Low Carb Cardiologist

Kidney Stones and Veggies- Which are Safe?

No good deed goes unpunished. I recently saw a young patient who had a severe coronary blockage requiring a stent. It was a true “Aha” moment and he dramatically improved his nutrition, lifestyle and stress management. He is one of my favorite patients (I’m probably not supposed to have favorites, but I’m human). Not just because of what a nice person he is, but because of his clear commitment to improving his health.

Gone were the processed foods and added sugars. They were quickly replaced by veggies, fish, healthy fats (including nuts and nut butters), and a clear focus on real foods. Not to mention his dediction to exercise and stress management. He re-examined his life, and revitalized his health.

Then it happened. Kidney stones. Ouch.

It turns out, some people absorb more oxalate from certain foods than others. Too much oxalate in your system can lead to calcium oxalate kidney stones (far and away the most common type of stone. Even though calcium is in the name, the oxalate is the more concerning component). Some of the biggest duetary offenders are spinach, beets and nuts.

As part of his real foods, veggie-based eating pattern he was consuming spinach and nuts every day. Ordinarily that would be fantastic! But not if you form oxalate stones. Oops.

The good news is, there are plenty of healthy veggie options that do not cause increased oxalate absorption. Some of the best greens for this are lacinto kale (also called dino kale), collard greens, and mustard greens.

Other low oxalate examples are broccoli, cauliflower, asparagus, Brussel sprouts

cabbage, zucchini, mushrooms, onions and peppers.

Last, taking more than 500mg of vitamin C has been implicated in increased oxalate production and should be limited.

Conclusion:

Don’t throw away your spinach or your almonds!

Most of us will do just fine eating spinach, nuts and taking vitamin C. However, for those few of us who are prone to forming calcium oxalate kidney stones, it makes sense to limit these foods and instead focus on the wealth of other healthy options listed above.

Do you have questions regarding your healthy lifestyles and your health? Let us know, info@DrBretScher.com

Thanks for reading

Bret Scher, MD FACC

Cardiologist, author, founder of Boundless Health

www.DrBretScher.com

PCSK9 inhibitors- Hype or Hope?

Hot off the presses, just published today in NEJM. The new drug class PCSK9 inhibitors reduce heart attacks by 15%. Should we all rush out and start on one? Not so fast.

Initial studies demonstrated that Repatha (a PCSK9 inhibitor) dramatically reduced LDL cholesterol levels, but now we have evidence that they reduce the risk of heart attacks. Get ready for the barrage of commercials and ads for Repatha, and get ready for the experts to start proclaiming the benefits of this drug.

But as always, the truth may not live up to the hype.

For starters, the FOURIER trial focused on high risk patients who have already had heart attacks or strokes, and who were already on statins. This is called a secondary prevention trial. It is crucial to point out that it was not a primary prevention trial. The results do not apply to the millions of people with cardiovascular risk factors who have never had a heart attack or stroke (or peripheral vascular disease).

Second, the study did not show any difference in cardiovascular deaths. This is another important point as people frequently equate heart attacks with death. That is not the case. There was absolutely no difference in the risk of dying between the Repatha group and the placebo group.

Third, the reduction in heart attacks, although statistically significant, was small. Over 2.2 years, the risk of heart attacks was reduced by 1.2%. That means we need to treat 66 people for over 2 years to prevent 1 heart attack. Another way to look at it is that 65 people will not get the end benefit, and one will.

Last, the study was only 2.2 years long. The risk of side effects was similar between the two groups, suggesting that PCSK9 inhibitors don’t cause any adverse effects beyond statins. However, this is likely a big question mark regarding these drugs. These drugs drive the LDL lower than any other medication we have ever had. In this study, the average LDL for the Repatha group was 30. Our goal used to be 100, then 70, and now apparently 30. That’s quite a drop.

Is there reason to believe an LDL this low could be dangerous? You bet. LDL, although commonly known is the “bad” cholesterol, is vital for our health. We need it for neurologic and cognitive function. We need it for hormone production. We need it for cell membranes and for absorbing fat soluble vitamins.

Are you satisfied that the drug is harmless after this 2.2-year study? Neither am I. Stay tuned for the discovery of significant adverse effects over the next few years.

So far, I haven't even mentioned cost. If the drug was free, it would still be questionable if it was worth taking. But the drug is most certainly not free. In fact, it costs $14,000 per year.

Since we need to treat 66 people for 2.2 years to prevent one heart attack, that makes it $2.03million per heart attack saved. <Cough> That's a tough pill to swallow.

So why are so many experts going to promote it and extol its benefits? Most physicians believe that medicines are the path to health. The more we can alter our natural environment with drugs the better. Even minimal reductions in our risk are worth the minimal side effects from drugs. That seems to be a common bias in our healthcare system.

My bias is the exact opposite. We can achieve incredible benefits from purposeful lifestyle changes, and all without adverse effects! Drugs are largely unnecessary beyond that. Therefore, in my mind, any drug should have a dramatic benefit and a minimal long-term risk at an acceptable cost. After all, are you interested in lowering your heart attack risk for two-years? Or are you interested in lowering your risk over your lifetime?

Don’t get me wrong. There may still be a very limited role for PCSK9 inhibitors.

For very high-risk patients in whom you have tried everything (especially intensive lifestyle modifications) yet they are still likely to have another heart attack in the near future, then PCSK9 inhibitors could be a good option to reduce their heart attack risk by 0.6% per year, even though it won’t affect their risk of dying.

Beyond that, however, they have no proven benefit and no clear role in medical therapy. They are very expensive, and they are likely going to show significant long-term adverse effects when used for more than 2-years. Tread lightly with PCSK9 inhibitors.

Action item:

When you read the headlines, and hear the news about the incredible benefits of PCSK9 inhibitors, please remember to put it all into context. Use this article as a guide to clarify where the trial has merits and where there are still unanswered questions. As always, if you have any questions, please do not hesitate to contact us at info@DrBretScher.com.

Thanks for reading.

Bret Scher, MD FACC

Cardiologist, author, founder of Boundless Health

www.DrBretScher.com

Can Eating Better Save 400,000 Heart Attack Deaths?

By now you have likely heard the news that poor nutritional choices cause almost half of all cardiovascular deaths. Wouldn’t it be amazing if by eating better 400,000 people would still be alive today? You bet it would.

While it’s no surprise that nutrition and heart health are directly related, causing half of all cardiovascular deaths is a dramatic finding that deserves further scrutiny.

The recent study, funded by the Bill and Melinda Gates Foundation, was presented at the 2017 annual AHA meeting. They retrospectively looked at years of observational data to correlate nutritional habits and the subsequent risk of dying. Instead of focusing only on the “bad” foods that people ate, they also looked at the “good” foods people did not eat. They concluded that Americans need to eat more nuts, vegetables and whole grains, and less salt and trans fats.

Yawn. That finding is hardly earth shattering as we have been hearing this for decades. Does this new study add anything to the current literature? I’m afraid not.

We have plenty of observational data suggesting the same. In fact, another similar study published in JAMA at the same time provided more observational evidence that 318,000 out of 702,000 cardiovascular and diabetes related deaths are related to (in order of statistical strength), too much salt, not enough nuts and seeds, too much processed meats, not enough omega 3 rich seafood, not enough veggies or fruit and too many sugary beverages.

Bad Studies Yield Bad Data

Two studies with similar results. Does that sound conclusive? Not so fast. The problem is that all this data is observational, and therefore weak data. It can point out associations, but it cannot prove cause and effect (see chapter 2 in my book, Your Best Health Ever for a more detailed discussion). What we need is a randomized, controlled trial investigating the question of nutrition and cardiac deaths, not more observational drivel (see my post on The Best Weight Loss Trial You Will Never See here)

As an example, processed food is high in salt. Fruits and veggies are low in salt. Can we say with certainty that the salt is the problem? Or is it the company it keeps, i.e. too much crackers, chips and baked goods instead of fruits and veggies? This study cannot determine between the two. Also, those who eat more veggies also tend to be more health conscious, more physically active, and have less dangerous habits (i.e. smoking). The opposite is true for those who eat more processed junk food. Again, observational studies cannot completely control for those variables (they can try, but statistics are imperfect for this).

Does this mean we need to throw out the study completely? Not necessarily. It raises important questions, even if it does not provide clear answers.

Instead, we should combine the findings with the higher quality, randomized trials to see what the science truly supports.

Good Studies Yield Good Data

The more conclusive studies are the randomized controlled trials. One such recent trial was the PREDIMED study (see more on this study and the Mediterranean diet here). Briefly, this trial investigated a diet that included a “high intake of olive oil, fruits, nuts and vegetables; a moderate intake of fish and poultry; a low intake of dairy products, red meat, processed meats, and sweets; and wine in moderation with meals.” This pattern of eating significantly reduced the risk of cardiovascular disease when compared to low-fat diet.

Since this was a randomized trial, there was no need to control for other healthy habits and self-selection bias. In addition, they didn’t measure surrogate outcomes like blood pressure, weight, or cholesterol. They measured the events we really care about- heart attack, stroke and death. In the end, a simple nutritional intervention reduced that risk.

This is an impressive study that tells us something conclusive about nutrition. I hope you can see the difference between this study and the throngs of poor-quality observational trials.

Do you see any similarities between the PREDIMED study and the recent observational trials?

Encourage nuts, veggies, and fish. Discourage processed meats and sweets.

In short, eat real food.

Can We Find A Common Ground?

After that, the science gets murky.

What about poultry? It was encouraged in the PREDIMED study and was not mentioned much in the recent observational trials. There doesn’t seem to be significant evidence to avoid it, and there may be reason to eat it. So be aware of your portion size and go for it.

What about salt? It wasn’t limited in the PREDIMED study. Some studies suggest increased risk with high sodium intake, and some studies suggest increased risk with low sodium intake. In the observational trials, it can be difficult to separate salt from processed foods, and therefore difficult to know if it is dangerous.

You may be thinking, if there is any question, why not just avoid it? Is there a compelling reason to eat salt? You bet there is. Taste. Salt helps food taste better. If you are adding it to your cookies, white bread or potato chips, you aren’t doing yourself any favors. However, if you are adding a sprinkle of sea salt on your freshly steamed veggies or your roasted broccoli, then go for it. An observational study can’t tell the difference between those two circumstances, but trust me, your body can.

What about red meat? This is a big one. We don’t have any evidence that red meat reduces the risk of cardiovascular disease. However, all the evidence suggesting that red meat and animal protein increase the risk of cardiovascular disease is poor quality observational data. In addition, there is plenty of poor quality observational data that claims the exact opposite, that red meat does not increase the risk of cardiovascular disease. So again, we must ask, if there is controversy, should we just avoid it? Is there a compelling reason to eat meat? For some there is. Animal meat is the most efficient source of B-vitamins, iron and protein, it is filling and it tastes great.

Once again, the specifics matter. Are you eating a 16oz porterhouse steak with mashed potatoes? Or are you eating a fresh vegetable salad with 6-ounces of grass-fed steak on top? A study may not know the difference, but your body sure does.

Wrap It Up

Can improving what you eat reduce your risk of heart attacks and strokes? It sure can. The PREDIMED study showed that.

Do these new observational studies add anything new? That’s debatable.

We come back to the basics. Eat more real food. Eat more veggies and fruits. Eat less processed junk. Avoid manufactured trans fats. If you do that, you are doing 95% of the work (I made up 95%, but it seems right to me).

Spend all the time you want arguing about the remaining 5%. There is plenty of evidence to support your claim whether you are for or against salt, meat, eggs etc.

As for me, I am going to step out of the argument and go eat my spinach and kale salad with Brussel sprouts, cauliflower, squash, nuts and seeds, topped with olive oil and 4 oz. of wild salmon and a hard-boiled pasture raised egg. Heaven on earth. Bon Appetite.

Bret Scher, MD FACC

Cardiologist, author, founder of Boundless Health

www.DrBretScher.com

Action Item:

Look for ways to add veggies, nuts and seeds to your meals. Sprinkle pumpkin seeds on your oatmeal, eggs or salad. Ask for a double portion of veggies and half the protein when you go out to dinner. Watch our veggies and eggs video to see how easy it is to make a veggie-based breakfast. Focus on real food, veggies first. Try it today and see how easy and rewarding it can be!

How Many Pills Do We Need to be Healthy?

How many pills do you need to be healthy? To be healthy we would want to do the following:

Lose weight
Lower LDL
Raise HDL
Lower blood sugar
Lower insulin levels
Reduce inflammation
Reduce your risk of heart attack and stroke

To do all that you would need five or more prescription drugs. But is that what it means to be healthy?

Our traditional medical culture seems to be saying, “Yes!” That type of thinking is why prescription drug use continues to rise, with over 60% of American adults taking prescription drugs, and 15% taking five or more drugs.

Guess what. It doesn’t have to be this way. Not even close.

Here is the secret you can do that is better than taking 5 or more pills.

You can commit to healthy lifestyle habits.

Do that and you will lose weight in a healthy manner. You will lower your blood sugar and insulin levels. You will improve your cholesterol profile, reduce your inflammation and lower your risk for heart attack and stroke.

And you can do it all without side effects, unless of course you consider being happier, having more energy, and feeling better as side effects!

Sounds easy? It can be. It won’t always be easy, and it certainly isn’t easy to be perfect. But being better, and seeing every day as a new opportunity is well within our grasp.

The Science Supports Lifestyle First

A 2016 study in NEJM investigated four different trials comprising over 55,000 subjects. They concluded that even those with the highest genetic risk of cardiovascular disease can reduce their risk by almost 50% with healthy lifestyle habits, defined as eating healthy, getting regular physical activity, not bring obese, and not smoking.

In addition, A 2014 study showed that 80% of all first heart attacks are explained by 5 risk factors (smoking, waist circumference, healthy diet, regular physical activity, moderate alcohol consumption). It turns out, all five of those factors are within our control. We don’t need a pill to control them. We just need to commit ourselves to controlling them.

Putting it into practice

Despite this encouraging information, A study published in the Mayo Clinic Proceedings concluded that an only 2.7% of the Americans studied led a healthy lifestyle (defined as regular physical activity, healthy eating, not smoking, and having a recommended body fat level).

It should be no surprise, therefore, that heart disease remains the leading cause of death in men and women. There are approximately 900,000 heart attacks annually in the U.S., one every 42 seconds, with 365,000 people dying from a heart attack every year. Heart disease costs $207 billion annually in the U.S. alone. And for the first time since 1993, the life expectancy in the U.S. has started to decline.

The Health-Drug Disconnect

If more and more people are taking prescription drugs, yet our life expectancy is declining, how do we rationalize the disconnect?

I propose it is because we have lost sight of what first line medical therapy should be.

Statins come with a litany of side effects, and at best reduce your risk of heart attack by 3% over 5 years.

Drugs that raise HDL level can worsen your risk of dying (CETP inhibitors).

Diabetes drugs can increase insulin levels, increase weight, and create a medication dependency.

Weight loss drugs are rarely sustainable over the long run, and come with severe side effects.

Do any of those sound like good choices for first-line treatments? Not to me. And I hope not to you either.

Change What We Reach For

Instead of reaching for our prescription pads, physicians should be reaching for cookbooks, lists of farmer’s markets, different options for activity trackers, stress management apps, and other healthy lifestyle tools.

That is where true health begins. That is our best chance of achieving real health. Not health that is dependent on a medication, or health that is defined by a lab value.

For more information on how to improve your health with healthy lifestyle habits, read more about our book and instructional video series. They may just change your life.

Thanks for reading

Bret Scher, MD FACC

Cardiologist, author, founder of Boundless Health

www.DrBretScher.com

Action item:

Take a look at Your Best Health Ever: A Cardiologists’ Surprisingly Simple Guide to what Really Works. You can buy it today on amazon (here is the link). It has all the information you need to prioritize healthy lifestyle practices over prescription drugs. Together, we can promote natural, long-lasting health that feels great.

Is Alzheimer’s Disease Preventable?

Is Alzheimer’s Disease Type III Diabetes? And Can it be Prevented?

By Bret Scher, MD

Alzheimer’s disease is one of the most devastating conditions in our country, and you may have the power to prevent it.

There is nothing more empowering than knowing you have the ability to prevent a chronic disease. Especially when some view that chronic disease as worse than death. While not all factors that lead to chronic disease is controllable (e.g., genetics), there are some diseases that you can protect yourself against. And one of those might be Alzheimer’s disease.

Alzheimer’s disease—which is the sixth leading cause of death in the U.S.—is a devastating condition that impairs your memory and ability to think. It progresses over time, eventually condemning an otherwise functional body to a life completely dependent upon care from others. It changes the lives of not just those affected by the disease, but their loved ones and caregivers as well.

In 2015 alone, approximately 15 million caregivers provided an estimated 18 billion hours of unpaid care to the 5 million Americans who suffer from Alzheimer’s disease. But the cost to families and to society as a whole cannot be measured in just dollars and cents. The emotional toll can also be enormous. The negative effects on caregivers can be vast, including:

Psychological distress
Impaired health habits
Psychiatric illness
Physical illness

To make matters worse, the number of people diagnosed with Alzheimer’s dementia is only getting larger and is expected to triple as baby boomers reach the at-risk age of 65 and older.

Paradigm Shift in Understanding Alzheimer’s

Modern medicine has struggled to find effective treatments for those who suffer from Alzheimer’s. The most effective medicines may slow the symptoms by a few months, but the inevitable progression always happens in the end.

A new paradigm shift, however, offers promise for methods to prevent and treat Alzheimer’s disease. The paradigm shift is that Alzheimer’s may be Type III Diabetes.

To understand this relationship, it helps to understand the basics about diabetes, blood sugar, and insulin. Insulin’s job is to signal cells to take sugar out of the blood and convert the sugar into energy. When a person has diabetes, the cells no longer listen to insulin, so the body needs to produce more and more insulin to get the message across.

As the efficiency worsens, the body can’t keep up, the blood sugar rises and diabetes develops. This causes two main problems:

Insulin levels rise sky high. Since insulin is a fat storage and pro-inflammatory hormone, higher levels equate to deterioration of overall health.
Blood sugar levels increase to dangerous levels. This can eventually lead to heart disease, vascular disease, kidney disease, vision loss, neuropathy, and other serious conditions.

It turns out that brain cells can become resistant to insulin as well, thus drawing a connection between diabetes and Alzheimer’s. The theory is that increased insulin and increased sugar in the brain leads to damage of brain cells and eventual dementia.

The Connection Between Alzheimer’s and Diabetes

Medical science is starting to explore the relationship between diabetes and dementia and is drawing a strong connection. One study, for instance, reviewed previous investigations of diabetes and dementia, accounting for over 2 million subjects. The study concluded that those with diabetes were 60 percent more likely to develop dementia.

While an association does not prove causation, it does raise an interesting potential link that deserves further exploration.

The next question is whether there is a reasonable explanation for why the two diseases might be related. And it turns out there is.

Another study demonstrated that individuals with type II diabetes are more likely to develop the same “brain tangles” that are seen in those affected with Alzheimer’s. It is thought that these tangles are directly responsible for the progressive cognitive decline. And they are present in both the brains of individuals with Alzheimer’s disease, and the brains of those with diabetes even in the absence of dementia.

How to Prevent Diabetes, and possibly Alzheimer’s

This emerging research could be discouraging news since the incidence of diabetes is on the rise, with an estimated increase from 285 million cases worldwide in 2010 to 439 million in 2030. The result could be an equal surge in new Alzheimer’s cases.

Or it could be encouraging news, since type II diabetes is almost entirely preventable with healthy lifestyle habits. Presumably, these same habits may help prevent Alzheimer’s as well.

In fact, a 2001 study in NEJM suggested that 90 percent of type II diabetes cases could be prevented with:

Proper exercise
Healthy eating
Not smoking
Maintaining a healthy bodyweight

Another study showed that a lifestyle program that included 150 minutes of weekly physical activity and a goal of 7 percent weight loss prevented diabetes better than the popular drug Metformin—an oral diabetes medicine that helps control blood-sugar levels.

Finally, a 2012 study followed 2,700 people over three years and found those who ate a diet higher in carbohydrates and sugars and lower in protein and fat were more likely to develop dementia.

This information shows that diabetes, and by extension Alzheimer’s disease, may be preventable by following a healthy lifestyle that includes these elements:

Exercise 150 minutes per week and remain physically active throughout the day
Maintain near ideal body weight
Eat a real-foods, vegetable-based diet with healthy fats
Avoid simple, refined carbohydrates
Avoid added sugars in food and drinks

A Healthy Lifestyle Is Necessary

Unfortunately, this is not hot-off-the-press news. These studies were published over 15 years ago, yet many people are still reluctant to adopt such healthy practices. In fact, one study of American adults found that only 2.7 percent of the subjects followed a truly healthy lifestyle.

The public shouldn’t need more inspiration to strive to be healthy, but knowing that Alzheimer’s disease and diabetes are likely preventable will hopefully be enough motivation to spark a revival for healthy lifestyles now and for decades to come.

Change doesn’t come easily, so start by making simple steps and find a support system that will help you adopt new ways of living.

Those in positions of influence (doctors, nurses, personal trainers, nutritionists, health coaches, chiropractors, and other medical professionals) need to actively educate society about the association between Alzheimer’s and diabetes.

If you fall into this category, it’s important to learn how to inspire individuals to adhere to healthy life habits, which may help prevent one of the most devastating conditions that touches the lives of tens of millions Americans every year.

Now that’s empowering.

Thanks for reading.

Bret Scher, MD FACC

Cardiologist, author, founder of Boundless Health

www.DrBretScher.com

ACTION ITEM:

Make 1 meal this week a Vegetable Based meal. Don’t have chicken with a side of veggies, or salmon with rice and a couple veggies. Make the basis of the meal veggies and add 4-6 oz. of high quality animal protein. Notice how it looks different, tastes different, and how you feel differently after you eat it. If you can do this, then you can increase it week after week until most of your meals are veggie-based. You will be amazed at how it improves your health and how you feel!

Statins- What do We Really Know?

45 million Americans “should” take statins. Are you one of them?

It may surprise you to find out that you might be. When your doctor plugs your information into a cardiac risk calculator, he or she may tell you that you should to take a statin.

You may not feel bad. You may not have many other cardiovascular risk factors. Yet you may be labelled with the “disease” of elevated cholesterol.

“New” Guidelines- Questionable Sources, Questionable Guidelines

Why are so many more previously healthy Americans now being treated for high cholesterol? We can thank the 2013 ACC/AHA guidelines, which increased the intensity with which physicians prescribe statins.

Interestingly, these were not based on any new data. Instead, they were based on new interpretations of old data, much of which has not been made available for third party reviewers. None the less, it is now recommended that physicians consider prescribing a statin to anyone with a 5% 10-year risk of cardiac disease (increased from a previous 20% risk).

To me it seems that a recommendation to dramatically increase the use of these drugs should save lives left and right and have almost no down side. Unfortunately, that is not the case.

Don’t get me wrong. Statins are not useless. They can reduce the incidence of heart attacks and strokes. For someone who has never had a heart attack (referred to as primary prevention) we need to treat between 60 and 104 people for 5 years to prevent one heart attack without any significant difference in the risk of dying.

That’s a little underwhelming, is it not? That seems like a “shotgun” approach where you send a hundred bullets out knowing that one will hit the right person (in this case getting hit by a bullet is a good thing). It doesn’t have to be this way.

In addition, statins are not perfect drugs. For every 50 people treated over five years there will be one new case of diabetes. There will also be at least 10% risk of muscle aches and pains with potential damage to the mitochondria (the energy producing part of the cell), and may even be linked to onset of dementia and memory dysfunction.

A system that potentially harms more people than it helps doesn’t seem like a viable solution to me. We can do better.

Better Define Your Risk

The problem is that our medical culture emphasizes prescribing drugs more than further defining your risk, and more than exploring alternatives to reducing your risk.

The current cardiac risk calculator uses:

Age
Gender
Race
Total cholesterol
HDL
Blood pressure or previous diagnosis of hypertension
Diagnosis of diabetes
Smoking status

Those are all reasonable initial risk factors to evaluate. But doesn’t it make sense that if we are using a drug that will only benefit one in 100, maybe we should try to further define those at high risk? To me that is a no-brainer.

For instance, one study showed that by measuring a coronary calcium score on statin eligible individuals, we could reclassify 50% of them so that they no longer “qualify” for statin treatment. We can avoid an enormous number of statin prescriptions with one simple test. A test that is readily available now. A test that has minimal risk (very low radiation dose, and a small chance of incidental findings), and is relatively low cost (about $100).

And we don’t have to stop there.

The Scripps Research Institute has developed an app to allow people to use their genetic information to better define their risks. This could potentially be used to define those who are not at high genetic risk for heart disease and therefore would likely not benefit from statin therapy.

Now we are starting to get somewhere. What if we could better define cardiac risk so that one in 5 people benefit from a statin, as opposed to the current 1 in 100? That is an admirable goal.

Even Better Than A Statin

Once we better define our risk, let’s not forget all the alternative to statins.

One recent study demonstrated that even those at the highest genetic risk for heart disease can cut their risk in half with healthy lifestyle habits (eating healthy, getting regular physical activity, not smoking and not being overweight). And that was the highest risk group! That’s likely just as good as, if not better than, a statin could do.

So why don’t we write prescriptions for intensive healthy lifestyle education programs instead of drugs?

Lifestyle changes are “harder.” Lifestyle changes take longer to see results. Lifestyle changes require more education, encouragement and follow up.

Do you know what else is associated with healthy lifestyle changes? Decreased risk of heart attack, strokes and death. Decreased risk of diabetes, high blood pressure and depression. And the only side effects are feeling better, having more energy, and being in control of your health.

That sounds like something that is well worth the extra work, the needed patience, and the more vigorous follow-up. Don’t you agree?

Start Asking Questions

So, what should you do if your doctor recommends a statin? Start asking questions. Lots of them.

How high is your calculated cardiovascular risk?
How much will a statin reduce that risk?
What else can be done to better define your risk (i.e. coronary calcium score)?
What else can be done to lower your risk (i.e. intensive lifestyle modifications)?

Ask yourself questions as well.

How can I improve my nutrition to focus on a vegetable based, real food, Mediterranean style eating that focuses on healthy fats and appropriate proportions of high quality animal products?
How can I improve my daily physical activities in addition to increasing my weekly exercise?
How can I improve my stress management and sleep habits?

Remember, the benefits of statins are small. Not zero, but small.

Also, remember that statins have not been directly compared to healthy lifestyle habits. We don’t know if they add anything to a comprehensive lifestyle modification program. In fact, I would wager that if you have healthy eating habits, you get regular physical activity, you exercise regularly, and you practice regular stress management, then statins will not reduce your cardiovascular risk at all.

It may seem like a bold prediction, but to me it seems obvious.

Unfortunately we will likely never see a head-to-head study between statins and healthy lifestyle interventions (I discuss the specifics of the study I would like to see in my prior blog post here).

We can do better than a drug

In the end, remember that we can do better than drugs. We can be in control of our health. We can achieve real health that is not dependent on blood tests or medications.

So, don’t blindly accept a prescription for a statin (or any drug for that matter) without further defining your risk, and without further exploring your alternatives. You and your health deserve at least that much.

Thanks for reading.

Bret Scher, MD FACC

Cardiologist, author, founder of Boundless Health

www.DrBretScher.com

Action Item:

If you are on a statin, or any drug for that matter, make sure you ask your doctor why you are on it, exactly what benefit you should expect, and what the potential short- and long-term side effects are. Also, ask what the alternatives are, specifically regarding your lifestyle and healthy habits. If you aren’t getting adequate answers, ask me! info@drbretscher.com. I welcome your emails.

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!

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

Category: Healthcare

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Statins- What do We Really Know?

Our Best Medicine- Pills Not Required

The Best Weight Loss Trial You Will Never See!

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