Category Archives: Lifestyle and Heart Disease

Does Eating Saturated Fat Lower Your Risk of Stroke and Dying?: Humility and Conscience in Nutritional Guidelines

A study presented at the European Society of Cardiology  meetings in Barcelona and simultaneously published in The Lancet earlier this month caught the attention of many of my readers. Media headlines trumpeted  “Huge New Study Casts Doubt On Conventional Wisdom About Fat And Carbs” and “Pure Shakes Up Nutritional Field: Finds High Fat Intake Beneficial.”

Since I’ve been casting as much doubt as possible on the  conventional nutritional wisdom  to cut saturated fat, they reasoned, I should be overjoyed to see such results.

What Did the PURE Study Find?

The Prospective Urban Rural Epidemiology (PURE) study, involved more than 200 investigators who collected data on more than 135000 individuals from 18 countries across five continents for over 7 years.

There were three high-income (Canada, Sweden, and United Arab Emirates), 11 middle-income (Argentina, Brazil, Chile, China, Colombia, Iran, Malaysia, occupied Palestinian territory, Poland, South Africa, and Turkey) and four low-income countries (Bangladesh, India, Pakistan, and Zimbabwe)

This was the largest prospective observational study to assess the association of nutrients (estimated by food frequency questionnaires) with cardiovascular disease and mortality in low-income and middle-income populations,

The PURE team reported that:

Higher carbohydrate intake was associated with an increased risk of total mortality but not with CV disease or CV disease mortality.

This finding meshes well with one of my oft-repeated themes here, that added sugar is the major toxin in our diet (see here and here.)

Higher fat intake was associated with lower risk of total mortality.

Each type of fat (saturated, unsaturated, mono unsaturated ) was associated with about the same lower risk of total mortality. 

 

These findings are consistent with my observations that it is becoming increasingly clear that cutting back on  fat and saturated fat as the AHA and the Dietary Guidelines for Americans have been telling you to do for 30 years is not universally helpful (see here and  here ).

When you process the fat out of dairy and eliminate meat from your diet although your LDL (“bad”) cholesterol drops a little your overall cholesterol (atherogenic lipid) profile doesn’t improve (see here).

Another paper from the PURE study shows this nicely and concluded:

Our data are at odds with current recommendations to reduce total fat and saturated fats. Reducing saturated fatty acid intake and replacing it with carbohydrate has an adverse effect on blood lipids. Substituting saturated fatty acids with unsaturated fats might improve some risk markers, but might worsen others. Simulations suggest that ApoB-to-ApoA1 ratio probably provides the best overall indication of the effect of saturated fatty acids on cardiovascular disease risk among the markers tested. Focusing on a single lipid marker such as LDL cholesterol alone does not capture the net clinical effects of nutrients on cardiovascular risk.

Further findings from PURE:

-Higher saturated fat intake was associated with a lower risk of stroke

-There was no association between total fat or saturated fat or unsaturated fat with risk of heart attack or dying from heart disease.

Given that most people still believe that saturated fat causes heart disease and are instructed by most national dietary guidelines to cut out animal and dairy fat this does indeed suggest that

Global dietary guidelines should be reconsidered …”

Amen!

Because the focus of dietary guidelines on reducing total and saturated fatty acid intake “is largely based on selective emphasis on some observation and clinical data despite the existence of several randomizesed trials and observational studies that do not support these conclusions.”

Pesky Confounding Factors

We cannot infer causality from PURE because like all obervational studies, the investigators do not have control over all the factors influencing outcomes. These confounding factors are legion in a study that is casting such a broad net across different countries with markedly different lifestyles and socioeconomic status.

The investigators did the best job they could taking into account household wealth and income, education, urban versus rural location and the effects of study centre on the outcomes.

In an accompanying editorial, Christopher E Ramsden and Anthony F Domenichiello, prominent NIH researchers,  ask:

“Is PURE less confounded by conscientiousness than observational studies done in Europe and North American countries?

 

“Conscientiousness is among the best predictors of longevity. For example, in a Japanese population, highly and moderately conscientious individuals had 54% and 50% lower mortality, respectively, compared with the least conscientious tertile.”

“Conscientious individuals exhibit numerous health-related behaviours ranging from adherence to physicians’ recommendations and medication regimens, to better sleep habits, to less alcohol and substance misuse. Importantly, conscientious individuals tend to eat more recommended foods and fewer restricted foods.Since individuals in European and North American populations have, for many decades, received in influential diet recommendations, protective associations attributed to nutrients in studies of these populations are likely confounded by numerous other healthy behaviours. Because many of the populations included in PURE are less exposed to in influential diet recommendations, the present findings are perhaps less likely to be confounded by conscientiousness.”

It is this pesky conscientiousness factor (and other unmeasured confounding variables) which limit the confidence in any conclusions we can make from observational studies.

I agree wholeheartedly with the editorial’s conclusions:

Initial PURE findings challenge conventional diet–disease tenets that are largely based on observational associations in European and North American populations, adding to the uncertainty about what constitutes a healthy diet. This uncertainty is likely to prevail until well designed randomised controlled trials are done. Until then, the best medicine for the nutrition field is a healthy dose of humility.

 

Ah, if only the field of nutrition had been injected with a healthy dose of humility and a nagging conscience thirty years ago when its experts declared confidently that high dietary fat and cholesterol consumption was the cause of heart disease.!

Current nutritional experts and the guidelines they write will  benefit from a keen awareness of the unintended consequences of recommendations which they make based on weak and insufficient evidence  because such recommendations influence the food choices  (and thereby the quality of life and the mechanisms of death) of hundreds of millions of people.

PUREly Yours,

ACP

Ignore The New York Times and The American Heart Association and Feel Free to Skip Breakfast

A friend recently sent the skeptical cardiologist  a link to a very disappointing NY Times article  entitled “The Case For A Breakfast Feast”

The writer, Roni Rabin (who has a degree in journalism from Columbia University)  struggles to support her sense that there is a “growing body of research” suggesting we should all modify our current dietary habits in order to eat a  breakfast and make breakfast the largest meal of the day.

Many of us grab coffee and a quick bite in the morning and eat more as the day goes on, with a medium-size lunch and the largest meal of the day in the evening. But a growing body of research on weight and health suggests we may be doing it all backward.

Rabin’s first  discussion is of an observational study of Seventh Day Adventists published in July which adds nothing to the evidence in this area because (as she points out):

The conclusions were limited, since the study was observational and involved members of a religious group who are unusually healthy, do not smoke, tend to abstain from alcohol and eat less meat than the general population (half in the study were vegetarian)

She then discusses experiments on mice from 2012 with a Dr. Panda, a short term feeding trial in women from 2013 and studies on feeding and circadian rhythm in a transgenic rat model from 2001.

There is nothing of significance in the NY Times piece that changes my previous analysis  that it is perfectly safe to skip breakfast and that it will neither make you obese nor give you heart disease.


In what follows I’ll repost my initial post on breakfast (Breakfast is Not The Most important Meal of the Day: Feel Free to Skip it) followed by a follow up post (Feel Free To Skip Breakfast Again) I wrote in 2015.

Finally, I’ll take a close look at a statment from the American Heart Association  from earlier this year which Rabin quotes and which many news outlets somehow interpreted as supporting the necessity of eating breakfast for heart health when, in fact, it confirmed the lack of science behind the recommendation.


Feel Free To Skip Breakfast

It always irritates me when a friend tells me that I should eat breakfast because it is “the most important meal of the day”. Many in the nutritional mainstream have propagated this concept along with the idea that skipping breakfast contributes to obesity. The mechanism proposed seems to be that when you skip breakfast you end up over eating later in the day because you are hungrier.

The skeptical cardiologist is puzzled.

Why would i eat breakfast if I am not hungry in order to lose weight?

What constitutes breakfast?

Is it the first meal you eat after sleeping? If so, wouldn’t any meal eaten after sleeping qualify even it is eaten in the afternoon?

Is eating a donut first thing in the morning really healthier than eating nothing?

Why would your first meal be more important than the last?

Isn’t it the content of what we eat that is important more than the timing?

The 2010 dietary guidelines state

eat a nutrient-dense breakfast. Not eating breakfast has been associated with excess body weight, especially among children and adolescents. Consuming breakfast also has been associated with weight loss and weight loss maintenance, as well as improved nutrient intake

The US Surgeon General website advises that we encourage kids to eat only when they are hungry but also states

Eating a healthy breakfast is a good way to start the day and may be important in achieving and maintaining a healthy weight

Biased  and Weak Studies on the Proposed Effect of Breakfast on Obesity (PEBO)

A recent study anayzes the data in support of the “proposed effect of breakfast on obesity” (PEBO) and found them lacking.
This is a fascinating paper that analyzes how scientific studies which are inconclusive can be subsequently distorted or spun by biased researchers to support their positions. It has relevance to how we should view all observational studies.

Observational studies abound in the world of nutritional research. The early studies by Ancel Keys establishing a relationship between fat consumption and heart disease are a classic example. These studies cannot establish causality. For example, we know that countries that consume large amounts of chocolate per capita have large numbers of Nobel Prize winners per capitaChocolate Consumption and Nobel Laureates

Common sense tells us that it is not the chocolate consumption causing the Nobel prizes or vice versa but likely some other factor or factors that is not measured.

Most of the studies on PEBO are observational studies and the few, small prospective randomized studies don’t clearly support the hypothesis.

Could the emphasis on eating breakfast come from the “breakfast food industry”?

I’m sure General Mills and Kellogg’s would sell a lot less of their highly-processed, sugar-laden breakfast cereals if people didn’t think that breakfast was the most important meal of the day.

My advice to overweight or obese patients:

-Eat when you’re hungry. Skip breakfast if you want.
-If you want to eat breakfast, feel free to eat eggs or full-fat dairy (including butter)
-These foods are nutrient-dense and do not increase your risk of heart disease, even if you have high cholesterol.
-You will be less hungry and can eat less throughout the day than if you were eating sugar-laden, highly processed food-like substances.


Breakfast Cereal

The “must eat breakfast” dogma reminds me of a quote  from Melanie Warner’s excellent analysis of the food industry, “Pandora’s Lunchbox.”

“Walk down a cereal aisle today or go onto a brand’s Web site, and you will quickly learn that breakfast cereal is one of the healthiest ways to start the day, chock full of nutrients and containing minimal fat. “Made with wholesome grains,” says Kellogg’s on its Web site. “Kellogg’s cereals help your family start the morning with energy by delivering a number of vital, take-on-the-day nutrients—nutrients that many of us, especially children, otherwise might miss.” It sounds fantastic. But what you don’t often hear is that most of these “take-on-the-day” nutrients are synthetic versions added to the product, often sprayed on after processing. It’s nearly impossible to find a box of cereal in the supermarket that doesn’t have an alphabet soup of manufactured vitamins and minerals, unless you’re in the natural section, where about half the boxes are fortified.”

The Kellogg’s and General Mills of the world strongly promoted the concept that you shouldn’t skip breakfast because they had developed products that stayed fresh on shelves for incredibly long periods of time. They could be mixed with easily accessible (low-fat, no doubt) milk to create inexpensive,  very quickly and easily made, ostensibly healthy breakfasts.

Unfortunately, the processing required to make these cereals last forever involved removing the healthy components.

As Warner writes about W.K. Kellogg:

“In 1905, he changed the Corn Flakes recipe in a critical way, eliminating the problematic corn germ, as well as the bran. He used only the starchy center, what he referred to as “the sweetheart of the corn,” personified on boxes by a farm girl clutching a freshly picked sheaf. This served to lengthen significantly the amount of time Corn Flakes could sit in warehouses or on grocers’ shelves but compromised the vitamins housed in the germ and the fiber residing in the bran”

This is a very familiar story in the world of food processing;  Warner covers, nicely, the same processes occurring with cheese and with milk, among other things.


The AHA (Always Horribly Awry) Weighs In

I pick on the American heart Association (AHA) a lot in this blog but the AHA scientific statement on “Meal Timing and Frequency: Implications for Cardiovascular Disease Prevention” published earlier this year in Circulation is for the most part a balanced summary of research in the field.

Unfortunately, the media grossly distorted the statement and we ended up with assertive headlines such as this one from Reuters:

Eating Breakfast and Eating Mindfully May Help The Heart

Reuters went on to say (red added by me for emphasis):

“Planning meals and snacks in advance and eating breakfast every day may help lower the risk of cardiovascular disease, new guidelines from U.S. doctors say.”

however, the AHA statement says nothing close to that.

This is the summary that was actually in the AHA paper:

“In summary, the limited evidence of breakfast consumption as an important factor in combined weight and cardiometabolic risk management is suggestive of a minimal impact. There is increasing evidence that advice related to breakfast consumption does not improve weight loss, likely because of compensatory behaviors during the day. …… Additional, longer-term studies are needed in this field because most metabolic studies have been either single-day studies or of very short duration”

The lead author of the paper, Marie-Pierre St-Onge, (Ph.D., associate professor, nutritional medicine, Columbia University, New York City) apparently very clearly told Reuters in an email:

“We know from population studies that eating breakfast is related to lower weight and healthier diet, along with lower risk of cardiovascular disease,” .

“However, interventions to increase breakfast consumption in those who typically skip breakfast do not support a strong causal role of this meal for weight management, in particular,” St-Onge cautioned. “Adding breakfast, for some, leads to an additional meal and weight gain.”

“The evidence, St-Onge said, is just not clear enough to make specific recommendations on breakfast.”

Health New Review published a  nice summary of news reports on the AHA statement with a discussion on the overall problem of making broad public policy dietary recommendations from very weak evidence.

New York Times Gets It Right

The New York Times does have writers who can put together good articles on health. One of them, Aaron Carroll wrote a piece in 2016 entitled “Sorry, There’s Nothing Magical About Breakfast” which does a great job of sorting through weak evidence in the field.

Carroll is a professor of pediatrics at Indiana University School of Medicine and writes excellent articles on The New Health Care blog for the Times.

His conclusions are identical to mine from 2013:

“The bottom line is that the evidence of breakfast is something of a mess. If you’re hungry, eat it. But don’t feel bad if you’d rather skip, and don’t listen to those who lecture you. Breakfast has no mystical powers.”

Mindful and Intentional Eating

If you read the AHA statement completely you come across a lot of mumbo-jumbo on intermittent fasting, meal frequency and “mindful” eating.  The abstract’s last sentence is

Intentional eating with mindful attention to the timing and frequency of eating occasions could lead to healthier lifestyle and cardiometabolic risk factor management.

and they reference this table:

 Yikes! I have no idea what they are talking about.
For those of us who need to get to work early in the morning, breakfast is likely to be the worst time for “mindful” eating.
I have a cup of coffee first thing upon arising and only eat much later in the day when I feel very hungry.
Dinner, on the other hand we can plan for, prepare with loved ones and consume  in  a very mindful and leisurely fashion with a glass of heart healthy wine or beer while enjoying good conversation.
So, ignore what apparently authoritative sources like the New York Times, Reuters, and  the AHA tell you about eating breakfast like a king, lunch like a prince, and dinner like a pauper, mindfully or otherwise.
After all, in the Middle Ages, kings likely didn’t eat breakfast as the Catholic church frowned on it. Per Wikipedia:
Breakfast was under Catholic theological criticism. The influential 13th-century Dominican priest Thomas Aquinas wrote in his Summa Theologica (1265–1274) that breakfast committed “praepropere,” or the sin of eating too soon, which was associated with gluttony.[2]Overindulgences and gluttony were frowned upon and were considered boorish by the Catholic Church, as they presumed that if one ate breakfast, it was because one had other lusty appetites as well, such as ale or wine.
Gluttonously Yours,
-ACP
 Image of king and pauper eating from the New York Times article created by Natalya Balnova.

 

Quackery Promotion By Mainstream Media: Part I, Reader’s Digest and Naturopathy

As the skeptical cardiologist surveys the heart health information available to his patients and the lay public, he sees two broad categories of misinformation.

First we have the quacks and snake oil salesman. These are primarily characterized by a goal of selling more of their useless stuff online.

I’ve described this as the #1 red flag of quackery. Usually I’m inspired to investigate these charlatans because a patient asks me about one of their useless supplements.

The second category is more insidious: the magazine or internet news site seems to have as its legitimate goal, promoting the health of its readers. There is no clear connection to a product.

Web MD, which I wrote about here, is an example of this second type.  Hard copy versions of these types of media frequently make it into doctor’s waiting rooms: not because doctor’s have read and approved what is in them. These companies send their useless and misleading magazines for free to doctor’s offices, and the staff believe it to be legitimate.

How does glaringly inaccurate and often dangerous information get into media that ostensibly has as its goal promoting its readers health? Most likely, it is a result of media’s need  to constantly produce new and interesting ways for readers to improve their health.

Clearly, readers will not continue subscribing, clicking and reading such sources of information if there isn’t something new and exciting that might prolong their lives: gimmicks, miracles cures, and “natural” remedies are more alluring than the well-known advice to exercise more, watch your weight, stop smoking and get a good night’s sleep.

Reader’s Digest and Stealth Quackery

A patient recently brought in a printout of Reader’s Digest’s “40 things cardiologists do to protect their heart” which is typical of the second category.

Reader’s Digest was a staple of my childhood. My parents subscribed to it consistently and I would read parts of it. It was small and enticing. Allegedly its articles were crafted so that they could be read in their entirety during a session in the bathroom.

To this day it has a wide circulation. Per Wikipedia”

The magazine was founded in 1920, by DeWitt Wallace and Lila Bell Wallace. For many years, Reader’s Digest was the best-selling consumer magazine in the United States; it lost the distinction in 2009 to Better Homes and Gardens. According to Mediamark Research (2006), Reader’s Digest reaches more readers with household incomes of $100,000+ than Fortune, The Wall Street Journal, Business Week, and Inc. combined.[2]

Global editions of Reader’s Digest reach an additional 40 million people in more than 70 countries, via 49 editions in 21 languages. The periodical has a global circulation of 10.5 million, making it the largest paid circulation magazine in the world.

Reader’s Digest used to run a recurring educational feature on the various body parts and organs of Joe and Jane which intrigued me.

Here’s the first paragraph of “I am Joe’s heart:”

I am certainly no beauty. I weigh 340 grams, am red-brown in color and have an unimpressive shape. I am the dedicated slave of Joe. I am Joe’s heart.

The health information in this series was generally accurate but the presentation lacks the kind of sizzle that apparently attracts today’s readers.

The article my patient brought to my attention is typical of the mix of good and bad information and fluff that mainstream media can produce to attract followers:

Not So Bad But Not Clearly True Medical Advice

#1. I keep a gratitude journal. An internist “at NYU” is quoted as saying: “Studies have recently shown that expressing gratitude may have a significant positive impact on heart health.”

Fact Check: following the links provided provides no evidence to support this claim.

#2  I get 8 hours of sleep a night, every night.  This cardiologist seems to have been misquoted, because her comment is actually “getting a good night sleep is essential. I make a point of getting seven to eight hours of sleep every night…Poor sleep is linked to higher blood pressure.”

Fact Check. One review noted that:

Too little or too much sleep are associated with adverse health outcomes, including total mortality, type 2 diabetes, hypertensionand respiratory disorders, obesity in both children and adults, and poor self-rated health.

Another broke down mortality according to number of hours of sleep.

A J-shaped association between sleep duration and all-cause mortality was present: compared with 7 h of sleep (reference for 24-h sleep duration), both shortened and prolonged sleep durations were associated with increased risk of all-cause mortality (4 h: relative risk [RR] = 1.05; 95% confidence interval [CI] = 1.02–1.07; 5 h: RR = 1.06; 95% CI = 1.03–1.09; 6 h: RR = 1.04; 95% CI = 1.03–1.06; 8 h: RR = 1.03; 95% CI = 1.02–1.05; 9 h: RR = 1.13; 95% CI = 1.10–1.16; 10 h: RR = 1.25; 95% CI = 1.22–1.28; 11 h: RR = 1.38; 95% CI = 1.33–1.44; n = 29; P < 0.01 for non-linear test)

Thus, in comparison to those who sleep 7 hours, those who sleep 5 hours have a 5% increase in mortality and those who sleep 11 hours have a 38% increase in mortality.

These data are based entirely on observational studies so it is impossible to know if the shortened sleep is responsible for the increased mortality or if some other (confounding) factor is causing both.

My advice: Some people do fine with 6 hours and 45 minutes of sleep. Some require 8 hours 15 minutes for optimal function. Rather than obsessing about getting a specific amount of sleep time, it makes more sense to find our through your own careful observations what sleep time works best for you and adjust your schedule and night time patterns accordingly.

#3. I do CrossFit.

Fact Check. There is nothing to support CrossFit as more heart healthy than regular aerobic exercise (which the vast majority of cardiologists recommend and perform).

#4. I meditate. “Negative thoughts and feelings of sadness can be detrimental to the heart. Stress can cause catecholamine release that can lead to heart failure and heart attacks.”

Fact Check. There is a general consensus that stress has adverse consequences for the cardiovascular system. Evidence of meditation improving cardiovascular outcomes is very weak.

A recent review

Participation in meditation practices has been shown to reduce depression, anxiety, and negative mood and thus may have an indirect positive effect on CV health and well-being. This possibility has led the American Heart Association to classify TM as a class IIb, level of evidence B alternative approach to lowering BP.32

Non randomized, non blinded studies with small numbers of participants have suggested a reduction in CV death in those performing regular TM.

However, we need better and larger studies before concluding there is a definite benefit compared to optimal medical therapy.

Thus far, the recommendations have been pretty mundane: exercise, stress reduction and a good night’s sleep is good advice for all, thus boring.

Seriously Bad Advice From Quacks Mixed In With Reasonable Advice

In order to keep reader’s interest (and reach 45 things) Reader’s Digest is going to need to add seriously bad advice.

My patient had circled #34. “I mix magnesium powder into my water. If sufficient magnesium is present in the body, cholesterol will not be produced in excess.”

This bizarre and totally unsubstantiated practice was recommended by Carolyn Dean MD, ND.

What do we know about Dr. Dean?

-She was declared unfit to practice medicine and her registration revoked by the College of Physicians and Surgeons of Ontario in 1995. From quackwatch.org :

  • After being notified in 1993 that a disciplinary hearing would be held, Dean relocated to New York and did not contest the charges against her.
  • Dean had used unscientific methods of testing such as hair analysis, Vega and Interro testing, iridology and reflexology as well as treatment not medically indicated and of unproven value, such as homeopathy, colonic irrigations, coffee enemas, and rotation diets.

-The initials after her name (ND, doctor of naturopathy) should be considered the second red flag of quackery. See quackwatch.org (here) and rational wiki (here) and the confessions of a former naturopath  (here ) for discussions of naturopathy. As noted at science-based medicine:

Naturopathy is a cornucopia of almost every quackery you can think of. Be it homeopathy, traditional Chinese medicine, Ayurvedic medicine, applied kinesiology, anthroposophical medicine, reflexology, craniosacral therapy, Bowen Technique, and pretty much any other form of unscientific or prescientific medicine that you can imagine, it’s hard to think of a single form of pseudoscientific medicine and quackery that naturopathy doesn’t embrace or at least tolerate.

-She has a website (Dr. Carolyn Dean, MD,ND, The Doctor of The Future) where she incessantly promotes magnesium as the cure for all ills.

-She has written a book called “The Magnesium Miracle” (hmm. wonder what that’s about).

-She sells her own (really special!) type of magnesium (see red flag #1 of quackery).

-She writes for the Huffington Post (I’m considering making this a red flag of quackery).

-She is on the medical advisory board of the Nutritional Magnesium Association (an organization devoted to hyping magnesium as the cure for all ills and featuring all manner of magnesium quacks).

Prevention Magazine 

Reader’s Digest is not alone in allowing the advice of pseudoscience practitioners to stand side by side with legitimate sources.

For example, Prevention Magazine in its August 2017 issue highlights “35 All-Time Favorite Natural Remedies” with the subheading

“Go ahead, try them at home: Experts swear by these nondrug cures for back pain, nausea, hot flashes, and other common ailments.”

Who are these “experts”? Let the reader beware because the first quote comes from “Amy Rothenberg, past president of the Massachusetts Society of Naturopathic Doctors.”

Finding The Truth

It’s getting harder and harder for the lay public to sort out real from fake health stories and advice.

When seemingly legitimate news media and widely followed sources like Reader’s Digest and Prevention Magazine  either consciously or inadvertently promote quackery, the truth becomes even more illusive.

Readers should avoid any source of information which

  1. Profits from selling vitamins and supplements.
  2. Utilizes or promotes  naturopaths or other obvious quacks as experts in health advice.

IamJoesfootingly Yours,

-ACP

Why Are The Dutch So Heart Healthy and Happy (And Tall)? Part I: Is It Their Diet?

The Skeptical Cardiologist and his  eternal fiancee’ recently spent 5 days in the Netherlands trying to understand why the Dutch are so happy and heart healthy.

We were driven by Geo (former statin fence-sitter) from Bruges to Haarlem, a city of 150,000, which lies about 15 km west of Amsterdam and about 5 km east of the North Sea.

 

Haarlem is one of the most delightful towns I’ve ever stayed in.

 

 

I was struck by  the beauty of its architecture, its canals and the happiness, height and friendliness of its inhabitants.

I was lucky enough to have a bike at my disposal. One day I set off randomly, and after 20 minutes of riding on delightfully demarcated bike lanes, I scrambled up a sand dune and looked out at the North Sea.

Just down the road was the  beach resort of Zandvoort, where one can enjoy sunbathing, surfing or a fine meal while gazing at a glorious sunset.

 

 

 

 

Like Amsterdam, which is a 15 minute train ride away, bikes and biking abound in Haarlem, but unlike Amsterdamers, the Haarlemers were universally engaging, polite and friendly. Everything and everyone seemed clean, well-organized, relaxed and pretty…and, well, …happy.

The Dutch High Happiness Rating

The World Happiness Report 2017, which ranks 155 countries by their happiness levels, was released in March of this year at the United Nations at an event celebrating The International Day of Happiness.

The report notes that:

Increasingly, happiness is considered to be the proper measure of social progress and the goal of public policy

Norway was at the top of the happiness list but

All of the other countries in the top ten also have high values in all six of the key variables used to explain happiness differences among countries and through time – income, healthy life expectancy, having someone to count on in times of trouble, generosity, freedom and trust, with the latter measured by the absence of corruption in business and government.

The top 4 were closely bunched with Finland in 5th place, followed by the Netherlands, Canada, New Zealand, and Australia and Sweden all tied for the 9th position.

Despite the immense wealth of Americans, the report notes:

The USA is a story of reduced happiness. In 2007 the USA ranked 3rd among the OECD countries; in 2016 it came 19th. The reasons are declining social support and increased corruption  and it is these same factors that explain why the Nordic countries do so much better.

Dutch children seem to be especially happy.

A UNICEF report from 2013 found that Dutch children were the happiest of the world’s 29 richest industrialized countries.  America ranked 26th, barely beating out Lithuania and Latvia.

Cardiovascular Disease in The Netherlands

Ischemic heart disease (IHD) deaths are due to blockages in the coronary arteries. Typically, this comes from the build up of atherosclerotic plaques in the arterial system and in most countries heart attacks from this process are the major cause of death.

The Netherlands has the third lowest rate of IHD deaths in developed countries, only slightly higher than France and less than half the rate of the USA.Screen Shot 2017-07-26 at 10.53.26 AM

In all developed countries over the last thirty years we have seen a marked drop in deaths due to IHD. In The Netherlands it has dropped 70% and the rate in 2013 was nearly as low as France’s rate.

In addition, the Netherlands has a very low rate of deaths from  hypertensive heart disease. This table from 2008 shows that they are second only to Japan and their mortality rate is a third of that in the US.

A recent update noted

The current Dutch age-standardised mortality from circulatory disease is 147 per 100,000, and only Spain and France have lower cardiovascular mortality rates (143 and 126 per 100,000, respectively). In all other European countries, including for instance Switzerland and Greece, cardiovascular mortality is higher [26].

What factors could be causing all this happiness and heart healthiness?

The Seemingly Horrid Dutch Diet

We have been programmed to believe that heart attack rates are related to saturated fat in our diets.

The fact that the French consume lots of saturated fat and rank so low in IHD deaths has been called the French Paradox as it seems to contradict the expected association.

One thing is clear-the Dutch are not following a whole foods, plant-based diet. They are among the world leaders in consumption of both fat and sugar as the graph below indicates.

While in The Netherlands I sought out raw herring,  a dish which Rick Steves and others indicate is a Dutch obsession.

Since there is evidence that fish consumption, especially fatty ones like herring and mackerel, is associated with a lower risk of coronary heart disease, perhaps this was protecting the Dutch.

I didn’t see much herring consumption in Haarlem (a native Haarlemer informs me that the Dutch raw herring consumption might be confined to older generations or tourists).

It turns out that the Dutch aren’t meeting their own nutritional guidelines for healthy food .

The recommendation to eat fish at least twice a week, of which at least once fatty fish such as salmon, herring or mackerel, is followed by a mere 14 percent of the population. Less than 25% of them meet the recommended daily amount of fish, fruit, and vegetable consumption.

Screen Shot 2017-07-26 at 11.58.57 AM
purple bar=women yellow bar=men orange bar= total

They do catch and export a lot of fish and shellfish and are in the top 10 of seafood exporting countries (99% of all those mussels consumed in Belgium come from The Netherlands).

And, to my great surprise, they eat lots of French, or as I have started calling them, Flanders fries.

 

I personally witnessed  massive amounts of cheese and butter consumption.

In fact, the Dutch average 15% of calories from saturated fat, which is far above the 10% recommended by the Dietary Guidelines for Americans.

A recent analysis of Dutch fat consumption found:

The mean baseline intake of total saturated fatty acids (SFAs)  in the population was 15.0% of energy. More than 97% of the population exceeded the upper intake limit of 10% of energy/d as recommended by the Health Council of the Netherlands.

The Dutch weren’t eating so-called healthy fats as “The main food sources of SFAs were cheese (17.4%), milk and milk products (16.6%), meat (17.5%), hard and solid fats (8.6%), and butter (7.3%).”

Surprisingly, the more saturated fat the Dutch consumed, the LOWER their risk of death from IHD:

After multivariable adjustment for lifestyle and dietary factors (model 4), a higher intake of energy from SFAs was significantly associated with a 17% lower IHD risk (HR per 5% of energy: 0.83; 95% CI: 0.74, 0.93)

The Dutch Paradox

Data shows that  the Dutch are eating lots of saturated fat from dairy and meat, but it appears to be lowering their risk for heart attacks

Yes, despite 40 years of high saturated fat consumption, the Dutch have seen a 70% drop in mortality from heart attacks. Their rate of dying from ischemic heart disease is lower than the US and only slightly higher than the French.

Thus, rather than talk about a French paradox, we should be talking about the Dutch paradox.

For the French paradox many theories, both fanciful and serious,  have been proposed

The one most laypeople remember (due to a 60 Minutes episode in 1991) is that the French are protected by their high red wine consumption. Although this theory proved a great boon to the red wine industry (sales rose 40% the year after Morley Safer made his presentation on 60 Minutes), it has never had any serious scientific credibility.  Current thinking is that all forms of alcohol in moderation are equally protective.

Others have proposed garlic or onion or faux gras consumption. My own theory for the French is that it is fine cheese and chocolate consumption that protects them.

In subsequent posts I’ll lay out the evidence for my startling new theory to explain the Dutch paradox.

 

 

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