Tag Archive for: CVD

Are Heart Meds Forever?

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The prevailing thought on pharmacological treatment of cardiovascular disease (CVD) is that once you’re on a class of medications, you’re on them for life—new meds may be developed to replace some, but treatment continues forever. That contributes to the conspiracies about big pharma and the greed of the medical community. I’m not going to say that never happens, but maybe a recent study can reveal a ray of hope.

Beta-Blocker Study

Researchers selected a very specific group of potential subjects from three countries. The subjects must have had a myocardial infarction (MI), also known as a heart attack; they must have had both angiography and an echocardiogram; they must have an ejection fraction equal to 50% or more; and they were tracked for 3.5 years.

This is the important part: On a randomized basis, half were given the typical treatment of beta-blockers while the other half were not. There were two intermediate analyses of the data to make sure the non-beta blocker group were not at greater risk for problems such as another MI, or worse yet, death.

The analyses demonstrated that there were no differences in outcomes related to any CVD condition between the groups. In other words, the beta-blocker did not provide any additional benefit. There are more trials underway to confirm these results, but we now have a first step on the path to determining whether medications are necessary for life or not.

The Bottom Line

Let me be clear: Do not stop any medication without discussing it with your physician! All physicians were aware that their patients were in the trial and who was and was not on beta-blockers. Also, the standard for ejection fractions (amount of blood pumped per beat) was relatively high. But it illustrates this point: Every visit to your physician or specialist should include a thorough discussion of your medications and whether you need to remain on each one.

There’s also another part to all this: What are you willing to do to help eliminate the need for the medication? Diet, exercise, reducing body weight? What will you do if it will help? In other words:

What are you prepared to do today?

        Dr. Chet

Reference:  N Engl J Med 2024;390:1372-81

Ice Cream, the Health Food

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Paula gave me an article to read from The Atlantic written last summer, in which author David Merritt Johns tackled the issue of outlandish results in nutrition-science studies. In this case, the issue was research demonstrating that eating ice cream regularly reduced the risk of developing type 2 diabetes and cardiovascular disease. He interviewed the chairman of acclaimed nutrition research schools and departments. He interviewed the scientists who published the results of the studies—or not, in one case, because they wouldn’t talk about it. No one could explain it, it didn’t fit their model, so the results got buried.

I reviewed the studies in question, including the dissertation of the researchers who wouldn’t talk about the study. Any way you look at it, two servings per week of a half cup of high-fat ice cream reduced the risk of the aforementioned conditions between 12–54%. The researchers didn’t want to talk about it or acknowledge it, but the data is the data.

Five Reasons the Data Should Be Accepted

  • The assumption is that the Dietary Guidelines are correct for everyone. Maybe they aren’t.
  • The studies used a food frequency questionnaire. They’ve been used forever and are still no better than they were when developed, like trying to paint the Mona Lisa with a 6-inch brush. For example, how many servings of carrots did you have in July? Few people could answer with any accuracy, so why are we still depending on these tools?
  • They could have assessed the data differently. Divide the subjects by caloric intake first, then by foods or macronutrients. They used the same approach as I’ve talked about before and statistically added a percentage of calories to see how it would impact the results.
  • Maybe the results are just the results. It really confirmed prior studies. Why would you ignore data just because it doesn’t agree with your view of how things should be?
  • Maybe it’s time to stop parsing the imparsible. When the data tell a different story, quit trying to make it fit your theory of nutrition.

Maybe what they should have done is find out what is found in full-fat ice cream but not in high-fat milk or cream, which do contribute to CVD and T2D. Maybe it’s a microbiome issue. Stop saying it’s an outlier and find out why it appears to work.

The Bottom Line

Nobody asked me, but I think it’s portion control. Two half-cup servings per week is very different from two pints a day. That may be the real reason behind the positive results. If you want to have a couple of half-cup servings of ice cream a week, I don’t think it will harm you and just may help. Just pay attention to the portion size.

What are you prepared to do today?

        Dr. Chet

References:
1. http://nrs.harvard.edu/urn-3:HUL.InstRepos:37925665
2. Arch Intern Med. 2005;165:997-1003
3. JAMA. 2002;287(16):2081-2089. doi:10.1001/jama.287.16.2081
4. https://www.theatlantic.com/magazine/archive/2023/05/ice-cream-bad-for-you-health-study/673487/

Fish Oil: Reserve Judgment

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Let’s put the fish oil study from Tuesday in perspective. The most important thing is that observational studies such as these cannot demonstrate cause and effect. That’s not just a way to weasel out of making definitive statements; it’s because while fish oil supplements are associated in some way with atrial fibrillation in people who have no diagnosed heart disease, it may be something else that people who take fish oil supplements do that’s actually the culprit. Remember the hazard ratio (HR) was only 13%. What were the remaining 87% doing that was different?

The Problems

As I see it, these were the problems with this research paper.

Just as in the multivitamin study, researchers collected a whole host of dietary data and didn’t use much of it; they adjusted for those who ate oily and un-oily fish, but that was it. Fruit intake, vegetable intake, fiber intake, and a whole lot more dietary factors that have been shown to limit the development of cardiovascular disease were not considered. That may have impacted the HR.

The major problem was that they didn’t report the rate of AFib in those who did not take fish oil supplements. How can you not? What happens to those who do not take fish oil supplements could have provided comparison groups, which seems like a better analysis to conduct. No explanation. They just chose not to do it.

The final critique is that this study was conceived and executed by statisticians and epidemiologists. There were no nutrition experts on the team reported in the paper. I don’t know how that’s possible. If you’re considering a nutritional intervention, such as taking a fish oil supplement, there has to be someone who understands nutrition to consider other factors. It can’t be all statistics without thoughtful guidance.

The Big Question

How? How would fish oil supplements cause the development of AFib?

Research has shown that eating oily fish does not appear to cause AFib. Why would fish oil? The researchers cited a couple of possibilities having to do with an impact on channels that control electrical pathways but overall, no one has given any explanation.

This was not the first study that has examined fish oil supplements in large studies and found some relationship with AFib; there are also several that show no relationship at all. In this case, we have to reserve judgment because we can’t prove things either way.

The Bottom Line

What should you do? First, eat the healthiest diet you can and exercise regularly, because lifestyle is more important than supplements. Second, if you have already been diagnosed with CVD as I have—a stent more than 20 years ago—taking fish oil may be beneficial. If you’re under 60, it seems taking fish oil isn’t an issue and there’s no reason to stop. If you’re older than 60, should you begin to take fish oil supplements? It’s a matter of choice. I have to reserve judgment for now.

Next Tuesday is our primary election day in Michigan, and I’m taking the day off—I’m an election worker—but you’ll still get a Memo that goes into questions on this fish oil issue. There’s more to consider and I’ll let you know what those issues are.

What are you prepared to do today?

        Dr. Chet

Reference: BMJMED 2024;3:e000451.doi:10.1136/ bmjmed-2022-000451

Fish Oil and Atrial Fibrillation

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Researchers recently published an observational study on over 415,000 subjects in the UK Biobank database who took a fish oil supplement. During a follow-up period of almost 12 years, they statistically demonstrated a 13% increased hazard ratio (a measure over time of how often a particular event happens in one group compared to another group) in the development of atrial fibrillation in subjects. Atrial fibrillation is a type of arrhythmia, or abnormal heartbeat, that can result in extremely fast and irregular beats from the upper chambers of the heart. In those subjcts, there was a 5% increased risk of stroke.

The resultant impact was an attack on dietary supplements for being too easily available, leading to overconsumption, and questionable because of the lack of purity in dietary supplements. The Medscape Cardiology online section put out a video by a reputable researcher explaining who should take fish oil supplements. But if they’re so bad, why would she recommend them at all?

The other part of the results showed that if someone already had cardiovascular disease (CVD), the hazard ratio of developing major cardiac events was reduced if they took fish oil supplements. That’s why the expert made the video, taking the good and trying to make sense of it. Still, it gave the appearance of being a pitch for a pharmaceutical solution.

That’s the set-up for this week’s Memos. I’ll give you at least one of the questions you might have: Yes, this study tested only supplement use (and dietary intake) upon entrance to the study and nothing the rest of the 11.9 years, just like the multivitamin study from last week. But there’s so much more that I’ll cover on Saturday about the problems with this study. Just so you know, I’m still taking my fish oil supplements.

What are you prepared to do today?

        Dr. Chet

Reference: BMJMED 2024;3:e000451.doi:10.1136/ bmjmed-2022-000451

A Closer Look at Ultra-Processed Food Risk

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I think the results of the UK Biobank ultra-processed food (UPF) study were interesting, as I relayed on Tuesday, but the researchers went further. They estimated how substituting non-UPF plant-sourced foods for any of the other three sources of food resulted in a reduction of cardiovascular disease (CVD) morbidity and mortality. Further, and what got the headlines, substituting UPF plant-sourced foods for any of the other three increased the risk of CVD morbidity and mortality.

That led some experts to speculate about how processing destroyed fiber and phytonutrients and may even increase the amounts of negative chemicals that have been associated with disease in UPF plant-sourced foods. The problem is that there are no randomized-controlled trials to prove that. Here are a few things that stood out to me.

Theoretically…

The most important issue was this: The determination made about UPF increasing or decreasing the risk of CVD was theoretical and based on calculations. They used a 10% substitution for the non-UPF or UPF plant-sourced foods to calculate the expected raising or lowering of risk. What they could have done was divide the subjects into actual groups based on percentage of nutrients they actually ate instead of running theoretical statistical formulae. My impression is that so few people were diagnosed or died from CVD during the nine-year observational period that they wouldn’t have enough subjects for each group.

So few subjects were diagnosed or died? In the entire subject population—over 118,000 subjects followed for nine years—there were only 7,806 people diagnosed with CVD and only 529 deaths from CVD. Only? Most of the subjects were between 40 and 70, prime time for being diagnosed with some form of CVD.

When looking at the percentage of UPF-plant-sourced foods, the highest percentages were from industrialized packaged breads (9.9%),

pastries, buns, and cakes (6.9%) and biscuits (the kind called cookies in the U.S.) at 3.9%. That’s over half the amount of UPF-plant based foods on the list provided in the research paper. While wheat and other grains were certainly stripped of nutrients in the ultra-processing, that’s nothing new—that’s been happening to flour for over 100 years. What was missing were any fruits or vegetables processed in that manner.

The Bottom Line

Should you take the corn chips and vegan burgers out of your cart? Don’t get the impression that I think UPF plant-based foods should be eaten in mass quantities. I don’t. But I don’t think this study provided much direction in a reasonable response to the issue. On top of that, the analysis of the data may be just plain wrong. We’re not done yet, but we’ll get to that after the 4th of July. One more holiday challenge coming up on Tuesday.

What are you prepared to do today?

        Dr. Chet

Reference: DOI:
https://doi.org/10.1016/j.lanepe.2024.100948


Is Ultra-Processed Food Worthless?

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Ultra-processed food (UPF) has been in the news again: researchers have found a relationship between plant-based UPF and cardiovascular disease (CVD) and mortality. Health news writers were brimming with opinions on what the study meant. The comment that got my attention was that UPF manufacturing destroyed good nutrients found in plant foods to the point that there was no benefit to eating them. For example, store-bought cereals and cookies are worthless no matter how much fruit or nuts are added.

Is that true?

Let’s begin by looking at the study. Researchers used data from the UK Biobank database. They selected only the participants who completed at least two 24-hour dietary recalls—118,397 subjects. All participants were part of the healthcare system in the UK, so the researchers were able to collect diagnostic and mortality data from electronic medical records.

Researchers divided the dietary data into four groups:

  • Non-UPF plant-sourced foods (fresh grapes or canned corn)
  • UPF plant-sourced foods (corn chips or vegan burgers)
  • Non-UPF animal-sourced foods (ground beef or canned tuna)
  • UPF animal-sourced foods (chicken nuggets or ice cream)

The two main findings were that the more UPF plant-sourced foods were eaten, the higher the risk of CVD and CVD mortality; second, the increase of non-UPF plant-sourced foods reduced the risk of CVD and mortality. I think those results were to be expected. In Saturday’s Memo, we’ll take a closer look at whether the expert diatribes about negating the benefits of UPF-plant-sourced foods were warranted.

Don’t forget that the Men’s Health Webinar is this Wednesday evening. If you want to participate, respond by tonight to get the login information. The live webinar is free.

What are you prepared to do today?

        Dr. Chet

Reference: DOI:
https://doi.org/10.1016/j.lanepe.2024.100948

Stretch Your Body, Stretch Your Lifespan

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“Stretching reduces your risk of dying from all causes” was the message from Tuesday’s Memo. How does that work? Why would stretching decrease mortality? There are no definitive answers, but here are a few possibilities.

It may be that stretching strengthens the blood vessels as well as the connective tissue; that may decrease the potential for blockages or building up plaque in the arteries. Or it may be that the deep breathing that’s associated with most forms of stretching also contributes to the health of the heart and lungs.

One of the other benefits of stretching is a resultant increase in strength, which could help keep the muscles more pliable, and that’s important at any age. I’ve already mentioned that there may be an improvement in arterial function when undertaking stretching, but associated with stretching is a reduction in resting heart rate and an increase in vasodilation. Their possible net impact could lower blood pressure, which would reduce mortality.

I think that one of the most important benefits is going to be related to mobility and balance. We often only think of the flexibility of the muscles of our hips and our knees, but something as simple as raising your hands above your head can benefit stretching those lower joints as well. And all that contributes to your ability to move in space as you get older; maybe you move more if you stretch regularly. By regularly, that means five days a week, the criterion in one of the studies I mentioned.

Finding out the why stretching helps may take a while, but the fact is that there are benefits to what we would consider the easiest forms of exercise. As you move forward through this year, when you have a few minutes in every day, whether it’s waiting for the microwave to finish heating a cup of coffee, washing your hands after using the bathroom, or standing alone on an elevator, taking the time to do purposeful stretching may provide a benefit that you don’t envision. To take it one step further, put together a short routine of three to ten minutes that you do every day; if you have old injuries or joint issues, an appointment with a physical therapist can help you devise a routine you can do safely. And now that spring has sprung and you can get out of the house a little easier, try a class in yoga, tai chi, or qigong. Be sure to look for one that’s within your abilities; Paula and I tried a class a few years ago and were embarrassed that we couldn’t get up and down as easily as the 20-somethings.

The net effect should be that your muscles and your connective tissue will be more pliable. Who knows, you just may end up living a little while longer as well! Sounds like a good investment of time to me.

What are you prepared to do today?

        Dr. Chet

References:
1. Med Sci Sports Exerc. 2020 Dec;52(12):2554-2562

2. BMC Public Health. 2023; 23:1148.

Reducing Your Risk of Dying the Easy Way

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Quick! If I were to ask you which form of exercise would decrease your chance of dying, and especially your chance of dying from cardiovascular disease (CVD), what would your answer be? You’d probably pick some form of aerobic exercise such as running, elliptical training, walking, and cycling—any type of exercise that works the heart and the entire body to improve your cardiovascular fitness. That’s on the list for sure, but it’s not the form of exercise that seems to decrease your risk of dying the most. Data from two large observational studies show this form of exercise decreases your risk of dying the most: stretching.

Stretching? Stretching is that toe-touching and heel-to-butt type of stretching we were all taught in high school or some other fitness class. But that’s not all. What also counts as stretching would be activities such as yoga, tai chi, and qigong. They feature slow, elaborate movements that control the body in ways that result in stretching the muscles and other connective tissue. That all counts as stretching.

How much does it reduce mortality? In two large studies, 10% and 12% respectively over the course of several years, the highest reductions in both studies. You get more benefit if you combine it with other forms of exercise such as aerobic training and weight training. But stretching? How or why? I’ll cover that on Saturday.

The Insider Conference Call is tomorrow night at 9 p.m. Eastern Time. Get your questions answered about anything related to health including exercise if you become an Insider by 8 p.m. tomorrow.

What are you prepared to do today?

        Dr. Chet

References:
1. Med Sci Sports Exerc. 2020 Dec;52(12):2554-2562
2. BMC Public Health. 2023; 23:1148.

How Many Steps Do We Need?

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Last week, we talked about how to lower blood pressure using a form of weight training called isometrics. As I made clear, you won’t look like a body builder, but it can help your cardiovascular health. This week, we’ll look at two recent studies to clarify how much aerobic exercise we need to reduce the risk of all-cause and cardiovascular disease mortality.

The typical recommendation for aerobic exercise is 10,000 steps per day. That was based more on marketing than on science, but it has stood as the standard for years—until recently. Several studies have shown the actual amount may be between 4,000 and 7,000 steps per day.

In a recently published study, researchers included data from 17 studies and over 225,000 subjects. They tracked the subjects for just over seven years to find out all-cause mortality and cardiovascular disease mortality. One more thing: all the data were collected electronically as opposed to relying on some sort of mechanical device that underestimates or overestimates steps per day.

After using meta-analysis, the researchers used 3,900 steps per day as a baseline for the median risk of mortality. For every 500 additional steps per day, the mortality risk decreased 7% and for every thousand additional steps per day it decreased 15%. As the number of steps increased, the cardiovascular and all-cause mortality risk decreased until about 12,000 steps where it leveled off.

Going with our theme of doing just enough to reduce our mortality rate, it would seem that 4,000 steps per day, whether as part of your regular day or in addition to your everyday activity, gives a baseline of protection. But do you really have to invest that much time? We’ll check that out on Saturday.

What are you prepared to do today?

        Dr. Chet

Reference: Eur J Prev Card (2023) 00, 1–11 https://doi.org/10.1093/eurjpc/zwad2292

Yes, Intensity Matters

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Can you get away with less time exercising and still protect your cardiovascular system? We know from Tuesday’s Memo that more time spent on physical activity will provide more protection. Can we save some time? Or perhaps better stated, can we do something in short bursts of time that can increase the moderate to intense exercise we get?

Before I answer that, remember that physical activity means everything you do that requires movement: walking to the kitchen, gardening, cooking, and the activity involved in your job. Exercise is also a part of your overall physical activity. In the study, all activity was registered by the accelerometer the subjects wore.

Intensity Matters to Reduce CVD Risk

With that in mind, the answer is yes: exercise intensity matters when it comes to protecting yourself from cardiovascular disease (CVD). I must admit that the charts and graphs published in the study were challenging to understand. They used a percentage of calories used per day as the way to measure outcomes. For the exercise intensity analysis, they considered the percentage of calories at moderate to high intensity. They found that as the percentage of activity at moderate to high intensity increased, the rate of CVD events decreased.

Here’s an example. Let’s take a 180-pound guy who uses a low amount of energy in physical activity such as five calories per kg body weight. The total calories he uses daily would be about 400 calories, including any exercise he did. But let’s say the percentage of moderate to severe intensity exercise rises from 10% of total exercise to 20% of that total. His risk of a CVD event would be reduced from 2% lower to 20% lower. He hasn’t invested any more time, yet he gets a jump in benefit just from increased intensity.

What Does That Mean for You?

Does this mean that everyone should be doing high-intensity interval training? Not in the classic sense; what’s high intensity for you may be impossible for your elderly neighbor and a breeze for your kid’s soccer coach. You don’t have to do special workouts such as high-intensity interval training where you’re going to bust a gut for 60 seconds and then take it easy for five minutes. That is intense, but it takes less time overall and you could do that if you want; there’s more info at drchet.com if you decide to try it.

In physical activity, everything counts from housework to walking the dog to breaking into a run to catch a bus. Those would show up as mild or moderate intensity, or high-intensity exercise for the running. It doesn’t mean that all the exercise you do has to be high intensity, but investing time in higher intensity exercise may provide you with additional benefits. Working a little harder is going to reduce your risk of cardiovascular disease and, while not assessed in this study, your risk of type 2 diabetes, hypertension, and cancer would be reduced as well.

Of course, the question is what’s high intensity for you. The chart above is geared toward weightlifting, but it will give you some ways to think about how hard you’re exercising, no matter what you’re doing. If you’re running for the bus, could you run one more block? If you’re cleaning house, do you have enough juice left to go for a bike ride?

The Bottom Line

You must be fit enough and ambulatory enough to actually do moderate to high-intensity exercise. But you know something? I know of one physical therapist who encourages patients to do jumping jacks while sitting in a wheelchair. Of course they can’t do the actual jumping part of it but for 60 seconds, their arms are going up and down, up and down, up and down at a very high rate, and maybe their legs are moving, too—and that’s high intensity for them. For others of you, it may be doing a two-minute walk up a very steep hill. The intensity of the exercise stresses the heart in ways that a nice easy walk does not. And for that, you get additional benefits, no matter where you’re starting.

So check with your doctor to find out your limitations as it relates to exercise intensity, and then get after it. Not to lose a whole bunch of weight, not to win the next 5K, not every day—but often enough to make your heart stronger and fitter.

What are you prepared to do today?

        Dr. Chet

P.S. Happy Canada Day to our neighbors to the north! We’re taking next week off to enjoy the July 4th holiday and hope you do as well (even if you’re not in the U.S.) We’ll be back with new Memos the week of the 10th. Meanwhile, it’s a great time to try increasing your exercise intensity.

Reference: Eur Heart J (2022) https://doi.org/10.1093/eurheartj/ehac613