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About DR. BRET SCHER

Dr. Bret Scher may just be the most unique cardiologist you have ever met. Sure, he is a card-carrying, board certified cardiologist, and he spent years learning the invasive procedures and medications used to treat heart disease. Now, he wants to make sure those multi-billion dollar tools and drugs go unused.

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Dr. Bret’s Latest Blog Posts



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Blog / NutritionHere it is again. The term “healthy” connected as a descriptor. We see it all the time. Healthy Whole Grains. It reminds me of the common use of “fruits and vegetables,” as if they are one in the same. Are whole grains, by definition, “healthy?” For a full, in depth description, see the Whole Grains Guide on Diet Doctor, where I was the medical editor and reviewer. For the quick answer, let’s leave it as a “maybe.” If you choose to eat refined grains, white flour, processed snack foods, in essence the Standard American Diet, then switching to whole grains will almost certainly improve your health. And that is where the majority evidence in favor of whole grains stops. Compared to refined grains, they are great. Who should eat whole grains? If you are insulin sensitive, live in a society where you are physically active for most the day, eat fewer calories than most industrialized nations, and maintain a healthy body weight, then whole grains can be a healthy part of your diet. Observation of the Blue Zone countries demonstrate that whole grains can be part of a healthy lifestyle in that setting. We cannot, however, extrapolate those findings above to apply to all Americans, Europeans, Asians etc. and say whole grains are by definition “healthy.” Who should not eat whole grains? If you are metabolically unhealthy with diabetes, metabolic syndrome or insulin resistance (estimated to be 88% of all Americans), then whole grains are anything but “healthy.” Borrow a continuous glucose monitor for a day and see how your blood glucose responds to whole grains. If you aren’t perfectly metabolically healthy, it isn’t pretty. Instead, if you eat a whole-foods, low carb diet without grains and sugars, then whole grains have no necessary role and no association with health. Enjoy the more detailed guide from DietDoctor. Thanks for reading, Bret Scher, MD FACC [...]
Blog / CommunityThey just keep getting better. These low carb conferences keep raising the bar, and they keep exceeding my expectations. Low Carb Denver was no exception.   Robb Wolf on Low Carb Myths   The conference started out with Robb Wolf dispelling the unfounded myths that low carb is dangerous or associated with dying earlier. The quality of science that gets promoted in the media is nauseating, and Robb did a wonderful job highlighting that. (Plus, we had a fantastic podcast interview later that day, so stay tuned for that!)   Georgia Ede on the EAT Lancet Report Next up was Georgia Ede, who destroyed the EAT Lancet report. By saying “destroyed,” I don’t mean she was malicious or attacking. Rather, Georgia was her usual incredibly analytical and science-based self. She showed how the report was based on faulty science, and how the recommendations weren’t even supported by the faulty data they used. It is mind boggling how this amounts to a well-funded PR campaign masquerading as science, and Georgia was masterful at demonstrating this fact.  Bonus- Georgia sat down for another action packed podcast interview. (You will love this one!)   Low Carb Practical Implications From there, we got into practical implications such as how low carb might be an adjunctive treatment in cancer, how it can be safe in pregnancy, and Jason Fung showing how PCOS is essentially a disease of hyperinsulinemia. What’s the best treatment for hyperinsulinemia? Let’s say it together… LCHF! (and I had an amazing podcast interview with Jason as well!) Then the controversy started.   LCHF Controversy Kudos to the organizers for stirring things up with presentations followed by a civil debate between Dr. Dariush Mozafarrian and Gary Taubes.  It’s important to recognize intelligent opinions and scientific interpretation don’t always agree. This was a nicely highlighted in this section. There are plenty of times when opinions and “data” against low carb are based on weak or nonexistent science. The discussion with Gary and Dariush showed the nuances of interpreting science, something I aim to continually help with!   Zoe Harcombe on Fiber Fast forward to day two when Zoe Harcombe brought down the house with a riveting talk on how we don’t need fiber. None. Not at all. Zilch. If we eat tons of refined carbs, then fiber is helpful. If we don’t, then don’t worry about fiber! This was a great talk with perfectly placed “potty humor” as Zoe called it.   My Talk Next came my favorite part of the conference. But then again I am biased. It was a 1-2-3 cholesterol punch with Dr. Paul Mason, myself, and Dr. Nadir Ali all discussing different aspects of cholesterol. The take home is that things are different with LCHF. The physiology changes and the existing cholesterol evidence does not reflect the specific subset who follow a healthy low carb diet. That much we know. Yet, there is much we don’t know. These back-to-back-to-back talks helped highlight this.  That’s why I advise everyone following a LCHF lifestyle to see a practitioner experienced with LCHF. It doesn’t mean ignore cholesterol, but it does mean seeing it in a different light. As if the first two days weren’t enough, day three kicked off with Dr. Eric Westman, followed by Dave Feldman sharing his amazing N=1 clinical data from the past year. Beware of coffee and high triglycerides!   The Diet Doctor on Long-Term LCHF Diets Then came The Diet Doctor himself, Dr. Andreas Eenfeldt showing us how low carb diets do work in the long term. We just have to stick with them. This was a nice compliment to the earlier talk from Dr. David and Jen Unwin showing us how hope is a powerful force to maintain compliance and behavioral change.   LCHF and Sexual Health And then we had a new topic for the LCHF meeting, sexual health. Perfectly delivered by stand-up comedian and low carb physician Dr. Priyanka Wali, her talk showed us how the number of problems LCHF helps continue to add up. That is why most of the time we are better off thinking of LCHF as an overall healthy lifestyle rather than a “treatment” for a specific disease. LCHF Community Despite all these amazing talks, however, the real star was the community. The interactions I had and witnessed between everyone, healthcare providers or not, showed the level of engagement, intelligence, and hope this community represents. My personal highlight may have been having dinner with an ER doc, family practice doc, forage agronomist and ceramics teacher.  All of us with eclectic backgrounds, and all of us wanting to improve the health of the world (people and the environment). It was a week’s worth of interactions packed into three days. And it leaves me hopeful for the future of science, the future of nutrition, and the future of health. Thanks for reading! Bret Scher, MD FACC [...]
Blog / HealthcareWe had an incredible turnout for our Webinar, aimed to help you transform your health in 2019. As a result, we decided to create a blog post that includes the full webinar recording, as well as an overview of the learnings for those that were unable to attend. Webinar Recording Webinar Overview Cardiovascular Disease Is the #1 Killer for Men and Women 1/3 of all Americans die from Cardiovascular disease Around 92 million Americans are living with CVD Every 34 seconds someone suffers a heart attack Annual health expenditure and lost productivity from CVD ~$330 billion It’s been estimated that 50-80% of these are preventable! Unfortunately, our healthcare system and associated lifestyle guidelines have failed to prevent disease. We could say at best they have failed to prevent heart disease, obesity and diabetes. At worst they have been implicit in its prevalence. While this graph doesn’t show causation, it certainly shows the association of instituting national nutritional guidelines and the rise in diabetes. Drugs Don’t Fix the Problem 60% of Americans take at least 1 prescription drug 15% take more than 5 drugs Despite this, our overall health and life expectancy continue to decline HEALTH IS NOT THE ABSENCE OF DISEASE! In this webinar, we will discuss how to be your own best advocate, why low carb, high fat nutrition should be an option for everyone, and how lifestyle really is the best medicine. 3 Interventions to Improve your Healthcare Experience and Be Your Best Advocate Make sure your doc is working with accurate information! Lipids and blood pressure are two prime examples of when doctors make decisions based on limited and faulty information. Get your questions answered by writing them down ahead of time so you don’t forget anything and tell your doctor at the beginning of the appointment that you have some questions you’d like to ask at the end. Make sure you understand the purpose and benefit of each and every medication. Not some vague answer like “It will improve your cholesterol,” or “It will lower your blood pressure.” Rather, “what impact will it have on my longevity and quality of life?” Will I live longer? Will I feel better? What are the chances the drug will actually benefit me? These are the questions we need answered. Why Low Carb, High Fat Nutrition Should be an Option for Everyone! LCHF vs Low Fat Diets LCHF Benefits Decreased hunger, increased energy, mental clarity Treats metabolic syndrome/insulin resistance Better weight loss Improves overall cardiovascular risk for most people LCHF may not be the best for everyone, but it certainly should be an option for everyone. If you want tips that do work for everyone, follow these bonus tips for weight loss and overall health! Don’t drink your calories – even “natural” drinks are full of unnecessary calories. Think about it this way, you would drink a glass of orange juice, but would you really sit down eat the 5 or so oranges it takes to make it? If not, why drink that same amount? Get rid of “Food Delivery Systems” – Think about the big sandwiches or burritos we see everywhere in our culture. What is the food? The stuff in the middle! The meat, the cheese, the veggies. What is the unnecessary food delivery system? The bread, the tortilla, the outer layer that has a fraction of the nutrients and a multitude of the carbs! Lifestyle Really is the Best Medicine! Science says lifestyle, not drugs, reverse disease: NEJM study reported findings on patients at highest genetic risk for heart attack, over 90% more likely to suffer heart attack. Those with healthy lifestyles had a 50% reduced risk with no drugs and no surgeries! JACC study found 85% of all heart attacks could be prevented with greater attention to lifestyle. A 2018 British Journal of Sports Medicine study found that increasing walking pace to “brisk” for those over 50 reduced all-cause mortality and cardiovascular mortality by 20-24%. Why is it so hard? We have all been told that in order to be healthy, we need to eat less, move more, and reduce fat in our diets. But if that is the case, why is it that only 12% of Americans are metabolically healthy, and only 3% of Americans follow a healthy lifestyle? Because the simple Eat Less, Move More, Reduce Fat approach DOESN’T WORK!!! I want to assure you that it’s not your fault, you’ve been given the wrong information. “I was always told I simply didn’t have enough willpower to stick to a diet. I couldn’t understand why I was always hungry and craving foods. I figured it was all genetics. But working with Dr. Scher showed me there is a better lifestyle that I can stick with and still feel great and enjoy my life! Thanks Dr. Scher!” E Keys to Making Lifestyle Change Stick Beware of one-size-fits-all nutrition and lifestyle claims Individually tailored and flexible nutrition is the key. When you eat is just as important as what you eat Move your body more Get Serious about your sleep Don’t be afraid to test and adjust A Word of Caution Don’t try to Change Everything at one time. Choose YOUR most important first step (nutrition, stress, fitness, etc.) and work on that until a new habit is created! And remember, you don’t have to do it alone! Working with an expert who can help you on your health journey will increase your likelihood for long term success. As you can see, this was a quick tour to highlight the main points in the webinar. To get the full benefit, I recommend watching the full recording to get all of the context and be able to see the Q&A session at the end. If you want to get the full experience, here is that recording again: If you’d like to see the date and content of our next webinar, or be notified when our next webinar will be, please visit our Webinar Page. I hope you enjoyed this recording, and that we will see you at the next live webinar!   Thanks for reading, Bret Scher MD FACC [...]
Blog / HealthcareWhat do I mean by “misunderstood?” Look no further than the common misnomer of “good” or “bad” cholesterol. Good and Bad Cholesterol While it may be true that High-Density Lipoprotein (HDL) has potentially beneficial functions (reverse cholesterol transport), we have to remember there is no such thing as good and bad cholesterol. The cholesterol carried by HDL is the same as that carried by LDL. The only thing that makes it good or bad is if it ends up synthesizing our hormones or bile acids (good), or if it ends up in our vessel walls (bad). If it’s true there is no such thing as good and bad cholesterol, why do we care about our HDL levels? First, let’s start with the basics. HDL is the smallest and most densely packed lipoprotein and has one or more ApoA protein on its surface. HDL can help lipids move around in circulation by accepting triglycerides or cholesterol from other particles, thus helping a VLDL turn into an LDL, or helping an LDL contain less cholesterol (turning a small dense LDL into a less densely packed LDL). Like LDL, HDL transports cholesterol to the liver for recycling or excretion, or to the hormone producing cells like in the adrenals. Unlike LDL, HDL does not have the potential to get retained in the vascular wall and does not, therefore, contribute to plaque formation. In fact, functioning HDL can remove cholesterol from the vessel wall, thus putting it back into circulation and possibly removing it from the body. Back to the question at hand.   Why should we care about HDL levels? Early epidemiological trials showed that lower HDL levels were associated with a higher risk of cardiovascular disease and even death.  With such a strong association, the medical profession promoted elevated HDL levels as protective and low levels as something we need to avoid. Since these were observational epidemiological studies, they do not prove that the low HDL caused the problems, only that HDL was associated with it. For instance, HDL is also known to be low in diabetes, metabolic syndrome and insulin resistance. It may, therefore, simply be a marker of underlying metabolic dysfunction that contributes to increased risk.  Yet, HDL’s function in reverse cholesterol transport, and its ability to remove cholesterol from vessel walls suggests a more direct impact on cardiovascular health. It is also important to note that the Framingham data suggested that increased cardiovascular risk with elevated total cholesterol and LDL-C was lost in the presence of high HDL. In fact, very low levels of LDL combined with very low HDL levels had a much higher risk than markedly elevated LDL levels when combined with elevated HDL. Thus, HDL proves to be a useful marker to help predict cardiovascular risk. For instance, one large meta-analysis showed that total cholesterol/HDL ratio was a much stronger predictor of cardiac mortality than total cholesterol alone. In addition, the PURE study, an observational trial in over 135,000 subjects, showed that when considering lipid changes brought about by nutritional changes, ApoB/ApoA1 (essentially LDL-P/HDL-P ratio) is the best predictor of clinical outcomes. Thus, HDL level is important in assessing cardiovascular risk.   Drugs Muddy the Picture While HDL may be a good predictor of risk, raising it with drugs does not seem to confer added benefit. For instance, cholesterol ester transferase protein inhibitors (CETP inhibitors) significantly reduced LDL by 20-30% and increased HDL 100-fold, yet showed either no clinical benefit or even worse, an increased risk of death. This was a shock to many in the lipid world as the notion of “good” and “bad” cholesterol would clearly predict lowering LDL and raising HDL would confer dramatic health benefits. So much so, that multiple pharmaceutical companies invested hundreds of millions of dollars developing these drugs only to abandon them when the trials showed no benefit. Part of the issue is that not all HDL lipoproteins function the same. There are subsets of people with genetically determined markedly elevated HDL levels who have an increased risk of CVD. They may have plenty of cholesterol circulating in HDL particles, but the HDL particles are dysfunctional and therefore  do not effectively remove cholesterol from vessel walls or LDL and do not effectively transport it to the liver. Conversely, there are those with a specific genetic mutation called ApoA1 Milano who have very low HDL-C and lower cardiovascular risk. Simply measuring the HDL cholesterol content, therefore, may not accurately reflect its function. While we do not have easily available tests to measure HDL function, we can potentially use HDL particle assessment as well as the company it keeps (i.e. low triglycerides, larger less dense LDL particles) to better assess the potential benefits of HDL. Thus, if there is any concern about potentially dysfunctional HDL, I usually recommend advanced lipid testing to see the specific subtypes of HDL. What can we conclude from all the HDL confusion? Raising HDL with drugs does not reduce cardiovascular events, yet having a naturally low HDL is associated with increased risk. The best answer, therefore, is to live a lifestyle that helps you have a “not low” HDL level. This means first and foremost avoiding the medical conditions associated with low HDL (i.e. insulin resistance, diabetes, and metabolic syndrome). Textbooks predictably state the interventions to naturally raise HDL include exercise and moderate alcohol intake. Unfortunately, these have minimal effects. In fact, they pale in comparison to a low carb high fat lifestyle. In my 20+ years in the medical field, I have never seen an intervention as effective as LCHF in raising HDL, and the studies agree. This brings us back to our question once again. Why are HDL levels important? HDL levels are important because it is a reflection of our underlying metabolic health and our lifestyle. A properly constructed LCHF lifestyle lowers triglycerides, raises HDL, and reduces the small dense LDL, among other benefits. Such a lifestyle likely reduces overall cardiovascular risk and will likely be shown to improve longevity and health span. While HDL may not be the main reason for this, we can’t ignore its role simply because it is more nuanced than “good” and “bad” cholesterol. My advice, therefore, is to see the whole picture. Embrace the nuance. And make sure you get a thorough and proper evaluation of your cardiovascular risk. If you are hungry for more, I created my Truth About Lipids program, a program focused on Cholesterol, to help break through the confusion and provide you with everything you need to thoroughly understand cholesterol and its impact on your health. Learn more: Truth About Lipids Program   If you still have questions, you may want to consider a one-on-one health coaching consultation so you can get the individual attention you deserve  with a thorough assessment of your lifestyle and its impact on you as an individual. Please comment below if you have any questions or comments that may help further the discussion. Thanks for reading. Bret Scher MD FACC [...]
BlogThis past weekend, I had the pleasure of attending the Low Carb USA Conference in West Palm Beach. I was blown away by the amazing community of providers and participants. Everyone I came across was very engaged and hungry for knowledge. There was also a special day devoted to the Spanish speaking audience. I was impressed by their growth from previous conferences. Low Carb Spanish-Speaking Leader Ignacio Cuaranta One leader in the Spanish speaking community is Ignacio Cuaranta, who is also a leader promoting low carb for the prevention and treatment of mental disorders. A big take home from his keynote was that that problems with our brains are not that different from the problems with our body. Metabolic derangements affect both, and low carb nutrition appears to be very beneficial for both.  I was lucky enough to record a podcast with him, so look for that in the near future! I don’t want to give away all the spoilers but suffice it to say, he is seeing outstanding success with Low Carb and Intermittent Fasting in his practice.   Dr. Robert Cywes on Carbohydrate Addiction The headliner of the meeting was Dr. Robert Cywes. He is a weight loss bariatric surgeon, and the most unique surgeon I have ever met. He doesn’t want to operate. He would rather cure people of their underlying carbohydrate addiction and help them heal themselves. He has a refreshing perspective focusing on the emotional and psychological aspects of weight gain and recognizes that food choices alone won’t help if these aspects aren’t also addressed.  I also recorded a podcast with him so stay tuned for that!   Dr. Will Cole Spoke About Vegetarian Keto Dr. Will Cole presented his case for Keto-tarians, essentially vegetarian ketosis. One of the predominate theories is that when we are in ketosis, our bodies require much less protein that we otherwise would. That way we can focus more on the non-animal fats and worry less about getting our 20+% of calories from protein. It is an interesting theory that he has had success with and highlights that a ketogenic diet can take many forms and mean different things to different people.   Dr. Ryan Lowery on Ketosis Being Protein Sparing Florida’s own Dr. Ryan Lowery from ASPI echoed Dr. Cole’s theory that something about being in ketosis appears to be protein sparing, thus we don’t have to eat as much for muscle growth or maintenance. He also shared his research in rats that suggests lifelong ketosis promotes longevity. And guess what? That’s right, I filmed a podcast with him as well! This one was packed with information and I know you will love it as much as I did.   The food was fantastic! Did I mention the food? WOW, the food was incredible! Some of the best conference keto buffets I have seen. The leg of lamb with onions on Friday night along with the spinach salad, avocado, and fat-soaked veggies were just what this doctor ordered (pun intended!) I was in Keto heaven.   Learning from the conference overall As usual the team from Low Carb USA did an incredible job and the event went off without a hitch. It inspired me to take away lessons on how they put together a successful conference for hundreds of people and adapt it to our upcoming intimate and personalized Low Carb Beach Retreat in April. At this retreat, we will combine the benefits of didactic teaching with small group discussions and development of individualized low carb programs.  Due to its small size spots are limited so reserve your spot today! [...]
Blog / HealthcareWe hear the words Heart Healthy a lot, especially when it comes to our nutrition.   By now, you’re likely used to seeing cereals with the “heart healthy” moniker. Is it really heart healthy? We all too frequently refer to foods as “heart healthy”, or we say that our doctor gave our hearts a “healthy” checkup.     It all sounds nice. But what does it mean? How do we define heart health?   How does LDL Cholesterol affect Heart Health?   Unfortunately, most of our current definitions center around LDL cholesterol concentration.  While LDL cholesterol plays a role in heart health, it by no means defines heart health in totality.   In fact, in many cases it is the least important factor.   Our healthcare system has simplified things too much, so as a result we focus on one bad guy, one demon to fight. In reality heart disease is caused, and made more likely to occur, by a constellation of contributing issues.   Elevated blood sugar, elevated insulin levels, inflammation, high blood pressure, poor nutrition, and yes, lipids all contribute to heart health.  It does us all an injustice to over simplify it to one single cause.   What food is heart healthy?   Our superficial definition of cardiac risk is how industrial seed oils containing polyunsaturated fatty acids (PUFAs) became known as “heart healthy.”   Studies show that they can lower LDL. But they can also increase inflammation and have no clinical benefit and even increase risk of dying. According to our simplified definitions, that doesn’t stop them from being defined as “heart healthy.”    That’s right! Something that increases our risk of dying is still termed “heart healthy.”  How’s that for a backwards medical system?!   Same for blood sugar. If you have a diagnosis of Type 2 Diabetes (DM2) that is a risk for cardiovascular disease. If you don’t have the diagnosis, you are fine. That ignores the disease of insulin resistance that can predate diabetes for decades and increases the risk of heart disease and possibly even cancer and dementia.   Cereal can also be called “heart healthy” as they may minimally lower LDL. But is that a good thing if they contain grains that also worsen your insulin resistance and metabolic syndrome? I say definitely not.   Time has come to stop this basic, simplified evaluation and start looking at the whole picture.   How Low Carb High Fat Diets Improve Heart Health   Low carb high fat diets have been vilified as they can increase LDL. But the fact of the matter is that it does so only in a minority of people. The truth is that they can improve everything else!   These diets reduce blood pressure, reduce inflammation, improve HDL and triglycerides, and reverse diabetes and metabolic syndrome! Shouldn’t that be the definition of “heart healthy” we seek? Instead of focusing on one isolated marker, shouldn’t we define heart health by looking at the whole patient?   Only by opening our eyes and seeing the whole picture of heart healthy lifestyles can we truly make an impact on our cardiovascular risk and achieve the health we deserve.   Join me in demanding more. Demand better.   Thanks for reading, Bret Scher, MD FACC [...]
Blog / FitnessWith New Year’s resolutions looming, many people are thinking about reinvigorating their health. In fact, 45% of people want to lose weight or get in shape as their New Year’s resolution. The LCHF Keto diet has been quickly gaining momentum, and it is piquing a great deal of curiosity. So, is this particular diet right for you? It may just be.   What are your diet goals? Before selecting a diet, it’s important for you to define why you want to diet in the first place. Are your goals weight loss, general health, or a combination? If you want to lose weight, reduce your hunger, enjoy your meals, and improve your metabolic health, then LCHF may be right for you.   Do you want to lose weight? The primary reason most people go on a diet is to lose weight. As far as weight loss, low carb has you covered. Out of 60 studies comparing low carb to low fat diets, low carb had better weight loss in 30 and they were equal in 30. Low carb was inferior in exactly zero of these studies. That’s an impressive record, and definitely something to consider if weight loss is your primary goal. But there is so much more to life and health than weight loss.   Do you want to reduce your hunger? One main struggle in health and weight loss is how hungry we are and how much we need to think about food during the day. Studies show that following a LCHF diet reduces our hunger in the long-term. That means less worry about constant snacks, and less concern with needing to eat every few hours. In fact, LCHF works so well at curbing appetite that more people can practice time-restricted eating by compressing eating into a 6-8 hour window, which has indicated potential beneficial effects for longevity.   Do you want to improve your focus? Food, especially the wrong food, can make us feel lethargic and unfocused. Many people report thinking more clearly and having better mental performance when on a low carb diet. The brain loves ketones, whereas carbs can cloud your thinking. Why not switch to low carb and see if your brain fog lifts?   Do you want to improve metabolic health? A recent study showed that only 12% of Americans are metabolically healthy. Low carb diets are one of the fastest and best ways to improve metabolic health. Studies show it puts type 2 diabetes in remission, improves insulin resistance, reduces visceral fat, and improves overall metabolic health.   Do you want to decrease your cardiovascular risk? Fat phobia is gone. Limiting carbs to real food veggies and eating plenty of healthy fats improves our cardiovascular risk profile. It reduces BP, reduces TG, increases HDL and improves the size and density of LDL, which all add up to a net improvement in cardiovascular health.   The main reason you should consider LCHF/Keto in the new year You will love it! No counting calories, no feeling hungry, no wild glucose swings and post meal crashes, no afternoon slump. With all of this research backing this diet, it’s definitely worth a try.   One last consideration A note of caution, most people will do great. But not everyone reacts to this diet the same way, so you may want to consult a doctor experienced in low carb nutrition. If you don’t already have a doctor to consult with or want to speak with one who specializes in Keto, I’m a professional who has extensive experience with LCHF diets and how they affect your health. If you’re just getting started, I recommend downloading my free LCHF/Keto starter tips e-book to get you on the right track:       If we can be of any additional service, please let us know! Thanks for reading, Bret Scher, MD FACC [...]
Blog / NutritionA new study published in the European Heart Journal says we should care about blood levels of a metabolite trimethylamine N-oxide (TMAO), but is that true? NBC News: Study explains how red meat raises heart disease risk For starters, this was a well run and controlled study. Researchers randomly assigned 133 subjects to one of three isocaloric diets with the only difference being the presence of red meat, white meat, or vegetarian protein. Similar to the study by Dr. Ludwig that we referenced earlier, a strength of this study was that the study team supplied all meals for the subjects. Therefore, there was no guessing about what the subjects ate or if they complied with the recommendations. That makes this a strong nutritional study. Subjects stayed on each diet for four weeks and then had a washout period before transitioning to the next diet. The main take home is that eating red meat increases the blood level of TMAO, which declines after four weeks off the red meat diet. As described in the article: a red meat diet raises systemic TMAO levels by three different mechanisms: (i) enhanced nutrient density of dietary TMA precursors; (ii) increased microbial TMA/TMAO production from carnitine, but not choline; and (iii) reduced renal TMAO excretion. Interestingly, discontinuation of dietary red meat reduced plasma TMAO within 4 weeks. It is important to note in our era of frequent conflicts of interest, NBC news reported that the lead investigator for the study is “working on a drug that would lower TMAO levels.” While that in no way invalidates the findings, it does legitimately raise suspicion for their importance. Interestingly, the study did not test eggs, another food reportedly linked to TMAO. They did, however, note that increased choline intake, the proposed “culprit” in eggs, had no impact on TMAO levels. The study also did not investigate fish. Fish, traditionally promoted as “heart healthy,” has substantially higher concentrations of TMAO than meat or eggs. One thought, therefore, is that high TMAO levels are produced by gut bacteria rather than the food itself. Although this is an unproven hypothesis, it would also explain variability among subjects. Now for the harder question. Does any of this data matter? For this study to be noteworthy, we have to accept the assumption that TMAO is a reliable and causative marker of heart disease. The main NEJM study linking TMAO to an increased risk of cardiovascular disease is not as conclusive as many promote. First of all, only those at the upper quartile of TMAO level had a significant increase in cardiovascular disease risk. Lower elevations had no significant correlation. Second, those with increased TMAO and cardiovascular disease risk also were more likely to have diabetes, hypertension and a prior heart attack; furthermore, they were older, and their inflammation markers, including myeloperoxidase, a measurement of LDL inflammation, were significantly higher. With so many confounding variables, it is impossible to say the TMAO had anything to do with the increased cardiovascular disease risk. This study in JACC that saw a correlation with TMAO and complexity of coronary lesions, also found an increased incidence of diabetes, hypertension, older age in the high TMAO group. Finally, this study found no association at all between TMAO levels and increased risk of cardiovascular disease. Based on these mixed findings, the jury is still out, and we have plenty of reason to question the importance of elevated TMAO as an independent risk marker or causative factor of coronary disease. Most importantly, however, since multiple studies continue to show no significant association between meat and egg consumption and increased heart attacks or mortality risk (references here, here, here, here and here) the weak surrogate markers don’t seem likely to matter much. Don’t get caught in the minutiae. Focus on a real-food diet that helps you feel better and improves the vast majority of your markers. And if you have elevated TMAO, the studies suggest you should also check your blood pressure, blood sugars, and inflammatory markers as they may also be elevated. In my opinion, until we have much more convincing data on TMAO, you are far better off targeting those more basic parameters than a blood test of questionable value. Thanks for reading, Bret Scher, MD FACC   Originally Posted on the Diet Doctor Blog  [...]
Blog / HealthcareThe medical world experienced yet another guideline update in 2018 telling doctors more medication is better. This guideline for treating hypertension was put out by the American College of Cardiology and the American Heart Association, and effectively lowered the definition of hypertension from 140/90 down to 130/80. The organizations also recommended drug treatment for all individuals with blood pressure greater than 140/90, regardless of underlying risk. Unfortunately, this seems like a common scenario — medical guidelines recommend more aggressive medication use for minimal potential benefit despite potential harm. A new study published in the Journal of the American Medical Association (JAMA), suggests the blood pressure guidelines go too far for low risk individuals, and the risk of harm outweighs the potential benefits. JAMA: Benefits and harms of antihypertensive treatment in low-risk patients with mild hypertension The JAMA study was an extensive chart review of over 38,000 patients at low risk for heart disease who had stage two hypertension (blood pressure between 149/90 and 159/99) and were treated with blood pressure medications. Over an average follow-up time of almost six years, they found no reduction in the risk of cardiovascular disease events or risk of death with medication use. They did, however, find an increased risk for low blood pressure, fainting, and acute kidney injury among those treated with medications. Based on these results, treating stage two hypertension in low risk patients tends to cause more harm than good. What makes this study valuable is that it documents real world experience. Guidelines are frequently made from trials conducted with more aggressive follow-up and monitoring than is typical in usual care. That fuels the medical community’s perspective that drug interventions are the best course of care, which is why we need more studies like this one from Dr. Sheppard et. al. showing us how low risk patients probably do not benefit from drug therapy in real world scenarios. Instead of reaching for drugs, we should continue to find the most effective lifestyle interventions to help lower blood pressure and reduce cardiovascular risk without a laundry list of side effects. Unless, of course, you consider losing weight, having more energy, and feeling great as side effects — those are the type of side effects (from low-carb eating) that we all can embrace! Thanks for reading, Bret Scher, MD FACC   Originally Posted on the Diet Doctor Blog  [...]
Blog / HealthcareDon’t tell the statin brigade, but elevated LDL cholesterol may actually help us as we age! A new study from China suggests that those with higher levels of LDL-C have a lower incidence of dementia. They evaluated 3,800 subjects with a mean age of 69 years, performing extensive neuropsychological and cognitive ability testing. They found that the diagnosis of dementia and cognitive impairment correlated with increasing age, decreasing education level, diagnosis of type 2 diabetes, and being an ApoE4 carrier. After controlling for all these factors, they also found that those in the highest tertile of LDL-C (>142 mg/dL or 3.7 mmol/L) had a 50% lower incidence of dementia than those in the lowest tertile (<110 mg/dL or 2.9 mmol/L). Frontiers in Neurology: High low-density lipoprotein cholesterol inversely relates to dementia in community-dwelling older adults: The Shanghai aging study These findings are consistent with a prior study (also observational) examining the Framingham Heart Study data that found lower risk of dementia in those over 85 years old with higher cholesterol levels. In fairness, these studies were observational studies, so they do not prove higher LDL-C directly protected against dementia. We can hypothesize why higher levels of LDL-C are associated with lower incidence of dementia. It could be a marker of overall health or nutritional status, it could be that LDL-C directly improves the health of neurons and prevents brain atrophy, or it could be more related to lack of diabetes or ApoE4 status for which a study may not always completely control. Even without proving causation, these studies are wonderful reminders that we can easily get caught up in one specific disease processes (i.e. cardiovascular disease) and forget about the rest of the patient. The old joke is that when the surgeon talks to the family after a complicated and risky coronary bypass surgery, he says, “The surgery was a great success. The grafts were perfect, and the anastomosis were flawless, some of the best I have ever done. I’m sorry the patient died, but the surgery was wonderful.” This is a fictional over-exaggeration, but it makes my point. Cholesterol’s effects on our health are far too intricate to simply label LDL-C as “bad” and leave it at that. Such oversimplifications harm our overall understanding and eventually harms our health. Instead, we need to focus on the whole patient, not one specific outcome. Trials should focus on all-cause mortality and overall morbidity rather than one or two specific outcomes. It doesn’t do us much good to lower heart attack risk by 0.5% over five years if we are also increasing the risk of dementia, cancer or other complications. Thanks for reading, Bret Scher MD FACC   Originally Posted on the Diet Doctor Blog  [...]
Blog / NutritionDespite what the sugary beverage and processed snack food companies want us to believe, all calories are not created equal. A new study from Harvard shows that individuals following a low-carbohydrate (20% of total calories) diet burn between 209 and 278 more calories per day than those on a high-carbohydrate (60% of total calories) diet. So the type of calories we eat really does matter. The New York Times: How a low-carb diet might help you maintain a healthy weight This isn’t the first study to investigate this topic, but it is likely the best. The current study was a meticulously controlled, randomized trial, lasting 20 weeks. Even more impressive, the study group provided all the food for participants, over 100,000 meals and snacks costing $12 million for the entire study! This eliminated an important variable in nutrition studies — did the subjects actually comply with the diet — and shows the power of philanthropy and partnerships in supporting high-quality science. After a run-in period where all subjects lost the same amount of weight, participants were randomized to one of three diets: 20% carbs, 40% carb, or 60% carbs, with the protein remaining fixed at 20%. Importantly, calories were adjusted to stabilize weight and halt further weight loss, thus making it much more likely that any observed difference in calorie expenditure was not from weight loss, but rather from the types of food consumed. After five months, those on the low-carb diet increased their resting energy expenditure by over 200 calories per day, whereas the high-carb group initially decreased their resting energy expenditure, exposing a clear difference between the groups. In addition, those who had the highest baseline insulin levels saw an even more impressive 308-calorie increase on the low-carb diet, suggesting a subset that may benefit even more from carbohydrate restriction. Why is this important? It shows why the conventional wisdom to eat less, move more and count your calories is not the best path to weight loss. Numerous studies show better weight loss with low-carb diets compared to low-fat diets, and now studies like this one help us understand why. Our bodies are not simple calorimeters keeping track of how much we eat and how much we burn. Instead, we have intricate hormonal responses to the types of food we eat. It’s time to accept this and get rid of the outdated calories in-calories, calories-out model, thus allowing for more effective and sustainable long-term weight loss. Originally Posted on the Diet Doctor Blog  [...]
BlogDon’t look now, but the updated clinical practice cholesterol guidelines from the American College of Cardiology, the American Heart Association and others are getting personal. Although the guidelines still contain their familiar approach — that I consider too aggressive with drug therapy — the latest 2018 version of the guidelines now includes an impressive update to emphasize lifestyle intervention, plus a more individualized approach for risk assessment. MedPage Today: AHA: Revised Lipid Guide Boosts PCSK9s, Coronary Calcium Scans Could this be the start of a progressive trend away from shotgun statin prescriptions? I sure hope so. Prior guidelines emphasized the 10-year ASCVD risk calculator as the main determining factor for statin therapy. In the 2018 update, the guidelines acknowledge that the calculator frequently overestimates the risk in those individuals who are more involved with prevention and screening. (In other words, those patients more interested in and proactive about their health; I find many in the low-carb world fall into this category.) The ensuing discussion with a healthcare provider should then focus on: he burden and severity of CVD risk factors, control of those other risk factors, the presence of risk-enhancing conditions, adherence to healthy lifestyle recommendations, the potential for ASCVD risk-reduction benefits from statins and antihypertensive drug therapy, and the potential for adverse effects and drug–drug interactions, as well as patient preferences regarding the use of medications for primary prevention… and the countervailing issues of the desire to avoid “medicalization” of preventable conditions and the burden or disutility of taking daily (or more frequent) medications. I appreciate the attention the new guidelines bring to the depth of the discussion that should ensue between doctor and patient. Considering the treatment burden is equally as important as the burden of disease, and possibly even more important in patients who have not been diagnosed with heart disease, these individualized discussions about trade-offs are critical to personalized care. Also worthy of mention is the increased use of coronary artery calcium scores (CAC) to help individualize risk stratification. The updated guidelines specify CAC may be useful for those age 40-75 with an intermediate 10-year calculated risk of 7.5%-20%, who after discussion with their physician are unsure about statin therapy. They specify that a CAC of zero would suggest a much lower risk than that calculated by the ASCVD risk formula, and thus take statins off the table as a beneficial treatment option. This is huge. I cheered when I read this! I have been critical of prior guidelines that focused on ways to find more people to place on statins. The mention of finding individuals unlikely to benefit from statins is a giant step in the right direction. The guidelines go even further: they mention that a CAC either over 100 or greater than the 75th percentile for age increases the CVD risk and the likely benefit of a statin. A CAC between 1-99 and less than the 75th percentile does not affect the risk calculation much and it may be worth following the CAC in five years in the absence of drug therapy. I would still argue that a CAC >100 does not automatically equal a statin prescription and we need to interpret it in context, but I greatly appreciate this attempt at a more personalized approach. The guidelines also go beyond the limited risk factors included in the ASCVD calculator by introducing “risk modifying factors” such as: Premature family history of CVD Metabolic syndrome Chronic kidney disease Chronic inflammatory conditions such as rheumatoid arthritis and psoriasis Elevated CRP > 2.0 mg/L Elevated Lp(a) > 50 mg/dL or 125 nmol/L Elevated triglycerides > 175 mg/dL Although they use these criteria to define an increased risk, the opposite would likely hold true. An absence of those criteria could define a lower risk situation. Some changes deserve mention from a controversy standpoint as well. For instance, the new guidelines recommend checking lipid levels as early as two years old in some circumstances. Two! They also recommend statin therapy for just about everyone with diabetes with no mention of attempting to reverse diabetes before starting a statin, a drug that has been shown to worsen diabetes and insulin resistance. In addition, the new guidelines do not mention the likely discordance between LDL-C and LDL-P in those with diabetes. Last, the new guidelines define an LDL-C > 190 mg/dL as an absolute indication for statin therapy with a treatment goal of 190 mg/dL is in familial hypercholesterolemia populations (and even then has heterogenous outcomes). There is a clear lack of data supporting that same recommendation for metabolically healthy individuals with no other cardiac risk factors and no other characteristics of familial hypercholesterolemia. This is a clear example of when a guideline turns from “evidence based” to “opinion based.” In summary, the guideline committee deserves recognition for its emphasis on an individualized care approach, its use of CAC, and its broader description of discussing potential drawbacks of drug treatment. It still combines opinion with evidence and believes all elevated LDL is concerning, but I for one hope it will continue its progression away from generalizations and someday soon see that individual risk variations exist, even at elevated LDL-C levels. Thanks for reading, Bret Scher MD FACC Originally Posted on the Diet Doctor Blog  [...]
Blog / NutritionDoes eating fat make us fat? According to a new article in The New York Times, it just might. With a heavy emphasis on “might.” The New York Times: Which kinds of foods make us fat? (Paywall) The article is based on a trial published in Cell Metabolism over the summer, which concluded that feeding mice up to 80% calories from fat causes weight gain. The same was not seen with higher levels of carbs or sugar intake. Does this end the debate on what make us fat? Does this prove Gary Taubes and all the low-carb pioneers wrong? Of course not. For starters, this was a study of mice. So, if you have pet mice, then you should definitely pay attention. The bigger question, however, is does this trial apply to humans? I would argue absolutely not. Here is what they found. The mice that ate a higher percentage of fat calories ate more total calories and gained more weight. They also found changes in the mice brains with increased gene expression of serotonin, dopamine and opioid receptors — the so-called “reward” receptors. Simply put, that means the mice found the fat so pleasurable, they ate more calories than any of the other mice and they even increased their reward-signaling pathways to match the pleasure they were experiencing. Here’s the crux of the problem. Humans do the opposite. That’s right. The exact opposite. A review of 23 randomized trials showed that low-carb, high-fat subjects lost more weight than low-fat subjects, plus trials show low-carb, high-fat subjects experienced less hunger and ate fewer calories than low-fat subjects. What about the reward center upregulation? In humans, that clearly happens in response to sugar, not fat. Once again, the exact opposite of the findings in the mice study. The biggest take home from this study, therefore, should be the cautionary tale of using a mice study to predict human behaviors. This is especially true when we already have human studies showing the opposite effect. Low-carb diets help us eat less and lose more weight, and sugar lights up our reward centers like a Christmas tree. We don’t need mice studies to tell us that. Thanks for reading, Bret Scher, MD FACC Originally Posted on the Diet Doctor Blog  [...]
Blog / NutritionIt's challenging enough to stick to your health, fitness, and dieting goals when you're at home. When you're traveling, it can be even harder. Nothing's worse than going on vacation only to be frustrated that you've gained back weight you worked so hard to lose. Let's be honest. When you travel, it's harder to pay attention to what you're eating, when you're eating and how much you're eating. If you prepre ahead of time, however, you can make this much easier. Focusing on intermittent fasting, limiting your carbs, and keeping up some version of your exercise routine can put you on a path to success.  How Travel Disrupts Your Diet We seem to be traveling more than ever. The U.S. Travel Association reports that spending on travel in the U.S. alone averages $2.8 billion per day. Per day! That's a lot of opportunity to fall off the wagon.  You're likely to be less physically active. While it may seem you're covering lots of ground rushing to the airport and flying (or driving) hundreds of miles, you're also spending most of that time sitting down. It's also common for travelers to abandon their usual workout routines. There are snacks and junk food everywhere. It's tempting to grab snacks at the airport or to worry that you may not have a chance to eat for a while, so yo ugrab whatever is available. Most of these choices are high carb, high sugar distractions.  Your internal clock is disrupted. If you're traveling through time zones, your circadian rhythm is a mess and youo will find yourself craving more, with diminished self control.  But it's not hopeless! Here are some recommendations for counteracting these issues and staying healthy when you travel. Limit Carbs When Traveling We can debate all we want the merits of low fat vs low carb diets. Especially when the carbs are high quality, real food carbs. However, when you travel, lower quality carbs are often the biggest temptation. Simple carbs like sweets, foods made with white flour, and many packaged and processed foods are everywhere.  Bring healthy snacks with you. Instead of relying on food counters at the airport or filling up on junk food at rest stops on the highway, take the time to prepare some healthy meals. Prepare snacks that include superfoods such as almonds and other mixed nuts, salads with broccoli, kale hemp seeds and chia seeds, and perhaps some dark chocolate for a treat. Do your own shopping and cooking. Just because you're on vacation doesn't mean you have to eat out every meal! Don't derpive yourself of trying some new restaurants, but remember you can still do some of your own cooking. Look for a hotel or Airbnb that lets you do at least a little cooking and that has a fridge. This gives you more control over your diet.   Research eating options ahead of time. Before you leave on your trip, identify hotels, restaurants, and eateries that offer healthy and low-carb options. Don't forget to find out when and where local farmer's markets are held. I find that is a fantastic way to check out the local scene and partake in healthy local food choices.  Drink water. Staying hydrated can help combat hunger, and it will keep you away from sodas, juices and other sugary distractions. Incorporate Fasting Into Your Trip  There are many health benefits to intermittent fasting. It can help you to lose weight and lower insulin, and there's even evidence that it contributes to longevity. But when it comes to travelling, the best part of IF is the convenience!  If you're fasting, you don't have to worry about finding a healthy meal at the airport or on the plane.  Stick with water and you are good to go! If you are fasting, do it in a responsible and healthy way. If you're on any kind of medication, consult with a health professional before fasting. If you've never fasted, start slowly. Most people can do an 18:6 fast without too much discomfort. This means fasting for 18 hours and then eating for the next 6 hours. When you get comfortable with this, you can increase the duration of your fasts to 24, 48, or even 72 hours. If you want to try fasting on your next trip, it's a good idea to try some short fasts before you begin your journey.  Other Tips to Stay Healthy on the Road Exercise regularly. Try to stay somewhere with a gym. Or a neighborhood that has a gym you can use. Even without this, you can schedule in a walk, jog or bike ride. If you're visiting tourist attractions, think of a walk or bike tour rather than a bus tour. Look into places where you can explore nature and get fresh air. Get enough rest. Travel can also disrupt your sleep patterns. Lack of sleep is associated with anxiety, depression, hypertension, and many other health problems. If you're going to be traveling through time zones, start adjusting to the new time before you leave for your trip. When on your trip, be careful not to burn the candle at both ends. If you're getting up early for a long day of sightseeing (or business meetings), go to bed at a reasonable time.  Limit your intake of alcohol. It seems that alcoholic beverages are everywhere when you travel. Whether you're ordering a cocktail to help you relax on a long flight, downing tropical drinks on the beach, or sampling local craft breweries or wineries, the temptations are everywhere. Alcohol is high in calories and sugar. It can also disrupt your sleep patterns. If you do drink, limit it to one or two per day.  Don't stress out. Stress is never healthy and travel, even the kind that's supposed to be relaxing, can contribute to it. Avoid trying to fit in too many activities on your trip. Rushing around tends to make you reach for junk foods for quick comfort or energy. When planning your schedule, leave time for spontaneous exploration or just lounging around.  Watching your diet when traveling is important, especially if you frequently find yourself on the road. It's easy to slip into bad habits when traveling which means you have to start all over when you return home. It's better if you can stay consistent even when you're away from home. Limiting your carbs, fasting, and maintaining regular exercise and sleep routines all help you maintain optimum health when you travel.    [...]

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