In 2010 the AHA came up with “Life’s Simple 7”-seven modifiable health behaviors and biological factors- as part of its 2020 impact goal to improve the cardiovascular health of all Americans by 20% while reducing deaths from cardiovascular disease (CVD) and stroke by 20%.
The seven factors (LS7) were smoking, body mass index [BMI], physical activity, diet, total cholesterol, blood pressure, and fasting blood glucose, Attainment of optimal LS7 status has been associated with a reduced incidence of coronary heart disease, stroke, and heart failure (HF).
A recent observationsl study found that high LS7 scores was associated with a lower risk of developing atrial fibrillation
Each individual component was categorized as poor, intermediate, or ideal according to the American Heart Association’s LS7 criteria.1 Ideal levels of health factors were: nonsmoker or quit >1 year ago; body mass index <25 kg/m2; blood pressure <120/80 mm Hg; total cholesterol <200 mg/dL; fasting blood glucose <100 mg/dL; ≥150 min/week of physical activity; and a healthy diet score (≥4 components). Study participants who were treated to target levels for hypercholesterolemia, hypertension, or diabetes mellitus were classified as intermediate for the respective health factor. An overall LS7 score ranging from 0 to 14 was calculated as the sum of the LS7 component scores (2 points for ideal, 1 point for intermediate, and 0 for poor). This score was classified as inadequate (0‐4), average (5‐9), or optimum (10‐14) cardiovascular health.
I found this figure from the paper particularly interesting
Notice that there is a substantially lower risk of AF with lower BMI , blood sugar and blood pressure but no relationship between the diet score and AF risk.
Clearly if you can get and keep your body weight down (which improves blood pressure and diabetes risk) you will be in a lower risk category for atrial fibrillation.
On the other hand, having a total cholesterol <200 mg/dl is not associated with lower risk of AF and in fact having an ideal score on this parameter is associated with higher risk. A total cholesterol is really not something that is a good marker for CV health and should be eliminated from the Life’s Simple 7 goals.
Even more enlightening is the total lack of any association between “healthy” diet and atrial fibrillation.
The healthy diet score was calculated as the sum of the scores for each of 5 individual components: fruits and vegetables (≥4.5 cups per day), fish (≥2 3.5‐oz servings per week), fiber‐rich whole grains (≥3 1‐oz‐equivalent serving per day), sodium (<1500 mg/day), sugar‐sweetened beverages (≤450 kcal/week). The range is from 0 to 5, with a lower score being unhealthy.
Taken in conjunction with studies showing reduced AF recurrence after weight loss it seems very clear that the single best thing obese afib patients can do to prevent recurrence is lose weight. And it doesn’t matter what diet they utilize to accomplish the weight loss.
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.
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.
The 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.”
“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.
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.
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 morbidly 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.
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.
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 ski 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.
On this fourth Thursday of November, 2015 the skeptical cardiologist would like to record some Thanksgiving thanks.
I’m thankful I’m not a turkey today.
I hear Americans consume 45 million turkeys on Thanksgiving, one sixth of the total during the year.
Americans have embraced turkeys nutritionally because they are low in saturated fat and provide lots of protein. Most nutritional advice suggests avoiding the dark meat and the skin, but I prefer to seek those portions out because they taste better and as I pointed out here last Thanksgiving, Up To Date, the major medical reference for physicians, now says “Don’t Worry About Saturated Fat Consumption.”
I’m thankful that dairy fat is good for you.
The eternal fiancee’ and I took a cooking class in New Orleans (New Orleans School of Cooking) recently, and butter seemed to be the basis for every dish we cooked: from dark roux in our gator sauce piquante’, to the blonde roux in the Louisiana meat pies.
When the teacher of the class, chef Austin, asked the students to introduce themselves, I told him I was the skeptical cardiologist and I was there to evaluate New Orleans dishes for my patients.
Chef Austin didn’t think I would be recommending the dishes to my patients, but I heartily endorsed them ( See here and here).
I’m thankful that cholesterol is no longer considered by the Dietary Guidelines for Americans Committee (DGAC) a nutrient of concern.
However, there is a backlash from the vegans on this revelation: the weirdly named Physicians Committee for Responsible Medicine (PCRM’s goal seems to be elimination of all animal testing and consumption, not responsible medicine) has erected billboards in Texas targeting the chairman of the House Agriculture Committee (K Michael Conoway (R-TX)).
The final guidelines have yet to be issued, but I’m betting on the egg industry over the vegans on this one, despite the billboards.
I’m thankful that studies continue to come out showing coffee is not bad for you.
This study, for example, followed 90 thousand Japanese for 19 years and found that the more coffee you drink, the lower your risk of dying-from cardiac, respiratory and cerebrovascular disease. Those consuming 3-4 cups/day were 25% less likely to die than those who never drank coffee.
-I’m thankful that correlation does not equal causation.
This means that I don’t have to stop eating bacon or beef brisket (assuming I am insensitive to global sustainability concerns). On the other hand, that association between higher coffee consumption and lower risk of dying over 19 years doesn’t mean that drinking more coffee is actually lowering the risk; but it’s certainly not increasing it.
Finally, I’m thankful that moderate alcohol consumption is good for your heart and I raise a toast of gratitude to patient patients, readers and correspondents.
A year ago one of my patients began experiencing chest pain when he walked up hills. Subsequent evaluation revealed that atherosclerotic plaque (95% narrowing of a major coronary artery ) was severely reducing the blood flow to his heart muscle and was the cause of his chest pain. When this blockage was opened up with a stent he no longer had the pain.
Along with other medications (aspirin and plavix to keep his stent open) I had him start atorvastatin, the generic version of Lipitor, a powerful statin drug that has been shown to prevent progression of atherosclerotic plaque and thereby reduce subsequent heart attacks, strokes and death in patients like him
I saw him in the office the other day in follow up and he was feeling great . He asked me “Doc I read your post yesterday.s Since you say that cholesterol in the diet doesn’t matter anymore, does that mean I don’t have to take my cholesterol drug anymore.?”
His question gets at the heart of the “diet-heart hypothesis”. The concept that dietary modification, with reduction of cholesterol and fat consumption can reduce coronary heart disease.
The science supporting this hypothesis has never been strong but the concept was foisted on the American public and was widely believed. It was accepted I would say because it has a beautiful simplicity which can be summarized as follows:
“If you eat cholesterol and fat it will enter your blood stream and raise cholesterol levels. This excess cholesterol will then deposit in your arteries, creating fatty plaque , clogging them and leading to a heart attack.”
This concept was really easy to grasp and simplified the public health recommendations.
However, cholesterol blood levels are determined more by cholesterol synthesized in the liver and predicting how dietary modifications will effect these levels is not easy.
Since the public has had the diet-heart hypothesis fed to them for decades and given its beautiful simplicity it is hard to reverse this dogma. My patient’s question reflects a natural concern that if science/doctors got this crucial question so wrong, is everything we know about cholesterol treatment and heart disease wrong?
In other words, are doctors promoting a great cholesterol hoax?
Evidence Strongly Supports Statins in Secondary Prevention
For my patient the science supporting taking a cholesterol-lowering statin drug is very solid. There are multiple excellent studies showing that in patients with established coronary artery disease taking a statin drug substantially reduces their risk of heart attack and dying.
These studies are the kind that provide the most robust proof: randomized, prospective and blinded.
When cardiologists rate the strength of evidence for a certain treatment (as done for lifestyle intervention here) we use a system that categorizes the evidence as Level A, B, or C quality.
LeveleA quality (or strong) evidence consists of multiple,large, well-done, randomized trials such as exist for statins in patients with coronary heart disease.
Level B Evidence comes from a single randomized trial or nonrandomized studies.
Level C evidence is the weakest and comes from “consensus opinion of experts, case studies or standard of care.”
When treatment recommendations are based on Level C evidence they are often reversed as more solid data is obtained. Level A recommendations almost always hold up over time.
The level of evidence supporting restricting dietary cholesterol and fat to reduce heart attacks and strokes has always been at or below Level C and now it is clear that it is insufficient and should be taken out of guideline recommendations.
Evidence Strongly Supports Atherogenic Cholesterol is Related to Coronary Heart Disease
There are other lines of evidence that strongly support the concept that LDL cholesterol (bad cholesterol) or an atherogenic form of LDL cholesterol is strongly related to the development of atherosclerosis. If you are born with really high levels you are at very high risk for coronary heart disease, conversely if you are born with mutations that cause extremely low levels you are highly unlikely to get coronary heart disease.
Thus, the cholesterol hypothesis as it relates to heart disease is very much till intact although the diet-heart hypothesis is not.
Conflating the Diet-Heart Hypothesis and the Cholesterol Hypothesis
There is an abundance of misinformation on the internet that tries to conflate these two concepts. Sites with titles like “The Great Cholesterol Lie” , “The” Cholesterol Hoax”, The Cholesterol Scam” abound .
These sites proclaim that cholesterol is a vital component of cell membranes (it is) and that any attempt by diet or drugs to lower levels will result in severe side effects with no benefit
Doctors, according to these types of sites, in collusion with Big Pharma, have inflated the benefits of statin drugs and overlooked the side effects in the name of profit. Often, a “natural” alternative to statins is promoted. In all cases a book is promoted.
The Great Cholesterol Truths
It’s unfortunate that nutritional guidelines have promoted restriction of cholesterol and fat for so long. These guidelines (like most of nutritional science) were based on flawed observational studies. They should not have been made public policy without more consensus from the scientific community. The good news is that ultimately the truth prevails when enough good scientific studies are done.
It is right to question the flimsy foundation of nutritional recommendations on diet and heart disease but the evidence for statin benefits in patients with established coronary heart disease is rock solid.
Hopefully, the less long-winded explanation I provided my patient in the office will persuade him to keep on taking his atorvastatin pills while simultaneously allowing him to eat eggs, shrimp and full fat dairy without guilt.
After a week of trying to track my salt consumption I have learned two things
1. Tracking salt consumption (unless you make all your meals at home from scratch or buy from fast food restaurants) is very tedious.
2. My salt consumption is low: less than the 1.5 grams per day recommended by the American Heart Association (AHA) every day (unless I attend a Cardinals game)
After reviewing the latest scientific publications on salt, however, I have to think that for most people, it is not worth the effort to track daily salt consumption.
Yes , this is nutritional heresy and goes against what my patients have been reading from authoritative nutritional sources for decades.
The AHA 1.5 gram/day limit for all Americans comes from a small, short term (4 weeks) study (Sacks FM, Svetkey LP, Vollmer WM, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. N Engl J Med2001;344:3-10.)
The findings are not applicable to all Americans because more than 50% of participants in the DASH study had hypertension or prehypertension, more than 50% of participants were of African ancestry, potassium intake was markedly lower than in the general U.S. population, the trial involved only 412 persons, and a limited range of sodium intake was studied (1.5 to 3.3 g per day).
I asked most of my patients this week about their salt consumption. None of them could tell me what their average daily salt consumption was. However, almost to a man (or woman) they told me they had been consciously limiting their consumption of salt because they knew that this was healthy.
Thus, the 35 year old white woman with a blood pressure of 110/50 , palpitations and periodic dizzy spells is following the same recommendations to limit salt consumption as the 70 year old African-American with poorly controlled hypertension.
In the last few years this focus on lower salt consumption has been questioned after close analysis by the Institute of Medicine and the Cochrane Analysis.
Two articles in the prestigious New England journal of Medicine published a few weeks ago have convinced me that most individuals who are following a Mediterranean diet do not need to be concerned about their salt consumption.
Salt and Blood Pressure
In the first PURE study paper,(a prospective cohort study that included 101,945 people from five continents)
very few participants had an estimated sodium intake of less than 2.3 g per day, and almost none had an intake of less than 1.5 g per day. This suggests that, at present, human consumption of extremely low amounts of sodium for prolonged periods is rare.
The PURE Study looked at sodium excretion versus blood pressure and
found a steep slope for this association among study participants with sodium excretion of more than 5 g per day, a modest association among those with sodium excretion of 3 to 5 g per day, and no significant association among those with sodium excretion of less than 3 g per day.
This graph of data from the PURE study shows that lower levels of sodium excretion , below about 3 grams per day were associated with a higher risk of death.
Starting above about 5 grams per day the risk of death increased with increasing amounts of sodium excretion.
This is quite a shocker for those of us who have assumed for the last 20 years that the less salt we consumed the longer we would live.
Drawing less controversy were the findings from these two studies on potassium consumption. Higher levels of potassium consumption were associated with lower blood pressures and lower risk of death. The authors point out that high potassium intake may simply be a marker of healthy dietary patterns that are rich in potassium (e.g., high consumption of fruit and vegetables).
You can read more about these papers, including critical and positive comments at the heart.org here.
My Recommendations on Salt Consumption
Here is what I will be telling my patients about salt after a week of tracking my consumption and reading the relevant scientific literature.
Spend a day or two accurately tracking your consumption of salt to educate yourself. I found this app to be really helpful. I’ll expand on this in a future post.
Recognize that not everybody needs to follow a low salt diet. If your blood pressure is not elevated and you have no heart failure you don’t need to change your salt consumption.
If your blood pressure is on the low side and especially if you get periodic dizzy spells, often associated with standing quickly liberalize your salt intake, you will feel better.
If you have high blood pressure, you are the best judge of how salt effects your blood pressure. In the example I gave in a previous post, my patient realized that all the salt he was sprinkling on his tomatoes was the major factor causing his blood pressure to spike.
The kidneys do a great job of balancing sodium intake and sodium excretion if they are working normally. If you have kidney dysfunction you will be more sensitive to the effects of salt consumption on your blood pressure and fluid retention.
If you are following a Mediterranean diet with plenty of fresh fruits and vegetables you are going to be in the ideal range for both potassium and sodium consumption.
Public health experts are always seeking a “one size fits all” message to give the public. In the case of salt consumption, however, the message of less is better does not apply to all.
Most of my patients think tofu and soy protein are particularly heart healthy food choices. Since tofu contains significant calcium and protein, it is often viewed as a healthier alternative to dairy (which has inappropriately been labeled as heart unhealthy).
A huge growth in the use of soy protein occurred between 1996 and 2009 with annual sales of foods containing soy expanding from $1 billion to $4.5 billion. This appears to have been driven by a perception that soy is more healthful than other sources of protein (especially animal protein).
Much of the success of soy foods followed a 1999 decision by the FDA which approved a food-labeling health claim for soy protein for the prevention of coronary heart disease (CHD):
25 grams of soy protein a day, as part of a diet low in saturated fat and cholesterol, may reduce the risk of heart disease.
Does soy deserve this designation? Should we be purposefully trying to consume more soy to lower our risk of heart disease?
Early studies, which compared consumption of 25 grams of soy protein versus control protein consumption, suggested a slight reduction in total and bad cholesterol levels. The problem with these studies is that a flawed surrogate marker (cholesterol or bad cholesterol) is being studied in place of the real disease (atherosclerosis and its associated complications, including heart attack and stroke). We now know that dietary interventions or drug therapies that lower cholesterol don’t necessarily reduce heart attacks or prolong life.
In 2000, the AHA published a document supporting the concept that 50 grams of soy protein per day would reduce heart disease risk .
However the AHA reversed this recommendation in a 2006 publication finding that
In the majority of 22 randomized trials, isolated soy protein with isoflavones, as compared with milk or other proteins, decreased LDL cholesterol concentrations; the average effect was approximately 3%. This reduction is very small relative to the large amount of soy protein tested in these studies, averaging 50 g, about half the usual total daily protein intake. No significant effects on HDL cholesterol, triglycerides, lipoprotein(a), or blood pressure were evident. Among 19 studies of soy isoflavones, the average effect on LDL cholesterol and other lipid risk factors was nil. Soy protein and isoflavones have not been shown to lessen vasomotor symptoms of menopause, and results are mixed with regard to soy’s ability to slow postmenopausal bone loss. The efficacy and safety of soy isoflavones for preventing or treating cancer of the breast, endometrium, and prostate are not established; evidence from clinical trials is meager and cautionary with regard to a possible adverse effect. For this reason, use of isoflavone supplements in food or pills is not recommended. Thus, earlier research indicating that soy protein has clinically important favorable effects as compared with other proteins has not been confirmed.
There is no scientific evidence that consuming soy protein lowers your risk of heart disease. There is no evidence that substituting soy protein for animal protein lowers your risk of heart disease. Certainly, if you like tofu (does anyone really like tofu?) and/or you have a philosophical desire to avoid meat and dairy consumption, tofu can provide a lot of the protein and calcium that you cannot get from eating only vegetables.
What does the searching the Internet tell us about tofu?
A Google search on the health benefits of tofu reveals stridently negative and positive (allegedly evidence-based) articles (as is typical for everything in the world of nutrition). Medical News Today (“a leading health care internet publishing company,” which gets 9,000,00 views a month for unknown reasons), for example, has an overwhelmingly positive article written by a dietician which claims:
Countless studies have suggested that increasing consumption of plant-based foods like tofu, decreases the risk of obesity and overall mortality, diabetes, and heart disease and promotes a healthy complexion and hair, increased energy, and overall lower weight
The “Foundation for Integrative Medicine” (when you see the word “integrative” before the word “medicine,” substitute “unproven” and move to another website. This is a marker for quackery) cites similar claims, adding that regular tofu consumption reduces breast and lung cancer and osteoporosis.
None of these claims are supported in the medical literature.
On the anti-tofu side, we have this blog post from a chiropractor (chiropractors are usually big advocates of “integrative” medicine) who finds unfermented soy consumption to be the cause of myriad health problems including:
Immune system impairment
Severe, and potentially fatal food allergies
Danger during pregnancy and nursing
None of these claims are supported by the medical literature
You can also read about why soy “May be a health risk and environmental Nightmare” here. The majority of soy grown in the US comes from genetically modified plants from Monsanto which have had a gene inserted that allows them to resist Roundup. Consequently, farmers can spray all the Roundup they want on the plants.
Nobody knows if this is a health risk or not. Monsanto likes to make the case that the overall effects of RoundupReady soy, as they like to call it, are positive, whereas Mother Jones writes that soy is “Scarier Than You Think”.
My bottom line recommendation on soy is that, like all other foods, we should try to consume it in its least industrially processed form as part of a balanced diet of real foods.
There is no scientifically proven reason to avoid it or seek it out.
A number of readers of The Skeptical Cardiologist have pointed out to me that Time Magazine’s latest issue has a picture of butter on the cover with the headline “Eat Butter. Scientists labeled fat the enemy. Why they were wrong.”
The lead article summarizes a lot of the evidence I have been writing about which suggests that saturated fat has been inappropriately vilified (here) and that added sugar and processed food may be the real root cause of the obesity epidemic (here).
It is well-written and reasonably balanced and has some catchy graphics. It doesn’t really specifically address issues with dairy fat or butter as the title implies. I have defended high fat dairy in numerous posts over the past two years.
Hopefully this article in a well-respected mainstream newsmagazine will help correct the misinformation about diet and nutrition that has become entrenched in the consciousness of Americans.
Ah Cheese. A most wondrous and diverse real food. Of the thousands of delightful varieties, let us consider Wensleydale, the 33rd type of cheese requested by John Cleese of Ye Olde Cheese Emporium proprietor, Henry Wensleydale (Purveyor of Fine Cheese to the Gentry and the Poverty Stricken Too) in the Monty Python sketch, Cheese Shop.
The cheese I have in front of me from Wensleydale creamery (which owes its continued existence to being the favorite cheese of Wallace (of Wallace and Gromit fame)) lists the following ingredients:
pasteurized cow’s milk
annato (a natural coloring that gives cheese and other foods a bright orange hue. It comes from the Bixa orellana, a tropical plant commonly known as achiote or lipstick tree (from one of its uses))
Other than annato, the above ingredients are components of all cheese and signify that it is a non processed, nonindustrial product.
A 1 oz serving of this cheese (28 grams), like cheddar cheese (“the single most popular cheese in the world”), provides 110 calories, 80 of which are from fat (9 grams total fat, 6 grams saturated fat), 25 grams of cholesterol, 170 mg of salt and around 200 mg of calcium.
For the last 40 years, Americans have been mistakenly advised that all saturated fat in the food is bad and contributes to heart disease. Since cheese contains such a high proportion of saturated fat, it has also been targeted. Dietary recommendations suggest limiting real cheese consumption and switching to low-fat cheese.
This concept is not supported by any recent analysis of data, and as I’ve pointed out in a previous post, saturated fat does not contribute to obesity, nor is it clearly associated with increased heart disease risk. There are many different saturated fats and they have varying effects on putative causes of heart disease such as bad/good cholesterol and inflammation. In addition, the milieu in which the fats are consumed plays a huge role in how they effect the body.
Cheese vary widely in taste, texture and color and the final ingredients depend on a host of different factors including:
the type of animal milk used
the the diet of the animal
the amount of butterfat
whether the product is pasteurized or not
the strain of bacteria active in the cheese
the strain of mold active in the cheese
As a result the bioactive ingredients in cheese will vary from type to type.
Recent scientific reviews of the topic note that dairy products such as cheese do not exert the negative effects on blood lipids as predicted solely by the content of saturated fat. Calcium and other bioactive components may modify the effects on LDL cholesterol and triglycerides.
In addition, we now know that the effect of diet on a single biomarker is insufficient evidence to assess CAD risk; a combination of multiple biomarkers and epidemiologic evidence using clinical endpoints is needed to substantiate the effects of diet on CAD risk.
Some points to consider in why dairy and cheese in particular are healthy:
Blood pressure lowering effects. Calcium is thought to be one of the main nutrients responsible for the impact of dairy products on blood pressure. Other minerals such as magnesium, phosphate and potassium may also play a role. Casein and whey proteins are a rich source of specific bioactive peptides that have an angiotensin-I-converting enzyme inhibitory effect, a key process in blood pressure control. Studies have also suggested that certain peptides derived from milk proteins may modulate endothelin-1 release by endothelial cells, thereby partly explaining the anti-hypertensive effect of milk proteins.
Inflammation and oxidative stress reduction. These are key factors in the development of atherosclerosis and subsequent heart disease and stroke. Recent animal and human studies suggest that dairy components including calcium and or its unique proteins, the peptides they release, the phospholipids associated with milk fat or the stimulation of HDL by lipids themselves, may suppress adipose tissue oxidative and inflammatory response.
Government and health organization nutritional guidelines have had a huge and harmful impact on what the food industry presents to Americans to eat. The emphasis on reducing animal fats in food led to the creation of foods laden with processed vegetable oils containing harmful trans-fatty acids. This mistake has been recognized and corrected, but the overall unsupported concept of replacing naturally occurring saturated fats with processed carbohydrates and sugar is ongoing and arguably the root of the obesity epidemic in America.
Converting mistaken nutritional guidelines into law
The USDA in 2012 following an act of Congress stimulated by Michelle Obama, changed the standards for the national school lunch and breakfast guidelines, for the first time in 15 years.
The law was intended to increase consumption of fruits, vegetables, whole grains and promote the consumption of low-fat or nonfat milk. It seemed like a good idea and likely to counter increasing obesity in children. However, the original recommendations were modified by Congress, due to heavy food industry lobbying, to allow the small amount of tomato paste in pizza to qualify as a vegetable.
Unfortunately, the food industry has responded by providing products which meet the government’s criteria for healthy lunches, but in actuality are less healthy.
Dominos Pizza, as a recent New York Times article pointed out, is now providing a specially modified pizza to schools which is unavailable in their regular stores. Their so-called “Revolution in School Pizza” is a…
line of delicious, nutritious pizzas created specifically for schools delivered hot and fresh from your local Domino’s Pizza store. Domino’s Pizza Smart Slice is the nutritious food that kids will actually EAT and LOVE!
This pizza, in contrast to the pizza sold in Domino’s stores, utilizes a “lite” Mozarella cheese to cut fat content, a pepperoni with lower sodium and fat content, and a crust that contains 51% whole grain flour.
This “smart slice” replaces dairy fat with carbohydrates; there is no evidence that this will improve obesity rate or reduce heart disease In fact, this change may lead to less satiety and a tendency for the children to want to snack on further carbohydrate or sugar-laden products when they get home. Furthermore, as critics have suggested, it may promote the consumption of “unhealthy” versions of pizza that are sold in stores.
If we are going to make laws that promote healthy eating, we have to be absolutely certain that they are supported by scientific evidence. These School Lunch Program Standards are an example of how getting the science wrong or getting ahead of the science can lead to worse outcomes than if there were no laws regulating school diets.
Hopefully, you will continue to consume real full-fat cheese without concerns that cheese is “artery-clogging” and you will be more successful in obtaining the “fermented curd” than John Cleese’s Mr. Mousebender was below:
The skeptical cardiologist participated in the Pedaler’s Jamboree this Memorial Day weekend. This is an annual bicycling/music festival centered around a 30 mile bike ride from Columbia to Boonville, MO along the KT trail as it tracks the Missouri River. It ends at Kemper Park in Boonville with a concert and campout (the highlight of which for me was SHEL)
At various stops along the way we were treated to excellent roots/blues/folk
music. Our favorite moment was listening to an awesome duo from Fort Wayne, Indiana, the White Trash Blues Revival, in a downpour at the McBaine stop. The lead singer/guitarist played a home-made lap steel (made from a skate board and a Red Stripe beer bottle) and the drummer played trash cans, a beer keg and a cardboard box with outstanding results.
During the day, I observed thousands of my fellow pedalers consuming hot dogs and bratwursts at the various stops. In America, during Memorial Day weekend, several million brats and dogs will be consumed which made me ponder: is this increasing Americans’ risk of dying from heart disease?
US dietary-guidelines recommend “eating less” red and processed meat. For cardiovascular disease, these recommendations are based largely on expected effects on blood cholesterol of saturated fat and dietary cholesterol in meats. However, multiple recent published analyses have found no relationships of meat intake with cardiometabolic disease outcomes, including coronary heart disease (CHD), stroke, and diabetes.
This is a really important fact to know when making food choices, so I’m going to highlight it and repeat it:
Scientific studies do not show an association between unprocessed red meat consumption and cardiovascular disease.
“Red meat” is usually defined as unprocessed meat from beef, hamburgers, lamb, pork, or game, and excludes poultry, fish, or eggs.
“Processed meat” is any meat preserved by smoking, curing or salting, or addition of chemical preservatives, such as bacon, salami, sausages, hot dogs, or processed deli or luncheon meats, excluding fish or eggs.
A 2010 meta-analysis of American studies on this showed no increased risk of coronary heart disease for the highest consumers of unprocessed meat versus the lowest.
On the other hand, each serving per day of processed meat was associated with a 42% higher risk of coronary heart disease. Restricted to US studies, each serving per day was associated with 53% higher risk of diabetes.
A recent European study of 448,000 people found no association between unprocessed red meat consumption and mortality. For processed meats, there was an 18% higher risk of death per 50 gm/day serving.
Scientists really don’t know what it is about processed red meat that makes it associated with higher mortality.
As the table below indicates, the amount of saturated fat and cholesterol is not higher, so that does not appear to be the cause.
Because sodium nitrite is used to cure most processed meats, processed meats have about 4 times the amount of sodium as red meats.
High dietary sodium intake significantly increases blood pressure. Habitual consumption may also worsen arterial compliance and promote vascular stiffness, so It’s possible this is a factor.
Nitrate and nitrite levels are about 40% higher in processed meats and this has been suggested as a contributor to higher CVD and cancer rates.
However, 80-95% of dietary nitrates come from vegetables sources and a very significant source of nitrites is the breakdown of nitrates to nitrites by bacteria in saliva. Recent studies suggest that the blood pressure lowering effect of vegetables may be mediated by their nitrate content.
At present, it seems that dietary nitrite and nitrate have cardiovascular protective effects. … the effects of nitrite and nitrate to enhance NO bioavailability, to improve endothelial function, to cause vasodilation, and to inhibit platelet aggregation may at least partly mediate their cardiovascular beneficial effects. … Taking the data presented above together with the failure of recent studies to show significant correlation between nitrite and nitrate exposure and cancer, we suggest that the benefits of dietary nitrite and nitrate will strongly outweigh any potential risks, particularly for cardiovascular disease patients.
So, there is a signal from observational data that processed meats may increase cardiovascular disease and death, but exactly which ones might be the culprits and how this might work is entirely unclear. I’m still consuming brats, sausages, and hot dogs on occasion. Riding a bike, listening to music and drinking beer is a fine occasion for that.
I would advise the following
Don’t worry about nitrates/nitrites in processed meats. Science has not determined whether this is good or bad for you. Brands of bacon/sausage that claim no nitrates/nitrites are often using “natural” forms of nitrates that come from sources such as celery powder or sea salt.
Processed meats contain a lot of salt. Your body likely senses that and cuts back on salt consumption in other food choices during the day, especially if you indulge moderately. If you eat too much, too often, you put yourself at risk for high blood pressure and its attendant consequences. What is “too much” is uncertain, but the higher rates of heart disease and death don’t really seem to kick in until you eat the equivalent of greater than 80 grams per day.
Personally, I choose sustainably, humanely, “naturally” and locally raised processed meats whenever possible but there is no evidence-based medicine supporting this choice.