I’ve been meaning to blog on the new ACC/AHA (ACC=American College of Cardiology, AHA=American Heart Association) guidelines for treatment of high cholesterol but have been waiting for the initial controversy to die down and to get more experience with using them. One of the areas of controversy has been the ASCVD (atherosclerotic cardiovascular disease) risk estimator. These guidelines attempt to look at risk of both stroke and heart attack (the components of atherosclerotic cardiovascular disease) and what published scientific research tells us works to reduce that risk.
They differ substantially from previous guidelines recommendations and suggest treatment with statin drugs(no other cholesterol lowering agents) for the following groups
2. Patients with known clinical ASCVD (this includes stroke/TIA, heart attack, and peripheral arterial disease)
3. LDL or bad cholesterol over 190
4. Individuals without ASCVD whose 10 year risk of developing ASCVD (heart attack or stroke) is > 7.5%
It is the last category that has garnered the most controversy as it appears this will substantially increase the number of patients in whom statin therapy is recommended. In addition, the accuracy of the risk estimator has been questioned. When the guidelines were released the risk estimator was available as a downloadable Excel spreadsheet which was very cumbersome to use (and did not work on my Mac).
Today, the ACC announced that an iphone/ipad app version of the risk estimator was available on itunes . You can download it for free here. (The app is now called ASCVD Plus) It’s pretty well done. You enter your age, race, gender, HDL (“good” cholesterol) and total cholesterol along with yes/no answers to whether you have diabetes, treatment for hypertension or are a smoker.
Your 10 year risk of ASCVD appears as a percentage.
In the example to the left, the individual (whose numbers are eerily similar to those of the skeptical cardiologist) has a 10 year risk of 6.2% compared to 5.2% for an individual with “ideal” risk factors. In this case, the 6.2% 10 year risk is below the proposed 7.5% cut point for treatment. (As a side note, this individual’s HDL rose from 53 to 80 when he switched from skim milk , egg-whites and low-fat processed food to full fat dairy, eggs and grass-fed beef. An HDL of 53 would raise the risk to 8.5% which would trigger a recommendation for statin therapy!)
A lifetime risk is also given for those aged 20 to 59 years but the app seems flawed because in every case I entered the lifetime risk was 50% for the individual and 5% for the ideal risk factor individual
I’ll be utilizing this on every patient I see that does not have clinical ASCVD. I would encourage everybody to download this app and find out what your risk is. The higher your risk, the more likely your are to benefit from taking a statin drug, the lower it is, the less likely the benefits of lifelong drug treatment will outweigh the risks.
Understanding your risk of ASCVD is the crucial first step to having an informed discussion with your physician about atherosclerosis and the risks and benefits of drug therapy to prevent strokes and heart attacks.
The skeptical cardiologist had to temporarily interrupt his scintillating research into Canola Oil and the Mediterranean diet in order to highlight a study published yesterday in the Journal of the American Medical Society that adds further evidence to the paradigm that sugar is not just causing obesity but is actually killing us.
In a previous post on low-fat yogurt I emphasized that a great pseudo-scientific scam had been foisted on Americans, the promotion of low fat substitutes for real food. The low-fat substitutes masquerade as more heart healthy because saturated fat has been removed but they are actually less healthy because sugar or high fructose corn syrup has been added. Substantial evidence indicates that consumption of sugar and refined carbohydrates are contributing to obesity and cardiovascular disease (CVD), not the unjustly demonized saturated fats. Now there is evidence to suggest sugar is actually directly promoting heart disease.
In the article, the authors analyzed data from subjects who participated in the National Health and Nutrition Examination Survey (NHANES). They estimated the “usual percentage of calories from added sugar” for individuals.
Added sugar “includes all sugars used in processed or prepared foods, such as sugar-sweetened beverages, grain-based desserts, fruit drinks, dairy desserts, candy, ready-to-eat cereals and yeast breads, but not naturally occurring sugar, such as in fruits and fruit juices.”
Among the 11733 participants there were 831 CVD deaths with a median follow up of 14.6 years.
Those who consumed 25% or more of calories from added sugar were 2.75 times more likely to die than those who consumed less than 10% of calories from added sugar. The risk of CVD mortality increased exponentially with increased percentage of calories from added sugar.
Major sources of added sugar in American adults diet included sugar-sweetened beverages (37%), grain-based desserts (14%), dairy desserts (6%) and candy (6%). One 360-ml can of regular soda contains about 35 g of sugar (140 calories) or 7% of total calories.
The authors discussed emerging evidence suggesting multiple pathways by which sugar might play a role, including promoting hypertension, increased de novo lipogenesis in the liver (resulting in high triglycerides) and promoting inflammation.
My first dietary recommendation to my patients is to cut out the added sugar. This is both for weight management and lower heart attack risk. The low-fat, processed “food-like substances” you have been choosing are far worse for you than the unprocessed high fat food they replaces.
The Skeptical Cardiologist occasionally wanders into the Doctors Lounge at the hospital and surveys the food choices available to him. One morning, descried amongst the carbohydrate bonanza of donuts, pastries, bagels and muffins was a bin containing little tubs of substances that could be spread on a bagel of slice of bread.
The choice was between something called Promise Buttery Spread
and Wholesome Farms Whipped Butter..
Conventional Wisdom and the recommendation of almost every nutritional authority for the last 30 years tells me that I should choose the Promise Buttery Spread. I would have taken this choice 5 years ago in the belief that butter with its high content of saturated fat was to be avoided. I used to spend a considerable amount of time in the pseudo-butter portion of the grocery aisles trying to determine which, of the myriad of competing alternatives, would be better than butter.
But, as I’ve noted in previous posts, the authorities have gotten it wrong. Let’s look carefully at the two choices.
Promise Buttery Spread
Certainly the packaging would suggest that this is a “promising” choice. It says very clearly in the small print circling the outside of the tub: “heart healthy when substituted for butter.” If you’d like to read the arcane FDA rules on which foods can make this sort of claim, they are here. Basically, if the product has less fat, saturated fat or cholesterol than butter it can make this claim.
From the website of Unilever, the giant food processing conglomerate that makes Promise and all of its siblings, we learn that Promise contains 8 grams of fat, 1.5 grams of which are saturated fat. Uniliver is very happy to provide you with the macronutrient content of Promise and its various variations. After all, they spent a lot of time researching what combination of fats, protein and carbohydrates would satisfy consumers desire for a heart-healthy substitute. Canola oil turns out to be high in monounsaturated fats just like olive oil, the major fat consumed in the heart-healthy Mediterranean diet
But how did they come up with this fine ratio of unsaturated to saturated fats? What actually goes into it?
Here are the ingredients (not obtainable from Unilever’s web site but from another source that, presumably could read the small print that I could not read on the little tub of Promise)
Vegetable Oil Blend (Liquid Soybean Oil, Canola Oil, Palm Oil, Palm Kernel Oil), Water, Whey (Milk), Salt, Vegetable Mono and Diglycerides, Soy Lecithin, (Potassium Sorbate, Calcium Disodium EDTA) Used to Protect Quality, Vitamin E Acetate, Citric Acid, Pyridoxine Hydrochloride (Vitamin B6), Artificial Flavor, Maltodextrin (Corn), Vitamin A Palmitate, Beta Carotene (Color), Cholecalciferol (Vitamin 13), Cyanocobalamin (Vitamin B12).
That’s 21 ingredients, most of which are made in a factory and added back to the mixture of exotic vegetable oils, most of which is canola oil.
What is Canola Oil? Does it come from a canola plant or seed?
A good source of information (and presumably positive) is the Canola Council web site which gives the history of Canola Oil. It all begins with oil from the seed of the rape plant, a crop grown in Canada.
Rapeseed oil naturally contains a high percentage (30-60%) of erucic acid, a substance associated with heart lesions in laboratory animals. For this reason rapeseed oil was not used for consumption in the United States prior to 1974, although it was used in other countries. In 1974, rapeseed varieties with a low erucic content were introduced. Scientists had found a way to replace almost all of rapeseed’s erucic acid with oleic acid, a type of monounsaturated fatty acid.
The Canola council website says that this process of developing rapeseed with low levels of the toxic erucic acid was not accomplished by genetic engineering, but the nongmoproject.org indicates 90% of Canola oil qualifies as genetically modified.
More history from the Canola Council:
By 1978, all Canadian rapeseed produced for food use contained less than 2% erucic acid. The Canadian seed oil industry rechristened the product “canola oil” (Canadian oil, low acid) in 1978 in an attempt to distance the product from negative association with the word “rape.” Canola was introduced to American consumers in 1986. By 1990, erucic acid levels in canola oil ranged from 0.5% to 1.0%, in compliance with U.S. Food and Drug Administration (FDA) standards.
The term canola was trademarked by the Western Canadian Oilseed Crushers’ Association (now the Canadian Oilseed Processors Association) to differentiate the superior low-erucic acid and low-glucosinolate varieties and their products from the older rapeseed varieties.
How is Canola Oil Processed?
Again, the Canola Council provides their summary of the process here.
Unlike olive oil which is just expeller expressed from olives, canola oil goes through quite a bit of processing. After pressing, about half of the oil is left, and the remainder is extracted by a solvent called hexane (interestingly, there is a controversy in the world of veggie burgers since hexane is used in processing soy and residual levels of this “neurotoxin” have been detected). This oil then goes through processes called degumming (which often involves mixing with acid), bleaching and deodorizing. To make a more solid form it is heated to hydrogenate the oil or palm kernel oil is mixed with it.
Is Canola Oil healthier than butter?
Research shows that replacing saturated and trans fat with unsaturated fats can help maintain heart health.
Unfortunately, none of this research involves canola oil so it is not really applicable. In the 1980s, at the urging of health authorities, the food industry went through a similar process and created butter substitutes that utilized oils hydrogenated in a factory. The result was the consumption by the public of large amounts of trans-fats which subsequent research has shown to be great promoter of coronary heart disease. Does it make sense to put our trust in these newer , factory produced ,butter substitutes?
There are NO STUDIES that would indicate substituting canola oil for butter is a heart-healthy choice. Personally, I have grave concerns about consuming a product that has gone through such a tortured process in order to make it appear safe and palatable.
In the Doctor’s Lounge, my butter choice lists pasteurized cream and salt as the ingredients. I like that, it’s simple and straightforward. I know that most studies that have looked at consumption of dairy fat have found that it lowers risk of heart disease. Wholesome Farms is a Sysco, Inc. label and Sysco says
Wholesome Farms farm-fresh cream, eggs and other dairy offerings are typically produced at dairies located closer to our foodservice customers, resulting in fresher, more dependable products with longer shelf lives.
I have tried to contact Sysco to get more information on where my little tub of butter came from and what the cows were fed but have gotten no information.
Choose Nature, not Industry, for good health.
The choice between a highly processed, genetically modified, industry promoted vegetable oil (or blend of oils) which has been manipulated to resemble a healthy natural vegetable oil and never shown to be safe or healthy in humans, versus butter, is clear to me. Give me butter every time. I’m not excited about the fact that I can’t be sure the milk used in this little tub of butter came from pasture-raised, grass-fed cows. However, I realize that compromises have to be made for convenience sometimes. I’d rather eat the butter from unknown cows than the vegetable oil from a known factory.
Most cardiologists don’t spend a lot of time talking about diet with their patients. When they do, they usually cite the mainstream maxim that you should cut down on saturated fat by reducing red meat consumption, choosing low-fat or skim dairy products, and lean cuts of meat. Patients are referred to standard recommendations that conform to this advice that comes from the American Heart Association.
This is certainly what I did for 30 years until I started examining the research supporting these recommendations in detail. It’s a lot easier to give advice to your patients when it conforms to what they are hearing from nutritional authorities. If it doesn’t conform, you have a lot of ‘splaining to do. If doctors spend time teaching or discussing diet with our patients, we do not get reimbursed for it.
However, a close examination of the research on dietary fat and heart disease shows that there is no good evidence supporting these recommendations.
The two major fallacies are:
Eating high fat foods will make you fat.
Eating high fat or cholesterol laden foods raises your cholesterol, thereby promoting the development of heart disease
Dietary Fat and Obesity
Although these concepts have become ingrained in the consciousness of Americans, they are not supported by scientific studies; more and more researchers, nutritional scientists, and cardiologists are sounding the warning and trying to change the public’s understanding in this area.
It seems logical that the fat that we consume goes into the body and is then converted into fat that appears on our thighs or belly and lines our arteries. This logic, and weak epidemiologic studies, led to national nutritional recommendations, beginning in 1977, that Americans cut back on fat (particularly saturated fat). The food industry seized on these recommendations and began providing consumers with “low-fat” alternatives to standard foods. To make these low-fat foods palatable, sugar had to be added. Often, due to a surplus of industrial farm produced corn, sweetening was accomplished with high-fructose corn syrup. This graph shows what happened with weight in the US:
Beginning in the late 1970s, the percentage of people with BMI > 30 (considered obese) increased dramatically.
More and more evidence points to increased consumption of sugar, HFCS, and refined carbohydrates as the root cause of this obesity epidemic.
I tell my overweight patients that reducing sugar and refined starch is the most important thing that they can do to shed excess pounds. They should avoid processed foods which the food industry have manipulated to make more palatable and less healthy. This means, among other things, avoiding or minimizing drinking sugar-sweetened beverages and avoiding “drinking your calories,” cutting way back on donuts, pastries, and potatoes and when consuming pastas or breads, try to make them whole-grain.
Dietary Fat and Heart Disease
I don’t tell my patients to cut fat consumption; this advice runs counter to everything they have heard about diet and heart disease. I encourage them to consume full fat dairy and this is considered particularly heretical.
However, as I have discussed in previous posts, there is no evidence that dairy fat increases cardiovascular risk. In fact, all studies suggest the opposite: a lower risk of heart disease associated with full fat dairy consumption.
Just as all fats are not the same (consider trans, saturated and unsaturated), all saturated fats are not the same. Some, particularly, the shorter chain fatty acids found in dairy, have beneficial effects on the lipid profile and likely lower overall cardiovascular risk.
What about red meat? All of my patients have received the dogma that they need to cut back on red meat. It hasn’t come from me (not since I began looking at the scientific evidence). When I look at my patients’ cholesterol profile before and after they institute what they perceive as the optimal “heart-healthy“ diet (cutting back on saturated fat and increasing carbohydrates by reducing meat consumption and shifting to skim or low-fat dairy products), their LDL or “bad” cholesterol has dropped a little, but proportionally their HDL or good cholesterol has dropped more and their triglycerides have gone up. What is the overall effect of this dietary change? There are no studies demonstrating that this change improves your heart health.
A recent systematic review and meta-analysis of 20 studies which included 1,218,380 individuals found no relationship between red meat consumption and coronary heart disease, CHD, (or diabetes). Conversely, processed meat intake was associated with a 42% higher rate of CHD and 19% higher risk of diabetes.
Analysis of data from the Multi-Ethnic Study of Atherosclerosis population indicates
After adjustment for demographics, lifestyle, and dietary confounders, a higher intake of dairy saturated fat was associated with lower cardiovascular disease risk [HR (95% CI) for +5 g/d and +5% of energy from dairySF: 0.79 (0.68, 0.92) and 0.62 (0.47, 0.82), respectively].
The Womens Health initiative was started in the early 1990s to test the hypothesis that a low fat diet would lower risk of cancer, stroke and heart attacks.Women were aged 50-79 at trial enrollment in 1993-98 and were followed for an average of 8.1 years. By the end of the first year, the low-fat diet group reduced average total fat intakes to 24 percent of calories from fat, but did not meet the study’s goal of 20 percent. At year six, the low-fat diet group was consuming 29 percent of calories from fat. The comparison group averaged 35 percent of calories from fat at year one and 37 percent at year six. Women in both groups started at 35-38 percent of calories from fat. The low fat diet group also increased their consumption of vegetables, fruits, and grains.
The study design reflected a widely believed but untested theory that reduction of total fat would reduce risks of breast or colorectal cancers. Among the 48,835 women who participated in the trial, there were no significant differences in the rates of colorectal cancer, heart disease, or stroke between the group who followed a low-fat dietary plan and the comparison group who followed their normal dietary patterns.
Yes, “widely believed but untested theory” is a great description of the current recommendation to cut saturated fat because no prospective trial has proven any benefit to this approach in reducing cardiovascular disease.
There is some evidence (but still fairly weak) to support the idea that replacing saturated fat with unsaturated fat is beneficial. Thus, the popularity of the Mediterranean diet which utilizes olive oil liberally. There is good evidence that industrially produced trans-fatty acids (from products designed to take the place of inappropriately demonized butter) increase cardiovascular risk. However, this evidence does not extend to natural trans-fatty acids such as those coming from the udders of cows.
Mounting evidence suggests that replacing fat or saturated fat in the diet with carbohydrates, however, contributes to obesity, insulin resistance, diabetes, and thereby may increase your risk of cardiovascular disease.
The skeptical cardiologist has to admit that when he drinks milk or puts it in his coffee or cooks with it he almost exclusively drinks “organic”, non-homogenized milk obtained from dairy cows which are grass-fed and spend most of their lives grazing in a pasture.. In previous blogs I’ve laid out the evidence that supports that dairy products in general do not increase the risk of heart and vascular disease and, in fact, may lower that risk.
Full fat dairy has gotten a bad rap because it contains high levels of saturated fat. However, just as total fats were inappropriately labeled as bad , it is now clear that all saturated fats are not bad for the heart.
Although I recommend full fat dairy products to my patients I haven’t emphasized the organic or grass-fed aspect because I didn’t think there was enough good evidence that this is healthier than other kinds of milk and it is more expensive. There is evidence from small studies that cows consuming a more natural diet of grass and legumes from a pasture have higher levels of omega-3 fatty acids in their milk than those confined indoors and eating corn.
I keep my eyes (and ears) open for papers in this area.. One such paper appeared in the online peer-reviewed publication PLOS recently. I was driving to the hospital, listening to NPR when I first heard about it. Melissa Block was interviewing NPR correspondent Allison Aubrey . Her take, in a more subdued written form here is similar to many news outlets.
Allison summarized the findings as follows
The researchers compared organic and conventional milk head-to-head. They analyzed about 400 samples over an 18-month period, to account for seasonal differences. And the samples were taken from, you know, all different parts of the country. And they found that organic milk had about 62 percent more of the heart healthy omega-3s, compared to conventional milk.
When asked for an explanation she said
It really comes down to watch what the cows were eating. Organic milk is produced from cows that spend a lot more time out on pasture, and they’re munching on grasses and legumes. And these greens are rich in omega-3 fatty acids. So as a result, the milk they produce has more omega-3 fatty acids.
Wait a minute! I said , you’re confusing “organic” and “grass-fed” or “pasture raised ” they are two totally different things although they can overlap. I totally get the concept of a healthier diet for the cows increasing omega-3s in their milk but I haven’t seen anything that would suggest reducing pesticide or antibiotic usage does that. The radio did not respond. Also, I asked, is it possible to use the term omega-3 without prefacing it with “heart healthy”?
Once you start demanding to know more about the conditions of the cows that made the milk you drink things can become complicated. A cow can be grass-fed but not pasture raised, meaning that it stayed indoors and was fed hay. A cow can be outside “grazing ” but be given corn to eat. Prior to looking at the PLOS one article, I did not assume organic implied anything about how the cows were fed or grazed.
It turns out that in 2010 the USDA announced guidelines that mandated, among other things, for a dairy to be called “organic”, its dairy cows had to spend at least 120 days grazing on pasture.Thus, there is some correlation between organic and pasture raised/grass-fed but not a complete one.
The PLOS one study looked at geographical variation in the difference between organic and conventional milk fatty acid content. Northern California was the only region in which there was no significant difference. The authors speculated that this was because conventional farmers in Norther California usually have cows that roam on the pasture and eat grass and legumes. Thus, it appears the differences between organic and conventional milk are primarily due to what the cows were eating rather than the presence or absence of pesticides, antibiotics, GMOs, or hormones.
Allison Aubrey went on to say
But you know, I should say that there’s a trade-off here because in order to get all these extra omega-3s, you’ve got to drink whole milk. And you know, if you opt for the low-fat dairy – say, 1 percent fat -you’ve skimmed off most of these omega-3s. So the question is, you know, can you afford the extra calories in fat. If you choose the whole milk, you might need to trim a few calories from elsewhere in your diet.
To which I responded “Yes, by all means drink whole milk, there is no evidence that it adds to obesity. You will naturally want less calories down the line and you will get the benefit of good saturated fats.”
I'll continue to pay extra to drink milk from Trader's Point Creamery that I pick up at Whole Foods. I like their milk because I've visited their farm in Indiana and talked to their (plastic surgeon) owner and I like what he says on the website about their milk (ignoring the part about a “better immune system”.
We let our cows graze on 140 acres of pesticide free pasture, which results in milk with more healthy fats like Omega 3 and CLA (conjugated linoleic acid). Grassfed milk also contains more nutrients like beta carotene and vitamins A and E than milk produced using standard feeds. To all of us this means more nourishment and a better immune system for our bodies.
I’m going to end with the summary from the PLOS one article (DMI=dry matter intake, LA=linolenic acid, an omega-6 fatty acid) which emphasizes the importance of grazing and forage-based feeds not the organic aspects of milk.
We conclude that increasing reliance on pasture and forage-based feeds on dairy farms has considerable potential to improve the FA profile of milk and dairy products. Although both conventional and organic dairies can benefit from grazing and forage-based feeds, it is far more common—and indeed mandatory on certified organic farms in the U.S.—for pasture and forage-based feeds to account for a significant share of a cow’s daily DMI. Moreover, improvements in the nutritional quality of milk and dairy products should improve long-term health status and outcomes, especially for pregnant women, infants, children, and those with elevated CVD risk. The expected benefits are greatest for those who simultaneously avoid foods with relatively high levels of LA, increase intakes of fat-containing dairy products, and switch to predominantly organic dairy products.
Doctors have been waiting a long time to read what the Eighth Joint National Commission on Hypertension (JNC8) would recommend for current treatment of patients with high blood pressure. They were finally published yesterday in the Journal of the American Medical Association online
These recommendations were based on only the most rigorous of scientific data, randomized controlled trials and so can be considered evidence-based.
The most important change in them compared to previous recommendations and current clinical practice is more lenient blood pressure goals.
There is strong evidence to support treating hypertensive persons aged 60 years or older to a BP goal of less than 150/90 mm Hg and hypertensive persons 30 through 59 years of age to a diastolic goal of less than 90 mm Hg; however, there is insufficient evidence in hypertensive persons younger than 60 years for a systolic goal, or in those younger than 30 years for a diastolic goal, so the panel recommends a BP of less than 140/90 mm Hg for those groups based on expert opinion.
This is a big change for the blood pressure target in older patients and a welcome one. As a cardiologist I see a lot of older patients who pass out, fall, become dizzy on standing or are imbalanced on walking. Sometimes passing out (syncope) is due to abnormal heart rhythms or major structural problems with the heart. But in many instances, the fall, dizziness, imbalance, instability is related to inadequate perfusion of the brain due to lower blood pressures on standing. I can often alleviate or prevent completely these problems by downward adjustment or elimination of some of the patient’s blood pressure medications.
With these less stringent BP goals, I think we will help to improve older individuals quality of life.
Higher BP goals will mean less BP medications and lower dosages and less interactions with other medications.
As I pointed out in an earlier blog , individual vitamins and multivitamins have been proven over and over to have no benefit for heart disease.
A recent series of articles in the Annals of Internal Medicine summarized in this accompanying editorial, confirms this and further shows that multivitamins have no benefit on preventing cognitive decline with aging.
The U.S. Preventive Services Task Force reviewed all studies on multivitamins, single and paired vitamins and concluded that there was no benefit of taking these on overall mortality, cardiovascular mortality or cancer.
Hopefully this series of articles will start the decline of the multibillion dollar Vitamins and Supplement industry in the U.S.
For my patients, I recommend a healthy diet that includes, fruits, vegetables, and fish which will provide all the micronutrients and vitamins they need. There is no evidence that you can substitute taking industry-processed micronutrients or fish-oil and expect the benefits to be the same