Tag Archives: mortality

Does Eating Saturated Fat Lower Your Risk of Stroke and Dying?: Humility and Conscience in Nutritional Guidelines

A study presented at the European Society of Cardiology  meetings in Barcelona and simultaneously published in The Lancet earlier this month caught the attention of many of my readers. Media headlines trumpeted  “Huge New Study Casts Doubt On Conventional Wisdom About Fat And Carbs” and “Pure Shakes Up Nutritional Field: Finds High Fat Intake Beneficial.”

Since I’ve been casting as much doubt as possible on the  conventional nutritional wisdom  to cut saturated fat, they reasoned, I should be overjoyed to see such results.

What Did the PURE Study Find?

The Prospective Urban Rural Epidemiology (PURE) study, involved more than 200 investigators who collected data on more than 135000 individuals from 18 countries across five continents for over 7 years.

There were three high-income (Canada, Sweden, and United Arab Emirates), 11 middle-income (Argentina, Brazil, Chile, China, Colombia, Iran, Malaysia, occupied Palestinian territory, Poland, South Africa, and Turkey) and four low-income countries (Bangladesh, India, Pakistan, and Zimbabwe)

This was the largest prospective observational study to assess the association of nutrients (estimated by food frequency questionnaires) with cardiovascular disease and mortality in low-income and middle-income populations,

The PURE team reported that:

Higher carbohydrate intake was associated with an increased risk of total mortality but not with CV disease or CV disease mortality.

This finding meshes well with one of my oft-repeated themes here, that added sugar is the major toxin in our diet (see here and here.)

Higher fat intake was associated with lower risk of total mortality.

Each type of fat (saturated, unsaturated, mono unsaturated ) was associated with about the same lower risk of total mortality. 

 

These findings are consistent with my observations that it is becoming increasingly clear that cutting back on  fat and saturated fat as the AHA and the Dietary Guidelines for Americans have been telling you to do for 30 years is not universally helpful (see here and  here ).

When you process the fat out of dairy and eliminate meat from your diet although your LDL (“bad”) cholesterol drops a little your overall cholesterol (atherogenic lipid) profile doesn’t improve (see here).

Another paper from the PURE study shows this nicely and concluded:

Our data are at odds with current recommendations to reduce total fat and saturated fats. Reducing saturated fatty acid intake and replacing it with carbohydrate has an adverse effect on blood lipids. Substituting saturated fatty acids with unsaturated fats might improve some risk markers, but might worsen others. Simulations suggest that ApoB-to-ApoA1 ratio probably provides the best overall indication of the effect of saturated fatty acids on cardiovascular disease risk among the markers tested. Focusing on a single lipid marker such as LDL cholesterol alone does not capture the net clinical effects of nutrients on cardiovascular risk.

Further findings from PURE:

-Higher saturated fat intake was associated with a lower risk of stroke

-There was no association between total fat or saturated fat or unsaturated fat with risk of heart attack or dying from heart disease.

Given that most people still believe that saturated fat causes heart disease and are instructed by most national dietary guidelines to cut out animal and dairy fat this does indeed suggest that

Global dietary guidelines should be reconsidered …”

Amen!

Because the focus of dietary guidelines on reducing total and saturated fatty acid intake “is largely based on selective emphasis on some observation and clinical data despite the existence of several randomizesed trials and observational studies that do not support these conclusions.”

Pesky Confounding Factors

We cannot infer causality from PURE because like all obervational studies, the investigators do not have control over all the factors influencing outcomes. These confounding factors are legion in a study that is casting such a broad net across different countries with markedly different lifestyles and socioeconomic status.

The investigators did the best job they could taking into account household wealth and income, education, urban versus rural location and the effects of study centre on the outcomes.

In an accompanying editorial, Christopher E Ramsden and Anthony F Domenichiello, prominent NIH researchers,  ask:

“Is PURE less confounded by conscientiousness than observational studies done in Europe and North American countries?

 

“Conscientiousness is among the best predictors of longevity. For example, in a Japanese population, highly and moderately conscientious individuals had 54% and 50% lower mortality, respectively, compared with the least conscientious tertile.”

“Conscientious individuals exhibit numerous health-related behaviours ranging from adherence to physicians’ recommendations and medication regimens, to better sleep habits, to less alcohol and substance misuse. Importantly, conscientious individuals tend to eat more recommended foods and fewer restricted foods.Since individuals in European and North American populations have, for many decades, received in influential diet recommendations, protective associations attributed to nutrients in studies of these populations are likely confounded by numerous other healthy behaviours. Because many of the populations included in PURE are less exposed to in influential diet recommendations, the present findings are perhaps less likely to be confounded by conscientiousness.”

It is this pesky conscientiousness factor (and other unmeasured confounding variables) which limit the confidence in any conclusions we can make from observational studies.

I agree wholeheartedly with the editorial’s conclusions:

Initial PURE findings challenge conventional diet–disease tenets that are largely based on observational associations in European and North American populations, adding to the uncertainty about what constitutes a healthy diet. This uncertainty is likely to prevail until well designed randomised controlled trials are done. Until then, the best medicine for the nutrition field is a healthy dose of humility.

 

Ah, if only the field of nutrition had been injected with a healthy dose of humility and a nagging conscience thirty years ago when its experts declared confidently that high dietary fat and cholesterol consumption was the cause of heart disease.!

Current nutritional experts and the guidelines they write will  benefit from a keen awareness of the unintended consequences of recommendations which they make based on weak and insufficient evidence  because such recommendations influence the food choices  (and thereby the quality of life and the mechanisms of death) of hundreds of millions of people.

PUREly Yours,

ACP

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

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

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

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

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

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

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

Trademark

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

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

Heres one example:

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

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

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

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

Applicant should submit a disclaimer in the following standardized format:

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

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

Nuts Reduce Mortality From Lots of Different Diseases

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

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

29% for coronary heart disease

7% for stroke (not significant)

21% for cardiovascular disease

15% for cancer

22% for all-cause mortality

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

52% for respiratory disease

35% for neurodenerative disease

75% for infectious disease

74% for kidney disease

The authors concluded:

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

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

Meditativeterraneanly Yours,

-ACP

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

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

Say Hello To Heart Nuts

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

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

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

Now I need a name for the squirrel.

Squirrelly Yours,

-ACP

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

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

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

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

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

Embrace the nuts I say!

 

Are 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

 

Nuts, Legumes, Drupes and Mortality

When I was a child in small town Oklahoma, I collapsed walking home from school one day after eating pecans. Apparently I had never encountered pecans in England where I grew up and I had a very severe, life-threatening  allergic reaction (anaphylaxis.)

My pediatrician was promptly called, drove over, picked me out of the street and (legend has it) with one hand on the steering wheel and the other jabbing me with epinephrine drove me to the local hospital (apparently ambulances were not invented at this time). There I spent several days in an oxygen tent recuperating.

Since then I had, until recently,  concluded (based on my own multiple food reactions and research) that I was allergic to “tree nuts.”

I would patiently explain to the uninitiated that I could eat almonds because they are in the peach family and I could eat peanuts because they are in the legume family: neither one of these, therefore, were true “tree nuts.”

To all whom I gave this seemingly erudite explanation I owe an apology for I have learned the earth-shattering truth that pecans are drupes! They are no more a nut than an almond is!

In fact, even walnuts are not nuts as hard as that is to believe.

Pecans, walnuts and almonds are all drupes.

Why, you may wonder, is any of this botanical folderol of any relevance to cardiology?

Nuts and Cardiovascular Death

For those paying attention to media reports on the latest food that will either kill you or make you live for ever you may already know the answer. This paper published in JAMA made big headlines.

Jane Brody of the New York Times wrote a piece extolling the virtues of nuts entitled “Nuts are a Nutritional Powerhouse”. Medical New Today wrote “Eating Nuts Linked to 20% Cut in Death Rates”.

It turns out, however, that most of what the 136,000 Chinese were eating and half of  the “nuts” the 85,000 low income Americans were eating in that JAMA study  were legumes: peanuts or peanut butter. The authors wrote:

“Our findings … raise the possibility that a diet including peanuts may offer some CVD (cardiovascular)  protection. We cannot, however, make etiologic inferences from these observational data, especially with the lack of a clear dose-response trend in many of the analyses. Nevertheless, the findings highlight a substantive public health impact of nut/peanut consumption in lowering CVD mortality, given the affordability of peanuts to individuals from all [socioeconomic status] backgrounds.”

These findings follow another large observational study published in 2013 which also found (in American doctors and nurses) an inverse relationship between nut consumption and mortality.

“compared with participants who did not eat nuts, those who consumed nuts seven or more times per week had a 20% lower death rate. Inverse associations were observed for most major causes of death, including heart disease, cancer, and respiratory diseases. Results were similar for peanuts and tree nuts, and the inverse association persisted across all subgroups.”

We also have a very good randomized trial (the PREDIMED study) that showed that  the Mediterranean diet plus supplementation with extra-virgin olive oil or mixed nuts performed much better than a control diet in reducing cardiovascular events.

Participants in the two Mediterranean-diet groups received either extra-virgin olive oil (approximately 1 liter per week) or 30 g of mixed nuts per day (15 g of walnuts, 7.5 g of hazelnuts, and 7.5 g of almonds) at no cost, and those in the control group received small nonfood gifts (I wonder what these were?)

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

Nuts versus Drupes versus Legumes

The evidence supporting “nut” consumption as a major part of a heart healthy diet is pretty overwhelming. But what is a nut and which nuts or nut-like foods qualify?

Let’s lay out the basic definitions:

Nut-Generally has a hard outer shell that stays tightly shut until cracked open revealing a single fruit inside. Examples are hazelnuts and acorns.

Drupe-Has a soft, fleshy exterior surrounding a hard nut. Classic drupes are peaches and plums with interior nuts so hard we won’t eat them. Examples are pecans, almonds, walnuts and coconuts.

Legume-generally has a pod with multiple fruit which splits open when ready. Examples are peas, carob, peanuts, soybeans and beans.

What Nuts Were Consumed in Studies Showing Benefits of Nuts?

Initially participants were given a questionnaire and asked

” how often they had consumed a serving of nuts (serving size, 28 g [1 oz]) during the preceding year: never or almost never, one to three times a month, once a week, two to four times a week, five or six times a week, once a day, two or three times a day, four to six times a day, or more than six times a day.”

After initial surveys, the questionnaires split out peanut consumption from “tree nut” consumption and whether you ate peanuts or nuts the benefits were similar.

Thus, for the most part, participants were left to their own devices to define what a nut is.  Since most people don’t know what a true nut is, they could have been eating anything from almonds (drupe related to peaches) to hazelnuts (true nut) to a pistachio “nut” (drupe) to a pine “nut” (nutlike gymnosperm seed).

Nutrient Content of Nuts

The nutrient components of these nuts varies widely but one consistency is a very high fat content. For this reason, in the dark days when fat was considered harmful, nuts were shunned.

However, in our more enlightened era we now know that fat does not cause heart disease or make you fat.

Please repeat after me “Fat does not cause heart disease or make you fat.”

A one ounce portion of pecans contains 20.4 grams of fat (11.6 arms monounsaturated and 6.1 polyunsaturated) so that 90% of its 204 calories come from fat.

Nuts, of course, also contain numerous other biologically active compounds that all interact and participate in the overall  beneficial effects that they have on cardiovascular disease and mortality.

They are a whole, real food which can be eaten intact without processing and these are the foods we now recognize provide the best choices in our diets, irrespective of fat or carbohydrate content.

They are also convenient, as they are easy to store and carry with you, providing a perfect snack.

If You Think It’s A Nut, It’s A Nut

IMG_3567

Hazelnut Death Experiment (Don’t try this at home!) A single hazelnut was partitioned into halves, quarters, slivers and little tiny bits. Progressively larger portions were consumed at 5 minute intervals. An Epipen (right) was available in case of anaphylaxis.

It turns out, that my attempts to put pecans and walnuts in to a specific family of nuts that increased my risk of dying if I consumed them were misguided.

I’m allergic to drupes.

In fact, I did an experiment recently and consumed a true nut (a hazelnut) and found I had no reaction.

I’m not allergic to nuts!!!

In the world of allergic reactions, thus,  there is no particular value to partitioning nuts from drupes from legumes.

Similarly, for heart healthy diets, it doesn’t matter if you are consuming a true nut or a drupe as long as you think of it as a nut.

Consume them without concern about the fat content and consume them daily and as along you are not allergic to them they will prolong your life.

Skeptically Yours,
-ACP