Tag Archives: heart disease

Quackery Promotion By Mainstream Media: Part I, Reader’s Digest and Naturopathy

As the skeptical cardiologist surveys the heart health information available to his patients and the lay public, he sees two broad categories of misinformation.

First we have the quacks and snake oil salesman. These are primarily characterized by a goal of selling more of their useless stuff online.

I’ve described this as the #1 red flag of quackery. Usually I’m inspired to investigate these charlatans because a patient asks me about one of their useless supplements.

The second category is more insidious: the magazine or internet news site seems to have as its legitimate goal, promoting the health of its readers. There is no clear connection to a product.

Web MD, which I wrote about here, is an example of this second type.  Hard copy versions of these types of media frequently make it into doctor’s waiting rooms: not because doctor’s have read and approved what is in them. These companies send their useless and misleading magazines for free to doctor’s offices, and the staff believe it to be legitimate.

How does glaringly inaccurate and often dangerous information get into media that ostensibly has as its goal promoting its readers health? Most likely, it is a result of media’s need  to constantly produce new and interesting ways for readers to improve their health.

Clearly, readers will not continue subscribing, clicking and reading such sources of information if there isn’t something new and exciting that might prolong their lives: gimmicks, miracles cures, and “natural” remedies are more alluring than the well-known advice to exercise more, watch your weight, stop smoking and get a good night’s sleep.

Reader’s Digest and Stealth Quackery

A patient recently brought in a printout of Reader’s Digest’s “40 things cardiologists do to protect their heart” which is typical of the second category.

Reader’s Digest was a staple of my childhood. My parents subscribed to it consistently and I would read parts of it. It was small and enticing. Allegedly its articles were crafted so that they could be read in their entirety during a session in the bathroom.

To this day it has a wide circulation. Per Wikipedia”

The magazine was founded in 1920, by DeWitt Wallace and Lila Bell Wallace. For many years, Reader’s Digest was the best-selling consumer magazine in the United States; it lost the distinction in 2009 to Better Homes and Gardens. According to Mediamark Research (2006), Reader’s Digest reaches more readers with household incomes of $100,000+ than Fortune, The Wall Street Journal, Business Week, and Inc. combined.[2]

Global editions of Reader’s Digest reach an additional 40 million people in more than 70 countries, via 49 editions in 21 languages. The periodical has a global circulation of 10.5 million, making it the largest paid circulation magazine in the world.

Reader’s Digest used to run a recurring educational feature on the various body parts and organs of Joe and Jane which intrigued me.

Here’s the first paragraph of “I am Joe’s heart:”

I am certainly no beauty. I weigh 340 grams, am red-brown in color and have an unimpressive shape. I am the dedicated slave of Joe. I am Joe’s heart.

The health information in this series was generally accurate but the presentation lacks the kind of sizzle that apparently attracts today’s readers.

The article my patient brought to my attention is typical of the mix of good and bad information and fluff that mainstream media can produce to attract followers:

Not So Bad But Not Clearly True Medical Advice

#1. I keep a gratitude journal. An internist “at NYU” is quoted as saying: “Studies have recently shown that expressing gratitude may have a significant positive impact on heart health.”

Fact Check: following the links provided provides no evidence to support this claim.

#2  I get 8 hours of sleep a night, every night.  This cardiologist seems to have been misquoted, because her comment is actually “getting a good night sleep is essential. I make a point of getting seven to eight hours of sleep every night…Poor sleep is linked to higher blood pressure.”

Fact Check. One review noted that:

Too little or too much sleep are associated with adverse health outcomes, including total mortality, type 2 diabetes, hypertensionand respiratory disorders, obesity in both children and adults, and poor self-rated health.

Another broke down mortality according to number of hours of sleep.

A J-shaped association between sleep duration and all-cause mortality was present: compared with 7 h of sleep (reference for 24-h sleep duration), both shortened and prolonged sleep durations were associated with increased risk of all-cause mortality (4 h: relative risk [RR] = 1.05; 95% confidence interval [CI] = 1.02–1.07; 5 h: RR = 1.06; 95% CI = 1.03–1.09; 6 h: RR = 1.04; 95% CI = 1.03–1.06; 8 h: RR = 1.03; 95% CI = 1.02–1.05; 9 h: RR = 1.13; 95% CI = 1.10–1.16; 10 h: RR = 1.25; 95% CI = 1.22–1.28; 11 h: RR = 1.38; 95% CI = 1.33–1.44; n = 29; P < 0.01 for non-linear test)

Thus, in comparison to those who sleep 7 hours, those who sleep 5 hours have a 5% increase in mortality and those who sleep 11 hours have a 38% increase in mortality.

These data are based entirely on observational studies so it is impossible to know if the shortened sleep is responsible for the increased mortality or if some other (confounding) factor is causing both.

My advice: Some people do fine with 6 hours and 45 minutes of sleep. Some require 8 hours 15 minutes for optimal function. Rather than obsessing about getting a specific amount of sleep time, it makes more sense to find our through your own careful observations what sleep time works best for you and adjust your schedule and night time patterns accordingly.

#3. I do CrossFit.

Fact Check. There is nothing to support CrossFit as more heart healthy than regular aerobic exercise (which the vast majority of cardiologists recommend and perform).

#4. I meditate. “Negative thoughts and feelings of sadness can be detrimental to the heart. Stress can cause catecholamine release that can lead to heart failure and heart attacks.”

Fact Check. There is a general consensus that stress has adverse consequences for the cardiovascular system. Evidence of meditation improving cardiovascular outcomes is very weak.

A recent review

Participation in meditation practices has been shown to reduce depression, anxiety, and negative mood and thus may have an indirect positive effect on CV health and well-being. This possibility has led the American Heart Association to classify TM as a class IIb, level of evidence B alternative approach to lowering BP.32

Non randomized, non blinded studies with small numbers of participants have suggested a reduction in CV death in those performing regular TM.

However, we need better and larger studies before concluding there is a definite benefit compared to optimal medical therapy.

Thus far, the recommendations have been pretty mundane: exercise, stress reduction and a good night’s sleep is good advice for all, thus boring.

Seriously Bad Advice From Quacks Mixed In With Reasonable Advice

In order to keep reader’s interest (and reach 45 things) Reader’s Digest is going to need to add seriously bad advice.

My patient had circled #34. “I mix magnesium powder into my water. If sufficient magnesium is present in the body, cholesterol will not be produced in excess.”

This bizarre and totally unsubstantiated practice was recommended by Carolyn Dean MD, ND.

What do we know about Dr. Dean?

-She was declared unfit to practice medicine and her registration revoked by the College of Physicians and Surgeons of Ontario in 1995. From quackwatch.org :

  • After being notified in 1993 that a disciplinary hearing would be held, Dean relocated to New York and did not contest the charges against her.
  • Dean had used unscientific methods of testing such as hair analysis, Vega and Interro testing, iridology and reflexology as well as treatment not medically indicated and of unproven value, such as homeopathy, colonic irrigations, coffee enemas, and rotation diets.

-The initials after her name (ND, doctor of naturopathy) should be considered the second red flag of quackery. See quackwatch.org (here) and rational wiki (here) and the confessions of a former naturopath  (here ) for discussions of naturopathy. As noted at science-based medicine:

Naturopathy is a cornucopia of almost every quackery you can think of. Be it homeopathy, traditional Chinese medicine, Ayurvedic medicine, applied kinesiology, anthroposophical medicine, reflexology, craniosacral therapy, Bowen Technique, and pretty much any other form of unscientific or prescientific medicine that you can imagine, it’s hard to think of a single form of pseudoscientific medicine and quackery that naturopathy doesn’t embrace or at least tolerate.

-She has a website (Dr. Carolyn Dean, MD,ND, The Doctor of The Future) where she incessantly promotes magnesium as the cure for all ills.

-She has written a book called “The Magnesium Miracle” (hmm. wonder what that’s about).

-She sells her own (really special!) type of magnesium (see red flag #1 of quackery).

-She writes for the Huffington Post (I’m considering making this a red flag of quackery).

-She is on the medical advisory board of the Nutritional Magnesium Association (an organization devoted to hyping magnesium as the cure for all ills and featuring all manner of magnesium quacks).

Prevention Magazine 

Reader’s Digest is not alone in allowing the advice of pseudoscience practitioners to stand side by side with legitimate sources.

For example, Prevention Magazine in its August 2017 issue highlights “35 All-Time Favorite Natural Remedies” with the subheading

“Go ahead, try them at home: Experts swear by these nondrug cures for back pain, nausea, hot flashes, and other common ailments.”

Who are these “experts”? Let the reader beware because the first quote comes from “Amy Rothenberg, past president of the Massachusetts Society of Naturopathic Doctors.”

Finding The Truth

It’s getting harder and harder for the lay public to sort out real from fake health stories and advice.

When seemingly legitimate news media and widely followed sources like Reader’s Digest and Prevention Magazine  either consciously or inadvertently promote quackery, the truth becomes even more illusive.

Readers should avoid any source of information which

  1. Profits from selling vitamins and supplements.
  2. Utilizes or promotes  naturopaths or other obvious quacks as experts in health advice.

IamJoesfootingly Yours,

-ACP

Are We Springing Forward to Death?: Daylight savings time and myocardial infarction

Tonight we will lose an hour of our lives when we observe Daylight Savings Time (DST).

Media reports suggest that DST, beyond robbing of us that nocturnal hour in the spring are also increasing our risk of heart attack (myocardial infarction or MI) and death.

Is this a valid concern or just media hype on a slow news day?

Scientific studies on this topic are mixed.

A recent study from Finland found MI rates increased 16% on the Wednesday after spring DST time change and dropped by 15% on the Monday after fall DST time change.

A 2015 German study found no difference in MI rate in the 3days or 1 week after spring or fall DST transitions.

However, some American studies have detected a bump in MI rate on the day after DST transition in the spring and a similar drop in MI rate on the day after the fall DST change.

A study of 42000 patients undergoing acute PCI for MI in Michigan found that

“The Monday following spring time changes was associated with a 24% increase in daily AMI counts (p=0.011), and the Tuesday following fall changes was conversely associated with a 21% reduction (p=0.044). No significant difference in total weekly counts or for any other individual weekdays in the weeks following DST changes was observed.”

Screen Shot 2016-03-12 at 2.28.26 PM

They concluded:

Our data argue that DST could potentially accelerate events that were likely to occur in particularly vulnerable patients and does not impact overall incidence. There is considerable controversy over the health and economic benefits of DST, and some authorities have argued that this practice should be abandoned.17 Although we are unable to comment on the merits of these arguments, our data suggest that while such a move might change the temporal fluctuations in AMI, it is unlikely to impact the total number of MIs in the broader population.

Mondays, in general, are the days of the week on which most MIs occur. This has been attributed to an abrupt change in the sleep–wake cycle and increased stress in relation to the start of a new work week

Manipulations of the sleep–wake cycle have been linked to imbalance of the autonomic nervous system, rise in proinflammatory cytokines and depression so presumably the additional disruption created by DST adds to this effect.

However, the data suggest that this very weak effect means only that if you were going to have an MI in the next week, after DST it is more likely to occur on the Monday of that week than on another day. Your overall risk of MI is not changed.

From a public health standpoint the major conclusion is that emergency rooms and cath labs should consider increasing staffing by 24% on the Monday after the spring DST time change.

I don’t think this is a significant factor for my patients. We have to deal with events and stressors that influence our sleep-wake cycle constantly. Good planning and sleep hygiene are the keys to success and reducing stress.

So, fear not the grim reaper as you set your clocks forward tonight.

Circadianly yours,

-ACP

PHOTO: PAVEL ŠEVELA/WIKIMEDIA COMMONS

 

What Cold Medications Are Safe For My Heart: 2016 Update

The most popular  skeptical cardiologist post is one written a year ago concerning over-the-counter (OTC)  cold medications.

Little has changed in the 8 billion dollar world of useless and confusing OTC  cold, flu, and sinus medications since then.

I still advise avoiding them and utilizing specific medications for specific symptoms.

I’m updating the article with additional comments on two frequently encountered drugs that I did not cover originally.

Alka-Seltzer Plops Into The OTC Cold Market 

I had always viewed Alka-Seltzer as an effervescent tablet which was a treatment for acid reflux, a.k.a. upset stomach, but the brand (now owned by Bayer) has moved aggressively into the bewildering morass of over the counter OTC cold meds. Indeed, when Alka-Seltzer began in 1931 it was a combination of aspirin and sodium bicarbonate (baking soda) marketed for upset stomachs. Popular commercials from the 1960s featured the catchy jingle (still stuck in my head) “Plop, Plop, Fizz, Fizz. Oh What a Relief It Is” often sung by Speedy, an odd anthropomorphic creature with an Alka-Seltzer thorax and cap.

(The jingle was written by Tom Dawes of The Cyrcle (Red Rubber Ball) and not by the father of Juliana Margulies)

Recently, I  received a request from an out-of-town guest who was suffering from a cough and upper respiratory infection (URI) to purchase Alka-Seltzer plus in the form of a tablet that dissolves in hot water .

At his request, Alka-Seltzer Plus Day Multi-Symptom Cold and Flu was purchased at the local Walgreen’s.

The ingredients are typical for many of  the Alka-Seltzer products:

-dextromethorphan (promoted for cough but ineffective with considerable side effects, see my initial post)

-acetaminophen (Tylenol, for pain and fever)

-phenylephrine (decongestant )

Phenylephrine: Ineffective Substitute for Pseudoephedrine

I didn’t cover phenylephrine in my previous post. It has taken the place of pseudoephedrine in  on the shelf over the counter URI (OTSOTCURI) medications.

Like pseudoephedrine, phenylephrine is a sympathomimetic drug, meaning it stimulates receptors of the sympathetic nervous system. Unlike pseudoephedrine, phenylephrine is useless as a decongestant when taken in the dosages available over the counter.

A study published in february, 2015 confirmed what previous studies had suggested: phenylephrine in dosages of 10 to 40 mg daily was no more effective than placebo in reducing symptoms of nasal congestion.

An accompanying editorial called on OTSOTCURI manufactures to remove this useless drug from their products.

Alas,  all of the Alka-Seltzer preparations that claim to treat congestion utilize phenylephrine as the decongestant.

The transition to useless phenylephrine took place when pseudoephedrine was taken off the shelves and put behind the counter to reduce its usage in making methamphetamine.

Therefor, Alka-Seltzer plus multi-symptom cold and flu contains two useless ingredients plus acetaminophen (Tylenol).

You can buy a large bottle of cheap generic acetaminophen and take exactly the right dose you need for relieving fever or body aches without paying for two useless accompanying drugs which have the potential for giving you unwanted side effects.

Nighttime Sleep Aids In OTC Cold Meds

I covered the most common drug found in OTC cold meds that are promoted for nighttime use, diphenhydramine/benadryl, in my previous post.

Nighttime Alka-Seltzer products contain a similar sedating antihistamine called doxylamine succinate. For example , Alka-Seltzer Severe Cold and Cough Liquid Night (ASCCLN) contains:

-Acetaminophen 650 mg

-Dextromethorphan hydrobromide 30 mg

-Doxylamine succinate 12.5 mg

Doxylamine is the active ingredient in the brand name sleep aid Unisom and the “ZZquil” products from the Nyquil brand that are promoted for inducing sleep. It is available in cheap, generic form at a cost of 7.90$ for 96 25 mg tablets.  According to drugbank.ca:

“It is also the most powerful over-the-counter sedative available in the United States, and more sedating than many prescription hypnotics. In a study, it was found to be superior to even the barbiturate, phenobarbital for use as a sedative.”

Note that the effective dosage recommended in separate sleep aids is 25 mg not the 12.5 mg found in Alka-Seltzer OTC cold meds, Thus, if you want an effective dosage of doxyylamine to help you sleep, you must double the recommended dosage of Alka-seltzer  SCCLN  which gives you too much acetaminophen and dextromethorphan.

Doubling these drugs raises the potential for side effects. Common dextromethorphan side effects include nausea/vomiting, dizziness, diarrhea, nervousness. Too much acetaminophen can damage the liver.

In addition, both dextromethorphan and acetaminophen interact with multiple other medications. Dextromethorphan is known to interact with 76 medications.

Acetaminophen can increase the INR (measure of blood thinning) in patients taking warfarin and increase the risk of dangerous bleeding.

As I summarized previously:

“I think you are much better off avoiding these brand name mixtures of different active ingredients.

Instead, you should take what you need for a specific symptom in the appropriate dosage and time interval.

Thus, if you have pain, take  the minimal dose of tylenol that relieves it and repeat when it comes back.

If you have a cough, recognize that the OTC ingredients are no better than placebo and are being abused as recreational drugs. Most coughs go away shortly but if one is particularly troublesome and persistent get a cough suppressing drug from your physician.

If you have a really runny nose with a lot of sneezing it is probably OK to take pseudoephedrine even if you are a heart patient or have high blood pressure. Take it as I described above. Start with 30 mg of the little red pseudoephedrine pills , wait an hour to see how you feel. Take a second if it has not been effective.  Repeat at 4-6 hour intervals as needed. Take your blood pressure at least once after starting it.

Don’t buy the multi-symptom multiple ingredient combinations which are simply a marketing tool to get you to spend more money on something from which you won’t benefit.”

Hypnotically Yours,

-ACP

 

Saturated Fat: Traditionalists versus Progressives

Why is death from coronary heart disease declining in the US at the same time that obesity and diabetes rates are climbing?

Two editorials recently published in The Lancet show the widely varying opinions on the optimal diet for controlling obesity , diabetes and coronary heart disease that experts on nutrition, diabetes and heart disease hold.

fats
Typical innocent and usual suspects rounded up in the war on fat: Cheese-data show it lower heart disease risk Full fat yogurt (Trader’s Point Creamery)-data show it is associated with lower heart disease risk Butter-Delicious. Used in moderation not a culprit.

The first paper contains what I would  consider the saturated fat “traditionalist” viewpoint. This is a modification of the misguided concept that was foisted on the American public in the 1980s and resulted in the widespread consumption of industrially produced trans-fats and high sugar junk food that was considered heart healthy.

The traditionalists have shifted from condemning all fats to vilifying only saturated and trans fats. They would like to explain at least part of the reduction in coronary heart mortality as due to lower saturated fat consumption and the accompanying lowering of LDL (“bad”) cholesterol.

The SFA traditionalists fortunately are in decline and more and more in the last five years, prominent thinkers, researchers and scientists working on the connection between diet and the heart believe saturated fats are neutral but sugar and refined carbohydrates are harmful in the diet.

Darius Mozzafarian, a highly respected cardiologist and epidemiologist, who is dean of the School of Nutrition Science and Policy at Tufts, wrote the second editorial and is what I would term a saturated fatty acid (SFA) progressive.

He makes the following points which are extremely important to understand and which I have covered in previous posts. I’ve included his supporting references which can be accessed here.

Fat Doesn’t Make You Fat, Refined Starches And Sugar Do

"Foods rich in refined starches and sugars—not fats—seem to be the primary culprits for weight gain and, in turn, risk of type 2 diabetes. To blame dietary fats, or even all   calories, is incorrect
Although any calorie is energetically equivalent for short-term weight loss, a food's long-term obesogenicity is modified by its complex effects on satiety, glucose–insulin responses, hepatic fat synthesis, adipocyte function, brain craving, the microbiome, and even metabolic expenditure Thus, foods rich in rapidly digestible, low-fibre carbohydrates promote long-term weight gain, whereas fruits, non-starchy vegetables, nuts, yoghurt, fish, and whole grains reduce       long-term weight gain.123
Overall, increases in refined starches, sugars, and other ultraprocessed foods; advances in food industry marketing; decreasing physical activity and increasing urbanisation in developing nations; and possibly maternal–fetal influences and reduced sleep may be the main drivers of obesity and diabetes worldwide".

There Are Many Different Kinds of Saturated Fats With Markedly Different Health Effects: It Makes No Sense to Lump Them All Together 

"SFAs are heterogeneous, ranging from six to 24 carbon atoms and having dissimilar biology. For example, palmitic acid (16:0) exhibits in vitro adverse metabolic effects, whereas medium-chain (6:0–12:0), odd-chain (15:0, 17:0), and very-long-chain (20:0–24:0) SFAs might have metabolic benefits.4 This biological and metabolic diversity belies the wisdom of grouping of SFAs based on a single common chemical characteristic—the absence of double bonds. Even for any single SFA, physiological effects are complex: eg, compared with carbohydrate, 16:0 raises blood LDL cholesterol, while simultaneously raising HDL cholesterol, reducing triglyceride-rich lipoproteins and remnants, and having no appreciable effect on apolipoprotein B,  5 the most salient LDL-related characteristic. Based on triglyceride-lowering effects, 16:0 could also reduce apolipoprotein CIII, an important modifier of cardiovascular effects of LDL and HDL cholesterol. SFAs also reduce concentrations of lipoprotein(a) ,6 an independent risk factor for coronary heart disease."

The Effects of Dietary Saturated Fats Depend on Complex Interactions With The Other Ingredients in Food

"Dietary SFAs are also obtained from diverse foods, including cheese, grain-based desserts, dairy desserts, chicken, processed meats, unprocessed red meat, milk, yoghurt, butter, vegetable oils, and nuts. Each food has, in addition to SFAs, many other ingredients and characteristics that modify the health effects of that food and perhaps even its fats. Judging the long-term health effects of foods or diets based on macronutrient composition is unsound, often creating paradoxical food choices and product formulations. Endogenous metabolism of SFAs provide further caution against oversimplified inference: for example, 14:0 and 16:0 in blood and tissues, where they are most relevant, are often synthesised endogenously from dietary carbohydrate and correlate more with intake of dietary starches and sugars than with intake of meats and dairy.4"

Dietary Saturated Fat Should Not Be a Target for Health Promotion

"These complexities clarify why total dietary SFA intake has little health effect or relevance as a target. Judging a food or an individual's diet as harmful because it contains more SFAs, or beneficial because it contains less, is intrinsically flawed. A wealth of high-quality cohort data show largely neutral cardiovascular and metabolic effects of overall SFA intake.7 Among meats, those highest in processing and sodium, rather than SFAs, are most strongly linked to coronary heart disease.7Conversely, higher intake of all red meats, irrespective of SFA content, increases risk of weight gain and type 2 diabetes; the risk of the latter may be linked to the iron content of meats.28 Cheese, a leading source of SFAs, is actually linked to no difference in or reduced risk of coronary heart disease and type 2 diabetes.910 Notably, based on correlations of SFA-rich food with other unhealthy lifestyle factors, residual confounding in these cohorts would lead to upward bias, causing overestimation of harms, not neutral effects or benefits. To summarise, these lines of evidence—no influence on apolipoprotein B, reductions in triglyceride-rich lipoproteins and lipoprotein(a), no relation of overall intake with coronary heart disease, and no observed cardiovascular harm for most major food sources—provide powerful and consistent evidence for absence of appreciable harms of SFAs."

Dietary Saturated Fats May Raise LDL cholesterol But This Is Not Important: Overall Effects On Obesity and Atherosclerosis Are What Matters

"a common mistake made by SFA traditionalists is to consider only slices of data—for example, effects of SFAs on LDL cholesterol but not their other complex effects on lipids and lipoproteins; selected ecological trends; and expedient nutrient contrasts. Reductions in blood cholesterol concentrations in Western countries are invoked, yet without systematic quantification of whether such declines are explained by changes in dietary SFAs. For example, whereas blood total cholesterol fell similarly in the USA and France between 1980 and 2000, changes in dietary fats explain only about 20% of the decline in the US and virtually none of that which occurred in France.11Changes in dietary fats11 simply cannot explain most of the reductions in blood cholesterol in Western countries—even less so in view of the increasing prevalence of obesity. Medication use also can explain only a small part of the observed global trends in blood cholesterol and blood pressure. Whether decreases in these parameters are caused by changes in fetal nutrition, the microbiome, or other unknown pathways remains unclear, thus highlighting a crucial and greatly underappreciated area for further investigation."

Dietary Saturated Fats Are Neutral For Coronary heart Disease Risk

Finally, SFA traditionalists often compare the effects of SFAs only with those of vegetable polyunsaturated fats, one of the healthiest macronutrients. Total SFAs, carbohydrate, protein, and monounsaturated fat each seem to be relatively neutral for coronary heart disease risk, likely due to the biological heterogeneity of nutrients and foods within these macronutrient categories.7Comparisons of any of these broad macronutrient categories with healthy vegetable fats would show harm,12 so why isolate SFAs? Indeed, compared with refined carbohydrates, SFAs seem to be beneficial.7

The overall evidence suggests that total SFAs are mostly neutral for health—neither a major nutrient of concern, nor a health-promoting priority for increased intake. 

Focusing On Reducing Saturated Fats Leads To Unhealthy Dietary Choices

I’ve written about this a lot. The most baffling aspect of this is the promotion of low or non-fat dairy.

There is no evidence that low fat dairy products are  healthier than full fat dairy products.

Non-fat yogurt filled with sugar should be considered a dessert, not a healthy food.

"Continued focus on modifying intake of SFAs as a single group is misleading—for instance, US schools ban whole milk but allow sugar-sweetened skim milk; industry promotes low-fat foods filled with refined grains and sugars; and policy makers censure healthy nut-rich snacks because of SFA content.13 "

It is extremely hard to change most people’s opinions on dietary fat.

My patients have been hearing the SFA traditionalist dogma for decades and thus it has become entrenched in their minds.

When I present to them the new progressive and science-based approach to fat and saturated fat some find it so mind boggling that they become skeptical of the skeptical cardiologist!

Hopefully, in the next few years, the progressive SFA recommendations will become the norm and maybe , some day in the not too distant future, the inexplicable recommendations for low-fat or non fat dairy will disappear.

As more data accumulates we may become SFA enthusiasts!

Saturatingly Yours,

-ACP

For another viewpoint (?from an SFA enthusiast) and  a detailed description of both editorials see Axel Sigurdsson’s excellent post here.

What Cold Medications Are Safe For My Heart?

It’s the cold and flu season here in St. Louis. That means the beds in my hospital are filling up with people who have upper respiratory infections of one kind or another and have developed complications. Not uncommonly,  the skeptical cardiologist is asked to consult on one of his  heart patients who has developed worsening heart failure or atrial fibrillation as a consequence of the pulmonary issues.

In the office it seems like every other patient has recently had a flu-like illness and is still dealing with lingering symptoms, most commonly a persistent cough.

At this time of year I get a lot of questions  from patients which come down to  “What over the counter medication can I take for my cold/flu/cough symptoms that is safe for my heart?”

My answer prior to writing this post  has always been  “Take anything that does not contain pseudoephedrine.”

Pseudoephedrine  (brand name Sudafed)is a decongestant, so often OTC cold meds that contain it will add a D to the title.

It is a sympathomimetic drug meaning that it stimulates the part of the autonomic nervous system that is responsible for “flight and fight” activation. This system kicks in the heart rate goes up, the blood pressure goes up and the heart beats stronger. Blood vessels constrict to nasal passages, thereby reducing fluid build up and resulting in the decongestant properties of the drug.

You won’t find it on the shelves in your local pharmacy because methamphetamine can be produced from it. Laws vary from state to state but at a minimum you will  have to present your driver’s license and you will be allowed to purchase a limited amount from the pharmacist.

A related drug, phenylpropanolamine,(which was used in OTC cold remedies and for weight loss)  was removed from the market in 2000 after the FDA warned of an increased risk of hemorrhagic stroke in young women

I use the little red 30 mg Sudafed pills when my nose is really running badly (think 30 tissue/ hour) and I’m sneezing frequently and it dries me up pretty effectively.  After I take it I feel like I’ve consumed a really highly caffeinated (think Starbucks) cup of coffee for about 4 hours. For this reason, I don’t take it within 6 hours of going to bed.

Sudafed is often combined with other cold , sinus and flu OTC remedies with names like:

Allegra-D, Alka-Seltzer Plus Cold Medicine Liqui-Gels, Aleve Cold and Sinus Caplets, Benadryl Allergy and Sinus Tablets, Claritin-D Non-Drowsy 24 Hour Tablets, Contac Non-Drowsy 12 Hour Cold Caplets, Robitussin Cold Severe Congestion Capsules, Sudafed  24 Hour Tablets, Triaminic Cold and Cough Liquid, Thera-Flu Cold and Cough Hot Liquid, Tylenol Sinus Severe Congestion Caplets, and Vicks 44M Cough, Cold and Flu Relief.

Adverse Effects of Pseudoephedrine: Stroke, Blood Pressure, Heart Rate

A 2003 paper from Mexico identified 22 cases of stroke (out of 2500 stroke cases at their center) that were associated with taking agents like pseudoephedrine within 24 hours. The majority were with phenylpropanolamine but there were 4 cases associated with pseudoephedrine. Given how often pseudoephedrine is taken and how few strokes were reported, it is difficult  to draw any conclusions that  pseudoephedrine causes stroke

In 2005, a review of all studies looking at oral pseudoephedrine concluded

This analysis demonstrates that pseudoephedrine causes a small but significant mean (1–mm Hg) increase in SBP, with no significant effect on DBP and a slight increase in HR (3 beats/min)

On average, these are very minor changes in blood pressure and heart rate and would be unlikely to cause any problems in the vast majority of patients with significant heart disease or hypertension.

The study found NO increased rate of adverse effects (such as heart attacks or strokes) in the patients taking pseudoephedrine.

Coridicin Hbp, A Typical Mixture Of OTC Ingredients

One of my patients pulled from her purse an OTC cold remedy that appeared to have the American Heart Association seal of approval.

IMG_3315

The HBP refers to high blood pressure and the blurb on the front claims this is cold relief for people with High Blood Pressure.

This is really just marketing hype to get patients to buy a more expensive combination of otherwise cheap ingredients.

Let us look closely at the benefits and side effects of this typical and common OTC cold/sinus/flu remedy

Typical “Multi-symptom” OTC Cold/Flu/Sinus/Cough Ingredients

-Acetaminophen (tylenol)- helps with aches, pain, headache and fever.

-Dextromethorphan (look for DXM or DM) is commonly found  in these kinds of multi-ingredient brand name products and is promoted as reducing cough (as an antitussive). However, there is very little evidence to support its efficacy.  This study found 30 mg dextromethorphan no better than placebo at reducing cough. The Cochran Database  Review in 2012 concluded :

There is no good evidence for or against the effectiveness of OTC medicines in acute cough.

In addition to lacking evidence for efficacy, dextromethorphan is used as a recreational drug due to its side effect as a  dissociative hallucinogen in very high doses. Per Wikipedia:

It may produce distortions of the visual field – feelings of dissociation, distorted bodily perception, and excitement, as well as a loss of sense of time. Some users report stimulant-like euphoria, particularly in response to music

-Chlorpheniramine is an antihistamine. It’s one of the oldest antihistamines and as such is “sedating”. This means it almost certainly is going to make you drowsy. I remember trying to function on medical wards 30 years ago when it was the only antihistamine available and it turned me into a zombie for 24 hours.

. Since newer non-sedating antihistamines (like loratadine which is available OTC and generic) have become available I cannot fathom how something like Coricidin has survived.

What is the antihistamine in this hodgepodge of drugs doing for your cold symptoms? Nothing, other than making you drowsy. Antihistamines are useful for allergically related runny nose or sneezing.

What Are the Downsides of Multiple Medication Cold Remedies

I think you are much better off avoiding these brand name mixtures of different active ingredients.

Instead, you should take what you need for a specific symptom in the appropriate dosage and time interval.

Thus, if you have pain, take  the minimal dose of tylenol that relieves it and repeat when it comes back.

If you have a cough, recognize that the OTC ingredients are no better than placebo and are being abused as recreational drugs. Most coughs go away shortly but if one is particularly troublesome and persistent get a cough suppressing drug from your physician.

If you have a really runny nose with a lot of sneezing it is probably OK to take pseudoephedrine even if you are a heart patient or have high blood pressure. Take it as I described above. Start with 30 mg of the little red Sudafed pills , wait an hour to see how you feel. Take a second if it has not been effective.  Repeat at 4-6 hour intervals as needed. Take your blood pressure at least once after starting it.

Don’t buy the multi-symptom multiple ingredient combinations which are simply a marketing tool to get you to spend more money on something from which you won’t benefit.

The second and third items are Coricidin bottles which had been used as slides
Various guitar slides. Includes two original Coricidin bottles from the 1970s–the favorite of many slide guitar players, including Duane Allman.. from king nate/Flickr user”johnny from space 1

I see no reason to ever take coricidin. In the late 1960s, however, legend has it that Duane Allman  had a cold on his birthday.  His brother Greg gave him two gifts: a glass bottle of coricidin pills and Taj Mahl’s debut album. From this he learned how to play slide guitar by listening to Statesboro Blues.

And the rest is history.

I “Ain’t Wastin’ Time no More” on OTC Cold Meds…. Super Bowl is approaching.

ACP

 

 

Ezetimibe (Zetia) Shown to Reduce Heart Attack and Stroke After Thirty Billion Dollars in Sales

Important findings from the IMPROVE-IT trial were presented at the American Heart Association meeting yesterday. They demonstrate for the first time that the cholesterol lowering drug ezetimibe (brand name Zetia) lowers the risk of heart attack and stroke when added to a statin drug in high risk patients (those who have sustained a heart attack or had unstable angina) over a statin drug plus placebo.

That study showed

 The primary endpoint of CV death/MI/UA/coronary revascularization beyond 30 days/stroke was significantly lower in the ezetimibe/simvastatin arm compared with the simvastatin arm over the duration of follow-up (32.7% vs. 34.7%, hazard ratio [HR] 0.94, 95% confidence interval [CI] 0.89-0.99; p = 0.016).

Prior to this study, Zetia had been prescribed to millions of patients since 2002 garnering Merck, its maker, profits of 30 billion dollars despite there being no evidence that it reduced heart attack or stroke.

Dr. Melissa Walton-Shirley wrote an excellent article on the status of Zetia at the beginning of 2014, summarizing thusly:

Perhaps the lesson to be learned is that starting in 2014, let’s not put compounds on the market for human ingestion without knowing if they help or hurt. Let’s make it unacceptable for a company to make tens of billion dollars from the sale of a compound without knowing if it lowers mortality or improves quality of life

I have previously bashed Zetia on this site and I only prescribe it in very rare cases. These new data may change my approach.

Before embracing Zetia, though, I want to see the full paper in published form and examine the data in detail. Many questions need to be answered. For example, the addition of the drug to simvastatin lowered heart attack and stroke compared to simvastatin alone but there was no difference in overall death rates or cardiovascular death rates. That raises a red flag.

In addition, this study does not support the use of Zetia in patients who have not had heart attacks or near heart attacks (primary prevention).

Science moves slowly but inexorably toward the truth if done properly. It’s important that public policy and drug prescribing not get in front of the science as it did with this drug.

 

Dealing With The (Cardiovascular) Cards You’ve Been Dealt

The skeptical cardiologist was in Atlanta recently  visiting  his Life Coach (LCOSC). Oddly enough, the wife of the LCOSC (who I’ll call Lisa) had just undergone a coronary calcium scan  and it came back with a high score.  Most women her age (58 years old) have a zero score but hers came back at 208 .

What is the significance of a calcium score of 208 in this case?

The CT scan for calcium (discussed by me in more detail here) focuses entirely on quantifying the intense and very specific kind of x-ray absorption from calcium. The three-dimensional resolution of the scan is such that the coronary arteries which supply blood to the heart can be accurately located and the amount of calcium in them very accurately and reproducibly added up. Calcium is not in the arteries normally and only accumulates as atherosclerotic plaque builds up over time. The build up of fatty plaque (atherosclerosis) is the major cause of coronary artery disease (CAD, sometimes termed coronary heart disease (CHD)) which is what causes most heart attacks and most death in both men and women in the U.S.

We can enter Lisa’s numbers into the online MESA calculator to see how she compares to other white 59 year old women. The calculator tells us that 72% of her peers have a zero calcium score and a score of 208  is higher than 95% of her peers. Although the 95th percentile is a good place to be for SAT scores it is not for atherosclerosis. This means substantial amount of fatty atherosclerotic plaque has built up in the arteries and puts the individual at significantly greater risk for heart attack and stroke. A calcium score of 100-300 confers a 7.7 times increased risk compared to an individual with similar risk factors with a zero calcium score.

Most of the risk factors that we can measure to assess one’s risk of heart attack (blood pressure, diabetes, smoking) were absent in Lisa. Her cholesterol levels had risen in the last 10 years but when I entered her numbers (total cholesterol 221, HDL 68) into the ASCVD risk estimator her 10 year risk came back at 2.5%. This is considered low and no treatment of cholesterol would be advised by the new guidelines.

The only clue that her cardiologist would have that Lisa has advanced premature atherosclerosis is that her mother had coronary heart disease at an early age, something we call premature CAD. Her mom at the age of 62 suffered a heart attack and had a stent placed in one of her coronary arteries. The occurrence of significant premature CAD in a parent or sibling  substantially increases the chances that a patient will have premature CAD and the earlier it occurred in the parent or sibling the higher the risk.

Some of this excess risk is transmitted by measurable risk factors such as hypertension and hyperlipidemia and some through lifestyle factors but the majority of it is through genetic factors that we haven’t fully identified.

How much of an individual’s risk for heart attack  is determined by genetics versus lifestyle?

A large Swedish study found that adopted men and women with at least one biological parent with CHD were 1.5 times more likely to have CHD than adoptees without. In contrast, men and women with one adoptive parent were not at increased risk.

Since 2007 an intense project to identify genetic factors responsible for CAD has been underway at multiple academic centers. Thus far 50 genetic risk variants have been identified. According to Dr. Robert Roberts

” All of these risk variants are extremely common with more than half occurring in >50% of the general population. They increased only minimally the relative risk for coronary artery disease. The most striking finding is that 35 of the 50 risk variants act independently of known risk factors, indicating there are several pathways yet to be appreciated, contributing to the pathogenesis of coronary atherosclerosis and myocardial infarction. All of the genetic variants seem to act through atherosclerosis, except for the ABO blood groups, which show that A and B are associated with increased risk for myocardial infarction, mediated by a prolonged von Willebrand plasma half life leading to thrombosis”

 How well do the standard risk factors capture the individuals risk for heart attack?

The standard approach to estimating risk fails in about 25% of individuals as it does not accurately convey the high risk of the patient with family history and it overestimates risk in many elderly individuals who have an excellent family history.

It is in these patients that testing for the actual presence of atherosclerosis, either by vascular screening or coronary calcium is helpful.

Reducing The Excess Risk of Premature CAD

For many individuals there are clear-cut lifestyle changes that can be implemented once advanced CAD is identified: cigarette smoking cessation, weight loss through combinations of diet and exercise with resulting control of diabetes, However, many patients like Lisa, are non-smokers, living a good lifestyle, eating an excellent diet with plenty of fresh fruit, vegetables, fish and healthy oils and  without obesity or diabetes. There is no evidence that modifying lifestyle in this group is going to slow down an already advanced progression of atherosclerosis.

Patients like Lisa have inherited predisposition to CAD, it is not due to their lifestyle.

Lisa’s cardiologist  suggested she get a copy of Dr. Esselstyn’s book “Prevent and Reverse Heart Disease”. This book, based on the author’s experience in treating 18 patients with advanced CAD espouses an ultra low fat diet. The author declares that “you may not eat anything with a face or a mother (meat/poultry/fish)” and bans  full fat dairy products and all oil (“not even a drop”)

Such “plant-based diets” (codeword for vegan or vegetarianism) lack good scientific  studies supporting efficacy and are extremely hard to maintain long term. There is nothing to suggest that Lisa’s long term risk of heart attack and stroke would be modified by following such a Spartan dietary regimen.

Her cardiologist did recommend two things proven to be beneficial in patients with documented advanced CAD: statins and aspirin.

Taking a statin drug will arrest the atherosclerotic process and reduce risk of heart attack and stroke by around 30% as I’ve discussed here and here.

An aspirin is now indicated since significant atherosclerosis has now been documented to be present as I’ve discussed here.

We can blame a lot of heart disease on lifestyle: poor diets and lack of exercise are huge factors leading to obesity, diabetes, hypertension and hyperlipidemia, but in many patients I see who develop heart disease at an early age, lifestyle is not the issue, it is the genetic cards that they have been dealt.

Until we develop reliable genetic methods for identifying those at high risk it makes sense to utilize methods such as vascular screening or coronary calcium to look for atherosclerosis in individuals with a family history of premature CAD.

Once advanced atherosclerosis is identified, we have extremely safe and effective medications that can help  individuals like Lisa deal with the cardiovascular cards they have been dealt.

 

 

Should All Men Over Sixty Take a Statin Drug?

The updated AHA/ACC Cardiovascular Prevention Guidelines (CPG) which include the   excessively wordy “The Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults Risk” were published late last year and immediately were the center of controversy.

After working with them for 9 months and using the iPhone app to calculate my patients’ 10 year risk of atherosclerotic cardiovascular disease (ASCVD, primarily heart attacks and strokes) it has become clear to me that the new guidelines will recommend statin therapy to almost all males over the age of 60 and females over the age of 70.

As critics have pointed out, this immediately adds about 10 million individuals to the 40 million or so who are currently taking statins.

Should we be starting all elderly Americans on statin drugs?

My simple answer is no. It doesn’t make sense to do this, because clearly not all elderly individuals have atherosclerosis or will ever develop its consequences of heart attack and stroke. Many have inherited the genes that allowed their parents to live free of heart disease into their 90s and will not benefit at all from long term statin therapy; they may actually suffer the expense and side effects instead.

How can we better decide who among the elderly will benefit from statin therapy?

If you have read my previous posts on searching for subclinical atherosclerosis here and here you probably know the answer. Let’s look at a specific case and apply those principles.

Robert is 69 years old. I see him because, in 2010, the posterior leaflet of his mitral valve ruptured, resulting in the mitral valve becoming severely incompetent at its job of preventing back flow from the left ventricle into the left atrium. I sent him to a cardiac surgeon who repaired the ruptured leaflet. Although he has a form of “heart disease,” this is a form that has nothing to do with cholesterol, hypertension or diabetes and is not associated with ASCVD.

However, it is my job to assess in him, like all individuals, the risk of developing coronary heart disease or ASCVD.

He has no family history of ASCVD and he feels great since the surgery, exercising aerobically 4-5 times per week.

His BMI is 23.87 which is in the normal range. His BP runs 116/80.

His total cholesterol is 210 and LDL or bad cholesterol is 142. Good or HDL cholesterol is 56 and triglycerides 59. The total and LDL cholesterol levels are considered “high,” but they could be perfectly acceptable for this man.

When I ran his 10 year ASCVD risk (risk of developing a heart attack or stroke over the next 10 years), it came back as 14%. The new guidelines would suggest having a conversation with him about starting a statin if his risk is over 7.5%. His risk is double this and statins are definitely recommended in this intermediate risk range. Interestingly, I cannot enter a cholesterol level or blood pressure for a man of this age that yields a risk less than 7.5%.

When I had my discussion with him about his risk for ASCVD, I plugged his numbers into my iPhone and showed him the results and gave him the guideline recommendation.

Lifestyle Changes to Lower Cholesterol

The new Cardiovascular Prevention Guidelines have a section devoted to Lifestyle Management to Reduce Cardiovascular Risk. Unfortunately, none of the lifestyle changes they recommend have been shown to reduce ASCVD risk in an individual like Robert. He already exercises the recommended amount, is at his ideal body weight and eats a healthy diet. If we were to tighten up on his diet by, say reducing red meat, eggs and high fat dairy, all we would accomplish would be to lower his LDL and HDL cholesterol levels and make his life and meals less satisfying. The lower total cholesterol and LDL cholesterol would not lower his risk of ASCVD and the calculated 10 year ASCVD risk would still be in the range where statins are recommended.

Therefore, I am not going to tell Robert that he should reduce his saturated fat consumption (he already has incorporated that into his diet since he’s been bombarded with the low fat mantra for 30 years).

Searching for Subclinical Atherosclerosis

I’m going to tell Robert that we need to know if he has atherosclerosis, the disease that we are attempting to modify.

We started with an ultrasound to look at the lining of the large arteries in his neck that supply blood to the brain, the carotid arteries (a process I describe in more detail here). Although severe atherosclerotic blockages in these arteries put one at risk of a stroke, I was much more interested in the subtle changes in the arteries that precede symptoms and are an early harbinger of atherosclerosis.

Careful ultrasound recording and measurement of the main common carotid arteries from both the left and right side showed that the IMT or thickness was lower than average for his age, gender and ethnicity. His carotid IMT was at the average for a 60 year old, therefore, his so-called vascular age was 60 years, younger than his chronological age. If I plug that age into the ASCVD risk estimator, I get an 8.2% 10 year risk, just barely above the statin treatment cut-off.

Careful scrutiny with ultrasound of the entire visible carotid system in the neck on both sides did not reveal any early fatty plaques or calcium in the lining of the carotid arteries. He had no evidence for atherosclerosis, even very subtle early forms, in this large artery, a finding which is usually predictive of what is going on in the other large arteries in the body, including the coronary arteries, which supply blood to the heart.

At this point, I think, we could have stopped the search for subclinical atherosclerosis and agreed that no statin therapy was warranted. However, Robert wanted further reassurance that his coronary arteries were OK, therefore we set him up with a coronary calcium study (see my full description of this test here).

Searching for Subclinical Atherosclerosis: The Calcium Score

Robert’s coronary calcium score came back at 21 (all in the LAD coronary artery) , which put him at the 26th percentile compared to normal men of his age and gender. A score of 21 is average for a 59 year old man and 82% of men aged 69 have a score greater than zero. Robert had much less calcium in his coronaries than men his age, another factor putting him in a low risk category.

Given the low risk findings from both the vascular screening and the coronary calcium, I felt comfortable recommending no statin therapy and going against the guidelines.

Statins: Better Targets for The Two-edged Sword

This is not an unusual scenario; many of my older patients without heart attacks, strokes or diabetes fall into the risk category that would warrant statin therapy and if they have no clinical or subclinical evidence of atherosclerosis, I don’t advise statin therapy. My patients are free to follow the guidelines and take statin drugs after this advice, but most are very grateful that another pill (which they likely have heard bad things about on the internet or from friends with adverse experiences) can be avoided.

Statins are wonderful drugs when utilized in the right population, but they also carry a  9% increased risk of diabetes and about a 10% real world risk of developing muscle aches and weakness (myalgia).

I think it is essential to aim these two-edged swords at the right targets if we are to maximize the overall health benefits.

Salt Consumption: Less Is Not Always Better

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.

Salt and Death

The second PURE study paper examined the relationship between sodium excretion (a measure of sodium consumption) and death and cardiovascular events

 

saltvsdeath
As Eric Topol has opined at the heart.org ” In other words, consumption of too little sodium is as harmful as consumption of too much sodium. In fact, the AHA guideline would lead — at least according to this latest research — to about a twofold risk for major adverse events.”

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.

 

Potassium Consumption

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.

 

 

Are You Consuming Too Much or Too Little Salt?

He is embarrassed to admit this, but the skeptical cardiologist has no idea how much salt he consumes.

I have never stressed to my patients that they engage in obsessive assessment of their salt consumption. The data that everyone needs to limit salt consumption to , say 1.5 grams/ day, as the AHA recommends are not compelling. If asked, my typical response is to recommend not adding additional table salt from the salt shaker and to avoid processed and fast foods (which apparently accounts for 75% of salt consumed in the US).

I definitely have some patients with hypertension and some with heart failure in whom watching for excessive salt consumption is important. One of my patients with fairly well controlled hypertension called me last week because he was recording blood pressures of 210/120. Before I could add another blood pressure agent he had decided to stop adding the salt to the tomatoes he was eating and over a period of a week the blood pressure came back to normal values. Manyl of my severe  heart failure patients will report weight gain due to ankle swelling after a particularly salty meal.

On the other hand, I have many patients who are symptomatic from low blood pressure. These patients have frequent episodes of dizziness and have been following the recommended low salt diet thinking that this was enhancing their health. When I get them to liberalize salt intake, blood pressures and their symptoms go away.

Recent papers on salt consumption suggest that either too much or too little salt is bad for you and consequently the public must be totally confused on what they should be doing.

Since I have high blood pressure which seems to randomly fluctuate I’ve decided to try to measure exactly how much salt I consume daily. Maybe I am consuming more than 5 grams daily (I think that is too much).

This is not going to be an easy task. If i eat out during this time I’m not sure how I will have any clue what amount of salt is in the meal. If I decided to fry a couple of eggs this morning , I will shake some salt on them from the salt cellar. Is it possible to measure this amount? If I put some cheese on the eggs, will I need to precisely measure the amount of cheese? Looks like there are some free iPhone apps I can utilize to assist me in the process.

To my readers and patients, please join me in this exciting and informative adventure. Over the next week, try to track your daily salt consumption and report the numbers to me. Or do it for one day.  The Great Salt Measurement Challenge is On!