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

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. 

We had an incredible turnout for our Webinar, aimed to help you transform your health in 2019. As a result, we decided to create a blog post that includes the full webinar recording, as well as an overview of the learnings for those that were unable to attend.

Webinar Recording

https://www.youtube.com/watch?v=pIyi11wMq5U&ab_channel=LowCarbCardiologist

Webinar Overview

Cardiovascular Disease Is the #1 Killer for Men and Women

• 1/3 of all Americans die from Cardiovascular disease
• Around 92 million Americans are living with CVD
• Every 34 seconds someone suffers a heart attack
• Annual health expenditure and lost productivity from CVD ~$330 billion

It’s been estimated that 50-80% of these are preventable! Unfortunately, our healthcare system and associated lifestyle guidelines have failed to prevent disease. We could say at best they have failed to prevent heart disease, obesity and diabetes. At worst they have been implicit in its prevalence. While this graph doesn’t show causation, it certainly shows the association of instituting national nutritional guidelines and the rise in diabetes.

Drugs Don’t Fix the Problem

• 60% of Americans take at least 1 prescription drug
• 15% take more than 5 drugs
• Despite this, our overall health and life expectancy continue to decline

HEALTH IS NOT THE ABSENCE OF DISEASE!

In this webinar, we will discuss how to be your own best advocate, why low carb, high fat nutrition should be an option for everyone, and how lifestyle really is the best medicine.

3 Interventions to Improve your Healthcare Experience and Be Your Best Advocate

1. Make sure your doc is working with accurate information! Lipids and blood pressure are two prime examples of when doctors make decisions based on limited and faulty information.
2. Get your questions answered by writing them down ahead of time so you don’t forget anything and tell your doctor at the beginning of the appointment that you have some questions you’d like to ask at the end.
3. Make sure you understand the purpose and benefit of each and every medication. Not some vague answer like “It will improve your cholesterol,” or “It will lower your blood pressure.” Rather, “what impact will it have on my longevity and quality of life?” Will I live longer? Will I feel better? What are the chances the drug will actually benefit me? These are the questions we need answered.

Why Low Carb, High Fat Nutrition Should be an Option for Everyone!

LCHF vs Low Fat Diets

LCHF Benefits

• Decreased hunger, increased energy, mental clarity
• Treats metabolic syndrome/insulin resistance
• Better weight loss
• Improves overall cardiovascular risk for most people

LCHF may not be the best for everyone, but it certainly should be an option for everyone. If you want tips that do work for everyone, follow these bonus tips for weight loss and overall health!

• Don’t drink your calories – even “natural” drinks are full of unnecessary calories. Think about it this way, you would drink a glass of orange juice, but would you really sit down eat the 5 or so oranges it takes to make it? If not, why drink that same amount?
• Get rid of “Food Delivery Systems” – Think about the big sandwiches or burritos we see everywhere in our culture. What is the food? The stuff in the middle! The meat, the cheese, the veggies. What is the unnecessary food delivery system? The bread, the tortilla, the outer layer that has a fraction of the nutrients and a multitude of the carbs!

Lifestyle Really is the Best Medicine!

Science says lifestyle, not drugs, reverse disease:

• NEJM study reported findings on patients at highest genetic risk for heart attack, over 90% more likely to suffer heart attack. Those with healthy lifestyles had a 50% reduced risk with no drugs and no surgeries!
• JACC study found 85% of all heart attacks could be prevented with greater attention to lifestyle.
• A 2018 British Journal of Sports Medicine study found that increasing walking pace to “brisk” for those over 50 reduced all-cause mortality and cardiovascular mortality by 20-24%.

Why is it so hard?

We have all been told that in order to be healthy, we need to eat less, move more, and reduce fat in our diets. But if that is the case, why is it that only 12% of Americans are metabolically healthy, and only 3% of Americans follow a healthy lifestyle?

Because the simple Eat Less, Move More, Reduce Fat approach DOESN’T WORK!!!

I want to assure you that it’s not your fault, you’ve been given the wrong information.

“I was always told I simply didn’t have enough willpower to stick to a diet. I couldn’t understand why I was always hungry and craving foods. I figured it was all genetics. But working with Dr. Scher showed me there is a better lifestyle that I can stick with and still feel great and enjoy my life! Thanks Dr. Scher!”

• E

Keys to Making Lifestyle Change Stick

• Beware of one-size-fits-all nutrition and lifestyle claims
• Individually tailored and flexible nutrition is the key.
• When you eat is just as important as what you eat
• Move your body more
• Get Serious about your sleep
• Don’t be afraid to test and adjust

A Word of Caution

Don’t try to Change Everything at one time.

Choose YOUR most important first step (nutrition, stress, fitness, etc.) and work on that until a new habit is created!

And remember, you don’t have to do it alone! Working with an expert who can help you on your health journey will increase your likelihood for long term success.

As you can see, this was a quick tour to highlight the main points in the webinar. To get the full benefit, I recommend watching the full recording to get all of the context and be able to see the Q&A session at the end.

If you want to get the full experience, here is that recording again:

https://www.youtube.com/watch?v=pIyi11wMq5U&ab_channel=LowCarbCardiologist

If you’d like to see the date and content of our next webinar, or be notified when our next webinar will be, please visit our Webinar Page.

I hope you enjoyed this recording, and that we will see you at the next live webinar!

Thanks for reading,

Bret Scher MD FACC

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

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