Tag Archive for: CVD

What Would You Invest in a Healthier Diet?

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Would you eat more vegetables and fruit if your health insurance paid for it? How about an overall healthier diet that also included whole grains, nuts and seeds, fish, and healthy oils? Would you eat healthier if it didn’t cost you more?

Researchers from Tufts and Harvard examined the potential cost and benefits of subsidizing 30% of the costs of both approaches in Medicare and Medicaid programs. This was a computer simulation using data from NHANES on dietary intake and the relationship to cardiovascular disease and type 2 diabetes. They used the CVD events and mortality data and the current costs of treatment. Then they created models, one with increasing vegetable and fruit intake and another increasing all the aforementioned food, to find out if a healthier diet would affect disease events, deaths, and costs associated with the treatments.

Their estimates found that over a lifetime, the vegetable and fruits model would prevent 1.93 million CVD events and 350,000 CVD deaths while saving $40 billion in healthcare costs. The healthy food model would prevent 3.28 million CVD cases and 620,000 CVD deaths, prevent 120,000 diabetes cases, and save $100 billion in healthcare costs.

However, the net cost of the first model—subsidies minus healthcare savings—would be $84 billion while the second would cost $111 billon. It would improve the quality of life, but at a price. It’s easy to get lost in big numbers so let’s bring it down to the individual. After deducting healthcare savings, it would cost $110 per person per year for the fruit and vegetable subsidy and $185 per person per year for the healthy foods model. Does that seem like a reasonable investment for a healthier life for everyone?

The unknowns are whether physicians would actually write the prescriptions for foods; they’re not known for their nutrition knowledge and have a tendency to look for a pharmaceutical solution. But I think that’s minor; the real unknown is whether people will actually buy healthier foods and eat them.

We’ll find out: $25 million has been set aside in the 2018 Farm Bill to run pilot programs. It will be years before we know the results, but it’s a start to see if the theoretical will meet the actual.


The Bottom Line

Using food to improve health and quality of life makes sense. Whether having insurance companies or government pay 30% for healthier foods will work, I’m not convinced. I get the reduction of CVD events and deaths that could potentially be saved and the reduction in healthcare costs, but I question the $100 billion price tag without a public health education program to go along with it. Maybe a better approach would be to invest in the public health education program to teach people and physicians how they can use food to be healthier.

But now you know how a healthier diet could affect your life. What are you prepared to do today?

        Dr. Chet

Reference: PLoS Med 16(3): e1002761. https://doi.org/10.1371/journal.pmed.1002761.

Drop and Give Me 41

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The study on firefighters, push-ups, and CVD was interesting—not only for the relationship between push-ups and CVD, but also for the other relationships between the number of push-ups and other variables. Here’s a summary:

As the number of push-ups increased:

  • Body mass index decreased
  • Systolic and diastolic blood pressure decreased
  • Blood sugar decreased
  • Total cholesterol, LDL-cholesterol, and triglycerides decreased
  • HDL-cholesterol increased

One more thing: age decreased as well. In other words, the men in the study who could do more push-ups were younger. Was that the real reason—they were younger so naturally they could do more push-ups? They accounted for age in the statistical analysis, so it doesn’t appear to be so.

Does this study show cause and effect? No, because it’s observational. What it shows is that the lifestyle of the subject is important in the development of CVD. The subjects who had the greatest reduced risk had the highest aerobic and strength fitness, which may be reflective of an overall healthy lifestyle. Because push-ups require no equipment, progress can be easily tracked in a physician’s office. That was the actual point of the study: a simple test that could be predictive of CVD among other factors.

Here’s my challenge to you. After you see how many you do as a baseline, work at doing push-ups every day until you can hit 41. If you can’t do one, start with knee push-ups, push-ups from an exercise ball or chair, or wall push-ups (stand more than an arm’s length from the wall). As you can get to 41 one way, move to the next more difficult type.

When you get to 41, send me an email saying you did it and I’ll send you a coupon code good for 30% off the Optimal Performance Program; Member and Insider discounts apply. I’ll take you at your word, no selfies and no videos. After all, the only person you would be cheating is yourself and your risk of heart disease. I know age doesn’t matter; one of my readers in his 80s can already do this challenge. All it takes is a little sweat equity. Check with your doctor and get started.

What are you prepared to do today?

        Dr. Chet

Reference: doi:10.1001/jamanetworkopen.2018.8341.

Push-Ups and CVD

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On Tuesday, I asked you to see how many push-ups you can do before you can’t do any more (if you’re fit enough with no real orthopedic issues). How did you do? I have torn biceps in both arms, but I managed to eke out 21. But you may be wondering why I asked you to do push-ups.

A study published in JAMA Online periodically tested a group of 1,500 firefighters between 21 and 66 in 2000 to 2007. They were given several tests including maximal exercise capacity, height, weight, blood pressure, blood glucose, and the number of push-ups they could do. They were tracked for 10 years.

Researchers divided the results into quintiles based on the number of push-ups. They found that as the number of push-ups increased, the rate of CVD decreased. While not all comparisons were statistically different, there was a definite pattern of benefit.

That wasn’t the only data that proved to be interesting in the study. I’ll finish it on Saturday, along with a challenge.

What are you prepared to do today?

        Dr. Chet

Reference: doi:10.1001/jamanetworkopen.2018.8341.

Once a Year, No Matter What!

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I was in the gym locker room recently when I heard a guy ask a question: “Can I use any locker or are they assigned?” I turned to see if he was talking to me, but another guy told him there were no assigned lockers and to use whatever is open. That’s when the locker seeker said, “I couldn’t remember because I’m here only once a year.”

I thought maybe he uses this gym only when he visits this area. Then I realized he meant he gets to the gym only once a year, probably making light of his infrequent visits. The problem is that seems to be what most Americans do: buy gym memberships and never use them.

That’s why a study just published this past week is important. Researchers examined a number of physical variables in a group of firefighters and tracked them for ten years; the goal was to look at factors related to cardiovascular disease. I’ll talk about that study this week.

In the meantime, if you’re fit enough with no real orthopedic issues, see how many push-ups you can do before you can’t do any more.

What are you prepared to do today?

        Dr. Chet

The Bottom Line on the 2018 Cholesterol Guidelines

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In Thursday’s Memo, I talked about the 2018 Cholesterol Guidelines and evidence-based medicine, focusing on the physician side of the treatment discussion. But I believe that’s not the most important part of the discussion; I think the critical part is the patient side. Here’s why.

The Cholesterol Guidelines focus on lifestyle changes first: a healthier diet, exercise, quitting smoking, and weight loss. That’s supposed to be the initial part of the potential treatment plan—lifestyle first. In other words, what will the patients do for themselves before the discussion leads to medications, especially statins?

The guidelines aggressively focus on the use of statins and other medications to get the LDL-cholesterol to desirable levels, so we have a dilemma during the discussion of a treatment plan. Do the physicians assume, based on experience, that the patients won’t do what they’re supposed to do to lower their risk of CVD and immediately prescribe medications? Or do the patients take the lifestyle route seriously and do what’s necessary to change their health?

To be blunt, we patients haven’t done our part. We lose weight and gain it back. We start to eat healthier and don’t sustain it. We start to exercise, but we let life get in the way and stop, or we push too hard and get injured and stop, or the weather turns colder or hotter and we stop. When we agree to change our health habits and then don’t follow through, we make our health issues worse—they’re still in there eating away at our lifespan and not being treated.

Don’t make promises you know you won’t keep; notice I didn’t say can’t keep, I said won’t keep. If you know in your heart you’ll never change your diet or keep up with exercise, the best thing you can do for your health is don’t delay: start taking the meds and start taking care of the problem.

Although I disagree with it, I get why physicians jump to meds. There’s only one way to change that: we have to prove them wrong when they assume we won’t stick to a healthier lifestyle.

The Bottom Line

The 2018 Cholesterol Guidelines put the responsibility for lowering the risk of CVD without medications in our hands—the patients. Work out a timeline with some concrete goals for each lifestyle area with your physician. It won’t be easy: regular exercise for life, eating better from now on, quitting smoking, plus getting to a normal weight and staying there will all take time and consistent effort. That’s okay because even if your risk of CVD is high, it doesn’t mean you drop dead tomorrow. Even if you fall into an at-risk scenario, I know you can do it. There are many tools to help you keep at it: an app, a workout buddy, a Facebook group, and more.

Instead of looking at your health challenge as an obstacle, look at it as an opportunity for better health. If you say you don’t want to take medications, this is your chance to prove whether you really mean it. I can’t guarantee you’ll never need the meds, but you can work your way down to a smaller dosage with fewer side effects.

It all depends on your answer to one question: what are you prepared to do today?

Dr. Chet

 

Reference: www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000625.

 

Aspirin and Unintended Consequences

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We began the week considering a type of shortcut to health called biohacking. The polypill was a biohack to reduce the risk of CVD events, but there’s no research showing whether the polypill will ever prove to be effective. However, the results of the ASPREE trial may give us an idea whether the long-term trials should ever be attempted (1-3). Let’s take a look at the results of the ASPREE trial and the effects of an aspirin a day on healthy older adults.

In the first paper, the researchers evaluated the data to see if those who took the aspirin had less disability (1). In other words, did taking the aspirin convey benefits that reduced the risk of death, disability, or dementia? The data showed no differences between the aspirin and placebo group as it related to those outcomes.

In the second paper, the researchers examined the differences in all-cause mortality (2). What surprised the researchers was a slight increase in death from cancers in the group that took the aspirin; no specific type of cancer seemed to be impacted. Because aspirin has been shown to be beneficial in almost all other studies of cancer and mortality, the researchers said the results should be taken with a degree of caution.

In the final paper, researchers examined whether aspirin reduced the rate of CVD events and stroke (3) and found no difference, but the risk of hemorrhagic stroke was significantly higher in the aspirin group versus the placebo. This was the primary reason the study was terminated after five years.
 

The Problem

There were several problems with the study including the low adherence in both the aspirin and placebo group: if people didn’t take the pills, obviously that impacts the results. But the biggest question I have is a very simple one: who thought it was a good idea to give healthy people a medication every single day? Taking an aspirin for a headache or muscle ache is one thing. Taking it when you don’t need it is another.

The study demonstrated the logical fallacy of the polypill. “People won’t take care of themselves, so let’s put everyone on the medications that can reduce the risk of CVD.” No, let’s not. The results were unintended consequences that put the entire idea of biohacking into question.
 

The Bottom Line

When it comes to health, there are no real shortcuts. Biohacking, while a cute contemporary term, is fool’s gold. Yes, you can use your time and resources more efficiently to improve your health, but there are no shortcuts.

There is also one other obvious conclusion. Healthy people shouldn’t take medication. I take an 81 mg aspirin every day because I have had a stent and my doctor told me to. But I don’t take a statin any more because I changed my diet and lifestyle to keep my cholesterol normal. I control my blood pressure with diet and exercise. I don’t take medications I don’t need.

If you’re willing to do all you can to avoid medications and you still need medication to help you out, do it. But don’t take them to avoid doing the work. There are unintended consequences of taking the easy way out.

What are you prepared to do today?

Dr. Chet

 

References:
1. DOI: 10.1056/NEJMoa1800722.
2. DOI: 10.1056/NEJMoa1803955.
3. DOI: 10.1056/NEJMoa1805819.

 

An Aspirin a Day

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In Tuesday’s Memo, I talked about biohacking. Specifically, I talked about the idea of having everyone over a certain age take a pill that can impact the risk factors for CVD: high blood pressure, cholesterol, high heart rate, and blood cell stickiness. The idea is that taking that single pill in low doses every day might help reduce CVD events such as strokes and heart attacks.

Researchers in Australia and the U.S. decided to test one component of the polypill: aspirin. The study was called the Aspirin in Reducing Events in the Elderly (ASPREE) trial. They recruited over 19,000 people 70 and older or 65 if they were Black or Hispanic in the U.S. They randomly assigned half the subjects to take 100 mg of enteric-coated aspirin while the other half got a similar looking placebo. The subjects were tracked for an average of 4.7 years. The researchers examined many variables including mortality and the incidence of disease.

The results were published in three separate papers in a recent issue of the New England Journal of Medicine. The study was terminated after five years by the primary funding organization, the National Institute on Aging. The results were not exactly what was hoped. We’ll get into the details on Saturday. If you’d like to read the studies, all are available online at the links in the references.

What are you prepared to do today?

Dr. Chet

 

References:
1. DOI: 10.1056/NEJMoa1800722.
2. DOI: 10.1056/NEJMoa1803955.
3. DOI: 10.1056/NEJMoa1805819.

 

Yes, Supplements Matter

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The study that was published in the Journal of American Academy of Cardiology created several issues that go beyond the headlines of supplements being of no benefit. Let’s first take a look at the published results of the study.

The researchers found that most supplements such as multivitamins, vitamin D, calcium, and vitamin C do not have a significant effect on cardiovascular disease or overall mortality. On the other hand, folic acid had a significant beneficial effect on reducing stroke and overall CVD, and B-complex, a vitamin with a variety of B vitamins in it, also helped reduce the incidence of stroke. However, the study showed antioxidants had a negative effect on all cause mortality as did niacin. Whether beneficial or not, the results, while statistically significant, were not clinically significant.

The researchers stated that they expected beneficial effects on the reduction of cardiovascular disease and overall mortality. The fact that they did not find those benefits resulted in the headlines that supplements don’t matter.

Here are just three of the issues with the study. They included studies with different nutrients as well as studies that didn’t have the same amount of nutrients. The RCTs included in the analysis did not have the exact same amounts of any given nutrient in the supplement; three of the studies on antioxidants and cancer mortality had different amounts of beta-carotene and vitamin E. Another way of putting it was they not only were comparing apples to oranges, but they also compared three oranges to a dozen apples.

Another issue was adherence to the study rules. The subjects did not necessarily take all the supplements they were given, and compliance varied between the studies. Positive or negative effects could be determined by whether subjects took all of their supplements or took them only when they remembered or felt like taking them. The adherence to supplement use varied by study.

Here’s one more issue. Every RCT used supplements as a potential treatment for a disease—in this case, diseases related to the heart and the death rate from heart disease or other diseases. It’s the treatment model used by physicians: the pill, whether pharmaceutical or supplement, must reduce the incidence of or cure the disease. While desirable, that’s not what nutrition is all about.

The Bottom Line

While we would like to see research results that prove that we can live longer or better by taking supplements, that isn’t really the point in my opinion. We take supplements to fill the gaps in our diet. As the researchers point out, if everyone ate more plant-based foods, we could meet the minimal amounts of nutrients our bodies needs. That hasn’t happened in the 30 years I’ve looking at this issue, and I don’t see it changing any time soon.

Taking vitamin and mineral supplements serves as nutritional insurance to support your body’s processes and to make sure you don’t open the door for deficiency diseases; supplements are more like shotguns than rifles. Supplements do matter and I’m going to continue to take mine every day.

There are so many issues with this research paper—much too long for this Memo—that I recorded a Straight Talk on Health about them. If you’re a Member or Insider, you can listen to Research Update on Supplements any time. If you’re not, now is a good time to join.

What are you prepared to do today?

Dr. Chet

 

References: Jenkins, D.J.A. et al. J Am Coll Cardiol. 2018;71(22):2570–84.

 

The Truth Behind the Obesity Paradox

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In my opinion, the short answer to the obesity paradox is that it doesn’t really exist. But what fun would that be? That doesn’t teach you anything. Let’s take a look at the problems with the research that contributed to this paradox.
 

Study One: Dialysis, BMI, and Mortality

A study of dialysis patients led to the first observation that people with higher BMIs lived longer (1). After tracking over 1,300 subjects on dialysis for a year, researchers found that those who were overweight had a decreased risk of dying and had fewer hospital stays when compared to those who were underweight. This may have been the study that yielded the name The Obesity Paradox. The problem? The study lasted only one year. Trying to generalize what will happen to all overweight and obese people on dialysis from a study that lasted only one year and at only a single location isn’t realistic. It raises an intriguing question, but we’ll need a much more extensive study to really make a solid prediction.
 

Study Two: The Rotterdam Study

I described this study on Thursday (2). While the study appeared to show a protective benefit from being overweight or obese, the subjects were elderly with an average age of 77 at the study’s beginning. One risk factor that you cannot change is age: the older you are, the more likely you are to die. But that’s not the whole story. We can probably say that older people may live longer with a little extra weight, but to extend that prediction to all age groups isn’t valid.
 

Study Three: BMI and Mortality

While this study claimed to analyze the data on over two million people, it was still a meta-analysis (3), which doesn’t yield cause and effect, just a statistical association. Further, they used studies of varying lengths without necessarily knowing exact causes of deaths. They also did not have precise BMIs on everyone; some studies included metrics such as BMI under 27.5 and over 27.5. They tried to include the highest number of subjects, but the quality of data varied and that made it a mess. Researchers chose too many different types of studies in the meta-analysis, and it just doesn’t work. I wouldn’t bet my life on it.
 

Study Four: A Broader Look

The real problem with every approach is the lack of acknowledgement that people with advanced disease may have lost weight before they were included in the study; diseases such as heart failure, diabetes, or renal disease will often lead to weight loss. Those who were heavier when disease hit had the benefit of extra energy stored as fat to deal with the disease, and that could explain the outcomes of those studies. It had nothing to do with being obese; it was a matter of timing.

A study published last month appears to confirm that (4). Researchers in the Cardiovascular Disease Lifetime Risk Pooling Project obtained data from 10 different longitudinal studies, including individual-level data and accurate mortality data. They found that as BMI increased, the death rate from all forms of CVD increased. For those who carried extra weight while younger, CVD occurred earlier, making it more likely they would die before their time.
 

The Bottom Line

As I said, there really is no obesity paradox. Being overweight or obese carries with it risks of degenerative disease. Some people may have better genes and may gain protection for a few years. But in the end, being overweight or obese carries a higher risk of various diseases than the limited protection from an advanced disease you may gain by carrying extra weight. So my advice is the same as it always was: if you’re overweight, your best bet for a long, healthy life is to lose it.

What are you prepared to do today?

Dr. Chet

 

References:
1. Kidney International, Vol. 55 (1999), pp. 1560–1567.
2. European Heart Journal (2001) 22, 1318–1327.
3. JAMA. 2013; 309(1): 71–82.
4. JAMA Cardiol. doi:10.1001/jamacardio.2018.0022.

 

What Is the Obesity Paradox?

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Did you ever hear something that didn’t seem to make sense? That seemed to go against everything you thought to be true? One example of this is something called “The Obesity Paradox.” I’ve seen a few headlines this week that have talked about it, so it’s time to address it in the Memo.

One of the variables that we would think is related to the development of cardiovascular disease would be body weight. It seems logical: as weight increases, so does the strain on pumping the blood through the additional blood vessels required to feed the extra fat and muscle. People who are overweight may eat the wrong foods, consume too much food, and move too little.

But since the early 2000s, several studies have been published seeming to show that body weight wasn’t necessarily a risk factor for CVD or an early death. They showed that those who were overweight, a BMI between 25.0 and 29.9, had lower mortality rates than those who were normal weight. Some showed that stage-one obesity, a BMI between 30.0 and 34.9, was also not related to mortality. Thus the term “The Obesity Paradox” was coined. But is it true? We’ll take a look at the research the rest of the week.

What are you prepared to do today?

Dr. Chet