Category Archives: Lifestyle and Heart Disease

Are Plant-Based “Milks” The Margarine of the 21st Century?

Full fat dairy doesn’t make you fat or give you heart disease. But nutritional guidelines still continue to recommend the substitution of non-fat or low-fat dairy for full fat, something that flies in the face of an overall movement to consume less processed foods.

The rise of plant-based milks resembles in many ways the rise of margarine as a substitute for butter. In both cases, industry and misguided scientists collaborated to produce an industrial product to substitute for a natural food, based on an unproven projection of health benefits. Subsequent studies have shown that this was an unmitigated health disaster, as the trans fats created in the production of margarine substantially increase the risk of heart disease.

Anti-Dairy Propaganda

Vegan/vegetarian sources of nutritional information like one green planet make unsubstantiated claims about the benefits of plant-based milks and the dangers of traditional milk:

the consumption of dairy products has been linked to everything from increased risk of ovarian and prostate cancers to ear infections and diabetes. Fortunately, plant-based milks provide a convenient and healthful alternative to cow’s milk. And if you are currently making the transition to a dairy-free diet, you will find that going dairy-free has never been easier. Soy, almond, hemp, coconut, and rice milks, among others, are taking over the dairy case—and claiming supermarket aisles all their own.

Growth of Plant-Based “Milks”

In response to consumers desire for healthier alternatives to dairy, non-dairy liquid milk-like substitutes  have been thriving. Almond milk, the current darling of plant-based milks (PMB) , sales have grown 250% in the last 5 years during which time,  the total milk market has shrunk by more  than $1 billion.

In western Europe, sales of almond, coconut, rice and oat milks doubled in the five years to 2014; in Australia they rose threefold, and in North America sales shot up ninefold, according to Euromonitor.

Big global beverage food and drinks companies have been entering the PBM market recognizing that American consumers have become aware of the unhealthiness of sugar-sweetened beverages.

Coca-Cola, for example, recently purchased Unilever’s AdeS soya brand. and believes that PBM consumption will grow faster than any other segment of the beverage industry over the next 5 to 10 years. Coca-Cola also recently purchased the China Green brand of plant-based protein drinks.

What’s in Soy Milk and Why It’s Not Real Food

The plant-based milks are a mixed bag of highly processed liquids. Let’s look at soy milk which has been widely promoted as a healthy substitute for dairy. Empowered Sustenance points out that there is reason to be concerned about all the added ingredients found in Silk, a popular soy milk.

Soymilk (Filtered Water, Whole Soybeans), Cane Sugar, Sea Salt, Carrageenan, Natural Flavor, Calcium Carbonate, Vitamin A Palmitate, Vitamin D2, Riboflavin (B2), Vitamin B12.

The long list of ingredients give you an idea of how much processing is needed to approximate the nutritional components of real dairy. Whether adding back synthetic Vitamin D2, synthetic Vitamin A and calcium carbonate simulates the nutritional benefits of the naturally occurring vitamins in a naturally fatty milieu, is anyone’s guess.

Variable Nutritional  Content of Plant-Based “Milks”

Bestfoodfacts.org asked 3 academic nutritional PhD’s how they would advise consumers on substituting nondairy “milk:”

Dr. Macrina: Plant-based milks are quite variable in what they contain while cow’s milk is pretty standard. We know where cow’s milk comes from. Plant-based milks are manufactured and can have a variety of additives. I urge consumers to read the label to determine what’s best for them.

Dr. Savaiano: Yes, consumers should read the label very carefully. Plant-based drinks certainly can be a healthy choice depending on how they’re formulated.

Dr. Weaver: The plant-based beverages all cost a good deal more than cow’s milk. So, one needs to determine how much they want to pay for the nutrients and determine which nutrients you need to get from other foods. A main nutrient expected from milk is calcium. Only soy milk has been tested for calcium bioavailability (by my lab) which was determined to be as good as from cow’s milk. But none of the other plant beverages have been tested and they should be.

Is There Scientific Evidence To Support Replacing Milk and Dairy Products with Plant-based Drinks?

A recent review paper from Danish researchers attempted to answer the question:

Milk and dairy products: good or bad for human health? An assessment of the totality of scientific evidence. 

They concluded:

The most recent evidence suggested that intake of milk and dairy products was associated with reduced risk of childhood obesity. In adults, intake of dairy products was shown to improve body composition and facilitate weight loss during energy restriction. In addition, intake of milk and dairy products was associated with a neutral or reduced risk of type 2 diabetes and a reduced risk of cardiovascular disease, particularly stroke. Furthermore, the evidence suggested a beneficial effect of milk and dairy intake on bone mineral density but no association with risk of bone fracture. Among cancers, milk and dairy intake was inversely associated with colorectal cancer, bladder cancer, gastric cancer, and breast cancer, and not associated with risk of pancreatic cancer, ovarian cancer, or lung cancer, while the evidence for prostate cancer risk was inconsistent. Finally, consumption of milk and dairy products was not associated with all-cause mortality.

They went on to examine the question: Is there scientific evidence to substantiate that replacing milk and dairy products with plant-based drinks will improve health?

They noted the marked variation in nutritional content of the plant-based milks:

the nutrient density of plant-based milk substitutes varies considerably between and within types, and their nutritional properties depend on the raw material used, the processing, the fortification with vitamins and minerals, and the addition of other ingredients such as sugar and oil. Soy drink is the only plant-based milk substitute that approximates the protein content of cow’s milk, whereas the protein contents of the drinks based on oat, rice, and almonds are extremely low,

and their similarity to sugar-sweetened beverages:

Despite the fact that most of the plant-based drinks are low in saturated fat and cholesterol, some of these products have higher energy contents than whole milk due to a high content of oil and added sugar.

Some plant-based drinks have a sugar content equal to that of sugar-sweetened beverages, which have been linked to obesity, reduced insulin sensitivity , increased liver, muscle, and visceral fat content as well as increased blood pressure, and increased concentrations of triglyceride and cholesterol in the blood

PBM and real milk also differ with respect to important electrolytes and elements:

Analyses of several commercially available plant-based drinks carried out at the Technical University of Denmark showed a generally higher energy content and lower contents of iodine, potassium, phosphorus, and selenium in the plant-based drinks compared to semi-skimmed milk

and some PBM contain potentially dangerous components:

Also, rice drinks are known to have a high content of inorganic arsenic, and soy drinks are known to contain isoflavones with oestrogen-like effects. Consequently, The Danish Veterinary and Food Administration concluded that the plant-based drinks cannot be recommended as full worthy alternatives to cow’s milk which is consistent with the conclusions drawn by the Swedish National Food Agency

Finally, the authors emphasize the importance of the health effects of whole foods rather than individual nutrients. Plant-based milks are not whole or real foods:

The importance of studying whole foods instead of single nutrients is becoming clear as potential nutrient–nutrient interactions may affect the metabolic response to the whole food compared to its isolated nutrients. As the plant-based drinks have undergone processing and fortification, any health effects of natural soy, rice, oats, and almonds cannot be directly transferred to the drinks, but need to be studied directly.

The Skeptical Cardiologist Recommendation

Consumers should be very cautious in their consumption of plant-based milks. Eerily reminiscent of the push to switch from butter to margarine in the past, these drinks cannot be considered as healthier than dairy products.

They are creations of industry, promoted and produced by large companies like Coca-Cola and Unilever, whose goal is profit, not consumer’s health.

The PBMs are not true whole or real foods and their nutritional content varies wildly. Some resemble sugar-sweetened beverages like Coca-Cola.

If one of the synthetic ingredients added to these beverages turns out to have the markedly negative health effect that trans fats had, the analogy to margarine will be complete.

My  Eternal Fiancee’ has true lactose intolerance and has baristas substitute almond or soy milk when ordering a latte’.  I understand that but I’ve been trying to convince her (with increasing success lately!)  to drink my Chemex pour-over coffee and adulterate it with nothing, butter, cream or coconut oil.

Skeptically Yours,

-ACP

Featured image courtesy of One Green Planet.

For your enjoyment I present a mind-bogglingly complicated table listing the various nutrients in a mind-bogglingly long list of different plant-based milks (including hemp milk!):

 

 

 

Beware Of More Misinformation From The American Heart Association On Coconut Oil and Saturated Fats

In a “presidential advisory” to the American Heart Association (AHA)  a panel of experts last week  strongly endorsed the heart healthy benefits of replacing any and all saturated fats in our diet with vegetable oils (like corn , soy, and canola oil) which contain predominantly poly  or mono unsaturated fats.

Examining the metrics of this article it appears that the vast majority of news media reporting on it have lead with a headline that reads:

  Coconut oil isn’t actually good for you, the American Heart Association says     

Given this brazen attempt by the AHA to smear coconut oil’s reputation I felt compelled to revisit my analysis of coconut oil from a year ago. I’ve included new discussion on a key paper referenced by the AHA advisory and some words of wisdom from Gary Taubes.

Coconut Oil: Poster Child for Dietary Fat Confusion

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

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

In many respects, the vilification of coconut oil by federal dietary guidelines and the AHA resembles the inappropriate attack on dairy fat and is emblematic of the whole misguided war on dietary fat. In fact, the new AHA advisory  after singling out coconut oil goes on to cherry-pick the data on dairy fat and cardiovascular disease in order to  support their faulty recommendations for choosing low or nonfat dairy..

The AHAs simple message to replace all saturated fats in your diet with poly unsaturated fats (PUFAs) or monounsaturated fats (MUFAs) is flawed because:

  1. All saturated fats are not created equal :the kinds of saturated fats in coconut oil differs markedly from both dairy SFAs and beef SFAs . Some  SFAs may have beneficial effects on blood lipids, weight, and cardiovascular health.

  2. The types of nonSFAs in vegetable oils differ markedly and may have differential effects on cardiovascular health.

All Saturated Fats Are Not Created Equal!

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

The major SFA in coconut oil, lauric acid, has a 12 carbon chain and is thus considered a medium chain fatty acid (MCFA).

The AHA advisory makes a cursory attempt to address the huge hole in their logic primarily relying on a meta-regression analysis published in 2003 by Mensink, et al., and concludes:

The Mensink meta-regression analysis determined the effects on blood lipids of replacing carbohydrates with the individual saturated fatty acids that are in common foods, including lauric, myristic, palmitic, and stearic ac- ids. Lauric, myristic, and palmitic acids all had similar effects in increasing LDL cholesterol and HDL cholesterol and decreasing triglycerides when replacing carbohydrates

In summary, the common individual saturated fats raise LDL cholesterol. Their replacement with monounsaturated or polyunsaturated fats lowers LDL cholesterol. Differences in the effects of the individual fatty acids are small and should not affect dietary recommendations to lower saturated fat intake.

But if we examine what the actual paper by Mensink et al (available in full here) we find their conclusions are the exact opposite of the AHA:

Lauric acid greatly increased total cholesterol, but much of its effect was on HDL cholesterol. Consequently, oils rich in lauric acid decreased the ratio of total to HDL cholesterol. Myristic and palmitic acids had little effect on the ratio, and stearic acid reduced the ratio slightly.

The differences in the effects of the individual fatty acids are not small they are quite significant if we look at the totality of the effects on lipids relevant to cardiovascular disease. In their discussion, Mensink, et al go on to say:

Our results emphasize the risk of relying on cholesterol alone as a marker of CAD risk. Replacement of carbohydrates with tropical oils markedly raises total cholesterol, which is unfavorable, but the picture changes if effects on HDL and apo B are taken into account.

What’s more :

The picture may change again once we know how to interpret the effects of diet on postprandial lipemia, thrombogenic factors, and other, newer markers. However, as long as information directly linking the consumption of certain fats and oils with CAD is lacking, we can never be sure what such fats and oils do to CAD risk.

This graph from Mensink, et al. shows what would happen to the total/HDL cholesterol ratio if we substituted various foods in place of 10% mixed fat. Theoretically a lower ratio is more heart healthy. Look at the drastic differences between palm oil, coconut oil and butter, all of which are condemned by the AHA

 

Misguided Dietary Fat Recommendations

The  AHA experts have doubled down on their recommendation to use cooking oils that have less saturated fat such as canola and corn oil. They advise, in general, to “choose oils with less than 4 grams of saturated fat per tablespoon.”

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

The most recent data we have on replacing saturated fat in the diet with polyunsaturated fat comes from the Minnesota Coronary Experiment performed from 1968 to 1973, but published in 2016 in the BMJ.

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

Cherry-Picking Data

The new AHA presidential advisory doesn’t include this study or  data from the Sydney Heart Study, another study with negative results for substituting PUFAs for SFAs.

As Gary Taubes pointed out in a post for Larry Husten’s cardiobrief.org blog, the AHA experts cherry-picked four “core trials” that  agreed with their hypothesis and excluded the ones that don’t agree:

They do this for every trial but the four, including among the rejections the largest trials ever done: the Minnesota Coronary Survey, the Sydney Heart Study, and, most notably, the Women’s Health Initiative, which was the single largest and most expensive clinical trial ever done. All of these resulted in evidence that refuted the hypothesis. All are rejected from the analysis. And the AHA experts have good reasons for all of these decisions, but when other organizations – most notably the Cochrane Collaboration – did this exercise correctly, deciding on a strict methodology in advance that would determine which studies to use and which not, without knowing the results, these trials were typically included.

Coconut Oil: The Bottom Line

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

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

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

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

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

Finally, I agree with Taubes that we deserve good scientific studies proving without a doubt that these drastic changes in diet are truly helping:

“telling people to eat something new to the environment — an unnatural factor, à la virtually any vegetable oil (other than olive oil if your ancestor happen to come from the Mediterranean or mid-East), …..is an entirely different proposition. Now you’re assuming that this unnatural factor is protective, just like we assume a drug can be protective say by lowering our blood pressure or cholesterol. And so the situation is little different than it would be if these AHA authorities were concluding that we should all take statins prophylactically or beta blockers. The point is that no one would ever accept such a proposal for a drug without large-scale clinical trials demonstrating that the benefits far outweigh the risks. So even if the AHA hypothesis is as reasonable and compelling as the AHA authors clearly believe it is, it has to be tested. They are literally saying (not figuratively, literally) that vegetable oils — soy, canola, etc — are as beneficial as statins and so we should all consume them. Maybe so, but before we do (or at least before I do), they have a moral and ethical obligation to rigorously test that hypothesis, just as they would if they were advising us all to take a drug.”

Cocovorically Yours,

-ACP

For those seeking more information.

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

F7.large

 

 

 

Unsure About Taking A Statin For High Cholesterol? Consider A Compromise Approach

In an earlier post the skeptical cardiologist introduced Geo, a 61 year old male with no risk factors for heart attack or stroke other than a high cholesterol. His total cholesterol was 249, LDL (bad) 154, HDL (good) 72 and triglycerides 116.

His doctor had recommended that he take a statin drug but Geo balked at taking one due to concerns about side effects and requested my input. My first steps were to gather more information.

-I calculated his 10 year risk of stroke or heart attack at 8.4% (treatment with statin typically felt to benefit individuals with 10 year risk >7.5%) and as I have previously noted, this is not unusual for a man over age 60.

-I assessed him for any hidden  or subclinical atherosclerosis and found

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

So Geo definitely has atherosclerotic plaque in his coronary arteries. This puts him at risk for heart attack and stroke but not a lot higher risk than most men his age.

Strictly speaking, since he hasn’t already had a heart attack or stroke, treating him with a statin is a form of primary prevention. However, we know that atherosclerotic plaque has already developed in his arteries and at some point, perhaps years from now it will have consequences.

What is the best approach to reduce Geo’s risk?

It’s essential  to look closely at lifestyle changes in everyone to reduce cardiac risk.

The lifestyle components that influence risk are

  1. Cigarette Smoking (by far the strongest)
  2. Diet
  3. Exercise
  4. Obesity (Obviously related to #1 and #2)
  5. Stress
  6. Sleep

Patients who try to change to what they perceive as a heart healthy diet by switching to non-fat dairy and eliminating all red meat will not substantially lower risk (see here.) Even if you are possess the rock-hard discipline to stay on a radically low fat diet like the Esselstyn diet or the Pritikin diet there are no good data supporting their  efficacy in preventing cardiac disease.

Geo was not far from theMediterranean diet I recommend but would probably benefit from increased veggie and nut consumption. He was not overweight and he doesn’t smoke. I encouraged him to engage in 150 minutes of moderate exercise weekly.

Low Dose, Intermittent Rosuvastatin

I engaged in shared decision-making with Geo.  Informing him, as best I could, of the potential side effects and benefits of statin therapy.

After a long discussion we decided to try a compromise between no therapy and the guideline recommended moderate intensive dose statin therapy.

This approach utilizes a low dose of rosuvastatin taken intermittently with the goal of minimizing any statin side effect but obtaining some of the benefits of statin drugs on  cardiovascular risk reduction.

I have many patients who have been unable to tolerate other statin drugs in any dosage due to statin related muscle aches but who tolerate this particular  treatment and I  see substantial reductions in the LDL (bad) cholesterol with this approach.

Studies have shown that rosuvastatin 5–10 mg or atorvastatin 10–20 mg given every other day produce LDL-C reduction of 20–40 %

Studies have also shown that In patients with previous statin intolerance, rosuvastatin administered once or twice weekly (at a mean dose of 10 mg per week) achieved an LDL-C reduction of 23–29% and was well tolerated by 74–80 % of patients.

In a recent report from a specialized lipid clinic, 90 % of patients referred for intolerance to multiple statins were actually able to tolerate statin therapy, although the majority was at a reduced dose and less-than-daily dosing.

Results in Geo

After several months of taking 5 mg rosuvastatin twice weekly Geo felt fine with no discernible side effects. He obtained repeat cholesterol  levels:

His LDL had dropped 52% from 140 to 92.

Hopefully, this LDL reduction plus the non-cholesterol lowering beneficial properties of statins (see here) will substantially lower Geo’s risk of heart attack and stroke.

We need randomized studies testing long-term outcomes using this approach to make it evidence-based. But in medicine we frequently don’t have studies that apply to  specific patient situations. In these cases shared decision-making in order to find solutions that fit the individual patient’s concerns and experience becomes paramount.

Faithfully Yours,

-ACP

 

 

 

More Incredibly Bad Science From Dr. Esselstyn’s Plant-Based (Vegan) Diet Study

A while back the skeptical cardiologist exposed “The incredibly bad science behind Dr. Esselstyn’s plant-based diet.

The diet has the catchy slogan “eat nothing with a face or a mother” and Esselstyn was featured in the vegan propaganda film “Forks Over Knives.”

After detailing the lack of science I concluded:

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.

The post garned little attention initially but in the last few months several hundred visitors per day apparently read it and Essesltyn followers have started leaving me testimonials to the diet along with nasty comments.

Here’s are some typical ones (with my comments in red)

“If your (sic) not backed by some meat industry or cardiac bypass group I would be much surprised.”

I am completely free of bias. Nobody is paying me anything to do the research and writing I do. My only purpose is to find the truth about diet in order to educate my patients properly. I have  saved many more patients from bypass surgery than I have referred for the procedure.

“it is so arrogant to think the only science could come from clinical studies which may be funded by an interested party.”

Doctors like randomized (and preferably blinded) clinical studies because they minimize the bias introduced by interested parties like patients and zealous investigators (like Dr. E)  motivated to see positive outcomes. Small, non-randomized studies can only generate ideas and hypotheses which larger, randomized studies can prove with a greater degree of certainty.

“the entire nentire western medical system is skewed due to the big pharma influence…unfortunately western medicine believes the only science is the pen and the scalpel..whereas …history is the best teacher of all…”

By pen I assume you mean medications. If we examine history as  you suggest we see that life expectancy was 50 years in 1945  but today in developed countries it is around 80 years. This advance corresponds to (among other things) advances in vaccines, antibiotics, anti-cancer drugs, cardiac and blood pressure medications and surgery: the pen and the scalpel. It does not correspond to following a vegan diet.

“Your foolishness is the embarrassment.”

Thank you for this insightful comment! I’m considering it as my epitaph.

One man felt that changing to the Esselstyn diet dramatically improved his cardiac situation and commented:

“Nothing like bashing something that works just because you want to eat meat. .”

I do enjoy meat in moderation but I also really enjoy vegetables, nuts, fish, legumes, olive oil and avocados. I looked into Esselstyn’s diet in detail because it stands out as particularly misguided in banning nuts, avocados, fish and olive oil to heart patients.

..”.So sicking (sic) to see people talk trash about something that works so well… It saved my life…”

I’m happy you are doing well with your cardiac condition but it is impossible to know what would have happened to you on a more reasonable diet such as the Mediterranean diet (which actually has legitimate scientific studies supporting it). And again criticizing Esselstyn’s ideas and “study” can hardly be considered trash talk.

“I personally have followed dr. esselstyn’s program for what will be 5 years in 11/17 and have made tremendous gains in my cardio pulmonary function….my cardiologist looks at me in wonder…why are you here? and often says , if everyone did what you have…Id be out of business…so…isnt that telling and sad?”

I’m glad you’re doing well with the program, most patients can’t follow this kind of diet for more than a few months.  But perhaps we shouldn’t judge its effectiveness until  we make sure you don’t suffer a heart attack next week. Your cardiologist is wrong: see what I wrote about “dealing with the cardiovascular cards you’ve been dealt.” Some individuals inherit genes that guarantee progressive and accelerated atherosclerosis that will kill them at an early age despite the best lifestyle.

“…the phrase “follow the money” comes to mind…and since theres no big money to be made….science will attempt to dispell the results and thousands of years of history that proves this dietary system works…”

Using a scientific approach to analyze Esselstyn’s diet (which tries to claim a scientific basis) seemed appropriate to me but I wasn’t motivated by money. I’m looking for what is best for my patients, pure and simple.

The Plural of Anecdote Is Not Data

One man wrote:

“But since this is only anecdotal evidence – it must be junk science…”

Esseslstyn devotees like to post what their personal experience is with the diet but as skeptical medicine has pointed out “the plural of anecdote is not data.” 

One woman described in detail a good response her husband had after starting the diet following a heart attack:

I’m concerned about the skeptical cardiologist going after the person of dr. Esselstyn versus the science, such as quoting how you States dr. Esselstyn came up with the diet. So there may be a personal bias there. I’m sure there are more people out there on the esselstyn diet that are not noted in the study years ago. I hope there is another book coming out

I’ve reviewed in detail my comments about how Esselstyn came up with the diet but I am at a loss to find any ad hominem attack.

This woman went on to say

We will keep you posted, as my husband is willing to get another cardiac Cath and 12 months to visually see the difference after the diet.

I have to point out that if his cardiologist performs a cardiac cath (which carries risks of stroke, heart attack and death) for the sole purpose of checking the effect of the diet he is engaging in unethical medical behavior and likely insurance fraud. By the way, I hope that your husband is on a statin like most of Dr. Esselstyn’s are!:)

and a man wrote

Calling Essylstein ilk shows a little too much biased hatred on your part

Please note the definition of ilk “a type of people or things similar to those already referred to.” No pejorative there. And no ad hominem attack.  I wrote:

 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.

I should be able to criticize the methods and ideas of Dr. E without it being considered an attack on his person

Completely wrong. Esselstyn has saved my life. His book explains it all, how the endothelium cells get ruined, inflammation … heart attack proof (his words). One does not continue as head of the Cleveland Wellness Center if one is a quack.

Words are easy to come by on the interweb but Dr. E’s are not supported by science and as for the “Cleveland Wellness Center” it is probably not wise to get me started. Dr. E ‘s program is listed as being part of the Cleveland Clinic Wellness Center which is an attempt to capitalize on the market for pseudoscientific enterprises. He is not the director. The director recently came under intense criticism for promoting anti vaccine quackery. (See here).

The Wellness Center promotes so-called functional, integrative, complementary and alternative approaches. (Functional medicine is fake medicine!) These are approaches that have not been proven to work and could arguably be called quackery. (Let me be clear, however, I am not calling Dr. Esselstyn a quack but the fact that he is part of the Wellness Center does not add any scientific validity to his work.)

“I’m sure there are more people out there on the esselstyn diet that are not noted in the study years ago. I hope there is another book coming out”

Fake News, Fake Science

As a matter of fact, Dr. E has been hard at work over the last 30 years and has added a grand total of 176 patients who are considered “adherent” to the diet: about 6 per year. The “original research” was published in The Journal of Family Practice in 2014. Unfortunately the bad science present in the original publication has only been amplified.

In addition to any randomization or suitable control group for comparison, the data collection techniques are unacceptable:

“In 2011 and 2012 we contacted all participants by telephone to gather data. If a participant had died, we obtained follow-up medical and dietary information from the spouse, sibling, off-spring or responsible representative.”

In other words, there was no actual systematic review of medical records, autopsies or death certificates, just word of mouth from whomever answered the phone.

“Patients who avoided all meat, fish, dairy, and knowingly, any added oils throughout the program were considered adherent.”

Imagine, if you will, that your husband died 10 years ago and you received a call from Dr. E’s office or perhaps Dr. E himself and he asks you if your husband “avoided all meat, fish, dairy and added oils.”  For one thing, it would be very difficult for you to answer that question with any degree of accuracy: was your husband cheating on Dr. E’s diet when you weren’t looking, do you remember his entire diet from 10 years ago?

For another thing, you know that the caller has an agenda. If your husband died of a heart problem the caller is not going to be happy until he/she gets you to admit that your husband had some guacamole on Cinco de Mayo in 2002. If he’s alive and doing well, the caller is likely to be satisfied with a simple answer that , yes, he’s following the diet.

Yes, we have more data from Dr. E but it turns out to be even more incredibly bad than the first lot.

Let the anecdotes and ad hominem attacks begin!

-ACP

Dr. P’s Heart Nuts: Preventing Death In Multiple Ways

The skeptical cardiologist has finally prepared Dr. P’s Heart Nuts for distribution. IMG_8339The major stumbling block in preparing them was finding almonds which were raw (see here), but not gassed with proplyene oxide (see here), and which did not contain potentially toxic levels of cyanide (see here).

During this search I learned a lot about almonds and cyanide toxicity, and ended up using raw organic almonds from nuts.com, which come from Spain.

I’ll be giving out these packets (containing 15 grams of almonds, 15 grams of hazelnuts and 30 grams of walnuts) to my patients because there is really good scientific evidence that consuming 1/2 packet of these per day will reduce their risk of dying from heart attacks, strokes, and cancer.

IMG_7965The exact components are based on the landmark randomized trial of the Mediterranean diet, enhanced by either extra-virgin olive oil or nuts (PREDIMED, in which participants in the two Mediterranean-diet groups received either extra-virgin olive oil (approximately 1 liter per week) or 30g of mixed nuts per day (15g of walnuts, 7.5g of hazelnuts, and 7.5g of almonds) at no cost, and those in the control group received small nonfood gifts).

After 5 years, those on the Mediterranean diet had about a 30% lower rate of heart attack, stroke or cardiovascular death than the control group.

It’s fantastic to have a randomized trial (the strongest form of scientific evidence) supporting nuts, as it buttresses consistent (weaker, but easier to obtain), observational data.

Trademark

I applied for a trademark for my Heart Nuts, not because I plan to market them, but because I thought it would be interesting to possess a trademark of some kind.

The response from a lawyer at the federal trademark and patent office is hilariously full of mind-numbing and needlessly complicated legalese.

Heres one example:

"DISCLAIMER REQUIRED
Applicant must disclaim the wording “NUTS” because it merely describes an ingredient of applicant’s goods, and thus is an unregistrable component of the mark.  See 15 U.S.C. §§1052(e)(1), 1056(a); DuoProSS Meditech Corp. v. Inviro Med. Devices, Ltd., 695 F.3d 1247, 1251, 103 USPQ2d 1753, 1755 (Fed. Cir. 2012) (quoting In re Oppedahl & Larson LLP, 373 F.3d 1171, 1173, 71 USPQ2d 1370, 1371 (Fed. Cir. 2004)); TMEP §§1213, 1213.03(a).

The attached evidence from The American Heritage Dictionary of the English Language shows this wording means “[a]n indehiscent fruit having a single seed enclosed in a hard shell, such as an acorn or hazelnut”, or “[a]ny of various other usually edible seeds enclosed in a hard covering such as a seed coat or the stone of a drupe, as in a pine nut, peanut, almond, or walnut.”  Therefore, the wording merely describes applicant’s goods, in that they consist exclusively of nuts identified as hazelnuts, almonds, and walnuts.

An applicant may not claim exclusive rights to terms that others may need to use to describe their goods and/or services in the marketplace.  See Dena Corp. v. Belvedere Int’l, Inc., 950 F.2d 1555, 1560, 21 USPQ2d 1047, 1051 (Fed. Cir. 1991); In re Aug. Storck KG, 218 USPQ 823, 825 (TTAB 1983).  A disclaimer of unregistrable matter does not affect the appearance of the mark; that is, a disclaimer does not physically remove the disclaimed matter from the mark.  See Schwarzkopf v. John H. Breck, Inc., 340 F.2d 978, 978, 144 USPQ 433, 433 (C.C.P.A. 1965); TMEP §1213.

If applicant does not provide the required disclaimer, the USPTO may refuse to register the entire mark.  SeeIn re Stereotaxis Inc., 429 F.3d 1039, 1040-41, 77 USPQ2d 1087, 1088-89 (Fed. Cir. 2005); TMEP §1213.01(b).

Applicant should submit a disclaimer in the following standardized format:

No claim is made to the exclusive right to use “NUTS” apart from the mark as shown."

I’ve gotten dozens of emails from trademark attorneys offering to help me respond to the denial of my trademark request. Is this a conspiracy amongst lawyers to gin up business?

Nuts Reduce Mortality From Lots of Different Diseases

The most recent examination of observational data performed a meta-analysis of 20 prospective studies of nut consumption and risk of cardiovascular disease, total cancer, and all-cause and cause-specific mortality in adult populations published up to July 19, 2016.

It found that for every 28 grams/day increase in nut intake, risk was reduced by:

29% for coronary heart disease

7% for stroke (not significant)

21% for cardiovascular disease

15% for cancer

22% for all-cause mortality

Surprisingly, death from diseases, other than heart disease or cancer, were also significantly reduced:

52% for respiratory disease

35% for neurodenerative disease

75% for infectious disease

74% for kidney disease

The authors concluded:

If the associations are causal, an estimated 4.4 million premature deaths in the America, Europe, Southeast Asia, and Western Pacific would be attributable to a nut intake below 20 grams per day in 2013.

If everybody consumed Dr. P’s Heart Nuts, we could save 4.4 million lives!

Meditativeterraneanly Yours,

-ACP

If you’re curious about why nuts are so healthy, check out this recent meta-analysis, a discussion of possible mechanisms of the health benefits of nuts complete with references:

Nuts are good sources of unsaturated fatty acids, protein, fiber, vitamin E, potassium, magnesium, and phytochemicals. Intervention studies have shown that nut consumption reduces total cholesterol, low-density lipoprotein cholesterol, and the ratio of low- to high-density lipoprotein cholesterol, and ratio of total to high-density lipoprotein cholesterol, apolipoprotein B, and triglyceride levels in a dose–response manner [4, 65]. In addition, studies have shown reduced endothelial dysfunction [8], lipid peroxidation [7], and insulin resistance [6, 66] with a higher intake of nuts. Oxidative damage and insulin resistance are important pathogenic drivers of cancer [67, 68] and a number of specific causes of death [69]. Nuts and seeds and particularly walnuts, pecans, and sunflower seeds have a high antioxidant content [70], and could prevent cancer by reducing oxidative DNA damage [9], cell proliferation [71, 72], inflammation [73, 74], and circulating insulin-like growth factor 1 concentrations [75] and by inducing apoptosis [71], suppressing angiogenesis [76], and altering the gut microbiota [77]. Although nuts are high in total fat, they have been associated with lower weight gain [78, 79, 80] and lower risk of overweight and obesity [79] in observational studies and some randomized controlled trials [80].

Longevity: Lifespan, Healthspan and Swimming Underwater At Age 98

img_7056
Eugene and Naomi.

The skeptical cardiologist has a few nonagenarian patients who seemingly defy the ravages of aging and remain vibrant and active into their late 90’s.

Eugene, for example, still ballroom
dances regularly with his wife, Naomi and swims underwater significant distances.

In this video, recorded when he was 97, you can see him swim the length of a swimming pool underwater

As life expectancy at birth has increased  from 35 years in 1900 to over 80 years now, we see more and more individuals reaching their nineties. Ongoing research seeks to further extend our lifespan.

But just as important as increasing lifespan is increasing healthspan, the portion of the life span during which function is sufficient to maintain autonomy, control, independence, productivity and well-being.

Eugene is an example of someone with a long lifespan and healthspan and this is what we truly seek, the combination of living well and living long.

Peter Attila writes that lifespan is driven by how long one can avoid the onset of diseases caused by atherosclerosis such heart attacks and strokes (see my  discussions on subclinical atherosclerosis here), cancer and neurodegenerative disease.

Healthspan,  Attila writes, is about preserving three elements of life as long as possible:

  1. Brain—namely, how long can you preserve cognition and executive function

  2. Body—specifically, how long can you maintain muscle mass, functional strength, flexibility, and freedom from pain

  3. “Spirit”—how robust is your social support network and your sense of purpose.

Problems with the body result in frailty, recognized as a major cause of disability and related falls, hospitalizations and death in the elderly.

The single best tool for warding off frailty appears to be physical exercise.

img_7051
Eugene and Noami tripping the light fantastic in our exam room

So, if you want to life a long life with lots of quality years at the
end of that life be like Eugene: swim and dance with your loved ones. Keep moving, stretch and exercise in some manner regularly.

Gerontologically Yours,

-ACP

Should Fitness Be A Vital Sign?

The skeptical cardiologist routinely probes his patients’ activity and exercise levels and encourages them to engage in 150 minutes of moderate exercise weekly. However, I’m somewhat skeptical of the benefit of treating such assessments as a vital sign (like blood pressure or heart rate)  as a recent AHA scientific statement suggests.

I can only envision still another item  on a chart checklist that will have to be recorded in the EHR or already over-worked physicians will have their payments withheld.

The AHA statement suggests that ideally we should be measuring  our patients’ fitness by obtaining  maximal oxygen consumption (VO2 max) utilizing an expensive and rarely utilized cardiopulmonary exercise test. Failing that we should consider doing a treadmill stress test. Failing that, rather than utilizing my simple question to patients: “How active have you been?”,  the statement recommends doctors utilize some sort of formal questionnaire to estimate their patients’ cardiorespiratory fitness (CRF) such as the one at World Fitness Level.

I went online to take this CRF estimator (based on this paper) and I remain skeptical.

The online site and  a free smartphone app both ask the following questions:

  • Country and City
  • Ethnicity
  • Highest Level of Education
  • Gender/Age/Height/Weight
  • Resting and Maximal Pulse
  • How often do you exercise?
  • How long is your workout each time? (over/under 30 minutes)
  • How hard do you train? (I had to choose between “I go all out”or “Little hard breathing and sweating”)

 

screen-shot-2016-12-03-at-11-33-13-amWhen you have finished answering the questions you are given an estimate of your fitness age. When I did this online a few days ago and answered truthfully I got the result to the right: I had the fitness of a 41 year old with an estimated VO2 max of 49 ! (interestingly this estimate corresponds exactly with VO2 max derived from a recent stress test I completed.)

I used the app (which unlike the online version did not ask me my waistline measurement) and changed a few parameters:

  • I increased my resting heart rate or pulse  from 60 to 68 beats per minute (BPM)
  • I increased my maximal heart rate from what I know is 158 BPM to what the app calculated (173 BPM, which makes no sense)
  • I switched from exercising 2-3 times per week  and longer than 30 minutes  at “all out” level to the lowest level for all 3 questions.

The change was dramatic and depressing: I went from 39 years old to 67 years old in the bat of an eyelid!img_8073

 

 

 

The app and online site direct you to a non-profit site where you can get information on a 7 week program to increase your fitness level. I haven’t checked this out.

I’ll be trying out this CRF estimator on my patients: assessing whether it adds anything to my usual line of questioning on activity and fitness.

I encourage you to give the CRF estimator a try. Let me know in the comments how you feel it works for you. Does it motivate you to exercise more knowing that, for example, your fitness age is substantially higher than your chronological age?

Are We Springing Forward to Death?: Daylight savings time and myocardial infarction

Tonight we will lose an hour of our lives when we observe Daylight Savings Time (DST).

Media reports suggest that DST, beyond robbing of us that nocturnal hour in the spring are also increasing our risk of heart attack (myocardial infarction or MI) and death.

Is this a valid concern or just media hype on a slow news day?

Scientific studies on this topic are mixed.

A recent study from Finland found MI rates increased 16% on the Wednesday after spring DST time change and dropped by 15% on the Monday after fall DST time change.

A 2015 German study found no difference in MI rate in the 3days or 1 week after spring or fall DST transitions.

However, some American studies have detected a bump in MI rate on the day after DST transition in the spring and a similar drop in MI rate on the day after the fall DST change.

A study of 42000 patients undergoing acute PCI for MI in Michigan found that

“The Monday following spring time changes was associated with a 24% increase in daily AMI counts (p=0.011), and the Tuesday following fall changes was conversely associated with a 21% reduction (p=0.044). No significant difference in total weekly counts or for any other individual weekdays in the weeks following DST changes was observed.”

Screen Shot 2016-03-12 at 2.28.26 PM

They concluded:

Our data argue that DST could potentially accelerate events that were likely to occur in particularly vulnerable patients and does not impact overall incidence. There is considerable controversy over the health and economic benefits of DST, and some authorities have argued that this practice should be abandoned.17 Although we are unable to comment on the merits of these arguments, our data suggest that while such a move might change the temporal fluctuations in AMI, it is unlikely to impact the total number of MIs in the broader population.

Mondays, in general, are the days of the week on which most MIs occur. This has been attributed to an abrupt change in the sleep–wake cycle and increased stress in relation to the start of a new work week

Manipulations of the sleep–wake cycle have been linked to imbalance of the autonomic nervous system, rise in proinflammatory cytokines and depression so presumably the additional disruption created by DST adds to this effect.

However, the data suggest that this very weak effect means only that if you were going to have an MI in the next week, after DST it is more likely to occur on the Monday of that week than on another day. Your overall risk of MI is not changed.

From a public health standpoint the major conclusion is that emergency rooms and cath labs should consider increasing staffing by 24% on the Monday after the spring DST time change.

I don’t think this is a significant factor for my patients. We have to deal with events and stressors that influence our sleep-wake cycle constantly. Good planning and sleep hygiene are the keys to success and reducing stress.

So, fear not the grim reaper as you set your clocks forward tonight.

Circadianly yours,

-ACP

PHOTO: PAVEL ŠEVELA/WIKIMEDIA COMMONS

 

Can The Garmin Vivosmart (Or Any Inactivity Monitor) Make You Healthier?

Americans do a lot of sitting. We sit in our cars, we sit watching TV , we sit reading or when interfacing with our computers and often our work involves many hours of sitting in front of a computer.

All this sitting or sedentariness  has been associated with an increased risk of obesity, metabolic syndrome, type 2 diabetes, and cardiovascular disease (CVD) mortality,

One recent study concluded

 “limiting sitting to <3 h/day and limiting television viewing to <2 h/day may increase life expectancy at birth in the USA by approximately 2.0 and 1.4 years, respectively, assuming a causal relationship.”

Even if you make your way to the gym and  meet current physical activity guidelines, excessive sedentary behavior may have adverse implications, particularly if you are older.

Recent studies suggests that longer-term consequences of not engaging in moderate to vigorous physical activity (too little exercise) are different from those of habitual sedentary behavior.

Dr. James Levine has been a leader of the “anti-chair mafia” and research on the negative effects of sedentariness and has written a book entitled “Get Up! Why Your Chair is Killing You and What You Can Do About It” , available here.

Sitting Is Not NEAT!

The energy expended during daily life (exclusive of purposeful exercise) has been measured with special sensor equipped underwear and is termed non exercise activity thermogenesis (NEAT).

Individuals who are lean have high NEAT. They are up and moving around 2 and  1/4 hours per day more than those who are obese and burn an extra 350 kcl/day of energy.

I advise all my patients to move as much as possible during their normal work or leisure day. Take frequent walking breaks, climb stairs, attach your computer to a treadmill, do anything to avoid prolonged sitting.

Activity and Inactivity Monitoring

You can now easily monitor your activity during the day with one of multiple smartphone apps and/or an associated wearable.

The skeptical cardiologist plunged into the wearable activity monitor world recently and purchased a Garmin Vivosmart (engadget review entitled “where fitness band meets smartphone”  here.)

I chose it from all the competing devices because of the following features

  • pairs with iPhone to sync data and display iPhone calls/messages-
  • monitors movement during sleep
  • monitors inactivity
  • monitors steps taken

I plan to report more extensively on all the features of this cool gizmo after I’ve had it longer.

Promotion of Physical Activity

The Vivosmart does a number of things that are designed to promote physical activity.

steps
The Vivosmart telling me I have taken 11, 639 steps. These were all taken during work, walking between patient rooms and between the hospital, the OR and my office. A read out on my steps motivates me to move more, take stairs, and embrace movement as a valuable thing.

It counts your steps pretty reliably and can monitor your heart rate when paired with a chest heart rate monitor.

It will help you visualize how close you are to reaching your steps per day goal and congratulate you when you reach it.

In addition it monitors your activity and takes note of your inactivity.

If you haven’t moved sufficiently in one hour it vibrates and displays “MOVE!” on its LEDs. If you don’t move enough to satisfy its criteria it will remind you every 15 minutes thereafter to MOVE!.

This sounds good on paper but it didn’t; work that well in practice for me.

A typical day at the office for me involves a lot of brief bursts of walking, some stair climbing, and a fair amount of standing.

MOve
The Vivosmart inactivity monitor, telling me that I have been inactive for 41 minutes. In 19 minutes it will warn me to move by vibrating and flashing. I’ve been active this whole time, however, never sitting more than 10 minutes.

For instance, I walk to the patient exam room and sit down to take the patient’s history. At some point I stand up and exam the patient. When the visit is done I either walk back to my office to complete the office note or go to the next exam room. There is very little prolonged sitting occurring but these frequent, brief bursts of activity do no reset the Garmin Vivosmart.

Prolonged sitting is really what we want to avoid but the Vivosmart will only reset your inactivity meter if you walk continuously about 200 steps. Standing still even if interspersed with brief bursts of walking for less than two min,tes will not reset it.

If your job or normal day consists mostly of sitting for prolonged periods of time then this reminder to move may be helpful. However, for zero dollars you could  program your cell phone to go off every hour and serve essentially the same function.

I heartily endorse anything that gets my patients up and moving and off the couch. I think the Garmin Vivosmart (and other similar fitness trackers) is a step in the right direction and can lend focus and motivation to the goal of keeping active during the day.

To accurately measure NEAT, however, we may need magic wired underwear, something the public may not be ready for :).

-spending entirely too much time sitting and blogging,

-ACP

Is Exercise Impotent In Preventing Obesity?

What if all that exercise that authorities have been recommending  is not helping to stem the rising tide of obesity?

What if all calories don’t have the same ability to add fat?

These twin heresies fly in the face of the usual dogma on the cause of obesity: more calories in (gluttony) than calories out (sloth). The skeptical cardiologist has been pondering these possibilities for some time, since reading Gary Taubes book Good Calories, Bad Calories.

I have been advising my patients through this blog and during office visits that added sugar and  refined  carbohydrates are much more of a culprit in their  weight gain than fat, thus embracing the concept that there are good calories and bad calories

Exercise and Obesity

5Boro Bike Riders crossing the summit of the Queensboro aka 59th Street aka "Feelin Groovy" Bridge

But I also spend a lot of time during my office visits discussing activity levels and encouraging my patients to engage in moderate aerobic physical activity for at least 150 minutes per week.

I do this because there is good evidence that regular physical activity is associated with lower cardiovascular risk, cancer risk, mortality, and improved brain, muscle, and bone function. Exactly  what level and type of exercise is needed to reap these benefits is still up for debate.

I, personally, engage in regular moderate exercise and I think it helps maintain my weight where I want it.

Throwing Down the Gauntlet

A recent editorial in the British Journal of Sport Medicine stridently  makes the claim that exercise is not useful for weight loss as conventional wisdom teaches and that the food industry has been promoting exercise while simultaneously promoting junk food and sugar-sweetened beverages (The link I provided is no longer active because the journal has removed the editorial -“This paper has been temporarily removed following an expression of concern.”)

The authors wrote:

“members of the public are drowned by an unhelpful message about maintaining a healthy weight through calorie counting, and many still wrongly believe that obesity is entirely due to lack of exercise. This false perception is rooted in the Food Industry’s Public Relations machinery, which uses tactics chillingly similar to those of big tobacco. “

Root Causes of Obesity

It would appear that science cannot tell us with total certainty what the cause of our current obesity epidemic is.

After publishing a paper in 2014 that suggested Americans had become less active over the last 20 years, Ladabaum, et al admitted this:

“Although there is no clear answer at this time regarding the relative contribution of energy intake or physical activity (or other variables including dietary components, patterns of activity, and environmental factors, including the gut micro biome) to the public health problem of obesity, we believe that public health messages should continue to emphasize the importance of both a healthy diet and remaining physically active throughout life.”

Is Exercise Amount  A Cause or Effect?

In my own practice, I have observed a tendency for  those patients who regularly exercise or have very physically active jobs to stay thin whereas those who don’t exercise, especially if they have sedentary jobs or are retired, tend to be obese and gain weight.

But, I also note that those patients who take my recommendations on exercise to heart  are also listening to my advice in other areas, including diet and medications and are, in general, much more proactive about their health.

Therefore, I can’t say for sure whether it is the exercise  or the other aspects of a healthy lifestyle (including diet)  being followed in any individual patient that is keeping the pounds off. How much my patients move during the day when they are not specifically exercising may also be playing a role and is hard for me to assess.

There is also the mind-boggling possibility, as Gary Taubes has written about (here and in his book Why We Get Fat) that our genetics are driving both our activity levels and our food consumption:

Ultimately, the relationship between physical activity and fatness comes down to the question of cause and effect. Is Lance Armstrong excessively lean because he burns off a few thousand calories a day cycling, or is he driven to expend that energy because his body is constitutionally set against storing calories as fat? If his fat tissue is resistant to accumulating calories, his body has little choice but to burn them as quickly as possible: what Rony and his contemporaries called the “activity impulse”—a physiological drive, not a conscious one. His body is telling him to get on his bike and ride, not his mind. Those of us who run to fat would have the opposite problem. Our fat tissue wants to store calories, leaving our muscles with a relative dearth of energy to burn. It’s not willpower we lack, but fuel. “

I’m not ready to accept the heresy that exercise and activity have nothing to do with weight gain or loss. I, like most cardiologists, walk the walk and talk the talk of regular vigorous exercise for health benefits, extended longevity, cardiovascular fitness and for helping in weight control.

Exercise is not the be all and end all of weight control because increased consumption of bad or good calories can overcome the most prolonged and intense workouts but it is a useful adjunct.

Still exercising regularly,

-ACP