I note patient awareness of the possibility of OSA is rising exponentially and many of my patient’s are being subjected to sleep studies because their wives are bothered by their excessive snoring.
The AASM guidelines state that
Increased risk of moderate to severe OSA is indicated by the presence of excessive daytime sleepiness and at least two of the following three criteria: habitual loud snoring; witnessed apnea or gasping or choking; or diagnosed hypertension
Although I have no reason to suspect that I have sleep disordered breathing (SDB-I feel like this term is becoming popular as it avoids the stigma of apnea), I decided to determine my Epworth Sleepiness Scale which is often utilized to measure excessive daytime sleepiness.
Developed by Dr. Murray Johns, this scale has its own website where you will learn that:
Johns (2002) introduced the term somnificity to describe the effects of different postures and activities on sleep propensity.
The somnificity of any particular posture, activity and situation is a measure of its ability to facilitate or impede sleep onset in the majority of people. It is not a characteristic of individual people or their sleep disorders.
and (no doubt after years of intense sleepiness research) Dr. Johns has discovered that:
Simply to lie down rather than stand up increases one’s likelihood of falling asleep – the change of posture increases one’s sleep propensity at the time.
After stumbling up on this revelation I have decided to test my hypothesis that playing electric guitar while standing has extremely low somnificity. (I also hope to use the word somnificity in a normal daily conversation without biting my tongue.)
This self-administered questionnaire asks you to rate how likely you are (on a scale of 0=never to 3=high chance of dozing) to doze off or fall asleep in certain situations. What follows are the situations with my observations and my self-rated score.
Sitting and reading (Principles of Nuclear Medicine=3, Brave New World=0) 1
Watching TV 1
Sitting, inactive in a public place (theatre or a meeting) 1
As a passenger in a car for an hour without a break 2
Lying down to rest in the afternoon when circumstances permit 3
sitting and talking to someone 1
sitting quietly after a lunch without alcohol 1
In a car while stopped for a few minutes in the traffic 2
They don’t ask about falling asleep while driving which seems much more important than the other situations. I’ve done that a lot.
The biggest soporific situation for me is sitting in a barber’s chair. No matter what small talk the hairdresser throws at me, I am asleep within 5 minutes. My bobbing head requires the rare skill of trimming a moving target.
My total score was 12 which puts me solidly in the land of sleep disordered breathing. In the original study by Johns the patient’s with sleep apnea (OSA-line 3 in below chart) had an average score of 11.7.
The AASM guidelines indicate that I could have gotten into some OSA studies with my score, especially if I add in that I have been caught snoring, gasping and choking (sometimes all three simultaneously!) and I have hypertension.
The Eternal fiancée got a respectable score of 7. Apparently she never falls asleep at traffic lights, watching TV/movie or sitting after lunch and believes these are masculine traits. However, I think she should get double points for taking long, intentional naps throughout the day.
The skeptical cardiologist is asked this question or variations of it (such as what caused me to go out of rhythm?) on a daily basis.
Most patients would like to have a reason for why their atria suddenly decided to fibrillate. It’s understandable. If they could identify the reason perhaps they could stop it from happening again.
There are two variations on this question:
For the patient who has just been diagnosed with afib the question is really “what is the underlying reason for me developing this condition?”
For the patient who has had afib for a while and it comes and goes seemingly randomly the question is “what caused the afib at this time? i.e. what triggers my episodes?”
For most patients, there is no straighforward and simple answer to either one of these questions
The Underlying Cause of Atrial Fibrillation
My stock response to this first question goes like this:
“Atrial fibrillation is associated with getting older and having high blood pressure. 10 % of individual >/= 80 years have atrial fibrillation. 90% of patients with afib have hypertension.
Aging and hypertension may increase scarring or damage in the left atrium or pulmonary veins that drain into the left atrium setting up abnormal electrical signals.
There are some specific things that cause afib and we will be doing a complete history and physical and some testing to check for the most common. We’ll check you for thyroid or electrolyte abnormalities and we will do an echocardiogram to look for any structural problems with your heart.
If we do find a treatable cause such as hyperthyroidism or a cardiac valve problem we will fix that and the afib may go away, however chances are we won’t find a specific reason why you developed atrial fibrillation.
Finally, and possibly most importantly, let’s take a close look at your lifestyle. Are you overweight? If so, losing 10% of your body weight will substantially lower your risk of recurrent atrial fibrillation. Let’s get you exercising regularly and eating a healthy diet, Make sure your sleep is optimized and your stress minimized.”
If you’d like a more sophisticated look into what causes afib take a look at this graphic from a recent paper.
Current theory has it that factors that we know are associated with atrial fibrillation including obesity, hypertension and sleep apnea cause atrial structural abnormalities or remodeling which then create various atrial electrical abnormalities.
Exhaustive List of Causes
If you’d like an exhaustive list of factors associated with atrial fibrillation, you can memorize the acronym P.I.R.A.T.E.S. which is sometimes used by medical students to remember the causes of atrial fibrillation which include:
Both of these mnemonics are a little outdated. For example, rheumatic mitral stenosis is quite rare as a cause of afib in the US but degenerative and functional mitral regurgitation is a common cause.
Ischemic heart disease (aka coronary heart disease) isn’t felt to cause atrial fibrillation unless it results in a myocardial infarction and subsequent heart failure. Way too many cardiac catheterizations are performed on patients who present with atrial fibrillation by doctors who don’t know this.
Congenital heart defects (not mentioned in either mnemonic) especially atrial septal defects often are associated with afib
There may be case reports of pheochromocytoma (a catecholamine-secreting neuroendocrine tumor) causing afib but they are few and far between.
Finally, genetics clearly play a role in the younger patient with afib without any known risk factors. One of my patients and his twin brother both developed symptomatic afib in their 40s.
In The Chronic Afibber What Triggers An Episode?
Alas, for most afibbers we won’t identify specific reasons why you go in and out of afib although there are some triggers you should definitely avoid such as excessive alcohol.
Some of the “causes” listed in the mnemonic are acute triggers of afib episodes.
For example low potassium or magnesium (typically induced by diuretics, diarrhea or vomiting) can bring on episodes .(See my discussion on potassium and PVCS here-much of it is relevant to afib.)
And I have definitely seen patients go into atrial fibrillation who have acute pulmonary problems such as pneumonia, pulmonary embolism or exacerbation of COPD. In these cases, it is felt that the lung process raises pressure in the pulmonary arteries thereby putting strain on the right heart leading to higher right atrial pressures.
Sleep apnea is associated with afib and I have had a few cases where after identifying that a patient’s afib always began during sleep we were able to substantially lower episodes by treatment of sleep apnea.
Pericarditis with inflammation adjacent to the left atrium not uncommonly causes afib. This is the likely mechanism for the afib that occurs frequently after cardiac surgery. Since pericarditis may never recur (especially in the cardiac surgery patient) we think the risk of afib recurring is low in these patients.
Anything that raises stress and stimulates the sympathomimetic nervous system can be a trigger. For example, a young and otherwise healthy patient of mine went into afib after encountering a car in flames along the side of the road. We found that beta-blockers (which block the sympathetic nervous system) helped prevent her episodes.
Some patients have odd but reproducible triggers. One of my patients routinely went into afib when he ate ice cream. I had a simple , very effective treatment plan for him.
Caffeine and Chocolate
Many afibbers have been told to avoid caffeine but a recent study of 34,000 women found that there was no increased risk of afib with increasing caffeine content and no sign that any of the individual contributors to caffeine in the diet (coffee, tea, cola, and chocolate) were more likely to cause afib.
Higher chocolate consumption, in fact, has recently been linked to a lower rate of afib. An observational study of 55 thousand Danish men and women found that those who consumed 2 to 6 servings per week of 1 oz (30 grams) of chocolate had a 20% lower rate of clinically apparent afib.
Alcohol and Atrial Fibrillation
Binge drinking has long been known to cause acute atrial fibrillation.
However, it appears that even light to moderate chronic alcohol consumption increases the risk of going into atrial fibrillation.
The review concludes that although light to moderate alcohol consumption lowers your risk of dying, any alcohol consumption increases your risk of afib.
This graph shows the relationship between dying from heart disease (red line) and risk of going into afib (blue line) and amount of alcohol consumed.
Looking at the 15 drinks per week point on the x-axis (about 2 drinks per day) we see that your CV mortality is reduced by 20% whereas your risk of afib has increased by 20%.
A better point on the x-axis is 7 (1 drink per day) which has a 25% lower CV mortality but only a 10% higher risk of afib.
Whatever caused you to go into afib the good news is that with lifestyle changes and the care of a good cardiologist chances are excellent that you can live a normal, happy, healthy , long and active life.
The results of the “Fourth Nut” poll are in and the winner is a nut first cultivated in Bronze Age Central Asia,
Almost 60% of readers who took the time to vote selected the pistachio nut.
Coming in a distant second was the macadamia nut. One reader prized it because it only contained saturated fat and monounsaturated fats. Another bemoaned their candy-like quality which makes over-consumption an issue.
A couple of readers were strong proponents of Brazil nuts. This prompted me to enter a selenium rabbit hole from which I have yet to emerge. If I can escape with my selenoproteins intact I’ll let you know.
Pistachios are a fine choice from a health standpoint and seem to be embraced by all nutritional cults, with the exception of the very nutty Caldwell “NO OIL” Esselstyn’s acolytes.
The Pistachio Principle PR Institute
I’m in the process of sorting through the nutritional studies on pistachios, and the hardest part is determining which data are sponsored by the pistachio industry.
For example, poorly researched online articles about pistachios will typically state that “research suggests” that “pistachios could help to reduce hypertension and promote development of beneficial gut microbes. They’re even gaining credibility as a tool for weight loss”
The first reference is an open access review article which clearly just wants to extoll any and all positive pistachio data and was paid for by the American Pistachio Growers. The second article comes directly from “The Pistachio Health Institute,” a PR voice for the pistachio industry.
To Shell or Not to Shell
My major dilemma was deciding if the pistachios should be shelled or left in-shell. (This has led me down the pistachio production rabbit hole).
I was concerned that the outsides of the pistachio shells could be contaminated in some way and the idea of mixing them in with unshelled nuts seemed a little strange.
If you Google images of mixed nuts pistachio you only see mixtures with unshelled pistachios.
Why, then, are most pistachios sold and consumed in-shell?
Between 70 and 90 percent of pistachios develop a natural split in their shells during the growing process, After those pistachios are shaken off the trees by harvesting machines, they can be salted and roasted while still inside the shells as that natural crack allows heat and salt access to the nut, eliminating a step in the industrial process and saving processors some money.
The pistachio PR machine would also have us believe that eating pistachios in-shell can lead to weight loss:
Why choose any other nut?
This pistachios principle is based on 2 studies in the journal Appetite (seems to be a legitimate journal) by JE Painter of the department of “Family and Consumer Sciences” Eastern Illinois University in Charleston, Illinois.
I’m awaiting a full copy of the paper, but the abstract notes that students offered in-shell pistachios consumed only 125 calories, whereas those offered shelled pistachios consumed 211 calories yet “fullness and satisfaction” were similar.
My skeptical sensors were exploding when I read about this study. I doubt that it will ever be reproduced.
If we look at cost, an unofficial analysis revealed:
The pre-shelled pistachios were priced at $5.99 for 6.3 oz of nuts.
The 8 oz bag of pistachios were priced at $4.49. After shelling he was left with 4.3 oz of nuts.
Un-shelled pistachios = $1.04 per oz.
Shelled pistachios = $0.95 per oz.
If you go the lazy route, you save $.09 per oz!
Most likely, the fourth nut will be a shelled pistachio unless readers convince me otherwise or the blather from the pistachio PR machine annoys me too much.
The eternal fiance’e has just weighed in and tells me that women who care about their well-groomed nails will not consume in-shell pistachio nuts for fear of damaging their manicures.
That, my friends, is the nail in the coffin for shelled pistachios as the fourth nut.
A study presented at the European Society of Cardiology meetings in Barcelona and simultaneously published in The Lancet earlier this month caught the attention of many of my readers. Media headlines trumpeted “Huge New Study Casts Doubt On Conventional Wisdom About Fat And Carbs” and “Pure Shakes Up Nutritional Field: Finds High Fat Intake Beneficial.”
Since I’ve been casting as much doubt as possible on the conventional nutritional wisdom to cut saturated fat, they reasoned, I should be overjoyed to see such results.
What Did the PURE Study Find?
The Prospective Urban Rural Epidemiology (PURE) study, involved more than 200 investigators who collected data on more than 135000 individuals from 18 countries across five continents for over 7 years.
There were three high-income (Canada, Sweden, and United Arab Emirates), 11 middle-income (Argentina, Brazil, Chile, China, Colombia, Iran, Malaysia, occupied Palestinian territory, Poland, South Africa, and Turkey) and four low-income countries (Bangladesh, India, Pakistan, and Zimbabwe)
This was the largest prospective observational study to assess the association of nutrients (estimated by food frequency questionnaires) with cardiovascular disease and mortality in low-income and middle-income populations,
The PURE team reported that:
–Higher carbohydrate intake was associated with an increased risk of total mortality but not with CV disease or CV disease mortality.
This finding meshes well with one of my oft-repeated themes here, that added sugar is the major toxin in our diet (see here and here.)
–Higher fat intake was associated with lower risk of total mortality.
–Each type of fat (saturated, unsaturated, mono unsaturated ) was associated with about the same lower risk of total mortality.
These findings are consistent with my observations that it is becoming increasingly clear that cutting back on fat and saturated fat as the AHA and the Dietary Guidelines for Americans have been telling you to do for 30 years is not universally helpful (see here and here ).
When you process the fat out of dairy and eliminate meat from your diet although your LDL (“bad”) cholesterol drops a little your overall cholesterol (atherogenic lipid) profile doesn’t improve (see here).
Another paper from the PURE study shows this nicely and concluded:
Our data are at odds with current recommendations to reduce total fat and saturated fats. Reducing saturated fatty acid intake and replacing it with carbohydrate has an adverse effect on blood lipids. Substituting saturated fatty acids with unsaturated fats might improve some risk markers, but might worsen others. Simulations suggest that ApoB-to-ApoA1 ratio probably provides the best overall indication of the effect of saturated fatty acids on cardiovascular disease risk among the markers tested. Focusing on a single lipid marker such as LDL cholesterol alone does not capture the net clinical effects of nutrients on cardiovascular risk.
Further findings from PURE:
-Higher saturated fat intake was associated with a lower risk of stroke
-There was no association between total fat or saturated fat or unsaturated fat with risk of heart attack or dying from heart disease.
Given that most people still believe that saturated fat causes heart disease and are instructed by most national dietary guidelines to cut out animal and dairy fat this does indeed suggest that
“Global dietary guidelines should be reconsidered …”
Because the focus of dietary guidelines on reducing total and saturated fatty acid intake “is largely based on selective emphasis on some observation and clinical data despite the existence of several randomizesed trials and observational studies that do not support these conclusions.”
Pesky Confounding Factors
We cannot infer causality from PURE because like all obervational studies, the investigators do not have control over all the factors influencing outcomes. These confounding factors are legion in a study that is casting such a broad net across different countries with markedly different lifestyles and socioeconomic status.
The investigators did the best job they could taking into account household wealth and income, education, urban versus rural location and the effects of study centre on the outcomes.
In an accompanying editorial, Christopher E Ramsden and Anthony F Domenichiello, prominent NIH researchers, ask:
“Is PURE less confounded by conscientiousness than observational studies done in Europe and North American countries?
“Conscientiousness is among the best predictors of longevity. For example, in a Japanese population, highly and moderately conscientious individuals had 54% and 50% lower mortality, respectively, compared with the least conscientious tertile.”
“Conscientious individuals exhibit numerous health-related behaviours ranging from adherence to physicians’ recommendations and medication regimens, to better sleep habits, to less alcohol and substance misuse. Importantly, conscientious individuals tend to eat more recommended foods and fewer restricted foods.Since individuals in European and North American populations have, for many decades, received in influential diet recommendations, protective associations attributed to nutrients in studies of these populations are likely confounded by numerous other healthy behaviours. Because many of the populations included in PURE are less exposed to in influential diet recommendations, the present findings are perhaps less likely to be confounded by conscientiousness.”
It is this pesky conscientiousness factor (and other unmeasured confounding variables) which limit the confidence in any conclusions we can make from observational studies.
I agree wholeheartedly with the editorial’s conclusions:
Initial PURE findings challenge conventional diet–disease tenets that are largely based on observational associations in European and North American populations, adding to the uncertainty about what constitutes a healthy diet. This uncertainty is likely to prevail until well designed randomised controlled trials are done. Until then, the best medicine for the nutrition field is a healthy dose of humility.
Ah, if only the field of nutrition had been injected with a healthy dose of humility and a nagging conscience thirty years ago when its experts declared confidently that high dietary fat and cholesterol consumption was the cause of heart disease.!
Current nutritional experts and the guidelines they write will benefit from a keen awareness of the unintended consequences of recommendations which they make based on weak and insufficient evidence because such recommendations influence the food choices (and thereby the quality of life and the mechanisms of death) of hundreds of millions of people.
The skeptical cardiologist has given out the entire first batch of Dr. P’s Heart Nuts to his patients.
This precisely constructed mixture of hazelnuts, almonds and walnuts designed to maximize heart healthiness has been warmly received and hopefully enthusiastically consumed.
To some extent I feel like I may be preaching to the choir as many of the Heart Nuts recipients told me they were already avid nut fans and consumers.
However, I plan to press on with my mission to increase the amount of nut snacking in the world.
To this end, I have reorganized my blog and created a page devoted to Nuts and Drupes. You can find it here and I’ll reproduce it below.
Furthermore, I have decided to add a fourth nut to the mixture. At this time, I am intensely researching pistachio nuts and macadamia nuts to be the honored nut.
Please feel free to suggest other candidates to be the Fourth Nut (along with appropriate justification) in the comments below and vote in the poll.
From The Nuts Page
Nuts, despite containing a lot of fat, are a fantastic heart-healthy snack.
I’ve started handing out my special Dr. P’s Heart Nuts to patients along with the following:
You have received a packet of cardiovascular disease-busting Dr. P’s Heart Nuts!
One packet 15 grams of almonds, 15 grams of hazelnuts and 30 grams of walnuts.
There is very good scientific evidence that consuming 1/2 packet of these per day will reduce your risk of dying from heart attacks, strokes, and cancer.
The exact components are based on the landmark randomized trial of the Mediterranean diet, enhanced by either extra-virgin olive oil or nuts (PREDIMED, in which participants in the two Mediterranean-diet groups received either extra-virgin olive oil (approximately 1 liter per week) or 30g of mixed nuts per day
In other observational studies it has been found that for every 28 grams/ day increase in nut intake, risk was reduced by:
29% for coronary heart disease 7% for stroke
21% for cardiovascular disease 15% for cancer
22% for all-cause mortality
Surprisingly, death from diseases, other than heart disease or cancer, were also significantly reduced:
52% for respiratory disease
35% for neurodenerative disease
75% for infectious disease
74% for kidney disease
So when you are considering snacking, snack on nuts not processed food! Dr. Pearson
Posts About Nuts
Posts relevant to nuts and prevention of heart disease on my blog are
After finding out the first two facts about almonds I ended up getting raw, organic almonds from Spain. Unfortunately, about 1 in 10 of these were extremely bitter. It turns out these bitter almonds have significant amounts of cyanide. So I wrote “Beware The Bitter Almond.”
I switched my raw, organic almond source to Nuts.com and with their almonds I very rarely encounter the bitter almond.
The other nuts in the mixture are raw and organic and obtained from Nuts.com.
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.
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.
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 .
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.
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.
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.
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.
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.
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.
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.
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.
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!):
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.
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!)
N.B. Miserlou is a very old folk song with a scale that sounds exotic to Western ears: the double harmonic scale
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.
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
Cigarette Smoking (by far the strongest)
Obesity (Obviously related to #1 and #2)
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.
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.