Category Archives: Travel

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.

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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.

 

 

The Skeptical Cardiologist Abroad

The skeptical cardiologist is about to embark on a two week vacation in Europe.

I and my Eternal Fiancee’ will fly into Paris and spend a few days  there lapping up the Parisian food, booze and ambiance. Then we will take a train from Paris to Bruges, Belgium for another few days of sight-seeing.

The tour will end in Haarlem, The Netherlands (aka Holland) where the Eternal Fiancee’s parents (Wendy and Geo of “Are you on the fence about statin drugs ” fame) have swapped their house (and car) in Annapolis, Maryland (temporarily) for a  house in Haarlem  (and car and bikes!).

For a cardiologist, a  two week vacation in Europe used to mean severing almost all communication with one’s practice. I can recall my first visit to France in 1987; there was no internet, no cell phone and no text messaging. A several minute phone call to talk to my children seemed prohibitively expensive.

For this trip, however, I am loaded up with a laptop, a cell phone and an ipad, anticipating the ability to stay in communication with everyone, everywhere.

This super-communicative status means I could do a whole lot of patient care on this European Vacation.

If I wanted to, I could log in to my hospital’s EHR and check on my patients. I could see what their latest blood pressure and weight was, or how low their potassium had dropped after diuretics. I could write orders to lower their diuretic dosage or for additional potassium.

For my outpatients, I could check labs results and send them messages. I could stop blood thinners prior to surgery or advise those having questions or problems.

If my patients have had diagnostic imaging studies, I could remotely read and report echocardiograms, nuclear stress tests, long term monitors, coronary calcium and CT angiograms.

In short, I could continue to keep an eye on my practice even while trying to vacation thousands of miles away.

Fortunately, I have an outstanding partner in my practice, Dr. Scott Brodarick and a wonderful medical assistant, Jenny Clancy, who will be covering me and handling the low potassiums and the surgical clearances and all the myriad unforeseen patient developments, making it possible for me to focus on being a skeptical tourist rather than a clinical cardiologist for two weeks.

Perhaps I shall encounter a grisette in Paris.

Mark Twain visited Paris 150 years ago. In “Innocents Abroad” he wrote about searching for grisettes in Paris whom he expected would be beautiful, graceful, happy and “charmingly, delightfully immoral.” When he finally saw them he was disappointed: “They were like nearly all the Frenchwomen I ever saw–homely. They had large hands, large feet, large mouths; they had pug noses as a general thing, and moustaches that not even good breeding could overlook; they combed their hair straight back without parting; they were ill-shaped, they were not winning, they were not graceful; I knew by their looks that they ate garlic and onions; and lastly and finally, to my thinking it would be base flattery to call them immoral.”

Innocently Yours,

-ACP