AliveCor (Kardia) Has A Premature Beat Problem: How PVCs and PACs Confuse The Mobile ECG Device

The skeptical cardiologist has many patients who are successfully using their AliveCor/Kardia devices to monitor for episodes of atrial fibrillation (afib).

However, a significant number of patients who have had atrial fibrillation also have premature beats. Sometimes patients feel these premature beats as a skipping or irregularity of the heart beat. Such palpitations  can mimic the feeling patients get when they go into atrial fibrillation.

The ideal personal ECG monitor, therefore,  would be able to reliably differentiate afib from premature beats for such patients.

Premature Beats: PVCs and PACs

I’ve discussed premature ventricular contractions (PVCs) here and here.  Premature beats can also originate from the upper chambers of the heart or atria.

Such  premature atrial contractions (PACs) have generally been considered benign in the past but a recent study showed that frequent (>30 s per hour) PACs  or runs of >20 PACs in a row were associated with a doubling of stroke risk.

For patients who experience either PVCs or  PACs the AliveCor device is frequently inaccurate.

PACs Misdiagnosed As Atrial Fibrillation

Here is a panel of recordings made by a patient of mine who has had documented episodes of atrial flutter in the past and who monitors his heart rhythm with Alivecor regularly:

Of the ten recordings , four were identified as “possible atrial fibrillation.”

Unfortunately only one of the four “possible atrial fibrillation” recordings has any atrial fibrillation: this one has 7 beats of afib initially then changes to normal sinus rhythm (NSR).

The other 3 recordings identified by AliveCor as afib are actually normal sinus rhythm with premature beats.

The first 3 beats are NSR. Fourth beat is a premature beat

In addition, frequently for this patient AliveCor yields an “Unclassified” reading for NSR with PACs as in this ECG:

PVCs Misread As Atrial Fibrillation

I wrote about the first patient I identified in my office who had frequent PVCs which were misdiagnosed by AliveCor as afib here.

Since then, I’ve come across a handful of similar misdiagnoses.

One of my patients began experiences period palpitations 5 years after an ablation for atrial fibrillation. He obtained an AliveCor device to rec  ord his rhythm during episodes.

For this patient,, the AliveCor frequently diagnoses “possible atrial fibrillation” but  all of his episodes turn out not to be afib. In some cases he is having isolated PVCs:

The first 3 beats in the lower strip are NSR. The fourth beat (purpose circle) is a PVC. AliveCor interpreted this as afib

At other times he has periods of atrial bigeminy  which are also called afib by AliveCor. In this tracing he has atrial bigeminy and a PVC.

 

 

PVCs Read As Normal

Premature beats sometimes are interpreted by AliveCor as normal. A reader sent me a series of  recordings he had made when feeling his typical palpitations. all of which were called normal. Indeed, all of them but one showed NSR. However on the one below the cause of his palpitations can be seen: PVCs.

The NSR beats (blue arrows) followed at times by PVCs (red arrows))

I obtained the “Normal”  tracing below from a patient in my office with a biventricular pacemaker and frequent PVCs who had no symptoms.

Paced beats (blue arrows) PVCs (red arrows)

PVCs Read As Unclassified 

A woman who had undergone an ablation procedure to eliminate her very frequent PVCS began utilizing AliveCor to try to determine if she was having recurrent symptomatic PVCs. She became quite frustrated because AliveCor kept reading her heart rate at 42 BPM and giving her an unclassified reading.

AliveCor is always going to call rhythms (other than afib) unclassified when it counts a  heart rate less than 50 BPM or greater than 100 BPM.

In this patient’s case, every other beat was a PVC (red circles). Her PVCs are sufficiently early and with low voltage so the AliveCor algorithm cannot differentiate them from T Waves and only counts the normal sinus beats toward heart rate.

Accurate AliveCor Readings

I should point out that many of my patients get a very reliable assessment from their devices. These tracings from a woman with paroxysmal atrial fibrillation  are typical: all the Normal readings are truly normal and all the atrial fibrillation readings are truly atrial fibrillation with heart rates  above 100.

AliveCor’s Official Position on Premature Beats

The AliveCor manual states

The Normal Detector in the AliveECG app notifies you when a recording is “normal”.  This means that the heart rate is between 50 and 100 beats per minute, there are no or very few abnormal beats, and the shape, timing and duration of each beat is considered normal.

What qualifies as “very few” abnormal beats is not clear. The manual goes on to state that the AliveCor normal detector has been designed to be conservative with what it detects as normal.

What is clear is that premature beats  significantly confuse the AliveCor algorithm. Both PVCs and PACs can create a false positive diagnosis of atrial fibrillation when it is not present.

Consequently, if you have afib and premature beats you cannot be entirely confident that a reading of afib is truly afib. Strongly consider having the tracing reviewed by a cardiologist before concluding that you had afib.

On the other hand if you are experiencing palpitations and make a recording with Alivecor that comes back as normal do not assume that your heart rhythm was totally normal. While highly unlikely to be afib, your palpitations could still be due to PACs or PVCs.

If a patient of mine has an abnormal or questionable AliveCor recording it is currently a very simple process for me to review the recording online  through my AliveCor doctor dashboard. The recordings can also be emailed to me.

However, Kardia appears to be trying to move new AliveCor purchasers to a subscription or Premium service. In addition, Kardia keep giving me messages that “the doctor dashboard is going away.”

Coralively Yours,

-ACP

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

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

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

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

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

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

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

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

Reader’s Digest and Stealth Quackery

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

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

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

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

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

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

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

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

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

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

Not So Bad But Not Clearly True Medical Advice

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

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

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

Fact Check. One review noted that:

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

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

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

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

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

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

#3. I do CrossFit.

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

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

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

A recent review

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

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

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

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

Seriously Bad Advice From Quacks Mixed In With Reasonable Advice

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

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

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

What do we know about Dr. Dean?

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

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

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

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

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

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

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

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

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

Prevention Magazine 

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

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

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

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

Finding The Truth

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

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

Readers should avoid any source of information which

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

IamJoesfootingly Yours,

-ACP

Dupixen Has Miraculously Cured My Eczema

Although this post is most unskeptical and decidedly noncardiac, the skeptical cardiologist feels compelled to share this information with readers who have or know friends or family with eczema or atopic determatitis, a chronic skin condition that results in itchy, scaly, dry and red skin.

For most of my life I have dealt with periodic flare-ups of eczema along with continuously itchy skin . Control of flare-ups was by meticulous attention to keeping my skin clean and moisturized along with frequent applications of topical corticosteroids.

Things worsened a few years ago and I began to think I might have Red Skin Syndrome, which some dermatologist believe is due to withdrawal from topical corticosteroids.

Two months ago, however, my spirits brightened when I heard that the FDA had approved a new biologic injectable called Dupixent (dupilumab), to treat adults with moderate-to-severe eczema (atopic dermatitis), whose eczema is not controlled adequately by topical steroids.

My fantastic dermatologist, Dr. Amy Ney, agreed this was appropriate therapy for me, and within a week I received a refrigerated package containing the initial dosage: two syringes filled with the drug.

The pre-loaded syringe filled with Dupixent. The syringes come with very detailed instructions to guide you through the process of injecting the liquid into either the abdominal region or the thighs.

 

Within a week of injecting the contents of the syringes into my abdomen, my itching ceased and I had no more eczematous rashes. For me this was a minor miracle.

Since then I’ve injected one 300 mg syringe every two weeks and I continue to be free of my life-long signs and symptoms of eczema.

Atopic Dermatitis and Dupixent

The cause of atopic dermatitis is a combination of genetic, immune and environmental factors. In atopic dermatitis, the skin develops red, scaly and crusted bumps, which are extremely itchy. Scratching leads to swelling, cracking, “weeping” clear fluid, and finally, coarsening and thickening of the skin.

Dupixent’s active ingredient is an antibody (dupilumab) that binds to a protein [interleukin-4 (IL-4) receptor alpha subunit (IL-4Ra)], that causes inflammation. By binding to this protein, Dupixent is able to inhibit the inflammatory response that plays a role in the development of atopic dermatitis.

Dupixent acts by inhibiting two cytokines that are responsible for the hyperimmune response in skin. They are called IL-4 and IL-13. IL is an abbreviation for interleukins, proteins that are produced by leukocytes (3) and play a part in regulation of the immune system. Steroids, such as prednisone, also suppress the immune system, but taking them for an extended period of time will get you into trouble. (See: Prednisone: Satan’s Little Helper) Unlike prednisone, Dupixent inhibits specific targets. It works more like a scalpel than a bomb.

More Stories of Miraculous Relief

I am not alone in experiencing miraculous relief from this new drug. I first heard of it from a  New York Times article in 2016 which details the dramatic responses of several patients who were involved in the clinical trials that proved the drug’s efficacy:

One participant in the trial, Lisa Tannebaum, a 53-year-old harpist in Stamford, Conn., was so thrilled that she wrote a letter to Regeneron suggesting they use her before and after photographs in advertisements. She developed a severe form of the disease 14 years ago and tried everything imaginable in conventional and alternative medicine without relief — specialized diets, immunosuppressive drugs, special clothing, bleach baths. She even had the gold fillings removed from her teeth on the theory that they may be causing an allergic response, but to no avail.

“It was like every day I had poison ivy and fire ants on myself,” she said. “You don’t sleep at all. You can’t go out, you have staph infections all the time,” because the skin’s protective barrier is broken by the rash. “I couldn’t drive my kids to school because the itching was so bad I couldn’t put my hands on the steering wheel.”

Now, she is performing again and will be playing her harp at Carnegie Hall on Oct. 30.

Randomized Controlled Trials Proving Efficacy

Of course we can’t rely on anecdotes to prove the safety and efficacy of drugs: we need randomized, controlled, double-blind studies.

Dupixent has three such clinical trials with a total of 2,119 adult participants, and the results were remarkable. (for details see here). Overall, participants who received Dupixent achieved greater response, defined as clear or almost clear skin, and experienced a reduction in itch after 16 weeks of treatment.

Panel A shows the proportions of patients with the primary end point (both a score of 0 or 1 [clear or almost clear] on the Investigator’s Global Assessment [IGA; scores range from 0 to 4, with higher scores indicating more severe disease] and a reduction from baseline of 2 points or more on the IGA at week 16) among patients who received dupilumab every week, dupilumab every other week, or placebo in SOLO 1 and SOLO 2. Panel B shows the proportions of patients with the key secondary end point (which was considered to be a coprimary end point by regulators in the European Union and Japan) of an improvement from baseline of at least 75% on the Eczema Area and Severity Index (EASI-75) at week 16 in the two trials. P<0.001 for all comparisons between dupilumab and placebo. For binary end points, patients who received rescue medications or withdrew from the study were categorized as having had no response, as were those with all other missing values.
The only side effect which was more common with Dupixent than placebo was conjunctivitis, an inflammation of the eye.

Cost of Dupixent

When I first read of this drug I assumed it would be horribly expensive. In cardiology we have two injectable biologics (Repatha and Praluent, PCSK9 inhibitors) for lowering cholesterol, which typically have been costing my patients with insurance coverage over 1000$ per month.

Fortunately Sanofi/Regeneron have learned from prior experience and priced the drug at $37,000, a number that insurance companies have apparently warmly welcomed. This article suggests that the drug is priced significantly lower than newer biologics now available for psoriasis and rheumatoid arthritis.

With my  insurance (United Health Care) coverage I was asked to pay 150$ for 2 injections per month.

I then discovered that Sanofi has a co-pay card that covers that 150$ so that for now I am paying zero dollars out of the 37,000$.

I’m paying nothing for a brand new biologic injectable that has cured my eczema. Now that is miraculous!

Unskeptically Yours,

-ACP

N.B. Featured Image before and after hand is from National Eczema organization and is not of my hand.

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

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

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

 

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

 

 

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

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

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

 

 

 

 

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

The Dutch High Happiness Rating

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

The report notes that:

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

Norway was at the top of the happiness list but

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

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

Despite the immense wealth of Americans, the report notes:

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

Dutch children seem to be especially happy.

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

Cardiovascular Disease in The Netherlands

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

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

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

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

A recent update noted

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

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

The Seemingly Horrid Dutch Diet

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

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

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

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

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

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

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

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

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

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

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

 

I personally witnessed  massive amounts of cheese and butter consumption.

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

A recent analysis of Dutch fat consumption found:

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

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

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

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

The Dutch Paradox

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

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

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

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

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

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

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

 

 

What Pain Medications Are Safe For My Heart?

The skeptical cardiologist is frequently asked by patients if it is OK to take certain pain medications.

Yesterday, I got a variation on this  when a patient called and indicated that he had been prescribed meloxicam and tramadol by his orthopedic surgeon for arthritic leg joint pain. The orthopedic surgeon said to check with me to see if it was OK to take either of these medications. (Patients, if you want to skip to my answer skip down to the last two sections of the post and avoid the background information.)

What Is The Risk Of Pain Medications?

Cardiologists have been concerned about the increased risk of heart attack and heart failure with non steroidal anti-inflammatory drugs (NSAIDs) since Vioxx was withdrawn from the market in 2004.

NSAIDS have long been known to increase risk of gastrointestinal (GI) bleeding  by up to 4-5 fold, Scientists developed Vioxx, a COX-2 inhibitor, hoping to reduce that risk but Vioxx  turned out to  increase the risk of heart attack.

Since this revelation it has become clear that NSAIDS in general increase the risk of heart problems as well as GI problems

This includes the two over the counter (OTC) NSAIDS:

-ibuprofen (in the US marked most commonly as Motrin or Advil, internationally known as Nurofen). For extensive list of brand names see here.

-naproxen (most commonly sold as Aleve. Per wikipedia “marketed under various brand names, including: Aleve, Accord, Anaprox, Antalgin, Apranax, Feminax Ultra, Flanax, Inza, Maxidol, Midol Extended Relief, Nalgesin, Naposin, Naprelan, Naprogesic, Naprosyn, Narocin, Pronaxen, Proxen, Soproxen, Synflex, MotriMax, and Xenobid. It is also available bundled with esomeprazole magnesium in delayed release tablets under the brand name Vimovo.)

In 2015  the FDA mandated  warning labels on all prescription NSAIDs including

1) a “black box” warning highlighting the potential for increased risk for cardiovascular  (CV) events and serious life-threatening gastrointestinal  bleeding, ulceration, and perforation;

(2) statements indicating patients with, or at risk for, CV disease and the elderly may be at greater risk, and that these reactions may increase with duration of use;

(3) a contraindication for use after coronary artery bypass graft surgery on the basis of reports with valdecoxib/parecoxib;

(4) language that the lowest dose should be used for the shortest duration possible

5) wording in the warning section that there is no evidence that the concomitant use of aspirin with NSAIDs mitigates the CV risk, but that it does increase the GI risk

Since then, hardly a day goes by without me having a discussion with a patient about what drugs they can safely take for their arthritis.

A reasonable approach to using NSAIDS, balancing GI and CV risks, that I have used in the past comes from a 2014 review
This table and many authorities recommend naproxen as the NSAID of choice for patients with high CV risk.

Indeed prior to the publication of the PRECISION study in 2016 I believed that naproxen was the safest NSAID for my cardiac patients. I told them it was OK to use from a CV standpoint but to use the least amount possible for the shortest time in order to minimize side effects.

The PRECISION study compared a COX-2 NSAID (celecoxicib or Celebrex) to ibuprofen and naproxen in patients who required NSAIDS for relief of their joint pain.

The findings:

cardiovascular death (including hemorrhagic death), nonfatal MI, or nonfatal stroke, occurred in 2.3% of celecoxib-treated patients, 2.5% of the naproxen-treated patients, and 2.7% of the ibuprofen group.

There was no placebo in this trial so we can only look at relative CV risk  of the three NSAIDS and it did not significantly differ.

GI bleeding was less with celecoxib than the other two NSAIDS.

Although this study has flaws it throws into question the greater CV safety of naproxen and suggests that all NSAIDS raise CV risk.

My Current Patient Advice on Cardiac Safety of Pain Meds

Here is an infographic I came across from the Arthritis Foundation (complete PDF….here)

It’s a reasonable approach for these OTC drugs and I will start handing this out to my patients.

We should consider that all NSAIDS have the potential for increasing the risk of heart attack and heart failure, raising blood pressure, worsening renal function and causing GI bleeding.

Therefore, if at all possible avoid NSAIDS.

Acetaminophen (Tylenol) is totally safe from a heart standpoint and overall if you don’t have liver disease it is your safest drug for arthritis. However, it provides no anti-inflammatory effects and often is inadequate at pain relief.

Treating The Whole Patient

Meloxicam is an NSAID so my patient should , if at all possible, avoid it.

The other drug he was prescribed, tramadol, is an opiod. Opiods have their own set of problems including, most importantly,  addiction and abuse.

A recent review concluded

 reliable conclusions about the effectiveness of long-term opioid therapy for chronic pain are not possible due to the paucity of research to date. Accumulating evidence supports the increased risk for serious harms associated with long-term opioid therapy, including overdose, opioid abuse, fractures, myocardial infarction, and markers of sexual dysfunction; for some harms, the risk seems to be dose-dependent.

As his cardiologist I am concerned about his heart, of course, but a good cardiologist doesn’t just focus on one organ, he looks at what his recommendations are doing to the whole person.

I certainly don’t want to have him become addicted to narcotics in order to avoid a slightly increased risk of a heart attack. On the other hand, the risks of the NSAIDS involve multiple organs, most of which don’t fall in the domain of the cardiologist.

My patient’s risk of taking either the meloxicam or the tramadol is best assessed by his primary care physician, who has the best understanding of his overall medical condition and the overall risk of dangerous side effects from these drugs.

Ultimately, I think the decision of which pain pill to take for chronic arthritis has to be made by an informed patient in discussion with his  informed (and informative) primary care physician. Only the patient can decide how much pain he is having and how much risk he/she wants to assume in relieving that pain.

Analgesically Yours,

-ACP

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

“Your Paper Really Attract Us”: Do Fake Scientific Journals Represent The Biggest Threat To Science Since the Inquisition?

When I was doing research in the field of echocardiography, and writing and publishing lots of research papers, there were only a few important cardiology journals that I wanted my papers published in.

It wasn’t easy getting my research published; after the paper was submitted, it was sent to two reviewers who critiqued it extensively and gave it  a thumbs up or down. Often, to satisfy the reviewers, I had to revise the manuscript multiple times, a process which could take months and months.

I knew once my work was published, however, that this heavy vetting process guaranteed that my paper appeared in a medium that was highly respected alongside similar important and well-vetted scientific work.

For the eighty-plus  papers that I published between 1987 and 1998, I paid not a dime, but I spent innumerable post-work hours reading, writing, and analyzing data.

In those years prior to the interweb, the process of researching a topic was laborious and time-consuming; I would spend hours in the medical libraries of various hospitals searching through the stacks of hard-bound medical journals for relevant articles. Once found, the very heavy tome containing the paper I needed would be lugged to a “Xerox” machine and copied.

I cannot recall one circumstance where a journal wrote to me asking me to submit a paper to them. The journals I published in were overwhelmed with high quality submissions from important scientists and only accepted a low percentage for publication.

The Rise of Open Access and Fake Scientific Journals

Unfortunately, we are now in an era of what I would term “fake scientific journals,” and in such journals it is quite easy to publish if one simply pays the asking price: somewhere between 150$ and 500$.

Publishers of these journals prey on scientists who are desperate to have their research published in order to survive in academia.

Jeffrey Beall, an academic librarian at the University of Colorado, Denver, noted the rise of this practice in 2008 and began researching what he termed “predatory journals.”  In a paper published in 2010 he wrote:

“These publishers are predatory because their mission is not to promote, preserve, and make available scholarship; instead, their mission is to exploit the author-pays, Open-Access model for their own profit.”

In 2012, Beall began listing (Beall’s list) predatory publishers and journals, and offered critical commentary on scholarly open-access publishing in a blog entitled  Scholarly Open Access.

Predatory journals have arisen in parallel with a change from print-only subscriptions to digitally available and free scientific publications.

It is important but often difficult to differentiate legitimate “open access” scientific journals from these profit-motivated sleazy journals.

A brief history of scientific publishing and the rationale for moving to open access publishing from Bowman:

Nature was first published in 1869, Science in 1880, and subsequently scientific journal publishing has increased to the point of a new paper being published every 20 seconds.1 In 2000, the future of scientific publishing was changed by the debut of PubMed Central and the Public Library of Science (PLoS). The next year, thousands of scientists called for a boycott of journals that would not allow free access on PubMed within 6 months. In 2002, for-profit Biomed Central began charging authors $500 to publish. In 2003, PLoS Biology was launched, charging authors $1500. By 2006, PLoS initiated the non-profit PLoS One, charged a $2500 author fee, and reviewed articles by placing scientific rigor over importance. In 2008, NIH mandated that papers published as a result of its funding be made free to the public within 12 months, and in 2009, the US Congress permanently required that all funded investigators submit electronic versions of their manuscripts to the National Library of Medicine’s PubMed Central.2 By 2010, PLoS generated revenues greater than costs and PLoS One became the world’s largest scientific publisher by volume.

My Brush With Fake Scientific Journals

From time to time since my days of research in academia, I have collaborated with medical residents at my hospital in writing what are termed “case reports.” These are descriptions of interesting patient cases and most prominent journals are not interested in publishing them.

However, I’ve noticed that with increasing frequency, I am receiving solicitations from journals I’ve never heard of based on my having published these types of papers.

Here’s my latest invitation. The editors of this journal (American Journal of Clinical and Experimental Medicine) first bizarrely ask me “how is everything going?”  then state that:

Your paper entitled Coronary Artery Fistula?\\Associated Endocarditis: Report of?Two Cases and a Review of the Literature from Echocardiography really attract us.
Are you interested in interested in sharing some other papers in this field?
If we may have the honor, we would like to publish your other papers in our journal.

Two weeks later they sent me a similar email with the verbiage slightly modified, but still horribly mangled:

We have learnt your paper entitled Coronary Artery Fistula?\\Associated Endocarditis: Report of?Two Cases and a Review of the Literature from Echocardiography, and are very attracted by its topic.
If you would like to publish other papers in the related subjects, you may consider to publish them in our journal

Both emails invited me to become a member of the editorial board!

How Can You Know Which Journals Are Fake?

Beginning in 2012, these types of journals were tracked by Beall’s list. In January 2017, Beall, “facing intense pressure from my employer, the University of Colorado Denver, and fearing for my job,” removed all of the blog contents from the internet.

(For a fascinating history of Beall’s work in this area see his article published here).

I found his list of predatory publishers resurrected  here.

Science Publishing Group, the publisher of  the journal that keeps emailing me is on the list.

A brief look at the website for Science Publishing Group does not reveal immediately that it is a predatory publisher. There are 80 scientific journals listed and they all have legitimate sounding names. However, I have never heard of any of them.

I searched in vain through the cardiology journals listed to find a paper that was the least bit interesting or important. Most of the listed editorial board members and authors were from third world countries. When I researched an American editorial board member  of one journal I found that he was a medical student.

Sting Operations on Fake Journals

Sting operations by academics have shown that papers that are composed of meaningless gobbledygook are often accepted by these types of journals as long as the publication fee is paid. The New Yorker has a great article describing such operations.

The Bohannon sting in Science two years ago found that 45% of a sample of publishers included in the directory of Open Access Journals accepted a bogus paper submitted for publication.

A recent sting operation also showed how anyone can become an editor or even “editor-in-chief” of one of these journals. From The NY times :

The applicant’s nom de plume was not exactly subtle, if you know Polish. The middle initial and surname of the author, Anna O. Szust, mean “fraudster.” Her publications were fake and her degrees were fake. The book chapters she listed among her publications could not be found, but perhaps that should not have been a surprise because the book publishers were fake, too.

Yet, when Dr. Fraud applied to 360 randomly selected open-access academic journals asking to be an editor, 48 accepted her and four made her editor in chief. She got two offers to start a new journal and be its editor. One journal sent her an email saying, “It’s our pleasure to add your name as our editor in chief for the journal with no responsibilities.”

Fake Conferences

Adding insult to scientific injury is the rise of fake scientific conferences.

I’ve been invited to lots of these important sounding conferences just based on publishing one case report. These emails are typically poorly written. If I didn’t know they were complete BS I would be flattered by the complements:

To ensure that you do not miss out, we extend our invitation to you again to express our sincere wish for your participation in BIT’s 9th Annual Congress of Cardiology-2017 (ICC-2017) with the theme of “Bridging Excellence in Cardiology and Clinical Aspects” will be held on 15-17 November 2017 in Singapore.

For your brilliant achievements and precious experience in the field of cardiology, on behalf of the organizing committee, we cordially welcome you to join us and give a presentation about Coronary Artery Fistula-Associated Endocarditis: Report of Two Cases and a Review of the Literature… at this congress.

I think I have had some brilliant achievements and my experiences are quite precious, but I’m definitely not  going to your ridiculous conference.

The Threat to Real Science

All of these fake and predatory scientific journals, editors and conferences could be dismissed as amusing if it weren’t for the fact that they are further contributing to the inability of the public to determine what is real science.

As Beall said

“predatory and low-quality journals are granting the imprimatur of science to basically any idea for which the author is willing to write an article and pay the author fees. This is polluting the scientific record with junk science”

This process is helping to fuel the rise of complementary and alternative medicine (CAM) which I have termed “fake medicine.” I’ve included below a long quote from Beall’s recent article which details this problem which he feels poses “the biggest threat to science since the Inquisition.”

Inquisitionally Yours,

-ACP

For your enjoyment, Beall’s full comments on the threat to science:

I think predatory publishers pose the biggest threat to science since the Inquisition. They threaten research by failing to demarcate authentic science from methodologically unsound science, by allowing for counterfeit science, such as complementary and alternative medicine (CAM) to parade as if it were authentic science, and by enabling the publication of activist science.

Because they aim to generate profits for their owners, gold (author-pays) open-access journals have a strong conflict-of-interest when it comes to peer review. They always want to earn money, and rejecting a paper means rejecting revenue. This conflict is at the heart of the ongoing downfall of scholarly publishing. Increasingly, the consumers of scholarly publishers’ services are the authors, not the readers, and not academic libraries. Businesses naturally always want to keep their customers content, for they want the revenue streams to continue and grow larger, as they add new services – such as more easy-acceptance journals – to their offerings.

Many of the larger predatory publishers, especially those based in Western Europe, offer a niche business. Their businesses are set up to publish manuscripts rejected by the top publishers, that is, papers rejected by Elsevier, Wiley, Sage, Taylor & Francis, Oxford University Press, and several others. They function something like a lender of last resort – they provide a publishing opportunity when no other publisher will, becoming, essentially, a Salon des Refusés for scholarly articles. However, the market is so lopsided now that there are more “publishers of last resort” than there are authentic ones, and they’re all competing with each other for subpar manuscripts.

Like counterfeit science itself, these publishers go through the motions of being a legitimate publisher. Some open-access publishers, even though they are not based in England, hire spokesmen with strong British accents to attend scientific conferences and other meetings and talk up the publisher, often renting a booth in the exhibit hall and even co-sponsoring some of the smaller meetings. They join publisher associations, make a show of donating to open-access causes, and manage to convince one or two aged Nobel Laureates to agree to serve on one of their editorial boards, no work required.

CAM is really taking off, and it’s being largely fuelled by pay-to-publish journals, though a few subscription journals have gotten in on the action as well. Predatory journals and even journals from legitimate publishers are legitimatizing this unscientific medical research in the public’s eye. Acupuncture and homeopathy are thriving, and numerous “studies” are being published each year to back up their effectiveness claims. In medicine, demarcation is failing, and there’s no longer a clear line where legitimate medical research ends and unsound medical research begins (5). More questionable medical research is being published now than ever before in history, including bogus research promoting fake medicines and nutraceuticals. There’s no longer a clear separation between the authentic and counterfeit medical research, even though medical research is the most important research for humankind today. Indeed, of all human endeavours, what surpasses medical research in importance, value, and universal benefit?

Removing Signs of The Confederacy in Forest Park

A few weeks ago I was interviewed by Fox2 News . Not for anything having to do with cardiology but because I randomly stumbled upon the City of St. Louis taking down a street sign.

This was no ordinary street sign.

It was associated with the small strip of road that runs adjacent to the Confederate Memorial that sits in Forest Park (America’s #1 Urban Park!)

Workman removing the Confederate Drive sign. He left the Cricket Road sign. Confederate Drive sign replaced by nothing.

The Forest Park Confederate Memorial became part of a national discussion after long-time St. Louis Mayor, Francis Slay, writing in his blog in 2015, proposed a a committee for reappraisal of the statue:

 

Their charge would be to recommend whether, with the benefit of a longer view of history, the monument is appropriately situated in Forest Park – the place where the World was asked to meet and experience St. Louis at its best and most sublime — or whether it should be relocated to a more appropriate setting.

They also should address whether the monument represents a peculiar memorial to what euphemistically was referred to in the American South as a “peculiar institution” – slavery-and wherever ultimately situated, whether the monument should be accompanied by a description of the reality and brutality of slavery, over which the war was waged, including in this city, and the bitter badges of slavery, Jim Crow and de facto discrimination and segregation, that are its continuing legacy.

I would ask the commission, also, to reappraise the name “Confederate Drive,” the Forest Park thoroughfare on which the monument is situated. They might consider whether “Freedom” or “Justice” would be more fitting.

Missouri was a deeply divided border state during the Civil War, pitting neighbors and kin against one another. As St. Louis was a Union stronghold, it is not surprising that even 50 years after the war ended, the erection of the Confederate Memorial was controversial. It was dedicated in December 1914 after the Ladies’ Confederate Monument Association spent 15 years raising $23,000 for its construction. To avoid provoking further antagonism to the project, the Association declared that the design they would choose could not depict any figure of a Confederate soldier or object of modern warfare. The resulting monument features a 32-foot-high granite shaft with a low relief figure of “The Angel of the Spirit of the Confederacy.” Below is a bronze group, sculpted by George Julian Zolnay, depicting the response of the South to this spirit as a family sends a youth off to war. Of Hungarian birth, Zolnay had come to St. Louis as director of the art department for the 1904 Louisiana Purchase Exposition and remained here for some years afterward, teaching at Washington University and the Art Academy in University City. Choosing Zolnay’s model over two other submissions caused another battle when one of the losers, Frederick Ruckstull, wrote to the committee demanding that Zolnay’s design be eliminated, as the male figure too closely depicted a soldier. Calling the letter “contemptible,” Zolnay shot back that Ruckstull’s allegorical group, featuring figures of Glory, History, Poetry and Sorrow, was “suitable for a wedding cake.” On the back of the shaft, designed by William Trueblood, is a tribute “To the Memory of the Soldiers and Sailors of the Southern Confederacy,” written by St. Louis minister Robert Catlett Cave, who had served as a Confederate soldier from Virginia. Beneath that is a quotation by Robert E. Lee: “We had sacred principles to maintain and rights to defend for which we were duty bound to do our best, even if we perished in the endeavor.”
I rode to Forest Park and asked in the visitor center where the confederate memorial was. When I arrived it was surrounded by this temporary fence, erected in the morning, presumably to protect workmen from pro-statue protestors.

 

 

It looks like the committee delivered their report in December , 2015 and it can be found here. They indicate their charge was to assess how best to get rid of the statue, not really to “reappraise” it.

They asked for proposals from various museums/historic organizations for moving the statue and received no satisfactory proposals. . The cost of moving the statue to another site was estimated at 268,000$ and moving it to storage at 122,000$.

A new mayor of St. Louis,  Lydia Krewson, was elected last November and she has vowed to move the statue.

Apparently, it’s a lot easier and cheaper to remove the street sign than the statue.

Don’t expect any brilliant insights into this controversy from my interview with Fox2 News.  Before I’m ready to make any public pronouncement on an issue I require hours and hours of research and clearly I have no expertise or background that would qualify me to pontificate on the fate of this statue.

Since then, I’ve thought about it and read more and hope to share some observations down the line.

-ACP

Since the interview aired it seems to have gone viral around St. Luke’s hospital with many marveling at my odd “beekeeper’s” hat and others impressed by my handling of a random cyclist’s yelled comments.

This is the link to the Fox 2 News Interview

 

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

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

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

Anti-Dairy Propaganda

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

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

Growth of Plant-Based “Milks”

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

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

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

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

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

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

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

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

Variable Nutritional  Content of Plant-Based “Milks”

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

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

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

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

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

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

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

They concluded:

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

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

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

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

and their similarity to sugar-sweetened beverages:

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

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

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

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

and some PBM contain potentially dangerous components:

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

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

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

The Skeptical Cardiologist Recommendation

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

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

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

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

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

Skeptically Yours,

-ACP

Featured image courtesy of One Green Planet.

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

 

 

 

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

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

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

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

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

Coconut Oil: Poster Child for Dietary Fat Confusion

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

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

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

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

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

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

All Saturated Fats Are Not Created Equal!

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

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

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

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

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

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

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

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

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

What’s more :

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

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

 

Misguided Dietary Fat Recommendations

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

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

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

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

Cherry-Picking Data

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

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

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

Coconut Oil: The Bottom Line

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

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

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

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

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

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

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

Cocovorically Yours,

-ACP

For those seeking more information.

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

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

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