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.
The father of the eternal fiancee’ of the skeptical cardiologist (FOEFOSC, let’s call him “Geo”) is a typical 61 year old white male. A year ago his primary care physician informed him that he needed to start taking a statin drug because his cholesterol was high. The note accompanying this recommendation also stated “work harder on diet and exercise to get LDL<130.” No particulars on how to change his current diet and exercise program were provided.
Neither of Geo’s parents and none of his siblings have had heart problems at an early age and Geo is very active without any symptoms. His diet is reasonably free of processed food and added sugar, he is not overweight and his blood pressures are fine. Due to concern about side effects he had read about on the internet and because he doesn’t like taking medications , Geo balked at taking the recommended statin,
Reluctance to start a new and likely life-long drug is understandable especially when combined with a constant stream of internet-based bashing of statins.
My advice was sought and I suggested a few things that would be helpful in making a more informed decision:
As I’ve pointed out before (here), the vast majority of men over the age of 60 move into a 10 year risk category >7.5%, no matter how great their lifestyle is, and Geo was no exception with a risk of 8.4%. His total cholesterol was 249, LDL (bad) 154, HDL (good) 72 and triglycerides 116.
The vascular ultrasound showed below normal carotid thickness and no plaque and his coronary calcium score was 18, putting him at the 63rd percentile. This is slightly higher than average white men his age.
When Geo presented these findings to his PCP, he seemed unaware of the ASCVD risk estimator (recommended by AHA/ACC guidelines first published in 2013), which no longer suggests LDL levels as goals. His PCP also seemed miffed that he had gotten the coronary calcium scan. Geo felt like the PCP’s attitude was “shut up and do what I tell you.”
Geo’s PCP’s approach exemplifies a not-uncommon traditional doctor-patient relationship, but a better approach is shared decision-making (see here). Geo, like many patients, welcomes more information on the risks and benefits of any recommended treatment so that he can participate in deciding the best course of action.
By giving patients more information on the risks, side effects, and benefits of the statin drugs along with a better understanding of their overall risk of heart disease and stroke, we can hopefully move more patients “off the fence” and onto the most appropriate treatment.
Stay tuned to find out what The Skeptical Cardiologist Recommended for Geo.
If you’d like to read the recently published recommendations of the US Preventive Services Task Force on statins for primary prevention of cardiovascular disease see here. Importantly this panel of unbiased experts concluded that statin therapy significantly reduced overall mortality and cardiovascular mortality. In addition, the review found no increased risk of diabetes overall with statin therapy. The only trial that identified an increased risk was using high intensity statin therapy (Crestor (rosuvastatin) >20 mg).
And, since the internet is jammed with people who believe statins robbed them of their brain power, I would advise noting that the writers concluded “These findings are consistent with those from a recent systematic review of randomized trials and observational studies that found no adverse associations of statins with incidence of Alzheimer disease, dementia, or decreased scores on tests of cognitive performance.”
When someone who had appeared to be healthy dies suddenly, it is often assumed that he/she died of “a massive heart attack.” Certainly, this was the case in the recent unexpected sudden death of Garry Shandling, the actor and comedian. Shandling, aged 66, died March 24 of this year.
ET online reported:
“His publicist Alan Nierob told the ET that Shandling had no history of heart problems, but that doctors believe he died as the result of a heart attack.”
Although a heart attack resulting in ventricular fibrillation is the most common cause of a sudden, unexpected death in individuals over the age of 40, it is not the only one.
In fact, People magazine reported that Sanders experienced shortness of breath and pain in his legs just a day before his death, and that he spoke to a doctor friend about his symptoms, who stopped by that night to check on him,
Shortness of breath and pain in the legs raise the possibility of a clot or DVT in the leg, which can break loose and embolize into the pulmonary arteries. Such a pulmonary embolism, if massive, can result in swift and sudden death.
The LA Coroner’s office could not get Sanders’ physician to sign his death certificate and the cause of death has still apparently not been determined, pending toxicology testing which typically takes 6 weeks.
What’s On Your Parent’s Death Certificate
More important than what is on Garry Shandling’s death certificate is what is on your parent’s death certificate, and whether it is accurate. If one of your parents died prematurely and suddenly, it is important to know with precision what caused it. If the cause was an heritable cardiovascular condition, hopefully, appropriate testing can determine if you have that condition, and steps can be taken to prevent your premature demise.
Examples of inherited cardiovascular conditions (in addition to heart attack (myocardial infarction) or pulmonary embolism) that can cause sudden and unexpected death include aortic aneurysm dissection, hypertrophic cardiomyopathy, arrhythmogenic right ventricular dysplasis, and long QT syndrome.
Unfortunately I find that, at least in my patients, uncertainty about the cause of death of one’s parents is the norm.
Many of my patients, for example, tell me one of their parents died of a “massive heart attack” and they assume that they are at increased risk of the same fate. When I press for details, typically no autopsy was performed. Mom or dad may have been found dead at home, or they may have suddenly keeled over but not survived to make it to the hospital for a definitive diagnosis.
Without an autopsy in such circumstances, it is not possible to be sure of the cause of death.
Even if you have a cause of death listed on your parent’s death certificate, there is no guarantee that it is accurate. The doctor that filled it out, without an autopsy in many circumstances, is just speculating on the cause based on what he/she knew about prior medical conditions and the circumstances surrounding the death.
I was recently asked to fill out the death certificate of an elderly patient of mine who had atrial fibrillation and congestive heart failure and was living in a nursing home.
One night she was noted by the staff to be very short of breath and was taken to a local emergency room where she was pronounced dead.
Based on the information available to me, I had no idea what caused her death. Although she had quite signifiant cardiac problems, when I last saw her she was stable and I have numerous patients with the same conditions who live for decades.
I filled out the death certificate, listing all of her conditions, and entered in that the cause of death was unknown.
Although the CDC guide for physicians filling out death certificates clearly states that this is acceptable, I was subsequently informed that the funeral home did not accept unknown cause of death and that they had found another doctor to fill in a cause of death.
I guarantee you, whatever he put on as the cause of death was total speculation.
Shandling mentions “I had hyperparathyroidism,” making a joke that “the symptoms are so much like being an older Jewish man, no one noticed!”
James Fallows, the excellent The Atlantic writer, highlights his own experience with hyperparathyroidism (a disease that leads to high calcium levels and is easily treated with surgery), in a recent Atlantic article. The subtitle of this article, “a rare and under-publicized condition that can sometimes be fatal,” suggests that hyperhyperparathyroidism might have led to Shandling’s death.
I don’t think this is likely because Shandling suggests that the disease is in the past tense (i.e. he has already had the surgery), and sudden death from hyperparathyroidism would be extremely unlikely.
Fortunately, Shandling is getting a full examination and autopsy to fully determine the cause of his death. If he has offspring, this will be extremely helpful to them in understanding what medical conditions they can expect later in life.
If he was not a celebrity, his death, like many of your parents’, most likely would have been ascribed to a “massive heart attack.”
The skeptical cardiologist stopped writing new prescriptions for niacin extended release tablets in 2011. For any patient who was taking niacin, I recommended stopping it.
Because niacin had favorable effects on the cholesterol profile, physicians had been utilizing it for many years in high risk patients on statins who had low HDL (good cholesterol) and/or high triglycerides.
The rationale was that, since high HDL was associated with lower risk of heart attacks, raising the HDL would lower that risk. Similarly, lowering the triglycerides would improve cardiovascular risks.
While niacin certainly improved the cholesterol profile, there was no good evidence that starting it in a patient already on statin would improve cardiovascular outcomes. The cholesterol profile is a surrogate endpoint: the actual treatment goal is reducing cardiovascular disease.
In 2011, the AIM-HIGH study proved there was no benefit to adding niacin to good statin therapy despite increasing HDL from 35 to 42 mg/dl, lowering triglycerides and lowering LDL. This and other studies showing no benefit of niacin therapy (and worrisome adverse effects) should have resulted in the total cessation of niacin prescriptions, especially in patients on statins.
Unfortunately, old habits die hard amongst physicians, and the allure of raising HDL and lowering triglycerides with niacin persisted despite a lack of evidence of any benefit in lowering cardiovacular risk.
Yesterday, the FDA announced it was removing from the market two drugs made by Abbvie, Advicor and Simcor, which are combinations of extended release niacin plus lovastatin or simvastatin, and removed its approved indication for niacin ER plus statin for lowering CHD risk stating:
“Based on the collective evidence from several large cardiovascular outcome trials (Refs. 1-3), the Agency has concluded that the totality of the scientific evidence no longer supports the conclusion that a drug-induced reduction in triglyceride levels and/or increase in HDL-cholesterol levels in statin-treated patients results in a reduction in the risk of cardiovascular events. Consistent with this conclusion, FDA has determined that the benefits of niacin ER tablets and fenofibric acid DR capsules for coadministration with statins no longer outweigh the risks, and the approvals for this indication should be withdrawn.”
This is good news for patients whose physicians were keeping them on the unproven brand name combination drugs, Advicor and Simcor.
There are still legitimate uses of niacin to prevent vitamin deficiencies but If you are still taking some form of niacin ER for the purpose of preventing heart disease with or without a statin I recommend presenting your doctor with the link to the FDA pronouncement above and having a good discussion with him about the rationale for staying on it.
The other drug mentioned in the announcement, fenofibric acid, is far less often prescribed and is not available as a combination. It is the most effective drug we have for extremely high triglyceride levels over 500 mg/dl which can cause pancreatitis. I have a few patients on the generic fenofibric acid strictly for the purpose of lowering their dangerously high triglycerides but not for the indication of lowering their cardiovascular risk.
Dr. Peter(Fritz) Kunz, a plastic surgeon, and his wife Jane, began selling milk from their farm after researching methods for rotational grazing , a process which allows the cows to be self-sustaining: the cows feed themselves by eating the grass and in turn help fertilize the fields, . After a few years of making sure they had the right grasses and cows, the Kunz’s opened Traders Point Creamery in 2003.
Two more studies (summarized nicely on ConscienHealth, an obesity and health blog) came out recently solidifying the extensive data supporting the health of dairy fat and challenging the nutritional dogma that all Americans should be consuming low-fat as opposed to full fat dairy.
The Dairy Industry’s Dirty Little Secret
Dr. Kunz opened my eyes to the dirty little secret of the dairy industry when i first talked to him: dairy farmers double their income by allowing milk to be split into its fat and non-fat portions therefore the industry has no motivation to promote full fat dairy over nonfat dairy.
Recently, I presented him with a few follow-up questions to help me understand why we can’t reverse the bad nutritional advice to consume low-fat dairy.
Skeptical Cardiologist: “When we first spoke and I was beginning my investigation into dairy fat and cardiovascular disease you told me that most dairy producers are fine with the promotion of non fat or low fat dairy products because if consumers are choosing low fat or skim dairy this allows the dairy producer to profit from the skim milk production as well as the dairy fat that is separated and sold for butter, cheese or cream products.”
I don’t have a clear idea of what the economics of this are. Do you think this, for example, doubles the profitability of a dairy?
Dr. Kunz: “Yes, clearly. Butter, sour cream, and ice cream are highly profitable products… All these processes leave a lot of skim milk to deal with, and the best opportunity to sell skim milk is to diet-conscious and heart-conscious people who believe fat is bad.”
Skeptical Cardiologist:” I’ve been baffled by public health recommendations to consume low fat dairy as the science would suggest the opposite. The only reason I can see that this persists is that the Dairy Industry Lobby , for the reason I pointed out above, actually has a vested interest from a profitability standpoint in lobbying for the low fat dairy consumption.. Do you agree that this is what is going on? ”
Dr. Kunz: “Yes, definitely. The obsession with low-fat as it relates to diet and cardiac health has been very cleverly marketed. Fat does NOT make you fat.
Skeptical Cardiologist: “Also, I have had trouble finding out the process of production of skim milk. I’ve come across sites claiming that the process involves injection of various chemical agents but I can’t seem to find a reliable reference source on this. Do you have any information/undestanding of this process and what the down sides might be? I would like to be able to portray skim milk as a “processed food” which, more and more, we seem to be recognizing as bad for us.”
Dr. Kunz:“The PMO pasteurized milk ordinance states that when you remove fat you have to replace the fat soluble vitamins A & D. Apparently the Vitamin A & D have to be stabilized with a chemical compound to keep them miscible in basically an aqueous solution. The compound apparently contains MSG!! We were shocked to find this out and it further confirmed that we did not want to do a reduced fat or skim milk product.”
Skeptical Cardiologist: ” Any thoughts on A2? Marion Nestle’, of Food Politics fame, was recently in Australia where there is a company promoting A2 milk as likely to cause GI upset. It has captured a significant share of the Aussie market.”
Dr. Kunz: “We have heard of this and have directed our farm to test and replace any A1 heterozygous or homozygous cows. We believe that very few of our herd would have A1 genetics because of the advantage of using heritage breeds like Brown Swiss and Jersey instead of Holstein. Because few people are actually tested for lactose intolerance and because of the marketing of A2, it’s imperative not to be left behind in this – whether or not it turns out to be a true and accurate cause of people’s GI upset.
Skeptical Cardiologist:” I like that your milk is nonhomogenized. Seems like the less “processing” the better for food. I haven’t found any compelling scientific reasons to recommend it to my patients, however. Do you have any?”
Dr. Kunz: Theliterature is fairly old on this subject, but xanthine oxidase apparently can become encapsulated in the fat globules and it can be absorbed into the vascular tree and cause vascular injury. I will look for the articles. Anyway, taking your milk and subjecting it to 3000-5000 psi (homogenization conditions) certainly causes damage to the delicate proteins and even the less delicate fat globules. Also remember that dietary cholesterol is not bad but oxidized cholesterol is very bad for you. That’s why overcooking egg yolks and high pressure spray drying to make powder products can be very dangerous – like whey protein powders that may contain some fats.
Skeptical Cardiologist: I spend a fair amount of time traveling in Europe and am always amazed that their milk is ultrapasteurized and sits unrefrigerated on the shelves. any thoughts on that process versus regular pasteurization and on pasteurization in general and its effects on nutritional value of dairy.
Dr. Kunz :“Absolutely crazy bad and nutritionally empty.. don’t know why anyone would buy it. The procedure is known as aseptic pasteurization and is how Nestle makes its wonderful Nesquik. If they made a full fat version of an aseptically pasteurized product it may have more oxidized cholesterol and be more harmful than no fat!!”
So there you have it, Straight from the doctor dairy farmer’s mouth:
Skimming the healthy dairy fat out of milk is a highly profitable process. Somehow, without a shred of scientific support, the dairy industry, in cahoots with misguided and close-minded nutritionists, has convinced the populace that this ultra-processed skim milk pumped full of factory-produced synthetic vitamins is healthier than the original product.
The two recent articles supporting full fat dairy are:
which concluded ‘In two prospective cohorts, higher plasma dairy fatty acid concentrations were associated with lower incident diabetes. Results were similar for erythrocyte 17:0. Our findings highlight need to better understand potential health effects of dairy fat; and dietary and metabolic determinants of these fatty acids
When individuals discover that they have abnormal cholesterol readings they are often told to initiate lifestyle changes to try to correct them.
Based on what physicians and patients have been taught over the last twenty years, the likely dietary change recommended and the easy , first step is likely to be to cut back on dairy fat.
After all, it’s a pretty easy transition to start using skim milk and non fat yogurt because these line the supermarket shelves and have been filled with chocolate or added sugar to taste more palatable.
You might miss the great taste that butter adds to bread or cooking but for your health you would be willing to switch to non butter spreads and cut down on the cheese in your diet because based on what you have heard from numerous media sources this is a giant step toward reducing your cholesterol numbers.
Unfortunately, it is a horribly misguided step.
Although, the switch to low or non fat dairy lowers your cholesterol numbers, it is not lower cholesterol numbers that you want: what you want is a lower risk of developing stroke or heart attack or the other complications of atherosclerosis.
Let me repeat: Don’t worry about your cholesterol numbers, worry about your overall risk of developing heart attack or stroke.
Due to 30 years of misinformation, the concept that lowering your cholesterol means lower risk of heart disease has become firmly entrenched in the public’s consciousness-but in the case of dietary intervention this has never been documented.
I take care of a 69 year old woman who has an abnormal heart rhythm and chest pain. As part of her evaluation for chest pain we performed a coronary CT angiogram (CCTA) which showed advanced but not obstructive atherosclerotic plaque in her right and left anterior descending coronary arteries.
This lady was not overweight, followed a healthy diet and exercised regularly. Her mother, a sedentary, heavy smoker, suffered a heart attack at age 54.
Her PCP had obtained lipid values on her 6 months before I saw her which were abnormal but the patient had been reluctant to start the recommended statin drug because of concerns about side effects.
After seeing her CCTA I advised that she begin atorvastastin 10 mg daily and aspirin to help reduce her long term risk of heart attack, stroke.
She decided without telling me not to take the statin, again due to side effect concerns, but started the aspirin, and began to pursue what she felt were healthy dietary changes.
When I saw her back in the office she told me “I don’t eat butter or cheese anymore and I’ve switched to skim milk.” She had substituted olive oil for butter.
Here are her lipid values before and after her dietary changes (TC=total cholesterol, LDL= bad cholesterol, HDL=good cholesterol, trigs=triglycerides)
Date TC LDL HDL trigs ASCVd 10 year risk
3/2015 275 173 72 149 7.9%
10/2015 220 122 43 274 8.3%
At first glance, and especially if we focus only on the total and bad cholesterol, this appears to be a successful response to dietary changes: a 29% reduction in the bad cholesterol and a 25% drop in the total cholesterol.
However, although the LDL or bad cholesterol has dropped a lot, the HDL or good cholesterol has dropped by more: 40%!
This is the typical change when patients cut out dairy fat-the overall ratio of bad to good cholesterol actually rises.
In addition, the pattern she has now, with a low HDL and high triglycerides is typical of the metabolic syndrome which is recognized as likely to contribute to early atherosclerosis: so-called “atherogenic dyslipidemia.”
When I plugged both sets of numbers into the ASCVD 10 year risk calculator app (see here) her estimated 10 year risk of heart attack and stroke had actually increased from 7.9% to 8.3%.
Hopefully, this anecdote will reinforce what population studies show:
There is NO evidence that dairy fat consumption increases risk of cardiovascular disease (see here)
Finally, my patient is another example of an inherited tendency to development of premature atherosclerosis: her diet, exercise, body weight were all optimal and could not be tweaked to lower her risk.
Such patients must deal with the cardiovascular cards they have been dealt. If they have advanced atherosclerosis, as much as they may dislike taking medications, statins are by far the most effective means of reducing their long term risk of heart attack and stroke.
Worldwide, however, as this cool graphic demonstrates (interactive at the Economist) tea dominates over coffee in lots of places.
Tea in general and particularly green tea is perceived by many to be incredibly healthy: fighting cancer, dementia, obesity and heart disease. But is this perception justified?
The Green Tea Superfood Hype
If you Google search the health benefits of green tea you might conclude that it is a panacea for all that ails modern civilization. However, bad nutritional advice is the norm on the internet and even websites like Web MD, which you might consider to be reliable, spread inaccurate, misleading and poorly researched information regularly.
“Green tea is so good for you that it’s even got some researchers raving.“It’s the healthiest thing I can think of to drink,” says Christopher Ochner, PhD. He’s a research scientist in nutrition at the Icahn School of Medicine at Mount Sinai Hospital.”
Who is Chris Ochner and why is he “raving” about the health benefits of green tea you might ask? That’s certainly what I wanted to know, particularly since this same quote or variations on it are all over the internet on sites like “Herbal Republic” which ups the green tea ante with the title “”Green Tea is Beyond a Superfood”-Dr. Christopher Ochner” (by the way, any source of nutritional information that uses the term superfood should be considered bogus.)
Although no source is provided for this quote from Dr. Ochner, there is a Christopher Ochner, Ph.D listed on the Icahn Medical School Staff. His Ph. D. is in psychology and he works in the areas of adolescent obesity (perhaps he pushes green tea on his obese adolescents). I can find no publications by him on the topic of green tea and no evidence that he made these comments. I have sent him an email asking for clarification and edification.
The website, juicing for health.com lists “5 scientifically proven reasons to drink green tea” (by the way, I consider articles with headlines that start with a number, i.e. “3 health foods that are actually killing you from the inside”, “5 veggies that kill stomach fat”, and “35 celebs who’ve aged horribly” are worthless and should be ignored and avoided at all costs)
Green Tea and Catechins: Magical Weight Loss elixir?
It’s hard to find good studies on green tea that aren’t somehow funded by the tea, nutraceutical or food industry. For example, one “S Wolfram” has written extensively on the benefits of green tea in marginal scientific journals. He works for DSM Nutritional Products, LTd., a Swiss food conglomerate.(“DSM Nutritional Products is the world’s largest nutritional ingredient supplier to producers of foods, beverages, dietary supplements, feed and personal care products” says one DSM PR release”).
DSM developed a highly concentrated extract of a catechin called Epigallocatechin Gallate (EGCG) in green tea that had been identified as having potential health benefits for humans.
In one recent “review” Wolfram wrote in somewhat vague but highly optimistic terms
“Dose-response relationships observed in several epidemiological studies have indicated that pronounced cardiovascular and metabolic health benefits can be obtained by regular consumption of 5-6 or more cups of green tea per day. Furthermore, intervention studies using similar amounts of green tea, containing 200-300 mg of EGCG, have demonstrated its usefulness for maintaining cardiovascular and metabolic health. Additionally, there are numerous in vivo studies demonstrating that green tea and EGCG exert cardiovascular and metabolic benefits in these model systems.”
I’m not sure what “model systems” he is referring to but it is certainly not humans. He may be talking about rodents, because in 2005 Wolfram published a paper entitled:
“TEAVIGO (epigallocatechin gallate) supplementation prevents obesity in rodents by reducing adipose tissue mass”
In the conclusions of this “landmark” study performed in mice and rats he wrote
“Thus, dietary supplementation with EGCG should be considered as a valuable natural treatment option for obesity.”
Voila! From a few experiments in rodents and a few short-term, small studies in humans performed by heavily biased scientists, DSM’s version of EGCG emerged as a leading nutraceutical (I prefer the term, snakeoil) and now you can buy this online from a host of bogus supplement/nutraceutical sites as Teavigo.
The production and marketing of TeaVigo is a classic example of how the cynical food/supplement/nutraceutical industry creates a product that has a thin veneer of scientific credibility for health promotion but is considered “natural” (despite being manufactured)
and therefore appeals to Americans who are seeking “natural” ways to prevent or treat the common chronic diseases of Western civilization.
Because there is no good scientific evidence supporting a role for green tea extracts or ECGC in preventing any specific disease, there is no FDA scrutiny of
the drug for efficacy and safety. This is fine for nutraceutical manufacturers as they have been granted the ability to sell their useless products without any regulatory or FDA approval.
Companies like DSM avoid making any specific health claims for their supplements (such as this drug reduces your chances of having a heart attack or stroke) because the FDA can then go after them.
“Green tea has long been used for health benefits and Teavigo® is the purest and most natural form of the most active substance in green tea – Epigallocatechin Gallate (EGCG). EGCG contains potent natural antioxidants and efficient free-radical scavengers (free radicals being the highly reactive compounds that cause cellular damage).
Notice the key marketing buzzwords in this statement
Who wouldn’t want to take a pill that is pure and natural and full of those wonderful antioxidants that stop those nasty free-radicals from causing cellular damage?
Unfortunately, any time a proposed powerful “anti-oxidant” ( b-carotene, vitamin E, vitamin C, selenium, retinol, zinc, riboflavin, and molybdenum ) has been studied in a well done scientific trial for prevention of cancer or cardiovascular disease it has failed.
We don’ know if this is because the wrong anti-oxidants have been chosen (for example in green tea there are hundreds of potential beneficial chemicals) or because extracting a single chemical from its milieu in a complex food/beverage makes it inactive or if the whole idea of stopping free-radical damage is misguided.
Why take the time to actually brew and drink green tea the website points out after all:
“To get the optimal benefits from ordinary green tea would take an intake of four to eight cups of green tea a day. With Teavigo® you get the same pure, natural and healthy effects, with more convenience and without the caffeine.”
Finally, consumers of Teavigo can be reassured because it is produced using
“A patented and unique production process with constant product quality”
Let me see here, Teavigo is natural but it is made by a “production process” with “constant product quality”. Isn’t natural production process an oxymoron?
I have asked the Teavigo people to tell me their “production process” but so far I’ve gotten no response. Your guess is as good as mine as to what chemicals or other potentially damaging processes tea undergoes to reach the colorless and tasteless powder that is Teavigo.
Green Tea Reality
The evidence supporting tea and green tea health benefits is weak, coming from observational studies. A recent review of all these observational studies (supported in part by the tea industry) concluded that
Although the evidence appears to be stronger for green tea than for black tea, which differ greatly in their flavonoid profiles, it is difficult to compare this evidence because the populations and their baseline risks of cardiovascular disease differ greatly between the individual studies on these 2 types of tea, and few studies of green tea provide evidence in non-Asian populations.
Whereas there is reasonable observational evidence that high tea consumption is associated with lower cardiovascular risk, the evidence for green tea being healthier is mostly marketing hype.
If you like green tea by all means drink it in whatever quantity you desire. It’s not bad for you. Weak observational data suggests it may reduce your stroke risk, especially if you are Asian.
On the other hand, if you like black tea or oolong tea you can feel very comfortable that it is not bad for you. It might also reduce your risk of stroke.
There is nothing to suggest tea is healthier than coffee.
Don’t add sugar or titanium dioxide to your tea but feel free to add cream or full fat milk.
Don’t worry about caffeine unless it makes you jittery or brings on palpitations. Common sense should tell you what amount you can tolerate.
Please don’t buy or consume green tea extracts or Teavigo or any other nutraceutical.
The makers of these products are cynically preying on consumer desire for “natural” treatments, selling chemicals which have not been proven either safe or effective, and employing misleading marketing and promotional material that implies “scientific” support that is either nonexistent or comes from very weak studies, often run by researchers employed by the industry.
Avid readers of the skeptical cardiologist know that he is not an advocate of fish oil supplements.
One of my first posts (1/2013) was devoted to taking down the mammoth OTC fish oil industry because recent scientific evidence was clearly showing no benefit for fish oil pills.
", the bottom line on fish oil supplements is that the most recent scientific evidence does not support any role for them in preventing heart attack, stroke, or death. There are potential down sides to taking them, including contaminants and the impact on the marine ecosystem. I don’t take them and I advise my patients to avoid them (unless they have triglyceride levels over 500.)"
Despite a lack of evidence supporting taking them, the fish oil business continues to grow buttressed by multiple internet sites promoting various types of fish oil (and more recently krill oil) for any and all ailments and a belief in the power of “omega-3 fatty acids”.
Fish Oil By Prescription: Superior to OTC?
A fish oil preparation, VASCEPA, available only by prescription, was approved by the FDA in 2013.
Like the first prescription fish oil available in the US, Lovaza, VASCEPA is only approved by the FDA for treatment of very high triglycerides (>500 mg/dl).
This is a very small market compared to the millions of individuals taking fish oil thinking that it is preventing heart disease.
The company that makes Vascepa (Amrin;$AMRN)would also like to have physicians prescribe it to their patients who have mildly or moderatelyelevated triglycerides between 200 and 500 which some estimate as up to 1/3 of the population.
Given the huge numbers of patients with trigs slightly above normal, before approving an expensive new drug, the FDA thought, it would be nice to know that the drug is actually helping prevent heart attacks and strokes or prolonging life.
After all, we don’t really care about high triglycerides unless they are causing problems and we don’t care about lowering them unless we can show we are reducing the frequency of those problems.
Data do not exist to say that lowering triglycerides in the mild to moderate range by any drug lowers heart attack risk.
In the past if a company promoted their drug for off-label usage they could be fined by the FDA but Amrin went to court and obtained the right to promote Vascepa to physicians for triglycerides between 200 and 500.
Consequently, you may find your doctor prescribing this drug to you. If you do, I suggest you ask him if he recently had a free lunch or dinner provided by Amrin, has stock in the company (Vascepa is the sole drug made by Amrin and its stock price fluctuates wildly depending on sales and news about Vascepa) or gives talks for Amrin.
If he answers no to all of the above then, hopefully, your triglycerides are over 500.
Fun Facts About Vascepa (Yes It Melts Styrofoam!)
-Vascepa does not contain fish oil in a natural form.
Although there marking material states “VASCEPA is obtained naturally from wild deep-water Pacific Ocean fish” the active ingredient is an ethyl ester form of eicosapentoic acid (EPA) which has been industrially processed and distilled and separated out from the other main omega-3 fatty acid in fish oil (DHA or docosohexanoieic acid).
Natural fish oil contains a balance of EPA and DHA combined with triacylglycerols (TAGS).
-Vascepa Does Eat Through Styrofoam.
I came across reports of this phenomenon while researching Vascepa: it is commonly cited by fish oil marketers who are using the natural form of fish oil.
I tested this for myself and watched as my little styrofoam cup bottom was eaten away.
I’m not sure what the significance of this is as many concentrated organic oils (like lemon oil apparently) will do the same thing but it does seem to be a marker for the chemically processed, synthetic ethyl esters of EPA or EPA plus DHA.
Most Patients Should Avoid Prescription Fish Oil Unless/Until Studies Show a Benefit
Fish oil in its natural form which is within the actual fish surrounded by a host of nutrients, vitamins, mineral, antioxidants and chemicals we don’t fully understand is the best fish oil to consume.
I’m willing to bet that if I put a raw piece of salmon in that cup it would not eat through it (I feel another experiment coming up!).
The documentary, The Widowmaker (available on Netflix streaming) should definitely be watched by everyone.
It presents some great information on dying suddenly from heart attacks in an entertaining way.
It makes two important points: coronary stents don’t prevent heart attacks and coronary scans can identify advanced coronary artery disease before heart attacks happen.
I am in total agreement with these two points and have made them several times in previous posts (here and here).
The film is a work of advocacy, however, and twists the truth to prove its underlying theory: that greedy doctors and hospitals are choosing to “push” expensive coronary stents that do no good until you are having a heart attack. Also, that doctors and hospitals are also somehow suppressing the use of coronary calcium scans, which could prevent millions of heart attacks and deaths.
Creating black and white heroes and villains in documentaries makes for riveting entertainment, but often at the cost of sacrificing the truth.
Let’s look at the villains that The Widowmaker presents.
First up is Julio Palmatz. Dr. Palmatz is a vascular radiologist who invented, along with Dr. Shatz, one of the three primary stents that ultimately gained widespread clinical usage. The Widowmaker implies that Palmatz was THE stent developer, and follows Julio as he revisits the garage in Texas where he developed prototypes for the slotted tube stent.
At this point in the movie, it would be understandable if you thought Julio was going to be one of the heroes. He seems very personable as he describes the inspiration for his stent design and points out the area in the garage where his work bench stood.
However, the documentary wants, ultimately, to portray Palmatz as greedy, unconcerned about patient welfare, and in the pocket of wealthy investors.
He has done well financially because the patent on his coronary stent was eventually sold to Johnson and Johnson for millions (and he is interviewed on the grounds of his Napa Valley vineyard).
A recent scholarly analysis of the process of the development of stents differs with this portrayal of Palmatz:
“We found that the first coronary artery stents emerged from three teams: Julio Palmaz and Richard Schatz, Cesare Gianturco and Gary Roubin, and Ulrich Sigwart. First, these individual physician-inventors saw the need for coronary artery stents in their clinical practice. In response, they developed prototypes with the support of academic medical centers leading to early validation studies. Larger companies entered afterwards with engineering support. Patents became paramount once the technology diffused. The case of coronary stents suggests that innovation policy should focus on supporting early physician-inventors at academic centers.”
Although stents ultimately have become over-utilized, they represent a tremendous invention and contribution to cardiac care.
In the setting of acute heart attacks, stents are clearly life saving and thousands of patients have had their clinical angina or claudication greatly relieved when stents are utilized appropriately for blocked coronary and peripheral arteries.
Consequently, Palmatz and many of the other interventional cardiologists who developed and performed early studies on coronary stents are widely considered heroes by the vast majority of knowledgeable cardiologists.
There is no evidence that they have colluded with industry to inappropriately promote stents or to suppress utilization of methods for early diagnosis and prevention of coronary artery disease.
The documentary then switches to characterizing the world of cardiology after stents were approved by the FDA in the early 90s.
There clearly was (and is) an irrational exuberance about stents and some of this sprang from excellent reimbursement for doing the procedures.
The focus moves to Mt. Sinai Hospital in Manhattan, and arguably the busiest interventional cardiologist in the world, Samir Sharmin.
The movie implies that Mt. Sinai was going broke until it began performing lots of catheterization and stent procedures. Sharmin who does over 1500 interventions per year and apparently earns over 3 million dollars per year is interviewed and filmed performing a stent procedure.
The average viewer likely gathers from the context of the interview with Sharmin, that he is only doing these procedures to make money.
At various points during the movie, Dr. Steven Nissen, past president of the American College of Cardiology, is interviewed and referred to as “America’s top cardiologist.”
In my opinion, Nissen has been an outstanding, independent voice of reason in the world of cardiology. During the interview, he makes the very valid points that coronary calcium scans have not been embraced for routine usage because there are no outcomes data.
At one point he says, “I don’t like medical cults” in reference to those who support more widespread coronary calcium scans.
The movie leaves the uninformed viewer thinking that Nissen is part of a cabal blocking coronary calcium scans, perhaps due to his connections with industry or an inappropriate resentment of the “calcium club” pushing the scans.
Nothing could be further from the truth. I think Nissen is one of the few prominent cardiologists who are not subject to major bias of one type or another and I strongly respect his opinions.
The movie also attempts to portray the editor of Circulation, a major cardiology journal supported by the American Heart Association as inappropriately withdrawing a paper that would have endorsed coronary calcium scanning. It’s not possible to really tell what the truth is about this withdrawal, but this is a very minor episode in the history of coronary calcium scanning.
Ultimately, The Widowmaker fails its audience in presenting the truth because it desperately wants to convince us that there is a connection between the promotion of coronary stents and the failure of coronary calcium scans to be accepted by guidelines and covered by insurance.
There is no such connection. Many interventional cardiologists are enthusiastic promoters of prevention and aggressive use of coronary calcium scans. I have seen no evidence of greedy interventionists trying to suppress coronary scans.
In Part II of this analysis, I will take a look at the “heroes” of The Widowmaker, the inventors and promoters of coronary calcium scans, and we will see if they are truly heroic.