Do we have to avoid meat if we have high homocysteine levels? Not really.

What our body does with homocysteine is more important than our food intake. I thought this was easier to explain in video form, so you can see my 4 minute explanation here:

https://www.youtube.com/watch?v=PYx4qvYy6_4&ab_channel=LowCarbCardiologist

The bottom line is we need to know our methylation status, make sure we have adequate levels of folate, B12 and B6, and make sure we have adequate choline (found in egg yolks).  If all those are perfect, and we still have elevated homocysteine, then we may want to experiment with a diet low in methionine to see if it makes a difference.

As always, however, we have to evaluate our overall health picture and not get too hung up on one blood marker. The more important questions to ask are how does homocysteine affect my overall health, and how will altering my supplements or diet change the big picture?

Hopefully this helps! Let me know if you have any comments or questions.

Thanks for reading (and watching!)

Bret Scher MD FACC

A 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

Here 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

Can you find a more polarizing topic than statins? One article says they are miracle drugs that should be given to everyone. Then you turn the page, and you read how they are poison and you should stay away from them no matter what.  How can one drug cause such differing views? And which should you believe?

The statin debate has intensified ever since the 2013 ACC/AHA cholesterol treatment guidelines increased the number of people without heart disease who “should” take a statin to 43 million Americans. That is for primary prevention, meaning the individual has never had a diagnosis of cardiovascular disease, never had a heart attack, and never had any type of a heart problem.

As you can imagine, this has been a windfall for the drug companies. But are we healthier and better off as a result? That is unknown.

The problem is understanding the bias of whoever is writing the story.

Subtleties of Science

But wait, you say. Won’t the science tell us if statins are good or not? Isn’t it an objective fact if they are good for us?

Not so fast. Beauty is in the eye of the beholder, and so is the application of science.

Are you getting advice from someone who believes prescribing more medicine is better? Or someone who believes a more natural lifestyle is better? 

Are you reading a report sponsored by the pharmaceutical company that paid for the research?

Or are you getting advice from a scientist who is more focused on statistical benefits, or someone who is more concerned with the potential benefit for the one individual they are taking care of at the moment?

It is a confusing sea of conflicting information, and you have to find which approach resonates more with your beliefs and your life.

The Three Keys

Regardless of who you are and your beliefs, I promised you the three most important things you need to know about statins. Here they are:

1. All statin studies are worthless! That’s right. All statin studies that have been done to date are worthless and don’t apply to anyone who follows healthy lifestyle principles.
2. Statins will not prolong your life. Not at all. Not for a single day.
3. Statins DO reduce your heart attack risk, by about 0.7% over 5 years.

All of a sudden, statins don’t seem so powerful, do they? Let’s go deeper into these points to learn why.

1-All Statin Trials Are Worthless

When designing a trial, you have to decide what your control group is going to be. You have to show that the drug is better than something. The key is defining what that something is.

Therein lies the problem. In order to show beneficial effects, primary prevention statin trials need thousands of subjects, studied over years. That is very expensive to do. The vast majority of trials, therefore, rely on drug company funding.

Do you think they are going to fund a trial that makes it easier or harder to show a benefit? Of course, that was a rhetorical question.

Pharma companies don’t have an interest in your health and wellbeing. Their priority is to their stock holders and their bottom line. They are going to sponsor trials that are most likely going to benefit them.

How does this make the trials worthless? They compare statins to “usual care.” That means a brief, and ineffective attempt to educate people about healthy nutrition and physical activity.

In addition, the specific nutritional guidance that was used has always been a low-fat diet. As we now know, what does a low-fat diet usually include? Lots of sugars and simple carbohydrates. What does that diet do? Increase your risk of obesity, diabetes, inflammation, and eventually heart disease.

That’s setting the bar pretty low to show a benefit from statins. And that is exactly what the drug companies want.

What we need is a control group that is involved in a comprehensive lifestyle intervention program. A program that helps participants get regular physical activity. Helps them eat vegetable based, real food, low in added sugars and simple carbs, and high in natural healthy fats.

Since that is the way we should all be living, THAT is what the control group should be. I guarantee you, the results would be far different compared to the standard control groups used to date.

That is the trial the drug companies never want to see and will never fund. And that is why all statin trials to date are worthless.

If you can focus on proper lifestyle interventions, using healthy foods, physical activity and stress management as medicine, then we have no idea what effect, if any, statins would have. But I assure you it will be minimal if any benefit.

2-Statins Will Not Prolong Your life

You read that right. For people who have never had heart disease before, the multi-billion dollar drug won’t help you live longer. The overwhelming majority of primary prevention trials involving statins show no difference in overall mortality between those who took the drug and those who did not.

That surprises a lot of people. Statins are promoted as if they are wonder drugs that save lives left and right. That’s good marketing and good PR. Reality is far different.

If they don’t help you live longer, they must increase the quality of your life, right? Nope. In fact, 30-40% of people on statins will experience muscle aches and weakness causing them to exercise less and decreasing the overall quality of their lives.

So, if they don’t help us live longer, and they don’t increase the quality of our lives, why do we take them????

3-Statins DO Reduce Your Heart Attack Risk

If the news was all bad there wouldn’t be any debate about their use. But the truth is that statins do reduce the risk of heart attacks, and that is why in some cases it may be beneficial for you to take one.

But the big question is: How much do statins reduce your heart attack risk? The answer is not as much as you would think. Considering the recommendations keep getting more and more aggressive for statin therapy, you would think statins would be immensely powerful at reducing heart disease risk.

In reality, they reduce the risk of a heart attack by 0.7-1.5% over 5 years. That means you need to treat 66-140 people for 5 years to prevent one heart attack.  (as an aside, for people with pre-existing heart disease, so called secondary prevention, you need to treat approximately 40 people for 5 years to prevent 1 heart attack and 85 people to prevent 1 death)

When presented like that, it should certainly temper the enthusiasm for statin therapy. Again, it may still be the right choice for some people, but given the potential risks and side effects, I would hope for a much greater benefit.

Better Than Statins

A common response is that statins are “the best we have to offer” to reduce one’s risk of cardiovascular disease.  If you are talking about a drug manufactured in a laboratory, then that would be correct. But what else are options?

It turns out following a Mediterranean eating pattern with vegetables, fruit, fish, legumes, and lots of nuts, olive oil and avocados reduces the risk of cardiovascular events as well. For something as simple as nutritional choices the benefit must be much less than a statin, right?

That is what the drug companies would want you to believe. In reality, you need to “treat” 61 people with the Mediterranean diet for 5 years to reduce 1 cardiovascular event (a “combined endpoint” of stroke, heart attack or death).

To be fair, you cannot compare one trial to another as they have very different populations studied, and the outcome measures are different. So, it is not scientifically fair to say, “The Mediterranean diet has been proven to be more beneficial that statins.”  That would require a head-to-head trial. Unfortunately, that trial is unlikely to ever happen.

But it makes for an obvious answer when asked “If statins aren’t all that helpful, what else can I do to reduce my risk of cardiovascular disease?

• Follow a real food, vegetable-based, Mediterranean style diet, low in sugar and high in healthy fats.
• Maintain a physically active lifestyle.
• Exercise with some form of moderate cardio exercise, resistance training and higher intensity interval exercises.
• Practice stress reduction techniques.
• Don’t smoke.
• Manage your other risk factors such as diabetes and high blood pressure.

If you can follow these healthy lifestyle principles, you will be doing far more for your health than any pill you could take. And the best part? The only side effects are having more energy, feeling more empowered, and reducing your risk for chronic diseases.  Sounds like a good trade off to me!

Thanks for reading.

Bret Scher, MD FACC

Cardiologist, author, founder of Boundless Health

www.DrBretScher.com

We 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