Our Best Medicine- Pills Not Required

“Walking is man’s best medicine”- Hippocrates (Greek physician 460 BC-377BC). That is one of my favorite all-time quotes. I can’t say it enough or hear it enough. Hippocrates didn’t have scientific studies, he didn’t have fitness trackers, yet it was inherently obvious to him that physical activity and simply moving our bodies provided unparalleled physical and psychological benefits.

 

Combine that with more modern observations from Dan Buettner’s book The Blue Zones, and it becomes clear that regular physical activity is an essential key to our health and longevity. Mr. Buettner evaluated the most common personal habits in societies where they routinely live into their 90s and 100s. He found that they didn’t hit the gym every day, they didn’t train for marathons. They simply moved their bodies consistently. They worked in the garden, they walked to do their errands, they walked for social purposes.  They moved their bodies.

 

Don’t get me wrong. I am a big proponent of regular exercise, including high intensity interval training and resistance training (more on this in another post), but it is becoming clear that the basis for health is moving our bodies.  But why is this a challenge?

 

Technological Advances = Health Disintegration

 

Our society does not encourage regular physical activity. Most of us work desk jobs sitting in front of computers for hours at a time. We live as part of urban sprawl with longer commutes. And what minimal leisure time we have is spent on computers, tablets and video games. The days of centralized communities encouraging regular physical activity are largely gone.

 

This isn’t necessarily all bad. The technological advancements in the past few decades are unprecedented. It just hasn’t been good for our health. The priority has shifted. Now it’s time to shift it back!

 

It is time to re-examine all our unconscious habits. Why do we automatically go to the elevator or escalator? Why do we instinctively look for the closest parking spot? Why do we automatically sit on the couch instead of going outside for a walk?

 

Don’t just read these questions and keep going. Stop. Think. Answer the questions in your mind and resolve to re-examine those reasons and change them! Look at your daily habits and find places to purposely add more physical activity.

 

As I frequently say, you don’t have to try to be perfect. Just try to be better. If you can change one unconscious habit today that helps you move your body more, then you have a major success. If you can change another one tomorrow…even better!

 

Activity Trackers

 

My advice: Get an activity tracker and use it!

“But wait! Didn’t I just read a story about activity trackers being useless? Doesn’t that mean being active isn’t helpful?” I’m glad you asked.

 

There was a study in JAMA that asked a specific question: When it comes to weight loss, is a simple pedometer better than a program with regular encounters and encouragement from research staff? The answer, not surprisingly, was no (read a more detailed analysis of this study here).

 

Regular human interaction and encouragement is one of the most important factors when it comes to successful lifestyle changes. In this study, those in the activity tracker group didn’t have that interaction. It’s no surprise that they didn’t fare as well.

 

It is important to realize that activity trackers are one part of an overall health program. They are not an end-all tool for weight loss. And remember, weight loss is not the best marker for health. Healthy habits themselves should be the goal, the weight loss will follow.

 

So, don’t throw out your Fitbit, Jawbone or Apple watch just yet. When used correctly, activity monitors are a powerful tool to get you moving.

 

You may feel like you did a good job being active today. But then you glance down at your wrist and see a measly 4000 steps for the day. Now you know it is time to get moving. You can’t talk your way out of that one!

 

Or you may notice you hit your 10,000 steps and you are feeling good about yourself. You log in to the computer and see your good friend is already at 12,000 steps today. Time to put down your remote control and get another 2,001 steps in just to show him that you can!

 

That’s the power of activity monitors. Objective motivation day after day. Get one. Use it. Listen to the motivation.

 

Exercise Lowers Risk of Death

 

Ok. So, it’s well established that being consistently physically active is important for our health. But what about exercise? Aside from being physically active, how much exercise should we try to get?

 

It turns out, we don’t need that much to save our life.

 

A 2015 study in JAMA followed 661,000 Middle Aged adults over 14 years. They found the highest risk of death in those who did not exercise at all. Even a “little amount” of exercise (less than the official guidelines but more than no exercise) reduced the risk of death by 20%. The benefit continued to increase linearly with increasing exercise duration until it plateaued at 450 min per week.  The following table summarizes the results.

 

Amount of exercise per week

Cardiovascular/Mortality result

Sedentary

Highest mortality and cardiovascular risk

Less than 150min

Reduced death by 20% over sedentary

150 min

Reduced death by 31%

450 min

Reduced death by 39%

More than 450 min

No additional benefit, but no increased harm either

 

In addition, the Copenhagen City Heart Study  showed that “light” running, even just 20-minutes once per week, resulted in reduced risk of death. The maximal benefit was in those who jogged at a slow or average pace between 1-2.5 hours per week.

 

So, although the official recommendation is 150 minutes of moderate exercise per week, even minimal amounts of exercise provides some benefit. And it wasn’t an obscure benefit that you may or may not care about. It was reducing the risk of dying! That’s something we can all get on board with.

 

Move Your Body

If your goal is to reduce your risk of death, move your body.

 

If your goal is to improve your health, move your body.

 

If your goal is to feel better, move your body.

 

Be active, and add in at least small amounts of exercise.

 

The science supports. Hippocrates supports it. Now it is your job to get out there and do it.

 

(Read more about Resistance training and high intensity interval training Here)

 

Thanks for reading.

 

Bret Scher, MD FACC

Cardiologist, author, founder of Boundless Health

www.DrBretScher.com

 

 

Action Item:

 

Tomorrow, wake up and set your intention to seek out ways to move your body. Spend the entire day parking further away, taking the stairs, walking or biking to do your errands, go for a walk with your kids, and anything else you can find. Make it the focus for your day. You will be amazed at how many ways to can improve your activity level. Then, if you can do it once, you can incorporate it into your life and make it a new healthy habit. But you have to start with the first step. Wake up tomorrow and set that intention!

 

 

Take 2 Eggs and Call Me in the Morning

(For my easy to make veggie and eggs breakfast, see the video link here)

If I gave you this advice, how would you react? Would you think I was trying to harm you?

Or would you realize this is sound advice as part of a healthy nutritional strategy?

While the latter is true, most people likely fall into the first category. We can thank governmental and professional societal recommendations for that. For years eggs have been lumped into the “fat is bad” trend that ruled American nutritional standards.

Here is the truth. Eggs, including the yolks, can be an important component of a nutrient dense, vegetable based, real-foods style of eating that is beneficial to our overall health.

Mis-Guided Guidelines

As recently as 2000, the American Heart Association and American College of Cardiology guidelines recommended limiting dietary cholesterol intake to less than 300mg per day. Interestingly they followed that recommendation with the following quote: “There is no precise basis for selecting a target for dietary cholesterol intake.” Essentially they admit that they just made up the 300mg limit. That doesn’t appear to be the strongest of guidelines.

To be fair, they felt there was a legitimate concern.  Eating cholesterol could increase blood cholesterol levels, or so they thought. In addition, they pointed out that foods high in cholesterol are also high in saturated fat, and therefore should be avoided. In a way, dietary cholesterol was vilified because of the company it keeps. Of course, now we know the restrictions on saturated fat were also misguided (see the specific post here).

Fortunately, the ACC/AHA has come around and their most recent guidelines state “There is insufficient evidence to determine whether lowering dietary cholesterol reduces LDL-C.”

That has not kept cereal makers, bread and bagel companies, and others from continuing to promote eggs as dangerous to our health and something we need to avoid.

The interesting and often misleading intersection of health, food, and marketing rises again.

 Setting the Record Straight

It turns out, there are numerous studies that all draw the same conclusion: For the general population, egg consumption is NOT associated with an increased risk of cardiovascular disease, and does not adversely affect our cholesterol levels. In fact, there is some evidence to suggest it is beneficial to our overall health.

A look back at the Physician’s Health Study of over 21,000 people found that eating up to 6 eggs per week had no association with an increased risk of heart attack or death.  Eating more than 7 eggs per week in diabetics may have had an association, but beyond that, there appeared to be no harmful link.

Analysis of both the Health Professionals study and the Nurses’ Health Study concluded that eating one egg per day had no significant impact of risk of heart disease or death.

A large meta-analysis of 17 trials and over 4 million person-years showed higher consumption of eggs was not associated with an increased risk of heart disease or stroke.

In aggregate, there is no evidence in the general population that egg consumption increases the risk of heart disease or death. While those with diabetes may be an exception, that requires further investigation.

 

Is There a Benefit?

Just because something isn’t bad for us doesn’t mean we should flock to it and make it part of our regular eating habits. But is there evidence that eggs may be good for us?

It turns out there is.

For starters, eggs are packed with vitamins and minerals that our bodies need. One large egg has

  • 78kcal
  • 6gm protein
  • 5gm fat (1.6 gm saturated fat, 2 gm monounsaturated fat)
  • Fat soluble vitamins: Vit A, D, E, and K2 (K2 is very difficult to get from other common nutritional sources)
  • Vitamins B-6 and B12
  • Calcium
  • Amino acid leucine
  • Choline
  • Selenium
  • Omega 3 fatty acids
  • And more…

If you just eat the whites, remember that the yolk has all the fat-soluble vitamins and 90% of the B vitamins, calcium, fatty acids and other nutrients (aside from the protein).

Packed with that many vitamins and minerals, it makes sense that eggs would be good for us.

One additional benefit is that they help fill us up. Compared to a bagel breakfast with the same total calories, an egg breakfast increased the feeling of being full and reduced how many calories subjects ate the rest of the day.

And remember the concern that eggs worsen our blood cholesterol levels? It turns out that couldn’t be further from the truth.

Eggs may minimally increase total cholesterol, but more importantly, they increase HDL and thus maintain the total cholesterol to HDL ratio, a more powerful predictor of heart disease risk than total cholesterol alone.

Whole egg consumption, compared to an egg white substitute, improves the atherogenic lipid profile (that means it makes the cholesterol less dangerous).  

Eggs increase HDL, and can change the LDL from dense, more dangerous particles to large, less dense less dangerous particles.

None of this means that eggs have been proven to lower our risk of cardiovascular disease, but absence of proof does not equal proof of absence. In other words, since eggs haven’t been proven to be harmful, and there are plausible reasons why they could be beneficial, we should welcome them as part of a vegetable-based, nutrient dense eating pattern.

 

 Eggs Got a Bad Rap

So, in the end, it turns out that eggs got a bad rap.

They were innocent bystanders caught up in the marketing storm that followed poorly understood guidelines regarding dietary cholesterol intake.

Eggs can be an integral component of a nutrient dense, real-food way of eating.

They provide essential vitamins and minerals, they are filling and enjoyable, and they can improve our overall blood lipid profiles. While there is still some hesitation about individuals with diabetes consuming more than one egg per day, the rest of us can freely “Take two eggs and call me in the morning.”

Remember, however, the company they keep is still important. Instead of having two eggs with hash browns, pancakes and low-quality processed sausage at your local dirty spoon, try preparations like my simple eggs and veggie dish. It takes less than 5-minutes to make start to finish, it is delicious, and it is the perfect way to start your day. Here is the video link.

 Interested in Cholesterol?

If so, you’ll love my new program, The Truth About Lipids.  In this video course, I walk you through the evidence for and against lipids being a health concern, and I show how we can all better assess our cardiovascular risk. Learn more or sign up here.

 

Thanks for reading.

Bret Scher, MD FACC

Cardiologist, author, founder of Boundless Health

www.DrBretScher.com

 

Action item:

Make it! You only need, eggs, avocado oil, a box of spinach, a sprig of kale, left-over veggies, celtic sea salt, and grass-fed cheese. It takes less than 5-minutes to make. And if you don’t have time to eat it, take it with you in a glass container. It even tastes great cold!

 

The Best Weight Loss Trial You Will Never See!

The Best Weight Loss Trial You Will Never See!

In my book, Your Best Health Ever: A Cardiologist’s Surprisingly Simple Guide to What Really Works, I make the point that we should be very careful with how we interpret nutrition, weight loss and health studies. Far too often we will read a decisive-sounding post about an observational trial. My favorite is the belief that eating animal products of any kind directly causes heart disease, but you can take your pick from hundreds of other examples. The bottom line is the same. Observational studies, ones that simply observe people in their normal activities rather than randomly assigning them to two different groups, cannot prove cause and effect. They can only point out associations, which may or not have a real causative relationship.

In the world of nutritional science, observational studies require someone to remember everything they ate, accurately document it in detail, and depends on the researchers to control for every possible variable. That’s a recipe for a poor study. In addition, there is no way to control for self-selection bias. My made-up example from the book is that an observational trial would likely show that people who eat at Whole Foods are healthier than people who eat at McDonalds. Seems straightforward. But it turns out, they are also likely to be more educated, in a higher socioeconomic class, exercise more, have more access to medical care, and hundreds of other differences that we cannot measure. In a nutshell, that is self-selection bias.

So, although it makes sense that Whole Foods is healthier, and we believe it to be true, an observational study cannot prove this. Only a randomized trial can hope to answer the question with scientific validity. Which leads me to the point of this article. When it comes to nutrition and lifestyle as medicine, there are two trials we need to see, but likely will never see.

APEVVV (Animal Protein Eaters Vs. Vegetarians and Vegans)

All good studies seem to need attractive acronyms. I did my best here.

Take 10,000 healthy individuals. Randomize them into one of three nutritional groups. All three groups will adhere to the following:

  • Every meal is at least 50% veggies with very limited processed foods and simple carbohydrates.
  • Encourage healthy fats with nuts, seeds, olive oil and avocados.
  • Strive for 10,000 steps per day plus 150 min of moderate exercise per week
  • Practice regular stress management and engage in healthy lifestyle courses

They will differ as follows:

  • 100% Vegan: No animal products at all are allowed.
  • Vegetarian: No meat is allowed, but eggs and dairy are allowed.
  • Meat Eaters: Every meal allows for 1-2 eggs, 4-6 ounces of animal protein (beef, chicken, fish, etc.), plus unflavored dairy, yogurt and cheese.

Follow them over 10 years to see who lives and who dies, who has heart attacks and strokes, and who enjoys their life more. Now that’s a trial that will tell us something! Do you see how this differs from observational trials? Since the subjects are randomized, we eliminate self-selection. They don’t get to choose which group they will be in.

In addition, since we measure hard-outcomes like heart attack, stroke and death, there is no debate about what the results mean clinically. We aren’t measuring “surrogate” endpoints like cholesterol, blood pressure, and other measures that may or may not be significant in this specific circumstance. Heart attacks, strokes and death are ALWAYS significant! 

Also, notice how weight loss is not mentioned anywhere. The focus is on health, not weight loss. They are most definitely not one in the same. The problem is that this trial will be very difficult and expensive to create. Without a drug company having a vested interest in the result, it will be difficult to find someone to pay for it, and therefore we are unlikely to see it in our lifetime. That’s even more of a problem with my second trial that we need to see.

HLVS (Healthy Lifestyle Vs. Statins)

If you have read my posts on statins, by now you are aware of the incredibly small benefits of statins in primary preventions (i.e. when used in people who have not had a heart attack).  In general, they do not reduce your risk of dying, and to save one person from a heart attack we need to treat anywhere from 60-140 people for five years. 

One of the most common arguments for starting a statin is, “It’s the best treatment we have for reducing your risk of heart attacks and strokes.” My response? Not so fast. If I change that to say “It’s the best prescription drug we have for reducing your risk of heart attacks and strokes” then maybe I would agree. 

What other treatments are better?

  • Nourish your body purposefully.
  • Move your body and exercise consistently.
  • Manage your stress.
  • Prioritize your sleep.
  • Maintain strong social connections.
  • Don’t smoke.
  • And other healthy lifestyle actions.

Can I scientifically prove that these healthy lifestyle habits are better than statins? Not yet. That is why we need the HLVS study. Start with 10,000 people who have never had a heart attack or stroke. Half of them get a statin and “usual medical care” from their doctor.

The other half enroll in a lifestyle management program focusing on the following habits:

  • Every meal is at least 50% veggies with very limited processed foods and simple carbohydrates.
  • Healthy fats such as nuts, seeds, olive oil and avocados are encouraged with most meals.
  • Appropriate proportion of animal proteins and animal products are allowed.
  • Participants will strive for 10,000 steps per day plus 150 min of moderate exercise per week.
  • Participants will practice regular stress management and mindfulness meditation.
  • Sleep hygiene is repeatedly reviewed with each participant.
  • Smoking cessation interventions are individually tailored to those who need it

They are followed for 10 years and we measure number of heart attacks, strokes and deaths. We also record subjective measures of happiness, depression and enjoyment of life. Then we will know. Are lifestyle interventions just as good as, if not better than, statins for primary prevention of cardiovascular disease?

I’m pretty sure I know what the answer will be. But alas, we will never see this trial either. Can you imagine if a drug company sponsored this trial and it showed the drug was inferior? Stock prices would plummet, and people will lose their jobs left and right. So, if we want to fund this trial, we better start our fundraising now (no bake sales or girl scout cookies please).

Conclusion

Does this mean we must disregard all nutritional and health science that isn’t a randomized prospective trial? That would mean throwing out most of our science. I don’t recommend that. Instead, we need to be vigilant about understanding the limits of the science and the limits to the catchy headlines. When we read a headline that “the Mediterranean diet has been proven to be better than statins,” we have to pause and think. We know that it may be intriguing, and we may want it to be true. However, until there is a head-to-head, randomized trial, we cannot prove that. Anyone who claims otherwise is inappropriately twisting the data.

What can we do instead?

In the absence of the trials that we need, we can continue to live our lives emphasizing healthy lifestyle habits. We can continue to demand a thorough and realistic explanation of the benefits and potential risks of prescription drugs. We can continue to seek out reliable and credible sources of information. And we can continue to talk about the need for better science. If we do this enough, we will transform ourselves for the better, and maybe, just maybe, we will change the world of nutritional and health science for generations to come.

Thanks for reading.

Bret Scher, MD FACC
Cardiologist, author, founder of Boundless Health
www.DrBretScher.com


Action Item:

Next time you hear a news story about a health study, take the time to look up the study and read it. Then you can decide, is this high-quality evidence? Does it apply to me? You may not understand everything, but the more you read, the more you will understand. And if you still have questions about it, ask me! I welcome your emails: info@drbretscher.com

Bret Scher, MD FACC

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