Animated educational graphics and descriptions of cadiac procedures and diseases
I recommend the Mediterranean diet (MED) to my patients. Every unbiased, systematic review of the research on diet and heart disease in the last 8 years has concluded that it is the most likely dietary model to provide protection against coronary heart disease. One review concludes
Among the dietary exposures with strong evidence of causation from cohort studies, only a Mediterranean dietary pattern is related to CHD (coronary heart disease) in randomized trials.
The MED is the only comprehensive dietary approach that has been proven to reduce total death and heart attacks in comparison to standard diets. There are two major randomized controlled trials (the only kind of study that proves the value of a dietary intervention) with this diet.
The first, called the Lyon heart Study, was in patients who had had heart attacks (secondary prevention) . As this graph demonstrates, those patients randomized to receive instruction on following the Mediterranean diet had a 60% lower death rate and a 70% lower heart attack rate. The second was published last year in the New England Journal of Medicine and was a primary prevention study: that is, participants had not had heart attacks. Participants were randomized to one of three diets: a MED supplemented with extra-virgin olive oil, MED supplemented with mixed nuts or a control diet (advice to reduce dietary fat). Participants received quarterly individual and group educational sessions and either free provision of olive oil, mixed nuts or small nonfood gifts. The high extra virgin olive oil group ingested an average of 3.6 tablespoons/day (51 grams/day equal to 459 calories/day) of olive oil with 98% of it being extra virgin olive oil. The high nut group ate 8.2% of their total daily calories in the form of nuts, including an additional approximately one ounce packet of nuts (15g of walnuts, 7.5 g of almonds, and 7.5g of hazelnuts) provided by the study coordinators. 7447 persons were enrolled (ages 55 to 80 years) for an average 4.8 years. Those persons following the MED diet (either supplemented with olive oil or nuts) were 30% less likely to have a major cardiovascular event (heart attack, stroke or death from cardiovascular causes.) There was a statistically significant reduction in stroke rate (≈39%) when considered as an isolated endpoint. We don’t know exactly what components of the MED are the most beneficial. This trial suggests that olive oil and nuts are at least two of the key ingredient so it makes sense to increase your consumption of these foods. Other studies strongly support fish consumption and alcohol consumption as key components. As I’ve discussed (?ad nauseam) in other posts, full fat dairy and eggs, although banned by most “heart healthy diets”, have not been shown to increase heart disease risk. Fermented dairy consumption, in particular, in the form of plain full-fat yogurt (not adulterated with sugar) and full-fat cheese is consistently associated with a lower risk of coronary heart disease. Plain full-fat yogurt and full-fat cheese (from goat milk) were consumed by the inhabitants of Crete, the Greek Island on which the original MED was based.
It has to be emphasized that within this pattern of eating you want to be consuming real foods, not processed products of the industrial food industry which have been manipulated to appear healthy due to being “low-fat” or “low cholesterol.”
This is a pattern of eating which is varied, interesting and sustainable.
It’s one that can last a lifetime. ,
When i tell my patients that I am fine with them consuming full fat dairy products including butter I see a mixture of responses. For many, there is a great relief that the butter they have been avoiding for the last 20 years (or consuming guiltily) can now be used. For others, the prospect of consuming full fat milk, cheese or yogurt still seems risky. After all, they have been hearing from the American Heart Association, the USDA nutritional guidelines and pretty much every nutritional advice column for the last 30 years that these products increase their risk of heart disease and contribute to obesity. Why should they believe their local cardiologist, a lone voice promoting full fat dairy against a chorus of naysayers?
Hopefully, by continuing to present scientific research on the topic I can make this concept more acceptable and counter the misinformation that is so prevalent
Researchers in Sweden have followed a cohort of rural men for over 12 years. In a previous study they found that daily intake of fruit and vegetables in combination with a high dairy fat intake was associated with a lower risk of coronary heart disease. Recently they examined their data to answer the question : how does dairy fat intake impact on the risk of developing central obesity in this middle-aged male cohort?
What is central obesity?
Central obesity refers to fat that builds up inside the abdomen. It is often measured by measuring the waist circumference: > 102 cm for males and 88 cm for females is a marker of central obesity. Central or abdominal obesity indicates insulin resistance and is part of the metabolic syndrome and well known to increase the risk of diabetes. It is also associated with heart disease, various cancers, and dementia. In this Swedish study, central obesity was defined as waist hip ratio ≥ 1.
The study found that 197 men (15%) developed central obesity during follow-up. A low intake of dairy fat at baseline (no butter and low fat milk and seldom/never whipping cream) was associated with a higher risk of developing central obesity (OR 1.53, 95% CI 1.05-2.24) and a high intake of dairy fat (butter as spread and high fat milk and whipping cream) was associated with a lower risk of central obesity (OR 0.52, 95% CI 0.33-0.83) as compared with medium intake (all other combinations of spread, milk, and cream) after adjustment for intake of fruit and vegetables, smoking, alcohol consumption, physical activity, age, education, and profession
Yes, these data show that participants were three times more likely to develop central obesity if they consumed skim milk and no butter compared to those who drank high fat milk and butter.
This is not an isolated finding. There is a wealth of data supporting the concept that full fat diary is less associated with obesity and markers of the metabolic syndrome, diabetes and insulin resistance.
Another recent study in a Basque population in Spain found that participants with low or moderate consumption of cheese (high fat) compared to high consumption of cheese (high fat) had a higher prevalence of excess weight
Why do people falsely believe that fat in general and high fat dairy in particular promotes obesity?
In the past, supporters of this concept (and there are less and less in the scientific world) would point to the energy density of fat which contains 9 calories per gram compared to 4 calories per gram for carbohydrates or protein. Obviously, if obesity is determined by calories in versus calories out then the food with more % fat compared to carbs or protein is providing more calories. All things being equal, one could expect to grow fatter on the higher % fat diet. All things are not equal, however, because one doesn’t determine how much one consumes based on the volume or weight of the food entering the mouth.
There are far more complex factors at work. How does the mixture of food components effect satiety? What is the insulin response to the food? What are the other components of the food such as vitamins, fiber, calcium and how do they interact with food absorption and metabolism?
So, even though this contradicts what has been drummed into your head for 30 years: eat full fat yogurt , cheese and milk , not fat-free, if you want to avoid getting fat
Recently, the skeptical cardiologist was asked by his old friend and life coach (OFALCSC) whether he was correct to refuse the annual electrocardiogram (ECG) which his primary care doctor had recommended during an annual physical.
Most of my patients feel that the ECG has the ability to tell me quite a bit about their heart. The technique utilizes electrodes on the arms, legs and chest region which record with precision, the depolarization and repolarization of the upper chambers (atria) and lower chamber (ventricles) of the heart.
The ECG is THE tool for assessing the rhythm of the heart. If performed and interpreted properly (not always a given) it tells us very precisely whether we are in normal (sinus) rhythm, wherein the atria contract synchronously before the ventricles contract, or in an abnormal rhythm. It is also very good at telling us whether you are having a heart attack.
If you are, however, like the OFALSC, and feel fine (meaning without symptoms or asymptomatic), exercise regularly, have never had heart problems, and have a pulse between 60 and 90, the value of the routine annual ECG is very questionable. In fact, the United States Preventive Services Task Force (USPFTF)
“recommends against screening with resting or exercise electrocardiography (ECG) for the prediction of coronary heart disease (CHD) events in asymptomatic adults at low risk for CHD events”
(for asymptomatic adults at intermediate or high risk for CHD they deem the evidence insufficient). The USPSTF feels that that the evidence only supports an annual BP screen along with measurement of weight and a PAP smear.
To many, this seems counter-intuitive: how can a totally benign test that has the potential to detect early heart disease or abnormal rhythms not be beneficial?
There is a growing movement calling for restraint and careful analysis of the value of all testing that is done in medicine. Screening tests, in particular are coming under scrutiny.
Even the annual mammogram, considered by most to be an essential tool in the fight against breast cancer, is now being questioned.
My former cardiology partner, Dr. John Mandrola, who writes the excellent blog at www.drjohnm.org, has started an excellent discussion of a recent paper that shows no reduction of mortality with the annual mammogram. He looks at the topic in the context of patient/doctor perception that “doing something” is always better than doing nothing, and the problem of “over-testing.”
In my field of cardiology there is much testing done. It ranges from the (seemingly) benign and (relatively) inexpensive electrocardiogram to the invasive and potentially deadly cardiac catheterization. For the most part, if patients don’t have to pay too much, they won’t question the indication for the tests we cardiologists order. After all, they want to do as much as possible to prevent themselves from dropping dead from a heart attack and they reason that the more testing that is done, the better, in that regard.
The Problem of False Positives and False Negatives
But all testing has the potential for negative consequences because of the problem of false positives and negatives. To give just one example: ECGs in people with totally normal hearts are regularly interpreted as showing a prior heart attack. This is a false positive. The test is positive (abnormal) but the person does not have the disease. At this point, more testing is likely to be ordered; specifically, a stress test. Stress tests in low risk, asymptomatic individuals often result in false positive results. After a false positive stress test, it is highly likely that a catheterization will be ordered. This test carries potential risks of kidney failure, heart attack, stroke and death. It is bad enough that the cascade of testing initiated by an abnormal, false positive, screening test results in unnecessary radiation, expense and bother but in some cases it end up killing patients rather than saving lives.
On the other end of the spectrum is the false negative ECG. Most of my patients believe that if their ECG is normal then their heart is OK. Unfortunately the ECG is very insensitive to cardiac problems that are not related to the rhythm of the heart or an acute heart attack.
Patients who have 90% blockage of all 3 of their major coronary arteries and are at high risk for heart attack often have a totally normal ECG. This is a false negative. The patient has the disease (coronary artery disease), but the test is normal. In this situation the patient may be falsely reassured that everything is fine with their heart. The next day when they start experiencing chest pain from an acute heart attack, they may dismiss it as heart burn instead of going to the ER.
More and more, screening tests like the ECG and the mammogram are rightfully being questioned by patients and payers. For a more extensive discussion about which tests in medicine are appropriate check out the American Board of Internal Medicine’s www.choosingwisely.org.
Keep in mind: not uncommonly, doing more testing can result in worse outcomes than doing less.
I’ve been meaning to blog on the new ACC/AHA (ACC=American College of Cardiology, AHA=American Heart Association) guidelines for treatment of high cholesterol but have been waiting for the initial controversy to die down and to get more experience with using them. One of the areas of controversy has been the ASCVD (atherosclerotic cardiovascular disease) risk estimator. These guidelines attempt to look at risk of both stroke and heart attack (the components of atherosclerotic cardiovascular disease) and what published scientific research tells us works to reduce that risk.
They differ substantially from previous guidelines recommendations and suggest treatment with statin drugs(no other cholesterol lowering agents) for the following groups
2. Patients with known clinical ASCVD (this includes stroke/TIA, heart attack, and peripheral arterial disease)
3. LDL or bad cholesterol over 190
4. Individuals without ASCVD whose 10 year risk of developing ASCVD (heart attack or stroke) is > 7.5%
It is the last category that has garnered the most controversy as it appears this will substantially increase the number of patients in whom statin therapy is recommended. In addition, the accuracy of the risk estimator has been questioned. When the guidelines were released the risk estimator was available as a downloadable Excel spreadsheet which was very cumbersome to use (and did not work on my Mac).
Today, the ACC announced that an iphone/ipad app version of the risk estimator was available on itunes . You can download it for free here. (The app is now called ASCVD Plus) It’s pretty well done. You enter your age, race, gender, HDL (“good” cholesterol) and total cholesterol along with yes/no answers to whether you have diabetes, treatment for hypertension or are a smoker.
Your 10 year risk of ASCVD appears as a percentage.
In the example to the left, the individual (whose numbers are eerily similar to those of the skeptical cardiologist) has a 10 year risk of 6.2% compared to 5.2% for an individual with “ideal” risk factors. In this case, the 6.2% 10 year risk is below the proposed 7.5% cut point for treatment. (As a side note, this individual’s HDL rose from 53 to 80 when he switched from skim milk , egg-whites and low-fat processed food to full fat dairy, eggs and grass-fed beef. An HDL of 53 would raise the risk to 8.5% which would trigger a recommendation for statin therapy!)
A lifetime risk is also given for those aged 20 to 59 years but the app seems flawed because in every case I entered the lifetime risk was 50% for the individual and 5% for the ideal risk factor individual
I’ll be utilizing this on every patient I see that does not have clinical ASCVD. I would encourage everybody to download this app and find out what your risk is. The higher your risk, the more likely your are to benefit from taking a statin drug, the lower it is, the less likely the benefits of lifelong drug treatment will outweigh the risks.
Understanding your risk of ASCVD is the crucial first step to having an informed discussion with your physician about atherosclerosis and the risks and benefits of drug therapy to prevent strokes and heart attacks.
The skeptical cardiologist had to temporarily interrupt his scintillating research into Canola Oil and the Mediterranean diet in order to highlight a study published yesterday in the Journal of the American Medical Society that adds further evidence to the paradigm that sugar is not just causing obesity but is actually killing us.
In a previous post on low-fat yogurt I emphasized that a great pseudo-scientific scam had been foisted on Americans, the promotion of low fat substitutes for real food. The low-fat substitutes masquerade as more heart healthy because saturated fat has been removed but they are actually less healthy because sugar or high fructose corn syrup has been added. Substantial evidence indicates that consumption of sugar and refined carbohydrates are contributing to obesity and cardiovascular disease (CVD), not the unjustly demonized saturated fats. Now there is evidence to suggest sugar is actually directly promoting heart disease.
In the article, the authors analyzed data from subjects who participated in the National Health and Nutrition Examination Survey (NHANES). They estimated the “usual percentage of calories from added sugar” for individuals.
Added sugar “includes all sugars used in processed or prepared foods, such as sugar-sweetened beverages, grain-based desserts, fruit drinks, dairy desserts, candy, ready-to-eat cereals and yeast breads, but not naturally occurring sugar, such as in fruits and fruit juices.”
Among the 11733 participants there were 831 CVD deaths with a median follow up of 14.6 years.
Those who consumed 25% or more of calories from added sugar were 2.75 times more likely to die than those who consumed less than 10% of calories from added sugar. The risk of CVD mortality increased exponentially with increased percentage of calories from added sugar.
Major sources of added sugar in American adults diet included sugar-sweetened beverages (37%), grain-based desserts (14%), dairy desserts (6%) and candy (6%). One 360-ml can of regular soda contains about 35 g of sugar (140 calories) or 7% of total calories.
The authors discussed emerging evidence suggesting multiple pathways by which sugar might play a role, including promoting hypertension, increased de novo lipogenesis in the liver (resulting in high triglycerides) and promoting inflammation.
My first dietary recommendation to my patients is to cut out the added sugar. This is both for weight management and lower heart attack risk. The low-fat, processed “food-like substances” you have been choosing are far worse for you than the unprocessed high fat food they replaces.
The Skeptical Cardiologist occasionally wanders into the Doctors Lounge at the hospital and surveys the food choices available to him. One morning, descried amongst the carbohydrate bonanza of donuts, pastries, bagels and muffins was a bin containing little tubs of substances that could be spread on a bagel of slice of bread.
The choice was between something called Promise Buttery Spread
and Wholesome Farms Whipped Butter..
Conventional Wisdom and the recommendation of almost every nutritional authority for the last 30 years tells me that I should choose the Promise Buttery Spread. I would have taken this choice 5 years ago in the belief that butter with its high content of saturated fat was to be avoided. I used to spend a considerable amount of time in the pseudo-butter portion of the grocery aisles trying to determine which, of the myriad of competing alternatives, would be better than butter.
But, as I’ve noted in previous posts, the authorities have gotten it wrong. Let’s look carefully at the two choices.
Promise Buttery Spread
Certainly the packaging would suggest that this is a “promising” choice. It says very clearly in the small print circling the outside of the tub: “heart healthy when substituted for butter.” If you’d like to read the arcane FDA rules on which foods can make this sort of claim, they are here. Basically, if the product has less fat, saturated fat or cholesterol than butter it can make this claim.
From the website of Unilever, the giant food processing conglomerate that makes Promise and all of its siblings, we learn that Promise contains 8 grams of fat, 1.5 grams of which are saturated fat. Uniliver is very happy to provide you with the macronutrient content of Promise and its various variations. After all, they spent a lot of time researching what combination of fats, protein and carbohydrates would satisfy consumers desire for a heart-healthy substitute. Canola oil turns out to be high in monounsaturated fats just like olive oil, the major fat consumed in the heart-healthy Mediterranean diet
But how did they come up with this fine ratio of unsaturated to saturated fats? What actually goes into it?
Here are the ingredients (not obtainable from Unilever’s web site but from another source that, presumably could read the small print that I could not read on the little tub of Promise)
Vegetable Oil Blend (Liquid Soybean Oil, Canola Oil, Palm Oil, Palm Kernel Oil), Water, Whey (Milk), Salt, Vegetable Mono and Diglycerides, Soy Lecithin, (Potassium Sorbate, Calcium Disodium EDTA) Used to Protect Quality, Vitamin E Acetate, Citric Acid, Pyridoxine Hydrochloride (Vitamin B6), Artificial Flavor, Maltodextrin (Corn), Vitamin A Palmitate, Beta Carotene (Color), Cholecalciferol (Vitamin 13), Cyanocobalamin (Vitamin B12).
That’s 21 ingredients, most of which are made in a factory and added back to the mixture of exotic vegetable oils, most of which is canola oil.
What is Canola Oil? Does it come from a canola plant or seed?
A good source of information (and presumably positive) is the Canola Council web site which gives the history of Canola Oil. It all begins with oil from the seed of the rape plant, a crop grown in Canada.
Rapeseed oil naturally contains a high percentage (30-60%) of erucic acid, a substance associated with heart lesions in laboratory animals. For this reason rapeseed oil was not used for consumption in the United States prior to 1974, although it was used in other countries. In 1974, rapeseed varieties with a low erucic content were introduced. Scientists had found a way to replace almost all of rapeseed’s erucic acid with oleic acid, a type of monounsaturated fatty acid.
The Canola council website says that this process of developing rapeseed with low levels of the toxic erucic acid was not accomplished by genetic engineering, but the nongmoproject.org indicates 90% of Canola oil qualifies as genetically modified.
More history from the Canola Council:
By 1978, all Canadian rapeseed produced for food use contained less than 2% erucic acid. The Canadian seed oil industry rechristened the product “canola oil” (Canadian oil, low acid) in 1978 in an attempt to distance the product from negative association with the word “rape.” Canola was introduced to American consumers in 1986. By 1990, erucic acid levels in canola oil ranged from 0.5% to 1.0%, in compliance with U.S. Food and Drug Administration (FDA) standards.
The term canola was trademarked by the Western Canadian Oilseed Crushers’ Association (now the Canadian Oilseed Processors Association) to differentiate the superior low-erucic acid and low-glucosinolate varieties and their products from the older rapeseed varieties.
How is Canola Oil Processed?
Again, the Canola Council provides their summary of the process here.
Unlike olive oil which is just expeller expressed from olives, canola oil goes through quite a bit of processing. After pressing, about half of the oil is left, and the remainder is extracted by a solvent called hexane (interestingly, there is a controversy in the world of veggie burgers since hexane is used in processing soy and residual levels of this “neurotoxin” have been detected). This oil then goes through processes called degumming (which often involves mixing with acid), bleaching and deodorizing. To make a more solid form it is heated to hydrogenate the oil or palm kernel oil is mixed with it.
Is Canola Oil healthier than butter?
Research shows that replacing saturated and trans fat with unsaturated fats can help maintain heart health.
Unfortunately, none of this research involves canola oil so it is not really applicable. In the 1980s, at the urging of health authorities, the food industry went through a similar process and created butter substitutes that utilized oils hydrogenated in a factory. The result was the consumption by the public of large amounts of trans-fats which subsequent research has shown to be great promoter of coronary heart disease. Does it make sense to put our trust in these newer , factory produced ,butter substitutes?
There are NO STUDIES that would indicate substituting canola oil for butter is a heart-healthy choice. Personally, I have grave concerns about consuming a product that has gone through such a tortured process in order to make it appear safe and palatable.
In the Doctor’s Lounge, my butter choice lists pasteurized cream and salt as the ingredients. I like that, it’s simple and straightforward. I know that most studies that have looked at consumption of dairy fat have found that it lowers risk of heart disease. Wholesome Farms is a Sysco, Inc. label and Sysco says
Wholesome Farms farm-fresh cream, eggs and other dairy offerings are typically produced at dairies located closer to our foodservice customers, resulting in fresher, more dependable products with longer shelf lives.
I have tried to contact Sysco to get more information on where my little tub of butter came from and what the cows were fed but have gotten no information.
Choose Nature, not Industry, for good health.
The choice between a highly processed, genetically modified, industry promoted vegetable oil (or blend of oils) which has been manipulated to resemble a healthy natural vegetable oil and never shown to be safe or healthy in humans, versus butter, is clear to me. Give me butter every time. I’m not excited about the fact that I can’t be sure the milk used in this little tub of butter came from pasture-raised, grass-fed cows. However, I realize that compromises have to be made for convenience sometimes. I’d rather eat the butter from unknown cows than the vegetable oil from a known factory.
Most cardiologists don’t spend a lot of time talking about diet with their patients. When they do, they usually cite the mainstream maxim that you should cut down on saturated fat by reducing red meat consumption, choosing low-fat or skim dairy products, and lean cuts of meat. Patients are referred to standard recommendations that conform to this advice that comes from the American Heart Association.
This is certainly what I did for 30 years until I started examining the research supporting these recommendations in detail. It’s a lot easier to give advice to your patients when it conforms to what they are hearing from nutritional authorities. If it doesn’t conform, you have a lot of ‘splaining to do. If doctors spend time teaching or discussing diet with our patients, we do not get reimbursed for it.
However, a close examination of the research on dietary fat and heart disease shows that there is no good evidence supporting these recommendations.
The two major fallacies are:
Eating high fat foods will make you fat.
Eating high fat or cholesterol laden foods raises your cholesterol, thereby promoting the development of heart disease
Dietary Fat and Obesity
Although these concepts have become ingrained in the consciousness of Americans, they are not supported by scientific studies; more and more researchers, nutritional scientists, and cardiologists are sounding the warning and trying to change the public’s understanding in this area.
It seems logical that the fat that we consume goes into the body and is then converted into fat that appears on our thighs or belly and lines our arteries. This logic, and weak epidemiologic studies, led to national nutritional recommendations, beginning in 1977, that Americans cut back on fat (particularly saturated fat). The food industry seized on these recommendations and began providing consumers with “low-fat” alternatives to standard foods. To make these low-fat foods palatable, sugar had to be added. Often, due to a surplus of industrial farm produced corn, sweetening was accomplished with high-fructose corn syrup. This graph shows what happened with weight in the US:
Beginning in the late 1970s, the percentage of people with BMI > 30 (considered obese) increased dramatically.
More and more evidence points to increased consumption of sugar, HFCS, and refined carbohydrates as the root cause of this obesity epidemic.
I tell my overweight patients that reducing sugar and refined starch is the most important thing that they can do to shed excess pounds. They should avoid processed foods which the food industry have manipulated to make more palatable and less healthy. This means, among other things, avoiding or minimizing drinking sugar-sweetened beverages and avoiding “drinking your calories,” cutting way back on donuts, pastries, and potatoes and when consuming pastas or breads, try to make them whole-grain.
Dietary Fat and Heart Disease
I don’t tell my patients to cut fat consumption; this advice runs counter to everything they have heard about diet and heart disease. I encourage them to consume full fat dairy and this is considered particularly heretical.
However, as I have discussed in previous posts, there is no evidence that dairy fat increases cardiovascular risk. In fact, all studies suggest the opposite: a lower risk of heart disease associated with full fat dairy consumption.
Just as all fats are not the same (consider trans, saturated and unsaturated), all saturated fats are not the same. Some, particularly, the shorter chain fatty acids found in dairy, have beneficial effects on the lipid profile and likely lower overall cardiovascular risk.
What about red meat? All of my patients have received the dogma that they need to cut back on red meat. It hasn’t come from me (not since I began looking at the scientific evidence). When I look at my patients’ cholesterol profile before and after they institute what they perceive as the optimal “heart-healthy“ diet (cutting back on saturated fat and increasing carbohydrates by reducing meat consumption and shifting to skim or low-fat dairy products), their LDL or “bad” cholesterol has dropped a little, but proportionally their HDL or good cholesterol has dropped more and their triglycerides have gone up. What is the overall effect of this dietary change? There are no studies demonstrating that this change improves your heart health.
A recent systematic review and meta-analysis of 20 studies which included 1,218,380 individuals found no relationship between red meat consumption and coronary heart disease, CHD, (or diabetes). Conversely, processed meat intake was associated with a 42% higher rate of CHD and 19% higher risk of diabetes.
Analysis of data from the Multi-Ethnic Study of Atherosclerosis population indicates
After adjustment for demographics, lifestyle, and dietary confounders, a higher intake of dairy saturated fat was associated with lower cardiovascular disease risk [HR (95% CI) for +5 g/d and +5% of energy from dairySF: 0.79 (0.68, 0.92) and 0.62 (0.47, 0.82), respectively].
There also appears to be no association between red meat consumption and mortality in Asian countries
The Womens Health initiative was started in the early 1990s to test the hypothesis that a low fat diet would lower risk of cancer, stroke and heart attacks.Women were aged 50-79 at trial enrollment in 1993-98 and were followed for an average of 8.1 years. By the end of the first year, the low-fat diet group reduced average total fat intakes to 24 percent of calories from fat, but did not meet the study’s goal of 20 percent. At year six, the low-fat diet group was consuming 29 percent of calories from fat. The comparison group averaged 35 percent of calories from fat at year one and 37 percent at year six. Women in both groups started at 35-38 percent of calories from fat. The low fat diet group also increased their consumption of vegetables, fruits, and grains.
The study design reflected a widely believed but untested theory that reduction of total fat would reduce risks of breast or colorectal cancers. Among the 48,835 women who participated in the trial, there were no significant differences in the rates of colorectal cancer, heart disease, or stroke between the group who followed a low-fat dietary plan and the comparison group who followed their normal dietary patterns.
Yes, “widely believed but untested theory” is a great description of the current recommendation to cut saturated fat because no prospective trial has proven any benefit to this approach in reducing cardiovascular disease.
There is some evidence (but still fairly weak) to support the idea that replacing saturated fat with unsaturated fat is beneficial. Thus, the popularity of the Mediterranean diet which utilizes olive oil liberally. There is good evidence that industrially produced trans-fatty acids (from products designed to take the place of inappropriately demonized butter) increase cardiovascular risk. However, this evidence does not extend to natural trans-fatty acids such as those coming from the udders of cows.
Mounting evidence suggests that replacing fat or saturated fat in the diet with carbohydrates, however, contributes to obesity, insulin resistance, diabetes, and thereby may increase your risk of cardiovascular disease.
The skeptical cardiologist was hard at work researching cardiovascular disease in the Virgin islands last week. It was a tough assignment, but I felt I was the right man for the job. It required me to leave the snow and freezing temperatures of St. Louis to fly to St. John where the daytime highs are 82 and the nighttime lows are 73 and the skies are clear to partly cloudy every day.
The United States Virgin Islands (USVI) are located 1100 miles southeast of Miami and cover 346 square miles, with an estimated population of 112,000 residents, who live primarily on three islands: St. Croix, St. Thomas, and St. John. About 78 percent of the residents are Black (African-Caribbean), 10 percent White, and 12 percent “other.” Just under half (49 percent) of the population was born in the Virgin Islands. Native born or naturalized Virgin Islanders are U.S. citizens.
Interestingly, the CDC has reported that the USVI has the lowest rate of heart attack (2.1%) of any state or territory in the US. (W. VA is highest at 6.4%). In addition, a recent study, has shown that blacks in the USVI have a significantly lower rate of cardiovascular disease than blacks in the other 50 states.
Using my cardiology sleuthing skills on site in several Cruz Bay bars and at various beaches and hiking trails I have come up with several hypotheses for the remarkably low rate of cardiovascular disease in this area.
1. Rum-based beverage consumption. Rum is big business in the USVI. As the result of a public-private partnership deal in 2009 the USVI helped Captain Morgan Rum move their distillery from Puerto Rico to St. Croix and helped expand and improve the Cruzan Rum distillery on the islands. As part of the deal the US Congress gives money from excise taxes back to the USVI
The “cover-over” program returns $10.50 of the total $13.50 distilled spirits tax collected per proof gallon to the territories. In 1999, Congress temporarily increased the “cover-over” rate to $13.25 and has extended that rate ever since when it comes up for a bi-annual vote. As part of the agreements with Diageo and Fortune, the USVI government will return a portion of the cover-over funds to the companies in the form of the marketing support, financing of the new or expanded distilleries and waste water treatment facilities, tax incentives and molasses support so companies can secure the key rum ingredient molasses at a competitive price.”
This must explain why rum-based drinks are incredibly cheap in St John. The skeptical cardiologist and the significant other of the skeptical cardiologist (SOSC) found, during the course of their research, that at many beachfront bars, multiple rum-based drinks such as Dark and Stormy’s, Painkillers, and Rum Punches were priced at 3$ during happy hour. Happy hours extended for particularly long hours.
It is well known that alcohol in general raises the good cholesterol, HDL, and lowers cardiovascular disease when consumed in moderation. But could rum have a special cardioprotective effect? More studies are clearly needed in this area.
2.Incredibly beautiful weather, beaches and topography. Our extensive investigations led us to detailed examinations of Solomon, Honeymoon, Caneel, Trunk, Cinnamon, Gibney, Jumbie, and Salt Pond Bay beaches on St. John At these beaches we found that the clear, warm, aquamarine waters with coral reefs close to shore allowed for excellent snorkeling, thus promoting extensive physical activity. Similarly, multiple hiking trails in the Virgin Islands National park (which covers two-thirds of St. John), stimulated the desire to walk. Physical activity is known to substantially reduce the risk of cardiovascular disease. Could increased physical activity related to a conducive environment be playing a role here?
3.Sun exposure. Some studies suggest a role of low Vitamin D levels in promoting heart attacks. Vitamin D deficiency links to cardiovascular disease can be found in a number of studies demonstrating a 30% to 50% higher cardiovascular morbidity and mortality associated with reduced sun exposure caused by changes in season or latitude. Conversely, the lowest rates of heart disease are found in the sun-drenched Mediterranean coast and in southern versus northern European countries. Cardiac death has been reported to be the highest during winter months.
Is increased sun exposure responsible for the lower heart attack risk on the Virgin Islands?
4.Diet. Our research took us to several restaurants in Cruz Bay, however, I don’t feel that we got a good feel for the typical diet of the people of USVI. The only restaurant that was not owned and operated by rich white people and frequented by predominantly rich white people was an overpriced BBQ joint. The food did not seem different from what one could easily get in a modestly sized mainland city.
5. Relaxed Lifestyle. Epidemiological data show that chronic stress predicts the occurrence of coronary heart disease (CHD). Employees who experience work-related stress and individuals who are socially isolated or lonely have an increased risk of a first CHD event. In addition, short-term emotional stress can act as a trigger of cardiac events among individuals with advanced atherosclerosis. Could the laid back life style in the Caribbean where every one seems to be on “island time” be a factor?
Clearly more research is needed into this topic. Rest assured, the skeptical cardiologist and SOSC will be actively investigating these potentially life changing issues in more detail next winter.
It’s Christmas Eve and you are starting to make merry. Time to break out the egg nog? Or should you eschew this fascinating combination of eggs, dairy and alcohol due to concerns about heart disease?
Cardiac deaths increase in frequency in the days around Christmas.
Could this be related to excessive consumption of egg nog?
Egg nog is composed of eggs, cream, milk and booze. All of these ingredients have become associated with increased risk of heart disease in the mind of the public.
Nutritional guidelines advise us to limit egg consumption, especially the yolk, and use low-fat dairy to reduce our risk of heart disease
A close look at the science, however, suggests that egg nog may actually lower your risk of heart disease.
Eggs are high in cholesterol but as I’ve discussed in a previous post, cholesterol in the diet is not a major determinant of cholesterol in the blood and eggs have not been shown to increase heart disease risk.
Full fat dairy contains saturated fat, the fat that nutritional guidelines tell us increases bad cholesterol in the blood and increases risk of heart attacks. But some saturated fats improve your cholesterol profile and organic (grass-fed, see my previous post) milk contains significant amounts of omega-3 fatty acids which are felt to be protective from heart disease.
Milk and dairy products are associated with a lower risk of vascular disease!
Whether you mix rum, brandy, or whisky into your egg nog or you drink a glass of wine on the side you are probably lowering your chances of a heart attack compared to your abstemious relatives. Moderate alcohol consumption of any kind is associated with a lower risk of dying from cardiovascular disease compared to no alcohol consumption.
So, drink your egg nog without guilt this Holiday Season!
You’re actually engaging in heart healthy behavior.