Why Did I Go Into Atrial Fibrillation?

The skeptical cardiologist is asked this  question or  variations of it (such as  what caused me to go out of rhythm?) on a daily basis.

Most patients would like to have a reason for why their atria suddenly decided to fibrillate.  It’s understandable. If they could identify the reason perhaps they could stop it from happening again.

There are two variations on this question:

For the patient who has just been diagnosed with afib the question is really “what is the underlying reason for me developing this condition?”

For the patient who has had afib for a while and it comes and goes seemingly randomly the question is “what caused the afib at this time? i.e. what triggers my episodes?”

For most patients, there is no straighforward and simple answer to either one of these questions

The Underlying Cause of Atrial Fibrillation

My stock response to this first question goes like this:

“Atrial fibrillation is associated with getting older and having high blood pressure. 10 % of individual >/= 80 years have atrial fibrillation. 90% of patients with afib have hypertension.

Aging and hypertension may increase scarring or damage in the left atrium or pulmonary veins that drain into the left atrium setting up abnormal electrical signals.

There are some specific things that cause afib and we will be doing a complete history and physical and some testing to check for the most common. We’ll check you for thyroid or electrolyte abnormalities and we will do an echocardiogram to look for any structural problems with your heart.

If we do find a treatable cause such as hyperthyroidism or a cardiac valve problem we will fix that and the afib may go away, however chances are we won’t find a specific reason why you developed atrial fibrillation.

Finally, and possibly most importantly, let’s take a close look at your lifestyle. Are you overweight? If so, losing 10% of your body weight will substantially lower your risk of recurrent atrial fibrillation. Let’s get you exercising regularly and eating a healthy diet, Make sure your sleep is optimized and your stress minimized.”

If you’d like a more sophisticated look into what causes afib take a look at this graphic from a recent paper.

Current theory has it that factors that we know are associated with atrial fibrillation  including obesity, hypertension and sleep apnea cause atrial structural abnormalities or remodeling which then create various atrial electrical abnormalities.

 

Exhaustive List of Causes

If you’d like an exhaustive list of factors associated with atrial fibrillation, you can memorize the acronym P.I.R.A.T.E.S. which is sometimes used by medical students to remember the causes of atrial fibrillation which include:

  • Pulmonary disease (COPD, PE)/Phaeochromocytoma
  • Ischemia (ACS)
  • Rheumatic heart disease (mitral stenosis)
  • Anemia (high output failure/tachycardia)/Atrial myxoma/Acid-base disturbance
  • Thyrotoxicosis (tachycardia)
  • Ethanol/Endocarditis/Electrolyte disturbance (hypokalaemia, hypomagnesaemia)/Elevated BP
  • Sepsis/Sick Sinus Syndrome/Sympathomimetics (Drugs)

And here’s a cute  mnemonic from the Family Practice Notebook using ATRIAL FIB itself (although you have to use the ph of pheochromocytoma to make the f of fib)

  1. Alcohol Abuse
  2. Thyroid Disease
  3. Rheumatic Heart Disease
  4. Ischemic Heart Disease
  5. Atrial Myxoma
  6. Lung (Pulmonary Embolism, Emphysema)
  7. Pheochromocytoma
  8. Idiopathic
  9. Blood Pressure (Hypertension)

Both of these mnemonics are a little outdated. For example, rheumatic mitral stenosis is quite rare as a cause of afib in the US but  degenerative and functional mitral regurgitation is a common cause.

Ischemic heart disease (aka coronary heart disease) isn’t felt to cause atrial fibrillation unless it results in a myocardial infarction and subsequent heart failure. Way too many cardiac catheterizations are performed on patients who present with atrial fibrillation by doctors who don’t know this.

Congenital heart defects (not mentioned in either mnemonic) especially atrial septal defects often are associated with afib

There may be case reports of pheochromocytoma (a catecholamine-secreting neuroendocrine tumor) causing afib but they are few and far between.

Finally, genetics clearly play a role in the younger patient with afib without any known risk factors. One of my patients and his twin brother both developed symptomatic afib in their 40s.

In The Chronic Afibber What Triggers An Episode?

Alas, for most afibbers we won’t identify specific reasons why you go in and out of afib although there are some triggers you should definitely avoid such as excessive alcohol.

Some of the “causes” listed in the mnemonic are acute triggers of afib episodes.

For example low potassium or magnesium (typically induced by diuretics, diarrhea or vomiting) can bring on episodes .(See my discussion on potassium and PVCS here-much of it is relevant to afib.)

And I  have definitely seen patients go  into atrial fibrillation who have acute pulmonary problems such as pneumonia, pulmonary embolism or exacerbation of COPD.  In these cases, it is felt that the lung process raises pressure in the pulmonary arteries thereby  putting strain on the right heart leading to higher right atrial pressures.

Sleep apnea is associated with afib and I have had a few cases where after identifying that a patient’s  afib always began during sleep we were able to substantially lower episodes by treatment of sleep apnea.

Pericarditis with inflammation adjacent to the left atrium not uncommonly causes  afib. This is the likely mechanism for the afib that occurs frequently after cardiac surgery. Since pericarditis may never recur (especially in the cardiac surgery patient) we think the risk of afib recurring is low in these patients.

Anything that raises stress and stimulates the sympathomimetic nervous system can be a trigger. For example, a young and otherwise healthy patient of mine went into afib after encountering a car in flames along the side of the road. We found that beta-blockers (which block the sympathetic nervous system) helped prevent her episodes.

Some patients have odd but reproducible triggers. One of my patients routinely went into afib when he ate ice cream. I had a simple , very effective treatment plan for him.

Caffeine and Chocolate

Many afibbers have been told to avoid caffeine but a recent study of 34,000 women found that there was no increased risk of afib with increasing caffeine content and no sign that any of the individual contributors to caffeine in the diet (coffee, tea, cola, and chocolate) were more likely to cause afib.

Higher chocolate consumption, in fact, has recently been linked to a lower rate of afib. An observational  study of 55 thousand Danish men and women found that those who consumed 2 to 6 servings per week of 1 oz (30 grams) of chocolate had a 20% lower rate of clinically apparent afib.

Alcohol and Atrial Fibrillation

Binge drinking has long been known to cause acute atrial fibrillation.

However, it appears that even light to moderate chronic alcohol consumption increases the risk of going into atrial fibrillation.

This graphic from an excellent recent review of the topic gives the potential mechanisms:

The review concludes that although light to moderate alcohol consumption lowers your risk of dying, any alcohol consumption increases your risk of afib.

This graph shows the relationship between dying from heart disease (red line) and risk of going into afib (blue line) and amount of alcohol consumed.

Looking at the 15 drinks per week point on the x-axis (about 2 drinks per day) we see that your CV mortality is reduced by 20% whereas your risk of afib has increased by 20%.

A better point on the x-axis is 7 (1 drink per day) which has a 25% lower CV mortality but only a 10% higher risk of afib.

Whatever caused you to go into afib the good news is that with lifestyle changes and the care of a good cardiologist chances are excellent that you can live a normal, happy, healthy , long and active life.

Etiologically Yours,

ACP

 

How Much Does or Should An Echocardiogram Cost?

One might assume the skeptical cardiologist has a quick and accurate answer to this question given that he has spent a very large amount of his career either researching, teaching or interpreting echocardiograms.

Surprisingly, however, it turns out to be extremely difficult to come up with a good response.

An echocardiogram is an ultrasound test that tells us very precisely what is going on with the heart muscle and valves. I’ve written previously here and here on how important they are in cardiology, and how they can be botched.

As in the  example of a severely leaking aortic valve  below, we get information on the structure of the heart (in grey scale) and   on  blood flow (color Doppler). This type of information is invaluable in assessing cardiac patients.

In the last week I’ve had 2 patients call the office indicating that even with insurance coverage, their out of pocket costs for an echocardiogram were unacceptably high – almost a thousand dollars.

Wide Variations In Equipment, Recording and Interpretation Expertise For Echocardiograms

A small, handheld ultrasound machine that performs the basics of echocardiography can now be purchased for 5 to 10K. More sophisticated systems with more elaborate capabilities cost up to 200K. In my echo lab the machines are typically replaced about every 5 years, but in smaller, more cost sensitive labs they can be used for decades.

An echo test typically takes up to an hour, and a sonographer performs up to 8-10 tests per day. At facilities trying to maximize profit, tests are shortened and sonographers might perform 20 per day.

In the U.S., echos are performed by sonographers who have trained for several years (specifically in the field of ultrasound evaluation of the heart) and earn on average around 30$ per hour, however, Medicare and third party payors usually don’t require any sonographer certification for echo reimbursement.

Physicians who read echocardiograms vary from having rudimentary training to having spent years of extra training in echocardiography, and gaining board certification documenting their expertise.

Interpretation of a normal echocardiogram takes less than 10 minutes, whereas a complicated valvular or congenital examination requiring comparison to previous studies, review of clinical records and other imaging modalities, could take more than an hour.

Given these wide parameters, estimating what one should charge for the technical or physician portions of the average echo is challenging.

Wildly Differing Charges For Echocardiograms

Elizabeth Rosental wrote an excellent piece for the NY Times in 2014 in which she described the striking discrepancy between 2 echos a man underwent at 2 different locations:

Len Charlap, a retired math professor, has had two outpatient echocardiograms in the past three years that scanned the valves of his heart. The first, performed by a technician at a community hospital near his home here in central New Jersey, lasted less than 30 minutes. The next, at a premier academic medical center in Boston, took three times as long and involved a cardiologist.

And yet, when he saw the charges, the numbers seemed backward: The community hospital had charged about $5,500, while the Harvard teaching hospital had billed $1,400 for the much more elaborate test. “Why would that be?” Mr. Charlap asked. “It really bothered me.”

Testing has become to the United States’ medical system what liquor is to the hospitality industry: a profit center with large and often arbitrary markups”

This graph shows the marked variation across the US in price of an echo.  In all the examples, however, what the hospitals were paid was around 400$ which is the amount that CMS pays for the complete echo CPT code 93306.

Costs Outside the US

At the Primus Super Specialty Hospital in New Delhi, India, apparently you can get an echocardiogram for $50.

This site looks at prices for private echos across the UK. The cheapest is in Bridgend in Wales (where suicide is rampant) at 175 pounds. You can get an echo for 300 pounds at the Orwell clinic (where their motto is “War is peace. Freedom is slavery. Ignorance is strength.”)

At one private  UK clinic, you can have your echo read by Dr. Antoinette Kenny, who appears extremely well qualified  for the task.

“In 1993, at the relatively young age of 33, she was appointed Consultant Cardiologist and Clinical Head of Echocardiography at The Regional Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne.  At that time only 19 (<5%) of consultant cardiologists in the UK were female and an even smaller percentage of cardiologists had achieved consultant status by the age of 33, facts which serve to highlight Dr. Kenny’s postgraduate career achievements.”

Whereas I would not be interested in getting an echo done in India or Mexico, I would definitely have one done in Dr. Kenny’s center if I lived nearby.

Self Pay Cost

My hospital, like most, will write off the costs of an echo for indigent patients. I will read the tests on such patients pro bono (although doctors never use that term because we feel it makes us sound to lawyeresque).

The hospital also has a price it charges for those patients who are not indigent, but who have excessively high deductibles or co-pays with their insurance. In some cases this “self-pay” charge is significantly less than what the patient would pay with their insurance.

Paying out of the pocket for the echocardiogram may also make sense if the patient and/or physician really thinks the test is warranted, but the patient’s insurance deems it unncessary.

If you find yourself in a situation where a needed echocardiogram performed at your ordering doctor’s preferred facility is prohibitively high, it makes sense to look around for a more affordable option.

However, I must advise readers to be very cautious. In the NY Times example, the hospital charges for Mr. Charlap seemed inversely proportional to the quality of the echo he received.

This is not necessarily the case for a self pay echo. It is more likely that a cheap upfront out-of-pocket cost quote in a doctor’s office or a screening company reflects cheap equipment with minimal commitment to quality and brevity of exam and interpretation time.

I have encountered numerous examples of this in my own practice.

One of my patients who has undergone surgical repair of her mitral valve decided to get an echocardiogram as part of a LifeLine screening (see here and here for all the downsides of such screenings).

The report failed to note that my patient had a bicuspid aortic valve and an enlarged thoracic aorta.  These are extremely significant findings with potentially life threatening implications if missed.

If a high quality echo recording and interpretation is indicated for you make sure that the equipment, technician and physician reader involved in your case are up to the task.

Ultrasonically Yours,

-ACP

What Is the Significance Of A Spot On The Lung? The Three-eyed Radiologist On Incidental Pulmonary Nodules

The Three-eyed Radiologist (TR) has been asked by The Skeptical Cardiologist (SC) to discuss the epidemic of incidental pulmonary nodules that are found on routine cardiac diagnostic studies including coronary calcium CTs, coronary CTAs, and myocardial perfusion scans (using CT for attenuation correction), not to mention a whole host of other CT (computed tomography or “CAT”) scans and x-ray exams performed for many reasons that have nothing to do with inspecting lungs for pulmonary nodules. The TR will herein anticipate and answer common questions that might be asked by the SC audience.

  1. What is a pulmonary nodule (and why should I care)?

A pulmonary nodule is a nonspecific “spot” or lesion or density seen in the lung (1). It could be nothing. It could indicate lung cancer, and that is why you should care. Larger nodules, say 8 mm or larger (bigger than one-third of an inch), are of greater concern than smaller ones, but size alone is not an indicator of malignancy or benignity.

An incidental pulmonary nodule (inside red circle) discovered on a CT scan of the chest which was done in conjunction with a nuclear stress test.

A nodule may initially appear to be benign but upon further investigation be malignant—or vice versa. It could be a scar. It could indicate an old infection of no consequence. It could indicate an active infection or inflammation.

Again, it is a nonspecific finding that requires further thought, analysis and maybe additional testing.

2. Okay, you scared me by mentioning cancer. What should I do about a pulmonary nodule?

In many instances, the nodule can be dismissed if it has characteristic imaging features of a granuloma (calcium) or hamartome (fat) or if it can be shown to be stable over time (at least two years in many typical nodules). In most other cases, the nodule will require a follow up scan or two, and occasionally a PET scan and or a consultation with a lung doctor (a pulmonologist). Less frequently, the nodule will need a biopsy or to be removed, especially if it is likely or proven to represent cancer.

3. How common are pulmonary nodules?

Very common. In fact, last week the TR’s own 85 year old father texted him to tell him about the incidental pulmonary nodule discovered in the right lung when he was having a CT scan of the kidneys for blood in the urine.

The TR spends a good deal of his work day following pulmonary nodules with serial chest CT scans and discovers them regularly, too. The American Thoracic Society estimates that as many as one half of all people getting an x-ray or CT scan that includes part of the lungs has a pulmonary nodule (1). The TR’s experience is that the number is quite a bit lower in actual practice.

4. I have a pulmonary nodule. What should I do about it?

First, do not panic. Much of the time, this amounts to very little.

There are evidence-based consensus recommendations called, The Fleischner Society Guidelines (2), created with input from leading chest radiologists, pulmonologists, and chest surgeons, to advise the doctor and patient to manage these incidental lung nodules. It was updated in early 2017, and the new guidelines represent the state-of-the-art for handling this medically common scenario.

Based on the size and appearance, there are standardized work up and follow up protocols. The TR was positively pleased to see that the new recommendations are much less aggressive than the early version, previously requiring more frequent workup and monitoring for minuscule nodules that never seemed to amount for much. As the TR ages, his visual acuity for small things is naturally declining, and he is thrilled that the tiniest nodules can now usually be ignored.

5. While I have you here, TR, what’s the deal with lung cancer screening?

Lung cancer screening is a newer test, using low dose CT scans, for the early detection of lung cancer in a subset of people with a history of smoking (3). It was graded “B”, by the USPSTF, for its life saving potential (for comparison, screening mammography gets a “C” grade) and is offered to Medicare and commercial insurance patients who qualify, based mostly on age and smoking history. The CT scans are used to detect and follow the same nodules discussed above. If you are a smoker or former smoker, consider a discussion with your doctor as to whether or not lung cancer screening might benefit you.

6. Thank you, TR. What can I do to repay you for this useful information?

Do not tell the SC, but the TR loves salted caramel gelato and will accept gelato donations.

1) https://www.thoracic.org/patients/patient-resources/resources/lung-nodules-online.pdf

2) http://pubs.rsna.org/doi/pdf/10.1148/radiol.2017161659

3)https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/lung-cancer-screening

N.B. The Three-eyed Radiologist is Robert Kanterman, MD, a radiology colleague at St. Luke’s Hospital in Chesterfield, MO. He can be followed on Twitter @3EyeRadiologist

 

Why Doesn’t The USA Have Graphic Warning Labels On Cigarette Packs Like The Netherlands?

While strolling the delightful (and typically debris-free) streets of Haarlem in The Netherlands the skeptical cardiologist espied an unusual cigarette pack on the ground.

In comparison to the typical American cigarette pack I noted a very prominent and disgusting picture of a leg which had been ravaged by peripheral artery disease.

The large print translates “smoking clogs your arteries.”

This is one of many potential warnings on Dutch cigarette packs. My favorite is

Roken kan leiden tot een langzame, pijnlijke dood

(Smoking can lead to a slow, painful death)

Perhaps, if such warning had been on American cigarette packs in the 1990s my mother would have been able to walk without severe pain in her legs (claudication) from the severe blockages caused by her decades of cigarette smoking.

When cigarette smoking patients tell me that “you have to die from something” I tell them that although they are greatly increasing their chance of dying from lung and cardiac disease, the smoking may not kill them but  leave them miserable and unable to walk or breath.

Experts on tobacco control note that these large, graphic and direct warnings are much more effective than the first small boxed warnings:

After the implementation of the first warning labels in 1966, the FTC’s 1981 report concluded that the original warning labels were not novel, overexposed and too abstract to remember and be personally relevant.46 Warning labels, like advertisements, wear out over time.47 Written warning labels wear out faster than graphic ones.48,49 In response, Congress passed a law mandating four rotating warnings. Studies on them began appearing in the late 1980s, demonstrating that several years after the implementation, those written labels on cigarette packs were also not noticed and not remembered by smokers and adolescents.5053 Since then, the diffusion and evolution of tobacco warning labels have been propelled by observational and experimental studies showing the effectiveness of large graphic warning labels in informing consumers about the health harms of smoking and reducing their smoking behavior.45,54

Here’s how Australia’s warnings have evolved

autralia-cigarette.jpg

 

 

 

 

 

 

 

In 2011 the US Congress passed legislation moving America towards such effective graphic warnings:

However, the law was challenged by Big Tobacco and has never been enacted. From the FDA site:

The Family Smoking Prevention and Tobacco Control Act requires the FDA to include new warning labels on cigarette packages and in cigarette advertisements. On June 22, 2011, the FDA published a final rule requiring color graphics depicting the negative health consequences of smoking to accompany the nine new textual warning statements. However, the final rule was challenged in court by several tobacco companies, and on Aug. 24, 2012, the United States Court of Appeals for the District of Columbia Circuit vacated the rule on First Amendment grounds and remanded the matter to the agency.[1] On Dec. 5, 2012, the Court denied the government’s petition for panel rehearing and rehearing en banc. In 2013, the government decided not to seek further review of the court’s ruling.

The FDA has been undertaking research related to graphic health warnings since that time.

[1] R.J. Reynolds Tobacco Co., et al., v. Food & Drug Administration, et al., 696 F.3d 1205 (D.C. Cir. 2012)

What Other Countries Are Doing

According to a Canadian Cancer Society report from late 2016,

More than 100 countries/jurisdictions worldwide have now required pictorial warnings, with fully 105 countries/jurisdictions having done so. This represents a landmark global public health achievement.

Increasingly, the United States stands alone, because of a constitutional doctrine privileging commercial speech above public health.

Here are the countries requiring pictorial warnings courtesy of that Canadian Cancer Society report.

And some of their warning pictures:

And this a picture that FDA would have required:

 

Skeptically Yours,

-AcP

Is September Really National Atrial Fibrillation Awareness Month (And Why Does It Matter?)

The skeptical cardiologist received an email from a woman telling him that September is atrial fibrillation awareness month and offering me the free use of an infographic given that I

“care deeply about helping people living with AF.”

Well, I do care about deeply about people living with atrial fibrillation and pretty much all cardiac diseases  (except perhaps Schuckenbuss syndrome.)

That’s the major reason I write this blog. I’ve written a lot about Afib and have a lot more i want to write (I really want to write about antiarrhythmic drugs, i.e. drugs that maintain you in normal sinus rhythm.)

But I don’t find it particularly helpful to assign a disease to a month or a day so my posts on atrial fibrillation come out randomly dependent on the mysterious machinations of my messy mind.

It turns out that September, 2009 was declared National Atrial Fibrillation Awareness Month (NAFAM) by Senate Resolution 262 although Stop Afib.org wants us to believe September is eternally NAFAM.

However, the email prompted me to better organize my atrial fibrillation and stroke page (now containing all that I have written on the subjects) which I have copied below.

Posts on Diagnosing Atrial fibrillation

Take your pulse and prevent a stroke

TIAs and silent atrial fibrillation. Sometimes strokes present in unusual ways, like the inability to differentiated a spade from a diamond when playing bridge and afib is often the cause.

Estimating Stroke Risk in Patients With Atrial Fibrillation You can estimate your stroke risk using an app that utilizes the CHAD2DS2-VASc score. I prefer to call the Lip score.

Posts About Using Personal Devices To Diagnose Atrial Fibrillation

Two That Work Reasonably Well

AliveCor

Using a Smart Phone Device and App To Monitor Your Pulse for Atrial Fibrillation (AliveCor)

AliveCor Is Now Kardia and It Works Well At Identifying Atrial Fibrillation At Home And In Office

AliveCor Successes and Failures.

Sustained Atrial Fibrillation or Not: The Vagaries and Inaccuracies of AliveCor/Kardia and Computer Interpretation of ECG Rhythm

AfibAlert

How Well Does The AfibAlert Remote Hand-Held Automatic ECG Device Work For Detection of Atrial Fibrillation?

AfibAlert Versus AliveCor/Kardia: Which Mobile ECG Device Is Best At Accurately Identifying Atrial Fibrillation?

And One of Several Devices To Avoid: AF Detect

Do NOT Rely on AF Detect Smartphone App To Diagnose Atrial fibrillation

Posts About Treatment Of Atrial Fibrillation

        Lifestyle Changes

How Obesity Causes Atrial Fibrillation in FatSheep and How Losing Weight helps prevent afib from coming back.

Drug Therapy: Rate Control and Anticoagulation

Foxglove Equipoise. When William Withering began treating patients suffering from dropsy in 1775 with various preparations of the foxglove plant he wasn’t sure if he would help or hurt them. After 240 years of treatment, we are still unsure if the drug obtained from foxglove is useful.

Should Digoxin Still Be Used in Atrial Fibrillation? Recent studies suggest that we should not.

Why Does the TV Tell Me Xarelto Is A BAD Drug? Anticoagulant drugs that prevent the bad clots that cause stroke also increase bleeding risk. A bleeding complication is not a valid reason to sue the manufacturer.  The lawsuit are strictly a money-making tactic for sleazy lawyers.

Cardioversion and Ablation

Cardioversion: How Many Times Can You Shock The Heart?

Ablation: Cautionary Words From Dr. John Mandrola and The Wisdom of a Team Approach

Miscellaneous Topics

What Happens If You Go Into Atrial Fibrillation On A Cruise?

Infographics

Are infographics really helpful? Someone should do a study on that. Perhaps we could use the money we spend on infographics in atrial fibrillation to research whether the left atrial appendage should be excised at the drop of a hat.

Here’s the infographic (because everyone loves an infographic!)

The first part lays out the problem of AF with patriotic bunting.

The second part uses the annoying numerical infographic approach.

 

 

 

 

 

 

 

The third part explains why I got the email. A product is being promoted. The woman who sent me the email works for MyTherapyApp.

 

 

 

Eagerly Awaiting Schuckenbuss Syndrome Day,

-ACP

 

 

 

The Harvard T.H. Chan School of Public Health Now Recommends Full Fat Dairy For Your Kid’s Lunch Boxes

The skeptical cardiologist became overjoyed while reading an email from The Harvard T.H. Chan School of Public Health (THTHCSPH) which outlined  their recommendations for packing kids‘ lunch boxes.:

The Kid’s Healthy Eating Plate was created as a fun and easy guide to encourage children to eat well and keep moving. The plate guidelines emphasize variety and quality in food choices.

The majority of the recommendations were pretty straightforward and mainstream:

The formula is simple: Fill half your plate (or lunch box) with colorful fruits or vegetables(aim for two to three different types). Fill about one-quarter with whole grains like whole grain pasta, brown rice, or quinoa, and the remaining quarter with healthy proteinslike beans, nuts, fish or chicken. Healthy fatsand a small amount of dairy (if desired) round out a tasty meal that will fuel an active, healthy lifestyle.

What caught my attention was the comment about dairy.

The dreaded words skim or low-fat did not appear in the sentence!

It would appear that a highly respect and mainstream source of nutritional advice is not making the typical (and scientifically unsupported ) recommendation to consume low fat or skim dairy products!

Indeed, if we look at their expanded comments on dairy they read:

Incorporating dairy (if desired). For example: unflavored milk, plain Greek yogurt, small amounts of cheese like cottage cheese, and string cheese.

No mention of fat content. Zip. Zero. To me, if you don’t put non fat low fat or skim next to the word diary it implies full fat.

Following their yogurt link we find no reference to preferentially consuming low fat yogurt despite the fact that the vast majority of yogurt sold in the US has been processed to remove healthy dairy fat, something the THCHSPH must be painfully aware of. (My wonderful MA Jenny’s husband, Frank, until very recently was unable to find full fat yogurt at Schnuck’s.)

As I pointed out here, a huge scam was foisted on Americans when allegedly healthy non fat yogurt filled with added sugar began to be promoted as a healthy treat.

It is almost  as if the THTHCSPH  has become agnostic about dairy fat and therefore is trying not to make recommendations.

Elsewhere on the THTHCSPH site however the old unwarranted advice  to avoid dairy fat rears its ugly head. On a page devoted to calcium we read:

Many dairy products are high in saturated fats and a high saturated fat intake is a risk factor for heart disease”

Then this interesting (and ?ironic) observation:

And while it’s true that most dairy products are now available in fat-reduced or nonfat options, the saturated fat that’s removed from dairy products is inevitably consumed by someone, often in the form of premium ice cream, butter, or baked goods.

Strangely, it’s often the same people who purchase these higher fat products who also purchase the low-fat dairy products, so it’s not clear that they’re making great strides in cutting back on their saturated fat consumption.

The THTHCSPH seems conflicted, as well they should. They want to keep up the nutritional party line that they have been spouting for 30 years that all saturated fats are bad but they now realize that supporting non fat dairy products has likely worsened rather than improved the diet of millions of Americans.

Galactosely Yours,

-ACP

N.B. The overall Kid’s healthy eating plate is not likely to be a favorite of kids  and I disagree with some aspects of it.

Namely, I think it is fine to have red meat and processed meats in moderation and I wouldn’t push the pasta, rice, and bread.

 

 

 

 

Pistachios: Are Their Shells A Portal to Contamination, The Key To Weight Loss, or A Manicure Destruction Device?

The results of the “Fourth Nut” poll are in and the winner is a nut first cultivated in Bronze Age Central Asia,

Almost 60% of readers who took the time to vote selected the pistachio nut.

Coming in a distant second was the macadamia nut. One reader prized it because it only contained saturated fat and monounsaturated fats. Another bemoaned their candy-like quality which makes over-consumption an issue.

A couple of readers were strong proponents of Brazil nuts. This prompted me to enter a selenium rabbit hole from which I have yet to emerge. If I can escape with my selenoproteins intact I’ll let you know.

Pistachios are a fine choice from a health standpoint and seem to be embraced by all nutritional cults, with the exception of  the very nutty Caldwell “NO OIL” Esselstyn’s acolytes.

The Pistachio Principle PR Institute

I’m in the process of sorting through the nutritional studies on pistachios, and the hardest part is determining which data are sponsored by the pistachio industry.

For example, poorly researched online articles about pistachios will typically state that “research suggests” that “pistachios could help to reduce hypertension and promote development of beneficial gut microbes. They’re even gaining credibility as a tool for weight loss”

The first reference is an open access review article which clearly just wants to extoll any and all positive pistachio data and was paid for by the American Pistachio Growers. The second article comes directly from “The Pistachio Health Institute,” a PR voice for the pistachio industry.

To Shell or Not to Shell

My major dilemma was deciding if the pistachios should be shelled or left in-shell. (This has led me down the pistachio production rabbit hole).

I was concerned that the outsides of the pistachio shells could be contaminated in some way and the idea of mixing them in with unshelled nuts seemed a little strange.

If you Google images of mixed nuts pistachio you only see mixtures with unshelled pistachios.

Why, then, are most pistachios sold and consumed in-shell?

According to How Stuff Works Louise Ferguson, author of the Pistachio Production Manual believes:

Between 70 and 90 percent of pistachios develop a natural split in their shells during the growing process, After those pistachios are shaken off the trees by harvesting machines, they can be salted and roasted while still inside the shells as that natural crack allows heat and salt access to the nut, eliminating a step in the industrial process and saving processors some money.

The pistachio PR machine would also have us believe that eating pistachios in-shell can lead to weight loss:

Why choose any other nut?

This pistachios principle is based on 2 studies in the journal Appetite (seems to be a legitimate journal) by JE Painter of the department of “Family and Consumer Sciences” Eastern Illinois University in Charleston, Illinois.

I’m awaiting a full copy of the paper, but the abstract notes that students offered in-shell pistachios consumed only 125 calories, whereas those offered shelled pistachios consumed 211 calories yet “fullness and satisfaction” were similar.

My skeptical sensors were exploding when I read about this study. I doubt that it will ever be reproduced.

If we look at cost, an unofficial analysis revealed:

The pre-shelled pistachios were priced at $5.99 for 6.3 oz of nuts.

The 8 oz bag of pistachios were priced at $4.49.  After shelling he was left with 4.3 oz of nuts.

Un-shelled pistachios = $1.04 per oz.

Shelled pistachios = $0.95 per oz.

If you go the lazy route, you save $.09 per oz!

Most likely, the fourth nut will be a shelled pistachio unless readers convince me otherwise or the blather from the pistachio PR machine  annoys me too much.

The eternal fiance’e has just weighed in and tells me that women who care about their well-groomed  nails will not consume  in-shell pistachio nuts for fear of damaging their manicures.

That, my friends, is the  nail in the coffin for shelled pistachios as the fourth nut.

Pistachoprincipaly Yours,

-ACP

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

The Fourth Nut

The skeptical cardiologist has given out the entire first batch of Dr. P’s Heart Nuts to his patients.

This precisely constructed mixture of hazelnuts, almonds and walnuts designed to maximize heart healthiness has been warmly received and hopefully enthusiastically consumed.

To some extent I feel like I may be preaching to the choir as many of the Heart Nuts recipients told me they were already avid nut fans and consumers.

However, I plan to press on with my mission to increase the amount of nut snacking in the world.

To this end, I have reorganized my blog and created a page devoted to Nuts and Drupes. You can find it here and I’ll reproduce it below.

Furthermore, I have decided to add a fourth nut to the mixture. At this time, I am intensely researching pistachio nuts and macadamia nuts to be the honored nut.

Please feel free to suggest other candidates to be  the Fourth Nut (along with appropriate justification) in the comments below and vote in the poll.

Macadamiamaniacaly Yours,

-ACP

From The Nuts Page

Nuts, despite containing a lot of fat, are a fantastic heart-healthy snack.

I’ve started handing out my special Dr. P’s Heart Nuts to patients along with the following:

Congratulations!

You have received a packet of cardiovascular disease-busting Dr. P’s Heart Nuts!
One packet 15 grams of almonds, 15 grams of hazelnuts and 30 grams of walnuts.

There is very good scientific evidence that consuming 1/2 packet of these per day will reduce your risk of dying from heart attacks, strokes, and cancer.

The 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

In other observational studies it has been found that for every 28 grams/ day increase in nut intake, risk was reduced by:

29% for coronary heart disease 7% for stroke
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

So when you are considering snacking, snack on nuts not processed food! Dr. Pearson

Posts About Nuts

Posts relevant to nuts and prevention of heart disease on my blog are

Nuts, Drupes, Legumes and Mortality

Kind Bars versus Nuts: Choose Just Plain Nuts

Although Nutella contains some hazelnuts it is full of sugar and other processed ingredients: why not eat hazelnuts instead?

Nutty Due Diligence

I spent a lot of time sourcing the nuts for my Dr. P’s Heart Nuts and discovered some disturbing things about almonds.

First, almost all almonds sold in the US have been gassed with proplyene oxide.

Second, roasting almonds can lead to an increase in toxic chemicals.

After finding out the first two facts about almonds I ended up getting raw, organic almonds from Spain. Unfortunately, about 1 in 10 of these were extremely bitter. It turns out these bitter almonds have significant amounts of cyanide.  So I wrote “Beware The Bitter Almond.”

I switched my raw, organic almond source to Nuts.com and with their almonds I very rarely encounter the bitter almond.

The other nuts in the mixture are raw and organic and obtained from Nuts.com.

 

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.

 

Unbiased, evidence-based discussion of the effects of diet, drugs, and procedures on heart disease

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