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

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:

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

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 

I live in McAllen, Texas, where it’s difficult to find a doctor who’s knowledgeable on the benefits of a low-carb lifestyle. Because I battle a high A1C AND high cholesterol, I reached out to Dr. Scher for a consultation to monitor my blood work and develop a plan that will keep my heart healthy and my A1C in check. Before our video-consultation, he responded personally to every question I had via email. When I first reached out, I figured it would take at least a month or more to schedule our consultation, but to my surprise, it was planned just over a week from my initial email!

I like Dr. Scher’s commonsense approach to a healthy lifestyle. He came up with a very-easy-to-follow plan and agreed to review my bloodwork every 6-8 weeks to make sure I’m on the right track. Because of my family’s history, it’s comforting to know I have a cardiologist monitoring my health so that I can prevent a significant problem down the road.

Nicole Southwell

I recently had a one-on-one Health Coaching Consultation with Dr. Bret Scher. I cannot adequately express the gratitude and respect I have for Dr. Scher. He took the time to consider all facets of my health and really listened to me and my concerns. He was not quick to insist I be on prescription medications, but rather he explored various avenues of suggested treatment/preventative measures I might consider taking…guiding, as opposed to dictating a plan of of action. The consultation was well worth my time and money! Loved his approach so much that my husband and I have decided to work with him long distance.

Jami Miltenberger
MS Counseling Psychology