Nail. Peruvian Anchoveta: Put Them On A Pizza Not in A Pill

Paul Greenberg’s recently published book, The Omega Principle, emphasizes the damage the fish oil supplement business is doing to the ocean environment,

During a recent interview on Fresh Air on NPR he summarized the concerns:

GREENBERG: So omega-3 supplements come from this critical layer of the ocean biosphere that are small – what are called pelagic fish. They’re the silvery, little fish like anchovies and herring and other fish called menhaden that most people haven’t heard of, but it’s actually the most caught fish in the lower 48 of the United States. These fish are really essential for ecosystem dynamics in the ocean.

So the way that oceans work is that all the energies coming from the sun – it goes – all that energy is processed by plankton, by phytoplankton. And it’s really these fish that are – these little fish that are used for omega-3 supplements that transfer the energy from plankton to larger fish. So in other words, you know, you have the solar energy going into the plankton. The little fish then eat the plankton. And then they are in turn eaten by larger fish. So if you harvest this middle layer – if you overharvest this middle layer of anchovies, of herring, of menhaden – if you take them out of the picture, there’s no way for the energy to be transferred from phytoplankton up to larger predators. So I guess that’s my main concern here.

So in particular, where are the omega-3 supplements coming from? Most of the omega-3 supplement oil is coming from a fish called a Peruvian anchoveta. And it is the most caught fish in the world. In some years, Peruvian anchoveta harvests have equaled as much as 10 million metric tons. Just to give you some perspective, that’s like one-eighth of all the fish caught in the world. And the crazy thing about it is that those fish are completely, totally edible. I’ve eaten them. They’re delicious. You can have them on a pizza. You could do anything with them. But 99 percent of those Peruvian anchoveta are ground up into animal feed, boiled down into oil and turned into supplements. So to me, to my mind, that is not necessarily the wisest use to be made of this really, really important source both for the ecology of the ocean but also for humans

Nail Three. Save the Krill!

The supplement industry is incredibly creative in their marketing. As the uselessness of fish oil supplementation has become clear, supplement manufacturers have begun touting krill oil as superior to fish oil.

Claims like the following are all over the internet:

Krill have an edge over your ordinary fish – when you take a krill oil supplement, you also get astaxanthin along with your DHA and EPA. It’s an antioxidant. In terms of antioxidant power of potency, it’s been found to be 500x to 6,000x stronger than regular vitamins like vitamin E and vitamin C.

This is just hogwash. There is no good clinical evidence to support any health claim for krill oil in general or astaxanthin in particular. Please read my post on the failure of anti-oxidant supplements and vitamins and recognize that claims of antioxidant power do not indicate any health benefit.

A technical paper from Greenpeace review the importance of krill to to the marine ecosystem in the Antarctic and this paper, entitled “License to Krill” details the problem.

Do you want to be responsible for starving penguins, whales and seals??!

Let me reiterate my original 2013 fish oil post pithy summary:

the bottom line on fish oil supplements is that  the most recent scientific evidence does not support any role for them  in preventing heart attack, stroke, or death. There are potential down sides to taking them, including contaminants and the impact on the marine ecosystem. I don’t take them and I advise my patients to avoid them (unless they have triglyceride levels over 500.)

Prokrilly Yours

-ACP

 

 

 

 

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

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