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

Don’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:

[T]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 

There’s a common assumption in the medical and nutrition world that a low carb, high fat diet, like a ketogenic diet, will automatically increase one’s risk for heart disease. However, it’s crucial for us to realize that this assumption is inaccurate and not supported by data.

In fact, it’s been well documented that low carb diets can help someone reverse type 2 diabetes and improve metabolic health, changes that dramatically lower one’s cardiac risk. Research and clinical experience supports that a properly formulated low-carb diet can help someone improve, rather than worsen, their heart health.

But many may wonder, how can this be true when I’ve heard that eating fat is bad for us and bad for our hearts?

A big problem comes from assuming that our bodies react the same way to a diet high in carbs + fat as we do to a diet LOW in carbs and high in fat. The truth is that our bodies react dramatically differently to those two versions of a high-fat diet.

How It Works

You see, when we eat lots of carbs, our body uses the carbs as fuel first. Therefore, we won’t burn the fat for energy, and we end up storing it as adipose or fat stores. But when we eat a very low carb diet, our bodies prefer to burn the fat for energy, and therefore there is much less left over to store as body fat. This is dramatically different from a high carb diet!

Studies also demonstrate that people eating a low carb, high fat diet naturally reduce their calories, thus eating less and losing weight seemingly without trying. But those eating high fat and high carb diets tend to eat more calories and gain weight.

So you can see how we can’t just refer to a “high fat diet” as if it is one thing. It makes a big difference if it is also a high carb or low carb diet.

The Main Contributors

Let’s review the main contributors to heart disease, and see how a low carb, high fat diet impacts them.

1- Blood pressure
One study demonstrated a ketogenic diet lowers blood pressure better than the DASH diet, the diet previously felt to be the best for blood pressure management. And others have shown safe and effective blood pressure lowering when starting a low carb, high fat diet that is similar to a low-fat diet.

2- Type 2 Diabetes
Numerous studies demonstrate the efficacy of low carb diets for treating and even reversing type 2 diabetes. Since diabetes is a major contributor to heart disease, reversing it will significantly improve one’s heart health.

3- Inflammation
Ketogenic diets have been shown to reduce many markers of inflammation, including the commonly used CRP.

4- Triglycerides and HDL cholesterol
Having low triglycerides and normal to mildly elevated HDL cholesterol levels are predictive markers of better heart health, likely because they occur with good metabolic health. Numerous studies demonstrate that ketogenic diets reliably help lower triglycerides and raise HDL, thus improving overall cardiac risk.

5- LDL cholesterol
Many assume that high fat diets raise LDL cholesterol. But again, that is not the case. Multiple studies demonstrate no net change in LDL on a ketogenic diet compared to a low fat diet. In fact, one analysis of multiple studies found a net reduction in LDL particles for those following a ketogenic diet.

Important to Note

However, there is a subset of individuals who can see a dramatic rise in their LDL cholesterol when following a ketogenic diet. These so-called Lean Mass Hyper Responders, have unique physiology that predisposes them to an increase in LDL. But it’s important to realize that these individuals are the minority, not the majority. And there’s even emerging evidence suggesting that elevated LDL may not place these individuals at a higher risk, although with much still to learn.

In Summary

The data does not support the assumption that low carb, high fat diets increase heart disease risk. In fact, many studies demonstrate overall improvement in most, if not all, cardiac risk factors. We need to stop assuming all high fat diets are the same, and realize the unique heart health-improving impact of low carb/high fat diets.

If you would like to learn more about the misperception and misunderstanding about ketosis and heart disease risk, please see the video links listed here:

Does Keto Cause Heart Disease?

Debunking a study claiming low carb diets cause heart disease

Analysis of a study demonstrating lowering of cardiac risk with low
carb diets

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

In the fall of 2018, I was diagnosed with Type 2 Diabetes. I was educated enough to know that there was something I could do about it and set out to change the path I was on by adopting a low carbohydrate/Ketogenic Diet to control my blood sugars. Fortunately, it worked right away- but soon after I discovered that I had some red flags on my cholesterol test results. There is a history of Cardiovascular disease in my family and I was disappointed that I might have to yet again make diet changes but was willing to do what was best for my whole health. After an appointment with a local Cardiologist, I felt somewhat confused about how to move forward. I wanted more information and not just a prescription.

I contacted Dr. Scher for a consult because I wanted to confer with someone who not only understood my condition but who could also give me the latest and soundest advice on how I might treat it and move forward in the best way for me as an individual- not as a statistic. I needed someone who came from a low carb perspective as well as a medical background. My interaction with him was positive, informative and went a long way to making me feel like I could make informed choices without the black and white thinking of well-meaning physicians. He sees the WHOLE person and not just one aspect of their health. Wellness is a journey- and having Dr. Scher along the way is a great way to make the trip!

Lisa K.