Tag Archives: netherlands

Why Are The Dutch So Heart Healthy and Happy (And Tall)? Part I: Is It Their Diet?

The Skeptical Cardiologist and his  eternal fiancee’ recently spent 5 days in the Netherlands trying to understand why the Dutch are so happy and heart healthy.

We were driven by Geo (former statin fence-sitter) from Bruges to Haarlem, a city of 150,000, which lies about 15 km west of Amsterdam and about 5 km east of the North Sea.

 

Haarlem is one of the most delightful towns I’ve ever stayed in.

 

 

I was struck by  the beauty of its architecture, its canals and the happiness, height and friendliness of its inhabitants.

I was lucky enough to have a bike at my disposal. One day I set off randomly, and after 20 minutes of riding on delightfully demarcated bike lanes, I scrambled up a sand dune and looked out at the North Sea.

Just down the road was the  beach resort of Zandvoort, where one can enjoy sunbathing, surfing or a fine meal while gazing at a glorious sunset.

 

 

 

 

Like Amsterdam, which is a 15 minute train ride away, bikes and biking abound in Haarlem, but unlike Amsterdamers, the Haarlemers were universally engaging, polite and friendly. Everything and everyone seemed clean, well-organized, relaxed and pretty…and, well, …happy.

The Dutch High Happiness Rating

The World Happiness Report 2017, which ranks 155 countries by their happiness levels, was released in March of this year at the United Nations at an event celebrating The International Day of Happiness.

The report notes that:

Increasingly, happiness is considered to be the proper measure of social progress and the goal of public policy

Norway was at the top of the happiness list but

All of the other countries in the top ten also have high values in all six of the key variables used to explain happiness differences among countries and through time – income, healthy life expectancy, having someone to count on in times of trouble, generosity, freedom and trust, with the latter measured by the absence of corruption in business and government.

The top 4 were closely bunched with Finland in 5th place, followed by the Netherlands, Canada, New Zealand, and Australia and Sweden all tied for the 9th position.

Despite the immense wealth of Americans, the report notes:

The USA is a story of reduced happiness. In 2007 the USA ranked 3rd among the OECD countries; in 2016 it came 19th. The reasons are declining social support and increased corruption  and it is these same factors that explain why the Nordic countries do so much better.

Dutch children seem to be especially happy.

A UNICEF report from 2013 found that Dutch children were the happiest of the world’s 29 richest industrialized countries.  America ranked 26th, barely beating out Lithuania and Latvia.

Cardiovascular Disease in The Netherlands

Ischemic heart disease (IHD) deaths are due to blockages in the coronary arteries. Typically, this comes from the build up of atherosclerotic plaques in the arterial system and in most countries heart attacks from this process are the major cause of death.

The Netherlands has the third lowest rate of IHD deaths in developed countries, only slightly higher than France and less than half the rate of the USA.Screen Shot 2017-07-26 at 10.53.26 AM

In all developed countries over the last thirty years we have seen a marked drop in deaths due to IHD. In The Netherlands it has dropped 70% and the rate in 2013 was nearly as low as France’s rate.

In addition, the Netherlands has a very low rate of deaths from  hypertensive heart disease. This table from 2008 shows that they are second only to Japan and their mortality rate is a third of that in the US.

A recent update noted

The current Dutch age-standardised mortality from circulatory disease is 147 per 100,000, and only Spain and France have lower cardiovascular mortality rates (143 and 126 per 100,000, respectively). In all other European countries, including for instance Switzerland and Greece, cardiovascular mortality is higher [26].

What factors could be causing all this happiness and heart healthiness?

The Seemingly Horrid Dutch Diet

We have been programmed to believe that heart attack rates are related to saturated fat in our diets.

The fact that the French consume lots of saturated fat and rank so low in IHD deaths has been called the French Paradox as it seems to contradict the expected association.

One thing is clear-the Dutch are not following a whole foods, plant-based diet. They are among the world leaders in consumption of both fat and sugar as the graph below indicates.

While in The Netherlands I sought out raw herring,  a dish which Rick Steves and others indicate is a Dutch obsession.

Since there is evidence that fish consumption, especially fatty ones like herring and mackerel, is associated with a lower risk of coronary heart disease, perhaps this was protecting the Dutch.

I didn’t see much herring consumption in Haarlem (a native Haarlemer informs me that the Dutch raw herring consumption might be confined to older generations or tourists).

It turns out that the Dutch aren’t meeting their own nutritional guidelines for healthy food .

The recommendation to eat fish at least twice a week, of which at least once fatty fish such as salmon, herring or mackerel, is followed by a mere 14 percent of the population. Less than 25% of them meet the recommended daily amount of fish, fruit, and vegetable consumption.

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purple bar=women yellow bar=men orange bar= total

They do catch and export a lot of fish and shellfish and are in the top 10 of seafood exporting countries (99% of all those mussels consumed in Belgium come from The Netherlands).

And, to my great surprise, they eat lots of French, or as I have started calling them, Flanders fries.

 

I personally witnessed  massive amounts of cheese and butter consumption.

In fact, the Dutch average 15% of calories from saturated fat, which is far above the 10% recommended by the Dietary Guidelines for Americans.

A recent analysis of Dutch fat consumption found:

The mean baseline intake of total saturated fatty acids (SFAs)  in the population was 15.0% of energy. More than 97% of the population exceeded the upper intake limit of 10% of energy/d as recommended by the Health Council of the Netherlands.

The Dutch weren’t eating so-called healthy fats as “The main food sources of SFAs were cheese (17.4%), milk and milk products (16.6%), meat (17.5%), hard and solid fats (8.6%), and butter (7.3%).”

Surprisingly, the more saturated fat the Dutch consumed, the LOWER their risk of death from IHD:

After multivariable adjustment for lifestyle and dietary factors (model 4), a higher intake of energy from SFAs was significantly associated with a 17% lower IHD risk (HR per 5% of energy: 0.83; 95% CI: 0.74, 0.93)

The Dutch Paradox

Data shows that  the Dutch are eating lots of saturated fat from dairy and meat, but it appears to be lowering their risk for heart attacks

Yes, despite 40 years of high saturated fat consumption, the Dutch have seen a 70% drop in mortality from heart attacks. Their rate of dying from ischemic heart disease is lower than the US and only slightly higher than the French.

Thus, rather than talk about a French paradox, we should be talking about the Dutch paradox.

For the French paradox many theories, both fanciful and serious,  have been proposed

The one most laypeople remember (due to a 60 Minutes episode in 1991) is that the French are protected by their high red wine consumption. Although this theory proved a great boon to the red wine industry (sales rose 40% the year after Morley Safer made his presentation on 60 Minutes), it has never had any serious scientific credibility.  Current thinking is that all forms of alcohol in moderation are equally protective.

Others have proposed garlic or onion or faux gras consumption. My own theory for the French is that it is fine cheese and chocolate consumption that protects them.

In subsequent posts I’ll lay out the evidence for my startling new theory to explain the Dutch paradox.

 

 

Urban Cycling, Part 2: Hit and Run Drivers and Bike Helmets

A doctor colleague of the skeptical cardiologist was riding his bike on a quiet road here in St. Louis recently when he suddenly awoke in a hospital bed. His friend who was riding in front of him heard a crash, turned and saw a black car making a U-turn and speeding off. Fortunately, the good doctor, suffered only the concussion and multiple bruised ribs and will live to ride again

He is in his seventies and I asked him if he would, indeed, climb onto the saddle of a two-wheeled vehicle in the future and he indicated yes, but never again on roads shared with cars.

I also inquired as to the state of his bike helmet post-trauma: it was shattered into multiple pieces.

In a previous post I pondered the question: Does cycling to work make you more or less likely to die?

cycling to work for many individuals would provide the daily physical activity that is recommended for cardiovascular benefits. However, cycling in general, and urban cycling in particular, carries a significant risk of trauma and death from accidents and possibly greater exposure to urban pollutants.

In the Netherlands cycling to work likely makes you less likely to die.

One study quantified the impact on all-cause mortality if 500,000  people made a  transition from car to bicycle for short trips on a daily basis in the Netherlands and concluded

For individuals who shift from car to bicycle, we estimated that beneficial effects of increased physical activity are substantially larger (3–14 months gained) than the potential mortality effect of increased inhaled air pollution doses (0.8–40 days lost) and the increase in traffic accidents (5–9 days lost). Societal benefits are even larger because of a modest reduction in air pollution and greenhouse gas emissions and traffic accidents.

In St. Louis, however, I suspect my longevity would be substantially reduced by cycling the 15 miles of heavily trafficked roads from University City to St. Lukes Hospital in Chesterfield. I would be cheek to jowl with SUVs, pick-up trucks, and mini-vans full of distracted, texting and chatting commuters.

Should  Bike Helmets Be Mandated?

Like most people I know, my colleague wears a bike helmet religiously when cycling. He, like many who have shared their bike accident stories with me, believes the bike helmet saved his life. I certainly can’t refute that possibility but it is impossible to know with certainty.

I’ve posted my analysis of the wisdom of mandating bike helmets here and even after hearing the good doctor’s story,  I still refuse to wear one.

Typical skeptical cardiologist bike riding garb. No helmet but safari (not bee-keeper) hat because sun is not his facial friend.

A commonly cited statistic is that bike helmets reduce serious head injuries by 85% and brain injuries by 88%.  This comes from an observational  study  published in 1989 which has serious limitations and has never been reproduced. For an exhaustive critique of these data see here.

I think a fair summary is in this British Medical Journal editorial which is behind a paywall but can be reviewed as a PDF here (bmj-june-2013.pdfbicycle helmets and the law).

 

Larry Husten, a journalist, who writes an excellent cardiology blog at cardiobrief.org apparently agrees with me and has recently written about “The Unintended Consequences of Bike Helmets.”

I encourage everyone to read his post which can be found here.

Here is his main point:

I am opposed to public health campaigns that focus on helmets, thereby implanting in people’s minds the dangers of cycling. Instead, in my view, the public health agenda regarding cycling should be to promote the far greater health benefits of cycling. The overarching goal of any public health campaign should be to dramatically increase cycling in the US, thereby encouraging physical activity and helping to reduce obesity and diabetes.  In tiny Denmark, by way of example, one expert, Lars Bo Andersen, PhD, of Western Copenhagen University of Applied Sciences, reports that “26 persons were killed in the whole country in cycle accidents last year, but more than 6000 deaths were avoided due to the huge amount of physical activity this behavior is a result of.”

Circuitously Yours,

-ACP

Speaking of Holland, the skeptical cardiologist will be visiting this hotbed of cycling, tulips and dikes in July.

I’ll be staying in Haarlem but wandering around the country researching cycling, assisted suicide and the Dutch dairy industry which may be responsible for the Dutch having gone from being among the shortest people in Europe to being the tallest in the world.