All posts by Dr. AnthonyP

Cardiologist, blogger, musician

Are Sweet Potatoes Healthier Than Potatoes?

In recent years, sweet potatoes have become a favored alternative to potatoes for health-conscious eaters for some reason. I’ve been noticing sweet potatoes more and more on the menus of trendy/healthy/locavore oriented restaurants as an alternative to potatoes.

A typical appraisal comes from Time’s Health magazine website:

“It’s no surprise that sweet potatoes are at the top of nearly everyone’s healthiest foods list.”

EatingWell. com proclaims,

“The sweet potato is a nutritional powerhouse. Deemed a ‘superfood’ by many nutritionists, sweet potatoes are loaded with vitamin A, vitamin C, fiber and potassium, plus phytochemicals like lutein and zeaxanthin, which promote eye health. ” (Appropriately, if you click on the nutritionists link on this quote it takes you to an Amazon.com listing of pull-up diapers!)

Please note that any article that takes the term superfood seriously should be dismissed as frivolous. Stop reading immediately and never revisit the source.

Screen Shot 2015-08-06 at 10.40.32 AMThe Cleveland Clinic website provides a comparison of the two vegetables and determines that sweet potatoes win the nutritional battle by “knock-out”. (This site also claims that sweet potatoes are far better than yams, a claim I have not had time to research)

Somehow, the idea that a sweeter, tastier vegetable is better for me than its not-so-sweet relative made no sense to me.

Call me skeptical.

Are they a healthier choice than regular potatoes or is this all driven by marketing hype?

Nutritional Differences

There are some minor differences in the nutrient content of SP and P:

Screen Shot 2015-08-06 at 8.36.39 AM
A 180 gram sweet potato has 12 grams of sugar, 6 grams of fiber and 37 grams of carbohydrate
Screen Shot 2015-08-06 at 8.35.45 AM
A 173 gram potato has 2 grams of sugar, 4 grams of fiber and 37 grams of carbohydrate

 

 

 

 

 

 

Sweet potatoes have  six times more sugar and 50% more fiber than regular potatoes. Sources that proclaim SP healthier like to focus on the large amount of Vitamin A. However, we don’t necessarily need more Vitamin A in our diet and nothing suggests these minor differences are of any importance in our overall health.

Potatoes have their own PR machine which will regale you with the wonders of spuds:

“It’s a surprise for many to discover one medium potato (5.3 oz) with the skin contains:

  • 10 percent of the daily value of B6;

  • Trace amounts of thiamine, riboflavin, folate, magnesium, phosphorous, iron, and zinc…and all this for just 110 calories and  no fat, sodium or cholesterol.

  • More potassium (620 mg) than even bananas, spinach, or broccoli;

  • 45 percent of the daily value for vitamin C

The potato people would also like you to know that:

Potatoes are a vegetable.  The popular tuber counts toward the total recommended servings of vegetables. One medium-sized potato (5.3 oz.) counts as 1 cup of starchy vegetables.

On the other hand, the Harvard School of Public health has decided potatoes are not a vegetable:

“However, potatoes don’t count as a vegetable on Harvard’s Healthy Eating Plate because they are high in carbohydrate – and in particular, the kind of carbohydrate that the body digests rapidly, causing blood sugar and insulin to surge and then dip (in scientific terms, they have a high glycemic load).”

There isn’t much good evidence that the glycemic load is something we should be focusing on with diet (see here) but the Harvard people like to point to observational studies that show that people who increased their consumption of  french fries and baked or mashed potatoes  gained more weight over time.

All observational studies try to control for confounding factors in their analysis, but in the case of food consumption it is particularly difficult because it is highly likely that those individuals who are eating french fries are also engaging in other lifestyle choices that are perceived as unhealthy.

The large observational study, which found that increased consumption of potato chips and potatoes was associated with the biggest weight gain, classifies yams or sweet potatoes as a vegetable (along with tomato juice (which is mostly sugar)and tomato sauce).  Vegetables were associated with a small loss of weight over time.

The sweet potato gets to hide amongst all the arguably really healthy vegetables (like chard and brussel sprouts and kale) that  those who are truly dedicated to a healthy lifestyle have embraced with enthusiasm.  This group also exercises optimally, avoids eating junk food and processed food, and engages in other subtle behaviors that the observational study did not measure.

Why Might Potatoes Be Associated with Obesity?

I view potatoes as a ubiquitous, cheap and quickly prepared food  that allows the rapid and easy accumulation of excess calories. The average American consumes 120 pounds of potatoes per year compared to only about 5 pounds of sweet potatoes.

French fries, a staple of fast food throughout the world, when consumed hot, combine many of the sensory elements that lead to overeating. When done properly, the frying process adds a wonderful crispness to the outside, and when combined with the warm, perfectly cooked potato on the inside, the result is irresistible.

A large order of McDonald’s french fries contains 510 calories, suddenly triple the number in a medium potato, but it only costs $2.19 and is available virtually instantaneously.

Chances are those who are consuming the McDonald’s french fries are saving further money and preparation time by combining it with a Big Mac (590 calories) and a medium Coke (210 calories). This Value Meal #1 only costs $5.69 but contains 1300 calories.

Even if you are avoiding fast food, french fries and potato chips are ubiqitous. For some reason, most restaurant breakfasts which are not pancake or waffle oriented are presented with a side of potatoes. Sandwiches always seem to come with an order of potato chips. Hamburgers are served with fries. Steaks with mashed potatoes.

For most meals that contain a potato side, up to  half of the total calories are coming from the spuds.

You have to make a concerted effort to not consume some form of potato when you are eating out, and when you do that, you are now importantly paying attention more to total calories than to macronutrient content of meals.

Your other choice is to not consume all of the french fries, potato chips, grilled potatoes or mashed potatoes that are presented as a side, but many individuals feel compelled to finish everything on their plate.

Dietary Recommendations

If sweet potatoes were as ubiquitous as potatoes and became a staple of fast food restaurants and a side for any and all dishes (and if they were separated out from the rest of vegetable world), I suspect they would also be associated with weight gain.

If, on the other hand, potatoes were not markers of fast, tasty, and easily prepared and consumed food and were only eaten at trendy locavore restaurants or prepared at home, I think they would no longer be associated with obesity.

Looking at the two on strictly nutritional or scientific grounds, it is not possible to choose one over the other.

If you are overweight and ready to lose weight, cutting out the potatoes when eating out will eliminate a lot of the carbohydrates and calories you consume. But don’t think that substituting sweet potato fries is a magical solution.

I yam what I yam,

-ACP

For a Michael Pollan video on the evil of McDonald’s french fries for other reasons take a look at:

 

 

 

 

 

 

The Incredibly Bad Science Behind Dr. Esselstyn’s Plant-based Diet

txorito pamplona
Txorizo Pamplona. This delightful sausage of Navarra in the basque region of Spain is right out in Esselsystn’s plant-based diets.

The skeptical cardiologist has heard a few cardiologist colleagues rave about the movie “Forks Over Knives” and promote the so-called “whole-foods, plant based diet.”

One of the two major physician figures in the movie is Dr. Caldwell Esselstyn, a former surgeon and now a vegan evangelist.

salad
You’ll be eating a lot of this on the Esselstyn diet but do not, under any circumstances add a salad dressing containing any oil of any kind to attempt to make it palatable or satiating.

Esselstyn, along with T. Colin Campbell (of the completely discredited “China Study” (see here for a summary of critical analyses of that data), Dean Ornish, and Nathan Pritikin, are the leading lights of a dying effort to indict any and all fat as promoting heart disease and all the chronic diseases of western civilization.

Esselstyn, in his book, “Preventing and Reversing Heart Disease” lists the following rules:

  • you may not eat anything with a mother or a face (no meat, poultry, or fish)
  • you cannot eat dairy products
  • you must not consume oil of any kind
  • generally you cannot eat nuts or avocados

What? No Fish or Olive Oil? You Cannot Be Serious!

oil
Whatever oil this might be (?sunflower) is right out even though it comes from a plant. According to Esselstyn, using his brilliant ‘logic and intuition” all fats, whether saturated or unsaturated are going to damage the lining of your arteries.

The best randomized controlled trials we have for diet to prevent coronary artery disease (CAD, the cause of heart attacks) have shown that supplementing diet with olive oil and nuts substantially lowers CAD.

Every observational study in nutrition has demonstrated that fish consumption is associated with lower cardiovascular disease.

Esselsstyn’s Really Bad Science

While working at the Cleveland Clinic, Esselstyn developed an interest in using a plant-based diet to treat patients with advanced CAD. He says he had an epiphany one rainy, depressing day when he was served a slab of bloody roast beef.

In his own words:

“my original intent was to have one group of patients eating a very-low fat diet and another receiving standard cardiac care and then compare how the two groups had fared after three years.”

If he had followed his original intent, and randomized patients entering the study, he could claim that he had performed a legitimate, important scientific study. Twelve of the 24 would be allocated by lottery to the Esselstyn diet and 12 to whatever was the standard recommended CAD diet at the time. Unfortunately this approach, due to a “lack of funding, was not practical.”

So instead, 24 patients were sent to him, “all suffering from advanced CAD” and began the horrifically strict dietary program he had developed based on his “logic and intuition.”

Interestingly, patients not only were put on Esselstyn’s incredibly low fat diet, but they were also given cholesterol lowering medications and were “switched to statin as soon as these became available in 1987.”

In addition, 9 of the 18 patients who stuck with the program had previously undergone coronary bypass surgery and two had undergone angioplasty of a coronary artery.

6 of the 24 original patients “could not comply with the program” and were sent back to their regular cardiologists. This gives you an idea of how difficult it was to follow this diet.

Esselsstyn’s “data” then consists of following 18 patients, 9 of whom had already undergone coronary bypass surgery, all of whom were taking statin drugs with his diet without any comparison group.

This group of 18 did well from a heart standpoint, of course. It is impossible to know if the diet had anything to with their outcome.  Most of them had already undergone the “knife” or had had angioplasties that took care of their most worrisome coronary blockages. They were all taking statin drugs . They were all nonsmokers and they were all highly motivated to take good care of themselves in all lifestyle choices.

Any patients who were not intensely motivated to radically change their diet would have avoided this crazy “study” like the plague.

This “study” is merely a collection of 18 anecdotes, none of which would be worthy of publication in any current legitimate medical journal.

Three of the 18 patients have died, one from pulmonary fibrosis, one presumably from a GI bleed, and one from depression. Could these deaths be related to the diet in some way? We can’t know because there is no comparison group.

Should Anyone Eat Ultra-low Fat Diets?

It is possible that the type of vegan/ultra-low fat diets espoused by Esselstyn and his ilk have some beneficial effects on preventing CAD, but there is nothing in the scientific literature which proves it.

Scientific reviews of the effect of diet on CAD in the last 5 years have concluded that the evidence is best for the Mediterranean diet, which emphasizes fish consumption, olive oil and nuts. These reviews dismiss ultra-low fat diets because of a lack of evidence supporting them, and an inability to get people to follow them.

If you have ethical or philosophic reasons for only eating things with no mother or face, then by all means follow your conscience.

Too often, however, I find that those who choose veganism for philosophic reasons want to find health reasons to support their diet and mix the bad science and philosophy into a bland evangelical stew they recommend for all.

I remain, therefore, in favor of cioppino, paella, butter and all the glories of the omnivore that make life so rich.

Omnivorously yours,

-ACP


I have updated this post with comments from readers and my response along with analysis of the latest “data” from Dr. Esseslstyn’s “study” at my post entitled:

more-incredibly-bad-science-from-dr-esselstyns-plant-based-vegan-diet-study


For an amazingly complete (and surprisingly entertaining) dissection of the scientific inaccuracies of “Forks Over Knives” with humorous overtones, I recommend Denise Minger’s post “Forks Over Knives: Is the Science Legit? (A Review and Critique). Be prepared for lots of graphs!

AliveCor Smartphone App Detects Atrial fibrillation: Potential for Stroke Prevention

Atrial fibrillation (AF)  is a common abnormal rhythm of the heart which causes 1 in 4 strokes. Those afflicted with AF may lack any symptoms or only have a vague sense of irregularity of their heartbeat and thus the first symptom of AF can be stroke.

The gold standard for diagnosing AF has long been the electrocardiogram (ECG or EKG) and typically the ECG involves placing 12 electrodes on the chest/arm/legs and recording the electrical activity of the heart on an expensive device.

I’ve been checking out a device made by Alive Cor which works with your smart phone to record a single channel ECG and is capable of accurately diagnosing if you are in the normal (sinus) rhythm or in AF.
Screen Shot 2015-07-12 at 8.45.49 AMYou can purchase the third generation (significantly smaller then earlier versions) AliveCor Mobile ECG from Amazon or from AliveCor directly for 74.99$ and it works with an app with both iOS and Android devices.

I used mine with my iPhone 6. At first I carried it separately, fearing the added bulk when stuck on to my iPhone case but after a while I realized that it was never with me when I wanted to use it and that there was a huge risk of losing it and so I used the backing adhesive to attach it to my case.

After pairing the device with the app you put two fingers on each of the metal pads and the smartphone screen displays the recording. After 30 seconds of recording it then interprets the rhythm.

Screen Shot 2015-07-12 at 8.56.47 AM
Typical recording in normal sinus rhythm. The red arrow indicates the small p waves which are the electrical signal of the upper chambers (the atria) depolarizing , the blue arrow indicates the electrical depolarization of the ventricles (QRS). The orange arrow indicates that the time interval between the QRS complexes is the nearly the same for each beat, indicating the regularity that we expect when in NSR compared to AF.

Above is a typical recording I made in my office on a patient who had a history of AF. The quality is good and I can clearly see that he is in normal sinus rhythm. The app correctly made the diagnosis of NSR and calculated his heart rate at 68 beats per minute.

One day I had most of my patients record their ECG’s using AliveCor and compared it to the standard 12-lead ECG we normally record. The device correctly identified the two patients with AF out of this group and correctly identified the normals.

Screen Shot 2015-07-12 at 9.26.42 AM
AliveCor recording of patient with AF with heart rate of 70 beats per minute. Note the absence of p waves before the QRS complexes and note the beat to beat variation in the RR interval (orange arrow)

This recording is from a patient with persistent AF which had recurred two weeks earlier. The device correctly identified AF.

Studies have documented that AliveCor Mobile ECG can accurately diagnose AF in a screening setting and the FDA approved the device for AF screening in 2014.

Given the high prevalence of silent AF, the strong association of AF with stroke and the availability of anticoagulants which reduce AF associated stroke by 70%, screening for AF with devices like AliveCor holds the promise of preventing large numbers of stroke.

(For my comments on taking the pulse and stroke prevention see here and on the inadvisability of a routine 12-lead ECG see here)

AliveCor allows physicians utilizing the Mobile APP and ECG to have a “dashboard” into which their patients can transmit their AliveCor ECG recordings.

I will be discussing this remarkable new device with my AF patients  who are smartphone enabled. I think it will advance our ability to more efficiently and quickly diagnose AF in them.

My standard approach if a patient with AF calls and says that they feel like they are out of rhythm is to have them come into the office for a full 12-lead ECG. If they are AliveCor enabled, they could make their own recording, and we could review that remotely and make a diagnosis without the office visit.

Let me know your thoughts on smartphone ECGs.

fibrillatorily yours,

-ACP

Foxglove Equipoise

I came across the word equipoise, used eight times, in a recent, brief editorial entitled “Digoxin: In the Cross Hairs Again.”

It’s not a word I hear outside of medical circles but it serves a great function in the clinical arena.

When used in medicine as in the phrase “clinical equipoise” it means that medical experts are uncertain as to whether a treatment for a disease is helpful.

Thus, for digoxin, a drug which has been utilized for patients with heart failure or atrial fibrillation for 240 years, we still don’t know if the benefits outweigh the risks.

foxgloveDigoxin is the major medicinally active chemical in the foxglove plant which was first described by Leonhart Fuchs (the plant and color fuchsia are named after him), a German botanist and physician in 1542. It was given the latin name digitalis purpurea, reflecting the plant’s purplish color and similarity to a thimble (German finger hut).

A vague understanding that the foxglove had medicinal and toxic properties existed in subsequent centuries, but it took a very observant physician from the West of England, William Withering, to give it a sold footing in the medical pharmacopeia.

Withering collected 10 years of his observations, using various preparations of foxglove to treat various diseases including the mysterious “dropsy” in the (now famous) An Account of the Foxglove and some of its Medical Uses.”

He writes of his rationale for beginning to give patients foxglove:

“In the year 1775, my opinion was asked concerning a family receipt for the cure of the dropsy. I was told that it had long been kept a secret by an old woman in Shropshire who had sometimes made cures after the more regular practitioners had failed. I was informed also, that the effects produced were violent vomiting and purging; for the diuretic effects seemed to have been overlooked. This medicine was composed of twenty or more different herbs; but it was not very difficult for one conversant in these subjects, to perceive, that the active herb could be no other than the Foxglove.”

(Excerpt From: William Withering. “An Account of the Foxglove and some of its Medical Uses.” iBooks. https://itun.es/us/ZeJDE.l)

Dropsy was that era’s term for edema: “The dropsy is a preternatural swelling of the whole body, or some part of it, occasioned by a collection of watery humour. It is distinguished by different names, according to the part affected, as the anasarca, or a collection of water under the skin; the ascites, or a collection of water in the belly; the hydrops pectoris, or dropsy of the breast; the hydrocephalus, or dropsy of the brain, &c. [Buchan1785].”

Foxglove was in clinical equipoise in 1775. When Withering started giving it to his patients with dropsy he did not know if it would help or harm them.

After trying various preparations of the foxglove in varying dosages in hundreds of patients he concluded that it was of a great benefit as long as it was carefully titrated to avoid the toxicities of overly slow pulse and vomiting.

With modern medicines that are proven to be safe and effective we demand evidence from randomized controlled trials in which the active drug is compared to a placebo. There are too many factors which affect the course of a disease to accept the kind of observational evidence that Withering collected.

Digitalis is currently utilized in heart failure and atrial fibrillation. Withering’s patients likely had one or both of these conditions.

A recent observational study found that digitalis usage in patients with newly diagnosed atrial fibrillation was associated with a 26% higher risk of dying.

The only large randomized trial of digoxin, the DIG (Digitalis Investigation Group) trial, showed no effect on mortality, but digoxin did reduce hospitalization among patients with heart failure and a reduced ejection fraction (HFrEF)

The DIG study was performed in the early 1990s, before current optimal treatment regiments for heart failure with reduced ejection fraction were developed and may no longer relevant. More recent observational studies suggest digoxin raises mortality in heart failure.

Thus, the foxglove or digitalis, although used for 240 years in hundreds of thousands of patients for both heart failure and atrial fibrillation remains in clinical equipoise.

Doctors must be very circumspect in prescribing this medicine. Personally, I do not use digoxin in heart failure patients.

I use digoxin in chronic atrial fibrillation only as a last resort when other agents do not allow adequate slowing of the heart rate and I carefully monitor levels and kidney function if a patient is on it.

jemimafoxglove
From The Tale of jemima Puddle-Duck. Jemima… rather fancied a tree-stump amongst some tall fox-gloves.

I have, however, decided to start growing foxglove in my garden. I will try to warn the ducks, rabbits and squirrels not to partake of its beautiful flowers as they might prove deadly.

I also plan to visit the grave of Withering on my upcoming trip to Europe, for upon his tombstone it is said, there is an engraving of the foxglove!

 

 

Digitally Yours,

-ACP

Dietary Guidelines 2015: Why Lift Fat and Cholesterol Limits But Still Promote Low Fat Dairy?

When the 2015 Dietary Guidelines for Americans (DGA2015) are finally issued they will likely follow the recommendations of the DGA committee. The DGA report (available here) has made giant strides in reversing four decades of bad advice coming from the government and the American Heart Association (AHA.)

Namely, as I discussed in detail here they no longer consider cholesterol a nutrient of concern and recommend lifting any specific limit on dietary cholesterol.

In addition, as a recent article in JAMA suggested  they have finally lifted  any recommended limit on percent daily intake of fat and we should celebrate and encourage this.

As we have pointed out multiple times, higher fat intake is not associated with heart disease or obesity and it makes no sense, therefore to impose limits on its consumption.

In fact, replacement of fat with carbohydrates is the worst dietary change you can make (with the exception of exchanging butter for industrial processed oils containing trans-fats).

Arguably, thanks to four decades of government and  AHA advice to cut fat and cholesterol we have seen the rise of sugar consumption and obesity as food manufacturers have agreeably made products that fulfill requirements for low fat but still taste good.

The new analysis and report from the DGAC 2015 will hopefully reverse this as they seem to have gotten most of the science right.

Non fat or Low-Fat Dairy Still Recommended

However, they have, inexplicably, left in recommendations for non-fat or low fat dairy.

As I have written about here and here there is no scientific evidence that supports the concept that dairy processed to remove dairy fat is healthier than the original unadulterated product.

In fact, evidence suggests full fat dairy reduces central obesity, diabetes and atherosclerosis in general.

It is virtually impossible in most grocery stores to find full fat yogurt or milk. The vast majority of the dairy aisle is devoted to various low or non fat concoctions which have had loads of sugar and chemicals added and are arguably worse than a Snickers bar.

Flawed Reasons for Low Fat Dairy Recommendations

I believe there are three reasons for this failure of the DGA 2015 and nutritional experts to correct the flawed advice to eat non or low-fat dairy over full fat:

1. In  few randomized dietary studies showing benefits of a particular diet over another, non fat or low fat dairy was recommended along with a portfolio of other healthy dietary changes.

The overall benefit of the superior diet had nothing to do with lowering the dairy fat but was due to multiple other changes.

2. The dairy industry has no motivation to promote full fat dairy. In fact, they do better financially when they can take the fat out of milk and sell it for other purposes such as butter, cheese, and cream.

3. Saturated fat is still mistakenly being treated as a monolithic nutritional element.  Although dairy fat is mostly saturated, the individual saturated fats vary widely in their effects on atherogenic lipids and atherosclerosis. In addition, the nature of the saturated fat changes depending on the diet of the cow.

If the DGA 2015 doesn’t get this issue right we risk another decade of the public consuming high sugar, low fat yogurt in the mistaken belief that they are engaging in healthy behavior.

-ACP

 

 

 

Are You Sabotaging Your Heart With Statin Drugs?

No, you are not “sabotaging” your heart with statin drugs. Neither are you “wrecking” your heart.

But that title probably got your attention if you are taking a statin drug and thought that it was helping your heart.

Typical appearance of Newsmax Health. Note that  the offer to assess cardiac risk is a self-serving promo of the book on natural cardiac cures written by the author of the article on the left which summarizes only the negatives of bypass surgery
Typical appearance of Newsmax Health. Note that the offer to assess cardiac risk is a self-serving promo of the book on natural cardiac cures, written by the author of the article on the left, which summarizes only the negatives of bypass surgery

This question is prominently displayed on the Health portion of a news website called Newsmax, that somehow interrupted my web surfing today. If you click on the banner, you will get to listen to the words of Dr. David Brownstein, “America’s most popular family physician.”

Dr. Brownstein, in my opinion, should more properly be termed “one of America’s most popular quacks, charlatans and purveyors of misinformation in order to market useless junk.”

What Brownstein says can be found on multiple similar sites across the internet which are promoting “alternative” or “natural” approaches to high cholesterol.

His claims can be summarized as follows:

  • statin drugs do nothing to protect you from heart attacks
  • statin drugs “weaken your heart,” muscles, cause fatigue and lower your sex drive, damage your kidneys and liver
  • statin drugs prevent the formation of cholesterol which is essential for brain, sex hormone and vitamin D production
  • 1/2 of people with heart attacks have normal cholesterol levels
  • CHF is increasing in frequency and it is related to an increase in statins and consumption of sugar and refined carbohydrates
  • Big pharma has perpetrated the biggest fraud in medical history on the American public by brainwashing doctors, beginning in medical school, to prescribe statin drugs

These claims resonate with patients who are reluctant to take medications and who feel that “natural” approaches to prevention and treatment are superior.

Brownstein uses a combination of alarmist rhetoric and pseudoscientific jargon that appeals to those seeking alternatives.

Let’s look at his claims.

Do Statins Prevent heart Attacks?

Statins unequivocally prevent heart attacks in patients who have had heart attacks or have evidence of advanced vascular disease due to atherosclerosis. This is called secondary prevention and there are almost no cardiologists/scientists with any credibility who dispute the value of statins in secondary prevention.

The only specific study that Brownstein cites is the ASCOT-LLA study, published in 2003 which looked at ten thousand patients with hypertension, no heart disease and low or normal cholesterol levels, half of whom got 10 mg of atorvastatin and half a placebo.

This was a primary prevention study and showed such a benefit of the atorvastatin on reducing heart attack and coronary deaths that the study was stopped early, at 3.3 years at which time 154 patients receiving placebo versus 100 receiving atorvastatin had had heart attacks or died from coronary disease.

This was a highly significant reduction in events. There are several ways to look at this data and present it to patients; Brownstein implies that “Big pharma” presented the most favorable way, which is that there was a 36% reduction in relative risk.

The absolute risk of an event in the atorvastatin group was 1.7% (2.7% in the placebo group), so the absolute risk reduction was from 2.7% down to 1.7% or 1%.

To help better understand the data, we can also look at the number needed to treat (NNT). The NNT is the inverse of the absolute risk reduction. So for the ASCOT trial, the absolute risk reduction was 1%. 1 divided by 1% is 100 — 100 people would need to be treated with atorvastatin (the generic of Lipitor) over the study period to prevent one heart attack. (For more discussion on the NNT check out this blog post and this paper on its limitations)

lipitorUnderstandably, Pfizer, the makers of atorvastatin, prominently displayed the 36% relative risk reduction in their direct to consumer marketing campaigns (featuring Dr.Robert Jarvik (proclaiming himself a doctor in direct to consumer videos), although he was never a licensed physician (see here for interesting discussion on the controversy that ensued)).

Until, the FDA compels them to do otherwise, big pharma will project their products in the most favorable light possible.

However, it is debatable whether presenting data to patients using absolute risk reductions or NNT info plus relative risk reductions results in better choices. As Mcalister has pointed out:

“For example, many British patients with atrial fibrillation who were likely to benefit from anticoagulant therapy because of their risk profiles and their similarity to the participants in randomized trials supporting the efficacy of warfarin declined warfarin therapy when presented with the data about their absolute risks and benefits.”

ASCOT really makes a strong case for taking a statin drug to prevent heart attacks, even in those with normal or low cholesterol levels, not the opposite, as Brownstein has implied.

Do Statin Drugs “Weaken” The Heart Muscle Or Cause Heart Failure?

After criticizing the now infamous “Seven Nations Study” of Ancel Keys, which found high fat consumption in countries with high rates of heart attacks, Brownstein trots out the weakest imaginable argument for statins causing heart failure: heart failure has increased in the last decades, statin use has increased, therefore statins are causing heart failure. 

Correlation does not equal causation!

There is no compelling evidence that statins cause heart failure or weaken heart muscle.

In fact, a recent review of heart failure and statins concluded that statins, while not reducing mortality in heart failure, do have favorable effects on reducing the rate of hospitalization for heart failure and increasing the strength of the heart muscle.

Statins may not be as beneficial in patients with heart failure, but they definitely don’t cause heart failure.

Much of the misinformation about heart failure and statins arises from sites like Life Extension, which promotes sales of its own preferred brand of vitamin CoQ10, ubiquinol. (According to their website, though, this is for altruistic reasons: “We at the Life Extension Foundation take a different view. Keeping our members in a youthful state of longevity is the most efficient way of maintaining the revenue stream we need to fund our scientific research projects. We had no problem reducing our margins to provide members with the clearly superior ubiquinol form of CoQ10.”)

As is typical for this slick organization (see my previous post here), the writing has the veneer of science but is all pseudoscience with references that are outdated, irrelevant or meaningless.

Statin Side Effects

I’ve written about statin side effects and the decision to take them based on analysis of risks and benefits here and here.
By far, the most common thing we see is myalgia, aching of the muscles, and this is reversible.
The bottom line is that the benefits of statins far outweigh the risks if you are at very high risk for heart attack and stroke.  The risks outweigh the benefits if you are at very low risk.
For those in the middle, I advocate a search for subclinical atherosclerosis either by vascular screening or coronary calcium detection.

Misinformation and Scare Tactics on the Internet

Brownstone is not the only purveyor of dangerous misinformation on Newsmax’s Health website. There seems to be a concerted effort to promote quacks and charlatans and any information on this website is suspect.

A good rule of thumb if you are searching for credible health information on the web:

Avoid sites that use scare tactics and inflammatory rhetoric to induce you to stop your prescription medication and buy a health newsletter or nutraceutical.

By the way, Big Pharma has not brainwashed me.

I have no ties to industry.

I stopped taking any pharma food or money years ago.

Listen all y’all, it’s not a sabotage!

-Boyishly yours,

ACP

 

My Dad’s Heart Murmur and The Botched Echocardiogram

My dad was recently told he had a heart murmur by his internist. An echocardiogram (ultrasound of the heart) was ordered.

A heart murmur is basically any unusual sound that the doctor hears when he/she places a stethoscope on the anterior chest  in the vicinity of the heart.  Blood flows across various valves as it makes its way through the cardiac chambers. If the valves are functioning normally we usually can’t hear anything because the blood velocity is low and the flow is not disordered.

The majority of murmurs that are detected are due to either:

(1) narrowing (stenosis) of a valve that results in an acceleration of blood velocity.

(2) failure of a valve to close properly (insufficiency or regurgitation) and prevent back flow.

Cardiologists have developed an absolutely awesome tool for  both visualizing the valves anatomical structure and movement, and precisely measuring the flow of blood through the heart.

The full name of this awesome tool is Doppler-echocardiography. The echocardiogram constructs a moving two-dimensional (more recently three-dimensional) “movie” from analyzing the time and intensity of sound waves reflected off the various valves, walls and structures within the heart.

The Doppler principle is utilized to precisely measure the location and velocity of blood flowing through the heart from high frequency sound waves reflected off red blood cells.

I call this test an echo or TTE (Transthoracic Echocardiogram)

The Importance of Being Expert in Echo Performance and Interpretation

I considered asking him to have the echocardiogram done at my hospital here in St. Louis. I’m the medical director of the laboratory and spend a lot of time making sure that we get high quality echocardiograms and that they are interpreted correctly.

When an echocardiogram is done elsewhere, I have no guarantees that it has been performed and/or interpreted properly.

One would hope that a TTE done in a doctor’s office in Tulsa, Oklahoma and one done in a hospital outpatient facility in St. Louis on the same patient would yield identical results on key findings, but this is often not the case.

On a regular basis, I see serious and highly significant errors made in the findings of TTEs performed elsewhere on patients that come to me for a second opinion or due to moving from another city.

Causes of Errors in Echos

The heart alone, among the body’s organs, is constantly moving. This means that standard ultrasound and x-ray techniques, which work great for static body parts, are useless. The techniques in a modern TTE that have evolved to fully evaluate all of the heart’s highly dynamic functions are complicated and require state-of-the art ultrasound equipment, as well as a sonographer who has been fully and expertly trained in using such equipment.

Such sonographers typically go through a two year program that is specific for cardiac ultrasound. To verify their knowledge and skills, they have a certification from either RDMS or CCT.

Will a competent, registered sonographer perform my dad’s exam? He and I have no way of knowing short of calling up the lab and asking very specific questions.

There is no government or insurance company mandate that a TTE be performed by a qualified, competent sonographer!

This, alone, is quite shocking, but it gets worse.

Who will read my dad’s TTE? Will it be read by a cardiologist trained like me who has gone through an additional year of cardiology training specifically in echocardiography, and who has reached what is termed Level III training?

Does that reading doctor have, like I do, verification of the acquisition and maintenance of the incredibly complicated knowledge base for echocardiography by taking and passing the National board of Echocardiography examinations?

Is he/she keeping up to date on new techniques and scientific findings in the field by attending regular CME sessions?

Does he/she regularly try to correlate the findings from the TTEs he/she reads with findings from other imaging techniques and surgical pathology?

Chances are the answers to all of the above questions will be no.

There is currently no country-wide government or insurance company mandate requiring the reader of a TTE to be competent to get reimbursed!

Thus, we have no guarantees that the TTE on my dad will be competently performed and interpreted.

This sad situation is the cause of the serious and significant errors in TTE results that I regularly encounter.

Dr. Kiran Sagar presented findings confirming this at the 2010 scientific meeting of the American Society of Echocardiography. According to news reports, she was fired shortly afterwards.

The study reported at the ASE meeting involved a review of 235 echocardiograms done at St. Luke’s hospital in Milwaukee, WI (not related at all to my St. Lukes hospital in Chesterfield, MO) from August 2007 to October 2008:

“Of the 35 physicians who performed clinical readings of the echocardiograms reviewed in the study, only three were Level 3 specialists within cardiology.
Sagar’s analysis revealed that 68 of the 235 imaging studies, or 29 percent, were misread.
In at least five of those cases, patients actually went into the operating room with a faulty diagnosis, although the problem was discovered before surgery was done.
In addition, 18 patients were subjected to more invasive echocardiography in which a probe was inserted down the throat and 19 underwent invasive coronary angiography. The misreadings also resulted in increased healthcare costs for the patients”

How Can You Be Sure Your Echo Is Competently Recorded And Interpreted.

I have no good answer to this question.

The only organization that provides any method for evaluation of individual echo labs is the Intersocietal Accreditation Commission. According to the IAC website “The purpose of the IAC Echocardiography accreditation program is “to ensure high quality patient care and to promote health care by providing a mechanism to encourage and recognize the provision of quality echocardiographic diagnostic evaluations by a process of accreditation.””

Echo labs that are accredited by IAC go through a process every three years that insures that they are following the IAC guidelines on acquisition and reporting. This means that the report from an IAC accredited echo lab will comment on all the structures of the heart that should be commented on and will report out basic, rudimentary measurements.

The IAC requires that the medical director of the echo lab have advanced training in echocardiography, but does not require the sonographers who perform the exams to be accredited.

There is no IAC requirement for significant evidence of competence or adequate training for the physicians who read echocardiograms. I quote from their documentation which states that a physician qualifies as a reader:

“if echocardiography training was completed prior to 1998 – three years of echocardiography practice experience and interpretation of at least 1200 echocardiogram/Doppler examinations…”

This type of physician reader does not have to document any significant training or competence, just that he/she has been reading echos for a while and has reached a certain volume.

My Dad’s Echo

We decided to let my dad get his echo done at the facility his primary care physician utilized. It was done at one of the largest hospitals in Tulsa, Oklahoma and I had him obtain both the report and the actual echo recordings for me to review.

The results were quite disappointing as several key elements of the exam were misinterpreted.

As I feared, my dad’s echo was botched.

What Americans Should Demand For Quality and Consistency in Echos

The payers in healthcare should mandate the following if an echo is to be reimbursed:

  • It is performed in an IAC accredited echo laboratory
  • It is performed by a registered sonographer
  • It is interpreted by a cardiologist with advanced training and competence in echocardiography (how advanced and how that is measured or certified can be debated)

Until this kind of quality assurance is tied to reimbursement, it won’t happen voluntarily.

You, as the consumer, have to make sure you are getting the best quality echocardiogram you can.
Ask questions about the lab, the sonographer and the reader who will be doing your exam.
A faulty interpretation of your echocardiogram could result in unnecessary and dangerous testing and surgery.
Failure to identify significant cardiac pathology could delay appropriate treatment.
HAPPY FATHER’S DAY!
To my dad, and all you other dads.
May your hearts keep pumping efficiently and may all your tests be interpreted correctly.
-ACP

I’m Having Chest Pain: Is It a Heart Attack?

IMG_4219I can tell you exactly when the pain started. I was riding  my bike in Forest Park, the great urban park of St. Louis. Ordinarily, I cycle from my house to the park, cutting across the  ivy-covered semi-Ivy league campus of nearby Washington University and circling its beautiful acres on a recently refinished bike path.

As I started the slow incline that parallels Skinker Avenue just West of Forest Park, a cyclist flashed past me. I could swear he said “Oh dear, oh dear. I shall be late.”

Instead of continuing straight along the bike path, the late cyclist suddenly veered to the left, following a heretofore untraveled spur that led up into the dark, impenetrable forests of the park.

At this point, the sensible, sixty-something portion of my psyche should have taken over and had me continue on the relatively straight, flat and well-traveled road that I had grown accustomed to. Alas, it was the teenage boy who took control and insisted on us taking the road less traveled.

The spur of the bike path had not been regularly maintained and there were numerous rough spots: ridges and chasms emerged with disconcerting frequency as I progressed.

The lure of exploration pulled me on. I kept my speed up as I descended a hill with the path turning sharply to the right. Suddenly an even sharper right turn emerged with a particularly uneven section of path. I lost control of the bike and landed heavily on my left side.

I felt a sudden sharp pain just to the left of my breastbone about midway in my chest.

As a cardiologist I spend a lot of time talking to people about chest pain and thinking about what is causing it.

The heart is in the chest and it is natural to believe that pain that comes from this area could be a manifestation of the dreaded heart attack. Since heart attacks are the #1 killer of both men and women  and they can very quickly lead to life-threatening arrhythmias it is wise to take seriously  any pain in the chest.

Three Types of Chest Pain

I was trained to sort what patient’s described to me about their chest pain  into three bins: Typical anginal pain, atypical anginal pain and non cardiac pain.

Angina is doctor-speak for chest pain that is due to the heart muscle not getting enough blood (usually due to a blocked coronary artery)

Cardiologists consider any discomfort from the lower ribs up to the bottom of the neck as chest pain although patients often don’t perceive it as a pain.

Heart attack pain often feels like a pressure, a heaviness or a burning and in addition to somewhere in the anterior chest region it can manifest in the neck or jaw or one or both of the upper arms.

My chest pain was  worse  when I took a deep breath (pleuritic) and this almost always indicates a lung cause or inflammation in the muscle/bones/joints that are related to breathing. Furthermore, pushing on the ribs  made it worse making it virtually certain that it was musculoskeletal.

A brief (well done) history and physical exam therefore would assign my chest pain to the “non cardiac” bin.

Typical anginal pain is brought on by exertion, lasts 3-15 minutes and is relieved by nitroglycerin or rest.

pretest likelikhood cadThe probability of a patient with non cardiac chest pain having significantly blocked coronary arteries is generally lower than that of a patient with typical anginal pain. However, as this chart demonstrates, patients (generally those with significant risk factors) can have severely blocked coronary arteries and have non cardiac chest pain.

For example, I have risk factors of age (>55 years), being male, hyperlipidemia and hypertension. A cardiac catheterization done on me at the time of my non cardiac chest pain might well show significantly blocked coronary arteries. Of course, these blocked arteries would have absolutely nothing to do with my pain.

This fundamental paradox is the source of a lot of the overtesting and over treatment that occurs in cardiology. Most of the time, chest pain that prompts a patient to come to the ER or doctor’s office does not fall easily into the non cardiac category or the typical anginal category: these are the atypical anginal patients.

Additional testing is required , progressing from EKGS and cardiac enzymes to stress testing to cardiac catheterization. If there are elevation of the cardiac enzymes or abnormalities of the EKG that indicate a recent or active heart attack then a cardiac catheterization is warranted because it is very highly likely that a tightly blocked coronary artery is the cause and opening that artery will be beneficial.

However, most patients have normal cardiac enzymes and unremarkable EKGS and can end up getting catheterizations (due to either  inaccurate stress tests or cardiologist’s recommendation) that they don’t need.

Once a catheterization is done, patients may then get a stenting procedure on a blocked coronary artery that wasn’t causing any problems. Not uncommonly, multiple blocked coronary arteries are found and the patient is rushed off to have a bypass operation. If the blocked arteries weren’t the cause of the patient’s chest pain (i.e. the pain was non cardiac) these procedures are likely doing more harm than good.

When To Go To ER With Chest Pain

I’ve spent thirty years fielding after hours telephone calls from patients who are having  chest pain.

It is not easy to make a reliable determination of who is likely having a heart attack or other potentially dangerous cardiac problem and who is not just based on the history.

If a patient called me describing what I described above I would likely advise him to go to the ER for evaluation (although I would be pretty sure it wasn’t a heart attack: sometimes rib fractures are associated with collapsed lungs or hemorrhage into the pleural space and sometimes trauma to the chest can cause heart damage). It’s always better to err on the side of caution when were’ dealing with potentially life-threatening problems.

After office hours, the only way to get an electrocardiogram and cardiac enzymes to be sure that the chest pain is or is not a heart attack is to go to an ER. Generally, if the patient has escalated the level of concern to calling the on call cardiologist, the symptoms are worrisome.

The bottom line for me is that you only get one chance to die (You only die once (YODO)

If you’re having a heart attack at any second your heart can go into ventricular tachycardia or ventricular fibrillation and you will die within minutes.

Thus, I have to have a very low threshold for advising trips to the ER. If I’m wrong, the patient  could die.

I didn’t go to the ER because I was 100% certain that my chest  pain was non cardiac. I’m also a doctor and therefore a very bad patient. I survived, however, and over several weeks the pain gradually subsided.

As a result of this fall (and several other bike falls I’ve had in the last few years) I’ve re-evaluated my cycling. I’m going to stay on very well-maintained paths and slow way down when the going gets rough.

Hopefully, this will allow me to continue the cycling which I’m convinced is helping to prevent me from visiting the ER with a true heart attack!

Skeptically Yours

-ACP

Far From The Madding Crowd: Doctoring in Literature

The skeptical cardiologist  suspected that the latest film adaptation of Thomas Hardy’s fourth novel was a chick flick (it is) but agreed to go with his fiancée recently and ended up liking it.

This prompted a read of the original novel which was published in 1874.

The book and movie focus on  Bathsheba Everdene (described usually as “independent, beautiful and headstrong”) and the three men who propose marriage to her. Bathsheba is played by the wonderful Carie Mulligan.

It provides a somewhat idyllic picture of pastoral life in Hardy’s fictionalized Wessex in the southwestern portion of Britain in the 1870s (I really wanted to get out in one of those fields and bail some hay).

For some time, I have been fascinated by the incompetence of doctors in Victorian literature and as I read the novel I noted doctoring references.

In the 1870s doctors did not have a lot to offer. In Dickens’ novels they usually recommend rest and for the most part confirm that the patient is getting better or worse, but offer little to nothing in the way of medications or ministrations that improve outcomes.

Here are the doctor references in Far From The Madding Crowd.

-At a gathering of farm workers, Jan Coogan urges Mark Clark to drink more alcohol.

To which, Mark Clark, responds, “Ay-that I will, ’tis my only doctor

-Bathsheva Everdene’s uncle (from whom she will inherit a large farm) becomes ill:

“Her uncle was took bad, and the doctor was called with his world-wide skill; but he couldn’t save the man.”

-Sergeant Troy, a rake and “a man to whom memories were an incumbrance, and anticipations a superfluity” who will ultimately marry Bathsheba is described by townspeople:

“He’s a doctor’s son by name, which is a great deal; and he’s an earl’s son by nature!”

“Which is a great deal more”

.-When Bathsheba’s husband, Sergeant Troy is presumed dead she seeks the advice of Gabriel Oak, her farm superintendent (who has long loved her) on whether she should marry the rich but boring Farmer Boldwood. When the local parson’s advice is recommended, she responds.

“No. When I want a broad-minded opinion for general enlightenment, distinct from special advice, I never go to a man who deals in the subject professionally. So I like the parson’s opinion on law, the lawyer’s on doctoring, the doctor’s on business, and my business-man’s—that is, yours—on morals.”

-When Sergeant Troy is shot by Boldwood, Bathsheba calls for the local “surgeon”, a Mr. Aldritch.

Unfortunately, by the time he arrives, Sergeant Troy is most assuredly dead and Bathsheba has cleaned the corpse and dressed it all in white.

“The doctor went in, and after a few minutes returned to the landing again, where Oak and the parson still waited.

“It is all done, indeed, as she says,” remarked Mr. Aldritch, in a subdued voice. “The body has been undressed and properly laid out in grave clothes. Gracious Heaven—this mere girl! She must have the nerve of a stoic!”

Thus, the typical input of the doctor in this era: making an official announcement of the obvious.

We can summarize Hardy’s impressions of doctors (or the people of his beloved Wessex’s opinion) as follows:

1. Alcohol is to be preferred to doctors.

2. Rather than seek medical advice from a doctor, it is better to have a lawyer providing it.

3. They have no personality, are ineffective and basically serve the function of officially commenting on the obvious.

4. Despite these impressions, doctors (and the sons of doctors) were highly respected.

In Victorian England:

“Doctors and physicians occupied the highest rung on the social ladder. Such citizens were considered gentleman because 1) their training did not include apprenticeship and 2) the profession excluded, supposedly, manual labor. Doctors were permitted to dine with the family during home visits, while other practitioners took dinner with the servants. A physician’s fee was wrapped and placed nearby, for theoretically gentleman did not accept money for their work. The prestige originated in their education: most often a higher degree from an esteemed school such as Cambridge, Oxford, or Edinborough. A medical degree, however, did not require any clinical experience. Students studied Greek and Latin theory, but they were not obligated to ‘walk the wards’. Not all ‘doctors’, however, attended a medical school. For the majority of the Victorian era no official licensing requirements existed, but the practice did become more professionalized and organized.”

Doctors and the medical profession have come a long way since 1874.

We now have multiple therapies that can preserve and improve lives.

Personally, I feel my profession is highly respected these days and, unlike the doctors in Far From the Madding Crowd, the respect is warranted.

Jude the Obscurely Yours

-ACP

Are Pasture-Raised Hen Eggs More Heart Healthy Than Conventional Eggs

Eggs (and dietary cholesterol) should no longer be restricted in a heart-healthy diet as the skeptical cardiologist has pointed out here.

But if we’re eating eggs should they come from “pasture-raised” (or grass-fed or pastured) hens?

The arguments for choosing hens that can roam freely and eat bugs, clover, and grass from the ground beneath them are of four types:

1. Ethical. The vast majority of eggs come from hens that are kept in a small cage most of their life and are never allowed to see the light of day or engage in their normal activities. This is inhumane.

2. Esthetic. Eggs from pasture-raised hens (PRH) taste better.

3. Health. PRH eggs are more nutritious because of the better food ingested by PRH and the manner in which they live and are treated.

4. Environmental. PRH operations are more sustainable and contribute less toxins and antibiotics to the environment.

Ethical Arguments

PETA gives a horrific description of what factory farm hens endure here. Here’s an excerpt:

“hens are shoved into tiny wire “battery” cages, which measure roughly 18 by 20 inches and hold up to 10 hens, each of whom has a wingspan of 32 inches. Even in the best-case scenario, each hen will spend the rest of her life crowded in a space about the size of a file drawer with four other hens, unable to lift even a single wing.

The birds are crammed so closely together that these normally clean animals are forced to urinate and defecate on one another. The stench of ammonia and feces hangs heavy in the air, and disease runs rampant in the filthy, cramped sheds. Many birds die, and survivors are often forced to live with their dead and dying cagemates, who are sometimes left to rot.”

PETA and vegans advocate not eating any animals or animal products. They have an inherent bias against omnivorous diets and their interpretation of the nutritional science always reflects that.

I sympathize with the plight of factory farms hens, but it is very difficult to martial scientific arguments in the area of the ethical treatment of animals.

 Nutritional Differences

A brief Google search yields dozens of websites which proclaim that PRH eggs are far more nutritious and better for you than conventional eggs. When a source for this claim is listed it comes from one of two studies:

1. Mother Earth News (Oct/Nov 2007). Mother Earth News is not known for its scientific rigor, but they did publish an analysis of the nutritional content of eggs from 14 farms with PRH and compared it to what the USDA had published for the nutritional content of conventional eggs.

Let me just say that this “study” would never be published in a reputable scientific journal due to flaws in the study design. For one thing, the PRH eggs should have been compared to conventional eggs analyzed at the same time in the same way in a blinded fashion. Also, there is no statistical analysis of the data.

Here is how Mother Earth News summarizes their findings:

These amazing results come from 14 flocks around the country that range freely on pasture or are housed in moveable pens that are rotated frequently to maximize access to fresh pasture and protect the birds from predators. We had six eggs from each of the 14 pastured flocks tested by an accredited laboratory in Portland, Oregon.

PRH eggs compared to the conventional eggs had

• 1/3 less cholesterol
• 1/4 less saturated fat
• 2/3 more vitamin A
• 2 times more omega-3 fatty acids
• 3 times more vitamin E
• 7 times more beta carotene

You can see the data in this PDF (PRH eggs versus conventional nutrients.)

Eggs were vilified during the heyday of the anti-fat movement because of their cholesterol and saturated fat content. We now know that neither one of these macronutrients causes heart disease; so the fact that PRH eggs have less of them is irrelevant. In addition, no other study has replicated the findings with respect to cholesterol and saturated fat content.

The higher levels of Vitamin A, Vitamin E and beta-carotene make sense given the differing food intake of PRH compared to factory hens, but again, there is nothing to suggest Americans aren’t consuming plenty of these vitamins in other foods. In addition, studies looking at supplementing diet with Vitamin E and beta-carotene have shown no overall health or cardiovascular benefits.

2.2010 paper by Karsten, et al. in Renewable Agriculture ad Food Systems.

This study is a legitimate peer-reviewed scientific study published in a reputable scientific journal by researchers who did not have any obvious bias or conflict of interest.. Bias can run both ways in these types of studies, as any research supported by the conventional egg industry would receive pressure to find no difference between conventional and PRH eggs. However, studies funded by advocates of PRH eggs would be hoping to find significant benefits of their eggs.

The 2010 study  found:

“Compared to eggs of the caged hens, pastured hens’ eggs had twice as much vitamin E and long-chain omega-3 fats, 2.5-fold more total omega-3 fatty acids, and less than half the ratio of omega-6:omega-3 fatty acids (P<0.0001).”

Of the nutrient differences reported between PRH and conventional eggs the omega-3 differences are the most intriguing. Both of these studies found a doubling of omega-3 fatty acids in PRH eggs, which are generally considered the healthiest of all fatty acids. The second study found a lower ratio  of omega-6:omega-3 in the PRH eggs. The relative benefits of omega-6 and omega-3 fatty acids in the diet is a topic of considerable controversy in the scientific literature right now but, in general, recommended diets like the Mediterranean feature higher omega-3 to omega-6 ratios than standard Western diets.

There are no studies looking at the differing effects of consuming PRH versus conventional eggs on biomarkers or outcomes in humans.

Thus, we have no idea whether the overall package of nutrients delivered in the PRH eggs would improve blood pressure, cholesterol parameters or markers of inflammation or whether they could lower your risk of heart attack or stroke.

 Taste

I have been eating PRH eggs whenever possible for the last few years and I swear they taste better than conventional eggs. In preparation for this post, I had decided that a blinded tasting of eggs would be needed to support my totally subjective assessment of PRH egg superiority.

However, it turns out that several blinded tasting egg comparison have already been done and the results are quite shocking to me.

The Food Lab at Serious Eats (which, by the way is dedicated to “unraveling the mysteries of home cooking through science”)  had 8 tasters  taste scrambled eggs prepared from PRH eggs, conventional hen eggs and various omega-3 supplemented eggs

One half of the tasters found no difference in taste between the various kinds of eggs, but those who did favor an egg favored the PRH eggs and the higher omega-3 eggs. The yolks of the PRH eggs and omega-3 eggs were more on the “intensely orange” end of the spectrum.

Did the more orange yolks taste better or were the tasters biased by the more intense color?

The tasting was repeated, this time with the color of the eggs masked by adding green food coloring. In this color-blind tasting:

“most people could not taste any difference in the eggs. Those who did taste a difference picked a totally different batch of eggs—this time, there was no clear winner, and no discernible trends based on how the eggs were produced or levels of omega-3’s”

A food writer for the Washington Post did a similar taste test, this time with actual blind folds, and although she was convinced that the eggs from her backyard hens would be superior, a panel of six tasters could find no difference between hers, conventional eggs, and organic eggs.

Although these taste tests haven’t been published in peer-reviewed scientific journals, they are likely as close as we are going to get to the truth. The fact that the organizers of the tests were biased towards PRH eggs tasting better but found no difference means almost certainly, alas, that there is no taste superiority for PRH eggs.

Are PRH Eggs Worth The Extra Cost?

Ultimately, this is a question for each individual. True PRH eggs cost upwards of 5 dollars per dozen compared to around 2$ per dozen (prior to the recent avian flu outbreak).

It is hard to justify that cost based on nutritional, health or taste considerations as I’ve shown.

Chelsea Pearson, communing with her hens

My oldest  daughter, Chelsea Pearson, has, along with thousands of other city dwellers, begun raising chickens in her backyard.  In addition to collecting delicious eggs from the hens, she has become attached to them and finds them to be interesting and enjoyable pets.

After weighing the ethical and environmental concerns despite the absence of conclusive health benefits or taste superiority I have elected to continue paying a premium for PRH eggs.

I have the financial resources to justify this decision but for those without such resources I totally  understand a decision to eat conventional eggs.

Eggstatically Yours,

-ACP