Tag Archives: cardiovascular disease

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.

 

 

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!):

 

 

 

Nonskeptical Musical Thoughts On Dick Dale and the Dead While Running For Longevity

Since determining that running would lower my cardiovascular risk and that it was actually good for my wonky knees (running is associated with a lower risk of ostearthritis or hip replacement, see here), I’ve been trying to do it regularly.

It has become therapeutic in many ways, aiding sleep and reducing stress levels. And, unlike my bike riding adventures, I have yet to fall and injure myself running and I don’t get dirty looks for not wearing a helmet.

I’ve even contemplated running 5 kilometers,  although not as part of any formal exhibition: just a personal , private goal. To this end I have for the first time recently run 4 kilometers.

Listening to music during these longer runs greatly helps the time pass and sometimes I am able to find songs which fit my running cadence, albeit not through any systematic analysis but through mere serendipity. I let my entire musical collection (nicely streamed by Apple music) be my running playlist and this ranges from the Talking Heads to Thelonius Monk to Bach.

This morning’s run (the second time I reached 4K) I was aided by two songs: one by the king of surf guitar, the other by the kings of psychedelic jam rock.

Dick Dale and Miserlou

Although, Dick Dale was huge in the early sixties, he did not register on my musical radar until  I watched Pulp Fiction and in its dazzling opening scene and  was jolted by Dale’s staccato machine gun guitar riffs alternating with his plaintive trumpet solo on  “Miserlou“.

I immediately strapped on my Strat and began trying to emulate his unique playing style.

Here’s Dick and the Del-Tones performing their version for the movie “A Swinging’ Affair”

This version contains none of the rhythmic power and electrifying guitar attack of the single and the band appears to be on tranquilizers. To make matters worse, Dick  doesn’t play that magical melodic moaning trumpet solo which contrasts so brilliantly with the pile-driving reverb-drenched guitar riffs on the original version.

You can see some of the power of the left-handed Dale in this live performance of Miserlou from 1995 but alas, no trumpet solo.

Dick Dale, remarkably, is still touring and playing well at age 80.

As fortune would have it the beats per
minute of this song is 173 which fits my preferred running speed stride cadence perfectly.

The Other One (Not Cryptical Envelopment)

The next song to aid me on my run was a live performance from the Grateful Dead’s 1972 European Tour  which is 36 minutes long.

I was slow to revere the Dead but when I first listened to their live album Europe ’72 I was hooked. Instead of studying in college, I spent way too many hours playing Sugar Magnolia (and Blue Sky, et al..)  thereafter.

The Other One highlights their free and wild improvisational style. While running I could focus on what Keith Godchaux was doing on the piano and that takes me to a psychic place in which I feel no pain.

Please excuse my hubris but I am convinced that I could have done a good job as the Dead keyboardist.  It’s probably a good thing I never got that gig, however, as it carries a very high mortality rate (not to mention that I’m a much better cardiologist than keyboardist.)

As Billboard pointed out in its obituary on the last keyboardist, Vince Welnick (who committed suicide by slitting his throat at age 55 in 2006):

Welnick was the last in a long line of Grateful Dead keyboardists, several of whom died prematurely, leading some of the group’s fans to conclude that the position came with a curse.

Welnick had replaced Brent Mydland, who died of a drug overdose in 1990. Mydland succeeded Keith Godchaux, who died in a car crash shortly after leaving the band. And Godchaux had replaced the band’s original keyboard player, Ron “Pigpen” McKernan, who died at 27 in 1973.

Last week a very good Grateful Dead documentary (Long Strange Trip) was released on Netflix. I’ve been somewhat mesmerized by what I’ve watched so far.  For example, at one point, Phil Lesh reveals that Jerry Garcia asked him to join the band as their bassist even though he had never played the instrument. (If only he had asked me!)

Strangetrippingly Yours

-ACP

N.B. Miserlou is a very old folk song with a scale that sounds exotic to Western ears: the double harmonic scale

per Wikipedia

The song’s oriental melody has been so popular for so long that many people, from Morocco to Iraq, claim it to be a folk song from their own country. In fact, in the realm of Middle Eastern music, the song is a very simplistic one, since it is little more than going up and down the Hijaz Kar or double harmonic scale (E-F-G#-A-B-C-D#). It still remains a well known Greek, Klezmer, and Arab folk song.

 

 

 

Unsure About Taking A Statin For High Cholesterol? Consider A Compromise Approach

In an earlier post the skeptical cardiologist introduced Geo, a 61 year old male with no risk factors for heart attack or stroke other than a high cholesterol. His total cholesterol was 249, LDL (bad) 154, HDL (good) 72 and triglycerides 116.

His doctor had recommended that he take a statin drug but Geo balked at taking one due to concerns about side effects and requested my input. My first steps were to gather more information.

-I calculated his 10 year risk of stroke or heart attack at 8.4% (treatment with statin typically felt to benefit individuals with 10 year risk >7.5%) and as I have previously noted, this is not unusual for a man over age 60.

-I assessed him for any hidden  or subclinical atherosclerosis and found

The vascular ultrasound showed below normal carotid thickness and no plaque and his coronary calcium score was 18,  putting him at the 63rd  percentile. This is slightly higher than average white men his age.

So Geo definitely has atherosclerotic plaque in his coronary arteries. This puts him at risk for heart attack and stroke but not a lot higher risk than most men his age.

Strictly speaking, since he hasn’t already had a heart attack or stroke, treating him with a statin is a form of primary prevention. However, we know that atherosclerotic plaque has already developed in his arteries and at some point, perhaps years from now it will have consequences.

What is the best approach to reduce Geo’s risk?

It’s essential  to look closely at lifestyle changes in everyone to reduce cardiac risk.

The lifestyle components that influence risk are

  1. Cigarette Smoking (by far the strongest)
  2. Diet
  3. Exercise
  4. Obesity (Obviously related to #1 and #2)
  5. Stress
  6. Sleep

Patients who try to change to what they perceive as a heart healthy diet by switching to non-fat dairy and eliminating all red meat will not substantially lower risk (see here.) Even if you are possess the rock-hard discipline to stay on a radically low fat diet like the Esselstyn diet or the Pritikin diet there are no good data supporting their  efficacy in preventing cardiac disease.

Geo was not far from theMediterranean diet I recommend but would probably benefit from increased veggie and nut consumption. He was not overweight and he doesn’t smoke. I encouraged him to engage in 150 minutes of moderate exercise weekly.

Low Dose, Intermittent Rosuvastatin

I engaged in shared decision-making with Geo.  Informing him, as best I could, of the potential side effects and benefits of statin therapy.

After a long discussion we decided to try a compromise between no therapy and the guideline recommended moderate intensive dose statin therapy.

This approach utilizes a low dose of rosuvastatin taken intermittently with the goal of minimizing any statin side effect but obtaining some of the benefits of statin drugs on  cardiovascular risk reduction.

I have many patients who have been unable to tolerate other statin drugs in any dosage due to statin related muscle aches but who tolerate this particular  treatment and I  see substantial reductions in the LDL (bad) cholesterol with this approach.

Studies have shown that rosuvastatin 5–10 mg or atorvastatin 10–20 mg given every other day produce LDL-C reduction of 20–40 %

Studies have also shown that In patients with previous statin intolerance, rosuvastatin administered once or twice weekly (at a mean dose of 10 mg per week) achieved an LDL-C reduction of 23–29% and was well tolerated by 74–80 % of patients.

In a recent report from a specialized lipid clinic, 90 % of patients referred for intolerance to multiple statins were actually able to tolerate statin therapy, although the majority was at a reduced dose and less-than-daily dosing.

Results in Geo

After several months of taking 5 mg rosuvastatin twice weekly Geo felt fine with no discernible side effects. He obtained repeat cholesterol  levels:

His LDL had dropped 52% from 140 to 92.

Hopefully, this LDL reduction plus the non-cholesterol lowering beneficial properties of statins (see here) will substantially lower Geo’s risk of heart attack and stroke.

We need randomized studies testing long-term outcomes using this approach to make it evidence-based. But in medicine we frequently don’t have studies that apply to  specific patient situations. In these cases shared decision-making in order to find solutions that fit the individual patient’s concerns and experience becomes paramount.

Faithfully Yours,

-ACP

 

 

 

More Incredibly Bad Science From Dr. Esselstyn’s Plant-Based (Vegan) Diet Study

A while back the skeptical cardiologist exposed “The incredibly bad science behind Dr. Esselstyn’s plant-based diet.

The diet has the catchy slogan “eat nothing with a face or a mother” and Esselstyn was featured in the vegan propaganda film “Forks Over Knives.”

After detailing the lack of science I concluded:

Any patients who were not intensely motivated to radically change their diet would have avoided this crazy "study" like the plague.

This "study" is merely a collection of 18 anecdotes, none of which would be worthy of publication in any current legitimate medical journal.

Three of the 18 patients have died, one from pulmonary fibrosis, one presumably from a GI bleed, and one from depression. Could these deaths be related to the diet in some way? We can't know because there is no comparison group.

The post garned little attention initially but in the last few months several hundred visitors per day apparently read it and Essesltyn followers have started leaving me testimonials to the diet along with nasty comments.

Here’s are some typical ones (with my comments in red)

“If your (sic) not backed by some meat industry or cardiac bypass group I would be much surprised.”

I am completely free of bias. Nobody is paying me anything to do the research and writing I do. My only purpose is to find the truth about diet in order to educate my patients properly. I have  saved many more patients from bypass surgery than I have referred for the procedure.

“it is so arrogant to think the only science could come from clinical studies which may be funded by an interested party.”

Doctors like randomized (and preferably blinded) clinical studies because they minimize the bias introduced by interested parties like patients and zealous investigators (like Dr. E)  motivated to see positive outcomes. Small, non-randomized studies can only generate ideas and hypotheses which larger, randomized studies can prove with a greater degree of certainty.

“the entire nentire western medical system is skewed due to the big pharma influence…unfortunately western medicine believes the only science is the pen and the scalpel..whereas …history is the best teacher of all…”

By pen I assume you mean medications. If we examine history as  you suggest we see that life expectancy was 50 years in 1945  but today in developed countries it is around 80 years. This advance corresponds to (among other things) advances in vaccines, antibiotics, anti-cancer drugs, cardiac and blood pressure medications and surgery: the pen and the scalpel. It does not correspond to following a vegan diet.

“Your foolishness is the embarrassment.”

Thank you for this insightful comment! I’m considering it as my epitaph.

One man felt that changing to the Esselstyn diet dramatically improved his cardiac situation and commented:

“Nothing like bashing something that works just because you want to eat meat. .”

I do enjoy meat in moderation but I also really enjoy vegetables, nuts, fish, legumes, olive oil and avocados. I looked into Esselstyn’s diet in detail because it stands out as particularly misguided in banning nuts, avocados, fish and olive oil to heart patients.

..”.So sicking (sic) to see people talk trash about something that works so well… It saved my life…”

I’m happy you are doing well with your cardiac condition but it is impossible to know what would have happened to you on a more reasonable diet such as the Mediterranean diet (which actually has legitimate scientific studies supporting it). And again criticizing Esselstyn’s ideas and “study” can hardly be considered trash talk.

“I personally have followed dr. esselstyn’s program for what will be 5 years in 11/17 and have made tremendous gains in my cardio pulmonary function….my cardiologist looks at me in wonder…why are you here? and often says , if everyone did what you have…Id be out of business…so…isnt that telling and sad?”

I’m glad you’re doing well with the program, most patients can’t follow this kind of diet for more than a few months.  But perhaps we shouldn’t judge its effectiveness until  we make sure you don’t suffer a heart attack next week. Your cardiologist is wrong: see what I wrote about “dealing with the cardiovascular cards you’ve been dealt.” Some individuals inherit genes that guarantee progressive and accelerated atherosclerosis that will kill them at an early age despite the best lifestyle.

“…the phrase “follow the money” comes to mind…and since theres no big money to be made….science will attempt to dispell the results and thousands of years of history that proves this dietary system works…”

Using a scientific approach to analyze Esselstyn’s diet (which tries to claim a scientific basis) seemed appropriate to me but I wasn’t motivated by money. I’m looking for what is best for my patients, pure and simple.

The Plural of Anecdote Is Not Data

One man wrote:

“But since this is only anecdotal evidence – it must be junk science…”

Esseslstyn devotees like to post what their personal experience is with the diet but as skeptical medicine has pointed out “the plural of anecdote is not data.” 

One woman described in detail a good response her husband had after starting the diet following a heart attack:

I’m concerned about the skeptical cardiologist going after the person of dr. Esselstyn versus the science, such as quoting how you States dr. Esselstyn came up with the diet. So there may be a personal bias there. I’m sure there are more people out there on the esselstyn diet that are not noted in the study years ago. I hope there is another book coming out

I’ve reviewed in detail my comments about how Esselstyn came up with the diet but I am at a loss to find any ad hominem attack.

This woman went on to say

We will keep you posted, as my husband is willing to get another cardiac Cath and 12 months to visually see the difference after the diet.

I have to point out that if his cardiologist performs a cardiac cath (which carries risks of stroke, heart attack and death) for the sole purpose of checking the effect of the diet he is engaging in unethical medical behavior and likely insurance fraud. By the way, I hope that your husband is on a statin like most of Dr. Esselstyn’s are!:)

and a man wrote

Calling Essylstein ilk shows a little too much biased hatred on your part

Please note the definition of ilk “a type of people or things similar to those already referred to.” No pejorative there. And no ad hominem attack.  I wrote:

 It is possible that the type of vegan/ultra-low fat diets espoused by Esselstyn and his ilk have some beneficial effects on preventing CAD, but there is nothing in the scientific literature which proves it.

I should be able to criticize the methods and ideas of Dr. E without it being considered an attack on his person

Completely wrong. Esselstyn has saved my life. His book explains it all, how the endothelium cells get ruined, inflammation … heart attack proof (his words). One does not continue as head of the Cleveland Wellness Center if one is a quack.

Words are easy to come by on the interweb but Dr. E’s are not supported by science and as for the “Cleveland Wellness Center” it is probably not wise to get me started. Dr. E ‘s program is listed as being part of the Cleveland Clinic Wellness Center which is an attempt to capitalize on the market for pseudoscientific enterprises. He is not the director. The director recently came under intense criticism for promoting anti vaccine quackery. (See here).

The Wellness Center promotes so-called functional, integrative, complementary and alternative approaches. (Functional medicine is fake medicine!) These are approaches that have not been proven to work and could arguably be called quackery. (Let me be clear, however, I am not calling Dr. Esselstyn a quack but the fact that he is part of the Wellness Center does not add any scientific validity to his work.)

“I’m sure there are more people out there on the esselstyn diet that are not noted in the study years ago. I hope there is another book coming out”

Fake News, Fake Science

As a matter of fact, Dr. E has been hard at work over the last 30 years and has added a grand total of 176 patients who are considered “adherent” to the diet: about 6 per year. The “original research” was published in The Journal of Family Practice in 2014. Unfortunately the bad science present in the original publication has only been amplified.

In addition to any randomization or suitable control group for comparison, the data collection techniques are unacceptable:

“In 2011 and 2012 we contacted all participants by telephone to gather data. If a participant had died, we obtained follow-up medical and dietary information from the spouse, sibling, off-spring or responsible representative.”

In other words, there was no actual systematic review of medical records, autopsies or death certificates, just word of mouth from whomever answered the phone.

“Patients who avoided all meat, fish, dairy, and knowingly, any added oils throughout the program were considered adherent.”

Imagine, if you will, that your husband died 10 years ago and you received a call from Dr. E’s office or perhaps Dr. E himself and he asks you if your husband “avoided all meat, fish, dairy and added oils.”  For one thing, it would be very difficult for you to answer that question with any degree of accuracy: was your husband cheating on Dr. E’s diet when you weren’t looking, do you remember his entire diet from 10 years ago?

For another thing, you know that the caller has an agenda. If your husband died of a heart problem the caller is not going to be happy until he/she gets you to admit that your husband had some guacamole on Cinco de Mayo in 2002. If he’s alive and doing well, the caller is likely to be satisfied with a simple answer that , yes, he’s following the diet.

Yes, we have more data from Dr. E but it turns out to be even more incredibly bad than the first lot.

Let the anecdotes and ad hominem attacks begin!

-ACP

Dr. P’s Heart Nuts: Preventing Death In Multiple Ways

The skeptical cardiologist has finally prepared Dr. P’s Heart Nuts for distribution. IMG_8339The major stumbling block in preparing them was finding almonds which were raw (see here), but not gassed with proplyene oxide (see here), and which did not contain potentially toxic levels of cyanide (see here).

During this search I learned a lot about almonds and cyanide toxicity, and ended up using raw organic almonds from nuts.com, which come from Spain.

I’ll be giving out these packets (containing 15 grams of almonds, 15 grams of hazelnuts and 30 grams of walnuts) to my patients because there is really good scientific evidence that consuming 1/2 packet of these per day will reduce their risk of dying from heart attacks, strokes, and cancer.

IMG_7965The exact components are based on the landmark randomized trial of the Mediterranean diet, enhanced by either extra-virgin olive oil or nuts (PREDIMED, in which participants in the two Mediterranean-diet groups received either extra-virgin olive oil (approximately 1 liter per week) or 30g of mixed nuts per day (15g of walnuts, 7.5g of hazelnuts, and 7.5g of almonds) at no cost, and those in the control group received small nonfood gifts).

After 5 years, those on the Mediterranean diet had about a 30% lower rate of heart attack, stroke or cardiovascular death than the control group.

It’s fantastic to have a randomized trial (the strongest form of scientific evidence) supporting nuts, as it buttresses consistent (weaker, but easier to obtain), observational data.

Trademark

I applied for a trademark for my Heart Nuts, not because I plan to market them, but because I thought it would be interesting to possess a trademark of some kind.

The response from a lawyer at the federal trademark and patent office is hilariously full of mind-numbing and needlessly complicated legalese.

Heres one example:

"DISCLAIMER REQUIRED
Applicant must disclaim the wording “NUTS” because it merely describes an ingredient of applicant’s goods, and thus is an unregistrable component of the mark.  See 15 U.S.C. §§1052(e)(1), 1056(a); DuoProSS Meditech Corp. v. Inviro Med. Devices, Ltd., 695 F.3d 1247, 1251, 103 USPQ2d 1753, 1755 (Fed. Cir. 2012) (quoting In re Oppedahl & Larson LLP, 373 F.3d 1171, 1173, 71 USPQ2d 1370, 1371 (Fed. Cir. 2004)); TMEP §§1213, 1213.03(a).

The attached evidence from The American Heritage Dictionary of the English Language shows this wording means “[a]n indehiscent fruit having a single seed enclosed in a hard shell, such as an acorn or hazelnut”, or “[a]ny of various other usually edible seeds enclosed in a hard covering such as a seed coat or the stone of a drupe, as in a pine nut, peanut, almond, or walnut.”  Therefore, the wording merely describes applicant’s goods, in that they consist exclusively of nuts identified as hazelnuts, almonds, and walnuts.

An applicant may not claim exclusive rights to terms that others may need to use to describe their goods and/or services in the marketplace.  See Dena Corp. v. Belvedere Int’l, Inc., 950 F.2d 1555, 1560, 21 USPQ2d 1047, 1051 (Fed. Cir. 1991); In re Aug. Storck KG, 218 USPQ 823, 825 (TTAB 1983).  A disclaimer of unregistrable matter does not affect the appearance of the mark; that is, a disclaimer does not physically remove the disclaimed matter from the mark.  See Schwarzkopf v. John H. Breck, Inc., 340 F.2d 978, 978, 144 USPQ 433, 433 (C.C.P.A. 1965); TMEP §1213.

If applicant does not provide the required disclaimer, the USPTO may refuse to register the entire mark.  SeeIn re Stereotaxis Inc., 429 F.3d 1039, 1040-41, 77 USPQ2d 1087, 1088-89 (Fed. Cir. 2005); TMEP §1213.01(b).

Applicant should submit a disclaimer in the following standardized format:

No claim is made to the exclusive right to use “NUTS” apart from the mark as shown."

I’ve gotten dozens of emails from trademark attorneys offering to help me respond to the denial of my trademark request. Is this a conspiracy amongst lawyers to gin up business?

Nuts Reduce Mortality From Lots of Different Diseases

The most recent examination of observational data performed a meta-analysis of 20 prospective studies of nut consumption and risk of cardiovascular disease, total cancer, and all-cause and cause-specific mortality in adult populations published up to July 19, 2016.

It found that for every 28 grams/day increase in nut intake, risk was reduced by:

29% for coronary heart disease

7% for stroke (not significant)

21% for cardiovascular disease

15% for cancer

22% for all-cause mortality

Surprisingly, death from diseases, other than heart disease or cancer, were also significantly reduced:

52% for respiratory disease

35% for neurodenerative disease

75% for infectious disease

74% for kidney disease

The authors concluded:

If the associations are causal, an estimated 4.4 million premature deaths in the America, Europe, Southeast Asia, and Western Pacific would be attributable to a nut intake below 20 grams per day in 2013.

If everybody consumed Dr. P’s Heart Nuts, we could save 4.4 million lives!

Meditativeterraneanly Yours,

-ACP

If you’re curious about why nuts are so healthy, check out this recent meta-analysis, a discussion of possible mechanisms of the health benefits of nuts complete with references:

Nuts are good sources of unsaturated fatty acids, protein, fiber, vitamin E, potassium, magnesium, and phytochemicals. Intervention studies have shown that nut consumption reduces total cholesterol, low-density lipoprotein cholesterol, and the ratio of low- to high-density lipoprotein cholesterol, and ratio of total to high-density lipoprotein cholesterol, apolipoprotein B, and triglyceride levels in a dose–response manner [4, 65]. In addition, studies have shown reduced endothelial dysfunction [8], lipid peroxidation [7], and insulin resistance [6, 66] with a higher intake of nuts. Oxidative damage and insulin resistance are important pathogenic drivers of cancer [67, 68] and a number of specific causes of death [69]. Nuts and seeds and particularly walnuts, pecans, and sunflower seeds have a high antioxidant content [70], and could prevent cancer by reducing oxidative DNA damage [9], cell proliferation [71, 72], inflammation [73, 74], and circulating insulin-like growth factor 1 concentrations [75] and by inducing apoptosis [71], suppressing angiogenesis [76], and altering the gut microbiota [77]. Although nuts are high in total fat, they have been associated with lower weight gain [78, 79, 80] and lower risk of overweight and obesity [79] in observational studies and some randomized controlled trials [80].

Nutella: Healthy and Natural Spread or Highly Processed, Slickly Marketed Junk Food?

It’s World Nutella day according to Ferrero, the Italian confectonery company and manufacturer of the globally beloved hazelnut-based spread.screen-shot-2017-02-05-at-6-28-42-am

“With Nutella we spread positive energy to families to bring more happiness to the world” we are informed. On this day, apparently, the world should be spreading Nutella on as many food products as possible, ramping up positive energy levels to unprecedented levels.

Here are some of the other products Ferrero sells:screen-shot-2017-02-05-at-9-08-21-am

Three of them are clearly recognized by consumers as candy.

Should Nutella be in the same category as tic-tacs?

 

 

Nutella Ingredients

Perhaps in anticipation of World Nutella Day, a graphic has been appearing on Twitter:

nutella-englisy

detailing the ingredients of Nutella. The English version of this was posted on Reddit on a subreddit that I can’t mention on my family-friendly blog. It is a translation of a graphic that was published in German originally.

screen-shot-2017-02-05-at-8-18-31-am
If you thought you were getting mostly hazelnuts under the lid as this Nutella website graphic implies, you will be disappointed.

I’m not sure where the original data for the graphic came from but it seems to be a reasonable illustration of how much of Nutella is made up of palm oil and sugar. A 2 tbsp serving of Nutella (37 grams) contains 12 grams of fat, 21 grams of sugar and 2 grams of protein. Only about 12% of Nutella comes from actual hazelnuts.

I don’t have any concerns from a cardiovascular risk standpoint with the fat content of either the palm oil or the hazelnuts in Nutella.

But the 5 teaspoons of sugar per serving screen-shot-2017-02-05-at-8-44-16-am

are just still another source of empty
sugar calories adding to the daily dietary glut of sugar consumers face when consuming highly processed foods.

Nutella definitely is a highly processed, highly sugared product that shouldn’t be a regular part of a healthy Mediterranean diet. Most of the ingredients have gone through  complex sourcing and factory processing although their marketing material strains to emphasize the freshness and naturalness of these ingredients.

screen-shot-2017-02-05-at-6-30-27-am

One ingredient not depicted on the now viral graphic of Nutella is vanillin. From Nutella’s ingredient graphic one might think the screen-shot-2017-02-05-at-6-34-38-amvanillin is being extracted from (per wikipedia)

“the seed pods of Vanilla planifolia, a vining orchid native to Mexico, but now grown in tropical areas around the globe.”

In reality, however, the Nutella people,  ” use synthetic vanillin, an aroma identical to the one naturally present in the vanilla pod.”

Is the Palm OIl In Nutella Carcinogenic?

Some question the healthiness of the palm oil in nutella, either due to its high saturated fat content or its carcinogenic potential. A european food safety authority paper in May, 2016 declared certain toxins found in palm oil in particular to be “genotoxic and carcinogenic”

EFSA assessed the risks for public health of the substances: glycidyl fatty acid esters (GE), 3-monochloropropanediol (3-MCPD), and 2-monochloropropanediol (2-MCPD) and their fatty acid esters. The substances form during food processing, in particular, when refining vegetable oils at high temperatures (approx. 200°C)

The highest levels of GE, as well as 3-MCPD and 2-MCPD (including esters) were found in palm oils and palm fats, followed by other oils and fats. For consumers aged three and above, margarines and ‘pastries and cakes’ were the main sources of exposure to all substances.

As a result, According to Reuters, In Italy, some products containing palm oil have been removed from grocer’s shelves and one pastry company has eliminated palm oil from it products, labeling them as “palm oil free.”

High temperatures are used to remove palm oil’s natural red color and neutralize its smell, but Ferrero says it uses an industrial process that combines a temperature of just below 200C and extremely low pressure to minimize contaminants.

Nutella has fought back, defending its use of palm oil, with television and print advertisements.

Healthier Alternatives To Nutella

Conner Middleman, nutritionist , cooking instructor and author of Zest For Life, has shared with me her recipe for Nutritella, a healthier version of Nutella you can make at home. She points out in her intro to the recipe:

Nutella was invented in the 1940s in the Piedmont region of northern Italy, where hazelnuts grow plentifully. Alas, modern, store-bought Nutella contains a mere 13% hazelnut and only a hint of cocoa; the rest is made up of sugar, palm oil and artificial vanilla flavoring. My home-made version of Nutella, on the other hand, contains very little sweetener (in the form of raw honey), 3 tablespoons of flavonoid-rich dark cocoa, and about 90% hazelnuts, which boast a particularly high concentration of antioxidants and healthy fats (mostly monounsaturated). This is not to say that you should eat this spread by the tablespoonful; its high fat content means it’s high in calories and it should be enjoyed in sensible amounts (1-2 tbsp/day). The good news is that a high-fat food such as this one keeps you sated for longer, and because it is made from whole, real foods, it’s not only rich in calories, but also in nutrients! 

Here’s the recipe:

1 cup/125g toasted hazelnuts (Trader Joe’s roasted Oregon hazelnuts work great here; alternatively buy plain, raw hazelnuts and roast them yourself as described below)

½ oz/2 tbsp/15g unsweetened cocoa

3 tbsp hazelnut oil (La Tourangelle is my favorite brand – available in the oils section of good supermarkets or online)

3 tbsp honey or maple syrup

2 tsp alcohol-free vanilla extract (e.g., Trader Joe’s)

6-8 tbsp milk/plant milk/water

If you are roasting the hazelnuts from scratch, preheat oven to 350F. Place nuts on a dry, clean baking sheet and roast for 8 minutes (set timer). Remove and tip hot nuts onto a clean kitchen towel (pictured here).

As they cool, the skins will loosen, crack and flake off. Gather up the towel by its corners and scoop together into a tight bundle. Hold the bundle with one hand and knead the nuts with the other through the cloth to rub the skins off them. Place bundle back on a flat surface and open; lift out the nuts and lightly shake off the skins. (Leave some skin on the nuts – it’s where most of the antioxidants reside.)

If using pre-roasted nuts, start here.

Place the hazelnuts in an electric blender with the cocoa, oil, honey/maple syrup and vanilla extract. Process on “high” for about 30-40 seconds until all the ingredients come together in a coarse paste.

With the motor running, add milk or water (whichever using), a tablespoon at a time, and keep processing until the mixture reaches the desired consistency.

Transfer to a clean glass jar and refrigerate. Keeps for at least 2 weeks.

You can check out Conner’s excellent website, Modern Mediterranean, replete with more recipes and information on the cancer-fighting benefits of the Mediterranean diet,  here. and her You-tube channel here.

Of course, the skeptical cardiologist Heart Nuts project advocates just eating  heartnutsunadulterated hazelnuts along with other healthy drupes, nuts and legumes for snacking and soon we will be distributing these to you using our trademark-pending walnut-auscultating squirrel, Sparky.

Notnutellingly Yours,

-ACP

 

Say Hello To Heart Nuts

The skeptical cardiologist nut project (aka the nutty cardiologist project) now has a logo. Say hello toheartnuts  the world’s only walnut-auscultating promoter of nut consumption. Soon you will see his smiling face on the packets of nuts I’ll be handing out to help defeat cardiovascular disease.

Special thanks to my wonderful Washington University computer-science major and  bass guitar wiz daughter, Gwyneth, for creating the squirrel doctor during her winter break.

I promised 10 bags of nuts and “oodles of glory” to the reader whose name I selected but I can’t identify who proposed Heart Nuts. Let me know who you are and I’ll get the nuts to you.

Now I need a name for the squirrel.

Squirrelly Yours,

-ACP

See here for my post on KIND bars versus Simply Nuts and here for my review of nuts, drupes and legumes and reduced mortality.

N.B. Nuts are recognized as promoting reduced cholesterol, oxidative stress, and insulin resistance thereby reducing the risk of cardiovascular disease.

I’ve focused on their cardiovascular benefits (perhaps mediated by dietary fiber, magnesium, polyunsaturated fats, vitamin E, and antioxidants)  but recent studies suggest  other health benefits that could contribute to improved longevity.

Nuts contain bioactive compounds both known (ellagic acid, anacardic acid, genistein, resveratrol, and inositol phosphates) and unknown which may reduce the risk of cancer or other chronic diseases.

A recent meta-analysis found that consuming one serving of nuts per day was associated with a 15% lower  risk of any cancer and a 22% lower risk of dying from any cause.

Embrace the nuts I say!

 

Are You On The Fence About Taking A Statin Drug?

The father of the eternal fiancee’ of the skeptical cardiologist (FOEFOSC, let’s call him “Geo”) is a typical 61 year old white male. A year ago his primary care physician informed him that he needed to start taking a statin drug because his cholesterol was high. The note accompanying this recommendation also stated “work harder on diet and exercise to get LDL<130.”  No particulars on how to change his current diet and exercise program were provided.

Neither of Geo’s parents and none of his siblings have had heart problems at an early age and Geo is very active without any symptoms. His diet is reasonably free of processed food and added sugar, he is not overweight and his blood pressures are fine. Due to concern about side effects he had read about on the internet and because he doesn’t like taking medications , Geo balked at taking the recommended statin,

Reluctance to start a new and likely life-long drug is understandable especially when combined with a constant stream of internet-based bashing of statins.

My advice was sought and I suggested a few things that would be helpful in making a more informed decision:

-Calculate Geo’s 10 year risk of heart attack and stroke using the ACC ASCVD Risk estimator app.

-Assess for early or advanced build-up of atherosclerotic or fatty plaque in the carotid arteries (vascular ultrasound) and coronary arteries (coronary calcium scan).

As I’ve pointed out before (here), the vast majority of men over the age of 60 move into a 10 year risk category >7.5%, no matter how great their lifestyle is, and Geo was no exception with a risk of 8.4%. His total cholesterol was 249, LDL (bad) 154, HDL (good) 72 and triglycerides 116.

The vascular ultrasound showed below normal carotid thickness and no plaque and his coronary calcium score was 18,  putting him at the 63rd  percentile. This is slightly higher than average white men his age.

When Geo presented these findings to his PCP, he seemed unaware of the ASCVD risk estimator (recommended by AHA/ACC guidelines first published in 2013), which no longer suggests LDL levels as goals. His PCP also seemed miffed that he had gotten the coronary calcium scan. Geo felt like the PCP’s attitude was “shut up and do what I tell you.”

Geo’s PCP’s approach exemplifies a not-uncommon traditional doctor-patient relationship, but a better approach is shared decision-making (see here). Geo, like many patients, welcomes more information on the risks and benefits of any recommended treatment so that he can participate in deciding the best course of action.

I steer patients who want more complete information towards my  evidence-based blog posts on statins (see here for discussion on statin side effects and here for statin benefits beyond cholesterol lowering.)

By giving patients more information on the risks, side effects, and benefits of the statin drugs along with a better understanding of their overall risk of heart disease and stroke, we can hopefully move more patients “off the fence” and onto the most appropriate treatment.

Stay tuned to find out what The Skeptical Cardiologist Recommended for Geo.

Decisively Yours

-ACP

For more discussion on the value of coronary artery calcification (CAC) and the value of statin in lower risk patients see this recent paper entitled “Refining Statin Prescribing in Lower-Risk Individuals: Informing Risk/Benefit Decisions”(PDF refining-statin-prescribing-in-lower-risk-individuals-informing-riskbenefit-decisions)

If you’d like to read the recently published recommendations of the US Preventive Services Task Force on statins for primary prevention of cardiovascular disease see here. Importantly this panel of unbiased experts concluded that statin therapy significantly reduced overall mortality and cardiovascular mortality. In addition, the review found no increased risk of diabetes overall with statin therapy. The only trial that identified an increased risk was using high intensity statin therapy (Crestor (rosuvastatin) >20 mg).

And,  since the internet is jammed with people who believe statins robbed them of their brain power, I would advise noting that the writers concluded  “These findings are consistent with those from a recent systematic review of randomized trials and observational studies that found no adverse associations of statins with incidence of Alzheimer disease, dementia, or decreased scores on tests of cognitive performance.”

 

 

What Does The Death of Robert Atkins Tell Us About the Atkins Diet?

In the spring of 2003 at the age of 72 years, Robert Atkins, the cardiologist and  controversial promoter of high fat diets for weight loss, fell  on the sidewalk in front of his Atkins Center for Complementary Medicine in Manhattan.  He lost his footing on a patch of ice, slipped and banged his head on the pavement.  At the time of his fall his book ”Dr. Atkins’ New Diet Revolution” lead the NY times paper-back best seller list.

He was taken to nearby Cornell Medical Center where a clot was evacuated from his brain. Thereafter he lapsed into a coma and he spent 9 days in the ICU, expiring on April 17, 2003.

screen-shot-2016-11-27-at-8-44-55-amThe cause of death was determined by the New York Medical Examiner to be “blunt injury of head with epidural hematoma.”

An epidural hematoma is a collection of blood between the skull and the tough outer lining of the brain (the dura) which can occur with blunt trauma to the head which results in laceration of the arteries in this area. It is a not  uncommon cause of death in trauma . Actress Natasha Richardson (skiing, see below)  died from this. Nothing about the manner in which Robert Atkins died would suggest that he was a victim of his own diet any more than  Natasha Richardson was.

However, within the year a campaign of misinformation and deception spear-headed by  evangelistic vegans would try to paint the picture that Atkins died as a direct result of what they perceived as a horribly dangerous diet.

Michael Bloomberg, then New York major,  was quoted as saying

“I don’t believe that bullshit that [Atkins] dropped dead slipping on the sidewalk.”

According to the Smoking Gun:

“The 61-year-old billionaire added that Atkins was “fat” and served “inedible” food at his Hamptons home when Bloomberg visited. The mayor’s inference, of course, was that Atkins was actually felled by his meat-heavy diet, that his arteries were clogged with beef drippings. “

Enter The Vegans

Richard Fleming, a physician promoting prevention of cardiovascular disease through vegetarianism and with close ties to an organization  called Physicians Committe for Responsible Medicine (PCRM) sent a letter to the NY Medical Examiner requesting a copy of the full medical examination of Atkins. The NYME office  should have only issued copies of this report to physicians involved in the care of Atkins or next of kin but mistakenly complied with this request.  Fleming, who would subsequently publish his own low fat diet book, conveniently gave the report to PCRM which is directed by animal rights and vegan physicians.

screen-shot-2016-12-18-at-7-50-24-am
From the front page of pcrm.org. The two major concerns of the group are converting everyone to veganism and animal rights.

Neal Barnard, the President of PCRM, in an incredibly unethical move sent the letter to the Wall Street Journal with the hope that the information would destroy the popularity of the Atkins diet, a diet he clearly despises..  Barnard said the group decided to publicize the report because Atkins’ “health history was used to promote his terribly unhealthy eating plan..” The WSJ subsequently published an article summarizing the findings.

To this day, advocates of vegetarianism and low fat diets, distort the findings of Atkins’ Medical Examination in order to depict high fat diets like his as dangerous and portray Atkins as a victim of his own diet.

To scientists and thoughtful, unbiased physicians it is manifestly apparent that you cannot base decisions on what diet plan is healthy or effective for weight loss on the outcome of one patient. It doesn’t matter how famous that one person is or whether he/she originated and meticulously followed the diet. It is a ludicrous concept.

Would you base your decision to engage in running  based on the death of Jim Fixx?  Fixx  did much to popularize the sport of running and the concept of jogging as a source of health benefit and weight loss. He died while jogging, in fact. An autopsy concluded that he died of a massive heart attack and found advanced atherosclerosis (blockage) of the arteries to his heart.

Fixx inherited his predisposition to heart disease and couldn’t run himself out of it. Multiple studies over the years have documented the benefit of regular aerobic exercise like running on longevity and cardiovascular risk.

Would you based your decision to engage in  a very low fat diet based on how Nathan Pritikin died?  Pritikin authored an extremely popular book emphasizing eliminating fat from the diet but developed leukemia and slashed his wrists,  committing suicide at the age of 69 years. Would vegetarians accept the premise that their preferred diet results in leukemia or suicidal depression based on Pritikin’s death?

The Distortion of Atkins Death

The NYME report lists Atkins weight at autopsy as 258 pounds. Low-fat zealots seized on this fact as indicating that Atkins was screen-shot-2016-12-17-at-5-32-56-ammorbidly obese throughout his life.  For example, a  you-tube video of an audio interview of Atkinas online posted by “plant-based coach”  has this obviously photoshopped head of Atkins put on the body of a morbidly obese man. Atkins actually weight around 200 pounds through most of his life and a hospital note on admission showed him weighing 195 pounds. A substantial weight gain of 63 pounds occurred in the 9 days after his admission due to the accumulation of fluid volume and swelling which is not uncommon in the critically ill.

screen-shot-2016-11-27-at-8-42-59-amscreen-shot-2016-11-27-at-8-42-39-am

No autopsy was performed on Atkins but the NYME wrote on the document that he had “h/o of MI, CHF, HTN.”

MI is the acronym for a myocardial infarction or heart attack. As far as we can tell without access to full medical records, Atkins never had an MI. He did have a cardiac arrest in 2002. While most cardiac arrests are due to a cardiac arrhythmia secondary to an MI they can also occur in patients who have a cardiomyopathy or weakness in the heart muscle from causes other than MI. In fact, USA Today reported that Stuart Trager, MD,  chairman of the Atkins Physicians Council in New York, indicated that Atkins was diagnosed with a cardiomyopathy at the time of his cardiac arrest and that it was not felt to be due to blocked coronary arteries/MI. Cardiomyopathy can be caused by viral infections or nonspecific inflammation of the heart muscle and would have nothing to do with diet.

Trager also stated that Atkins, as a result of the cardiomyopathy, had developed heart failure (CHF) and the pumping ability of his heart (ejection fraction )had dropped to 15 to 20%. While CHF can be due to heart attacks causing heart weakness in Atkins case it appears it was unrelated to fatty blockage of the coronary arteries causing MI and therefore not related in any way to his diet.

What Does Atkins Death Tell Us About His Diet 

The information about Atkins death tells us nothing about the effectiveness or dangers of his diet.  In one individual it is entirely likely that a genetic predisposition to cancer or heart disease overwhelms whatever beneficial effects the individual’s lifestyle may have had. Thus, we should never rely on the appearance or the longevity of  the primary promoter of a diet for the diet’s effectiveness.

The evangelists of low-fat, vegan or vegetarian diets like PCRM have shamelessly promoted misinformation about Atkins death to dismiss high fat diets and promote their own agenda. If their diets are truly superior it should be possible to utilize facts and science to promote them rather than a sensationalistic, distorted focus on the body of one man who slipped on the ice and fell to his death.

Epidurally Yours

-ACP

Addendum: Earlier versions of this post cited  MLB pitcher Brandon McCarthy as a victim of a fast ball to the head causing epicardial hematoma. I was corrected by astute reader Fred N who pointed out that McCarthy is still pitching for the Dodgers and was hit by a line drive (off the bat of Erick Aybar). McCarthy had emergency surgery for the epicardial hematoma in 2012. His diet had nothing to do with the epicardial hematoma.

N.B. Natasha Richardson fell while taking beginner skin lessons at a Canadian Ski resort. According to a release from the resort:

Natasha Richardson fell in a beginners trail while taking a ski lesson at Station Mont Tremblant,” the statement said. “She was accompanied by an experienced ski instructor who immediately called the ski patrol. She did not show any visible sign of injury but the ski patrol followed strict procedures and brought her back to the bottom of the slope and insisted she should see a doctor.

“As an additional precautionary measure, the ski instructor as well as the ski patrol accompanied Mrs. Richardson to her hotel,” the statement continued. “They again recommended she should be seen by a doctor. The ski instructor stayed with her at her hotel. Approximately an hour after the incident Mrs. Richardson was not feeling good. An ambulance was called and Mrs. Richardson was brought to the Centre Hospitalier Laurentien in Ste-Agathe and was later transferred to Hôpital du Sacre-Coeur.”

A spokesperson for the resort noted Richardson was not wearing a helmet while skiing and didn’t collide with anything when she fell. Thursday, in the wake of her death, Quebec officials said they are considering making helmets mandatory on ski slopes, according to The Associated Press.”

The last time I skied I found myself falling and banging my head an extraordinary amount. If I ever ski again (in contrast to my resistance to bike helmets) I plan to wear a helmet.