A Healthier Grilled Cheese For The Whole Family

I know what you are thinking. Grilled cheese, healthy? What? I admit it may not be the healthiest choice, but sometimes you want to mix it up and your crave some comfort food. It helps to have a healthier go-to version of the old facorite. Plus, my kids love this. They love it so much that my 7-year old insisted that he film us making it for all of you. Enjoy!

https://www.youtube.com/channel/UCg6pXO7gfB2GapwRjMKEIbQ/videos

Why I Ate My Wife’s Chocolate Chips. All of Them.

I didn’t sleep at all Saturday night.

 

 In college, that may have been an exciting statement full of fun and intrigue.

 

In medical school and residency, it was a badge of honor and usually involved clinical challenges and valuable experiences.

 

This past Saturday, it involved consoling my son as he kept throwing up. Changing his sheets, wiping his head with a damp towel, and most importantly, just letting him know I was there and that he would be OK. It is a rite of passage all parents go through, more than once.

 

On Sunday, he was much better and slowly getting back to his usual self. Me? I was hungry and craving carbs.

 

I also almost never crave carbs. I practice intermittent fasting, I eat a “veggie first diet” with healthy fats, appropriate portions of animal sources, some fruit and almost no refined carbs. Through years of this practice, I have been able to drastically diminish my sweet tooth and control my hunger and cravings

 

A Different Story

 

Sunday was a different story. I had the carb cravings and munchies all day. Instead of eggs, veggies, and avocado, I had fruit and granola for breakfast. But didn’t stop there. I still had this crazy craving so I added toast and a banana.

 

Later in the day the cravings really hit. Chocolate.

 

I was craving chocolate like you wouldn’t believe. Fortunately, my wife had some chocolate chips in the freezer. Let’s just say I need to make a run to replenish the supply before she sees what I have done. Without thinking, I polished off what was left in the bag.

 

How could this be? This was all so unlike me. What could have happened?

 

Sleep.

 

Or more importantly, lack of sleep.

 

Sleep and Our Hormones

 

Sleep is intimately involved with our hunger and our cravings. As a result, sleep is intimately involved with our weight gain, weight loss and our health. It effects not only our ability to make decisions, but also alters our hormones, our cravings and our feelings.

 

That’s powerful stuff!

 

It turns out that inadequate sleep affects our hormones ghrelin and leptin. They sound like comic book villains, but they are hormones that control our feelings of being hungry or feeling full. Ghrelin, the “hunger hormone,” signals to your body that you’re hungry and need to eat. Leptin has the opposite effect, and signals that you’re full and don’t need to eat. Research consistently shows that poor sleep spikes ghrelin and suppresses leptin levels.

 

The result? Poor sleep leaves you feeling hungrier than usual regardless of what you eat or how much you eat. You eat more and expend less energy. Bad combination.

 

Leptin and ghrelin load the gun, our lack of mental clarity pulls the trigger (it’s a terribly violent analogy, but it makes the point none the less).

 

When we are sleep deprived we don’t think with the same level of clarity and with the same emotional control. We tend to react impulsively when we feel hungry. Impulse decisions rarely end in a well-balanced meal of veggies with healthy fats and proteins. More often, the result is standing in front of the freezer, door open, eating your wife’s stash of chocolate chips.

 

Guilty as charged.

 

Ripple Effect

 

Guess what else I did (or more importantly, didn’t do) in my sleep-deprived state on Sunday.

 

I didn’t go to the gym as I had planned.

 

I didn’t get out for a hike or nature walk.

 

I drove to the grocery store instead of riding my bike.

 

I sat and watched a movie with my son rationalizing that he wanted me there so it was OK to plant myself on the couch for an hour and a half.

 

Sound familiar? When we are tired and run down from poor sleep, the rest of our healthy lifestyle decisions suffer. It is the classic ripple effect.

 

And poor sleep can cause it all.

 

The solution?

 

Sleep better.

 

“No kidding. We already knew that. Thanks for nothing doc!”

 

Ok. We all know we need more sleep. And there is a laundry list of sleep hygiene techniques that I review in more detail in my book and elsewhere.

 

But life happens. We can’t always prepare for the night of consoling our children. Or the night before a big presentation when we are too excited/nervous/scared (take your pick) to get to sleep. What do we do then?

 

Be mindful and be aware.

 

Mindful Power

 

In this case, knowledge truly is power. Simply being aware that our hormones will be off kilter and our decision making will be impaired gives us the power to control our day.

 

You may need an extra reminder, or you may have to try harder than usual, but staying in the present and being mindful of your decisions is the skill you need to counteract the effects of poor sleep.

 

Instead of acting rashly, take a breath. Step back, breathe and realize you did not sleep well. Remind yourself that poor sleep alters your hormones and your perceived needs. And realize that you can still control these feelings and cravings. When you are mindful, you are in control.

 

It turns out, studies show mindfulness also helps you sleep better. When compared to a group of individuals given sleep hygiene education, individuals who practiced regular mindful meditation slept more and felt more refreshed. So not only does being mindful help you get through your day with minimal damage, it also helps you get back on track.

 

Once again, that’s a pretty powerful effect. If that were a pill you better believe there would be a multi-million-dollar marketing campaign behind it.

 

But it isn’t a pill. It’s free for anyone to do. It’s a skill anyone can try and everyone can improve. Being mindful is like exercising a muscle. The more you practice it, the stronger it becomes. The stronger it becomes, the easier it is to use.

 

You won’t be perfect and it may not always be easy. But I promise you this. Practice being mindful, practice your breathing, and you will be better.

 

Action Item:

Start recording your sleep. Activity monitors like FitBit Alta HR, FitBit Charge, Garmin Vivosport, Mio Slice, the Apple watch and many others all record sleep duration. Or simply record it yourself with a pen and paper (old school). When you get less sleep than usual, make a concerted effort to control your surroundings more. Make a concerted effort to practice your mindfulness techniques more. Treat yourself with more compassion and more love.  And make sure you get to bed a little earlier that night to help break the cycle. You can do this. You just need to be aware.

 

 

Thanks for reading.

 

Bret Scher, MD FACC

Cardiologist, author, founder of Boundless Health

www.DrBretScher.com

 

 

 

 

Whole30 Mexican Salmon Cakes with Mango Relish

I am a big fan of Melissa Hartwig and her Whole30 program. First there is the general concept that how and why we eat are just as important as what we eat. Then there are her recipes. Some people feel it can get boring eating real foods, no added sugars or grains or processed food. Melissa's recipes show us that it is anything but boring. Try these Mexican Salmon Cakes with Mango Relish and you will drop the word boring from your vocabulary. I'm a spice wimp so I did it without the cayenne pepper and jalopenos, and I served it with sauted spinach and some leftover broccoli/carrots/cauliflower I had in the fridge. Deliscious!

Rainbow Carrot and Brussels Sprout Salad with Pecans

Here is another one of our favorites from Dr. Hyman’s site. Rainbow carrotts, salad greens, cabbage, brussels sprouts, nuts and seeds. Yum! Great variety of colorful veggies and healthy fats. Delicious, nutritious and satisfying. Give it a try and let us know what you think.

Saturated Fat Kills! Or does it? Let the debate continue!

Dietary Saturated Fat Kills! Or does it? The Debate Rages On…..

 

A recent editorial publication in BMJ has once again stirred the raucous debate about dietary saturated fat. One subject with two completely opposing viewpoints, each one filled with ardent supporters who know in their hearts (pun intended) they are correct.

 

So……does dietary saturated fat directly cause heart disease, strokes and death? Or does it not?

 

Wait a second. This is science we’re talking about. Shouldn’t it be clear who is right? Shouldn’t the evidence prove one group right and the other wrong?

 

Nope.

 

Nutritional science is messy and rarely conclusive. That’s why we got into this mess in the first place.

 

Hooray for Debate

 

Before we get into the details, let’s all celebrate the debate itself. We should all be grateful that we can take part of an open and emotional debate among intelligent, successful and reputable individuals. Recent history has too many examples of some individuals trying to shut down debates in favor of declaring the “truth.” We all should know by now that isn’t going to fly.

 

Instead, we should celebrate every chance to debate the science and its impact on our lives. After all, we can still have free speech even if we can’t have free healthcare.

 

Bad Data

 

Here is the problem with nutritional science. It is really bad science.

 

Remember your science fair project as a kid? You were supposed to design an experiment that tested a hypothesis, controlled for one variable, and proved if that hypothesis was valid or not.

 

Nutritional science doesn’t work that way. Instead, most nutritional studies are observational studies. We observe how people live their lives, collect as much data as we can, and follow them to see who has heart attacks, who has diabetes, who lives and dies, etc. We can then see what habits each person had and try to draw statistical associations.

 

The problem is that this cannot prove anything. It can only suggest an association. When compared to your middle school science fair experiment, you can see the stark differences.

 

The observational study does not control any variables (they try to control for certain variables, but that is an impossible task especially since we can’t know all the variables for which we need to control), does not test a single hypothesis, and does not prove anything.

 

Why Does This Matter?

 

Here’s the problem. There are lots of studies that show an association between saturated fat intake (mostly animal products) and an increased risk of heart disease, strokes and death.

 

But here is the kicker. There are also lots of studies that show there is no association between saturated fat intake (mostly animal products) and an increased risk of heart disease, strokes and death.

 

Huh? How can that be?

 

There are many reasons why but here are the two big ones. 1- People are all different, and 2- Food is all different

 

People are Strange, I mean Unique

 

In the BMJ article, the authors propose that inflammation, not saturated fat, is the main cause of heart disease. There is definite sound evidence to support inflammation as a contributing causative factor in heart disease.

 

However, we need to acknowledge that inflammation is different in everyone. We are all unique. Our internal environments, from our degree of inflammation to our gut microbiome, are all different.

 

Therefore, how we respond to our external environment (i.e. the food we eat) is going to vary from person to person.

 

LDL cholesterol is a prime example. LDL is not inherently “evil.” Why would our bodies evolve to produce a substance whose job it is to kill us?

 

LDL is a necessary component in our cells, our brains and for making our hormones. We cannot live without it. Our internal environment, however, can alter LDL and turn it into an oxidized and inflamed structure that is more likely to cause heart disease. That may not be an inherent property of LDL, but rather, something our body’s environment does to LDL.

 

The same can be said of eating saturated fat. It is certainly plausible that introducing large quantities of saturated fat into an oxidized and inflamed environment can cause harm. But what if the individual exercises regularly, eats a veggie-first/real foods diet, practices mindfulness regularly, gets regular restorative sleep, and therefore has very low levels of inflammation and oxidation?  Chances are, the same amount of saturated fat in this individual is unlikely to cause damage (that’s my hypothesis, I haven’t don’t my science fair project on this yet).

 

Observational studies cannot tell the difference between these two types of people with different degrees of inflammation and oxidation. Instead, the trials try to reach a general conclusion that then is applied to everyone.

 

Does that sound like good science to you? I’d give it a C- in the middle school science fair (and that is being generous with extra points for their passion). Should we be making decisions about our health based on C- science?

 

We Don’t Eat Saturated Fat, We Eat Food!

 

Picture a big greasy burger on a huge bun, soaked in ketchup, with a side of fries and a coke. Observational studies call that a saturated fat eater.

 

Now picture a spinach and kale salad with beets, strawberries, walnuts, carrots and tomatoes topped with 4 ounces of grass fed steak. No fries. No coke. Observational studies also call this person a saturated fat eater.

 

I’ll say it once again. We don’t eat saturated fat. We eat food! It is crazy to think we can isolate one specific macronutrient and know all that it does. For starters, there multiple different types of saturated fat of highly variable quality with variable effects on our bodies.

 

Second, what we don’t eat (i.e. avoiding saturated fat) is just as important as what we do eat (instead, eating refined, processed, simple carbohydrates and sugar vs. veggies, fruit, nuts etc.). 

 

In the example above, the first person had a huge bun, fries and a coke. There wasn’t a veggie to be seen. Tough to pick just one villain in that so-called meal.

 

Don’t Throw It All Away

 

Don’t get me wrong. I am not about to suggest that we throw out all nutritional research. We still need it to guide future research and help us generate hypothesis.

 

I will suggest, however, that we need to be very careful about interpreting the research. Anyone who claims observational trials definitively prove anything must be seriously questioned.

 

And when they claim a “vast collection” of evidence, or an “overwhelmingly consistent conclusion” from the evidence, keep in mind that a vast collection of dog poop is still just a bunch a dog poop.

 

I respect and value ardent supporters on both side of the saturated fat aisle. But I also know that neither has the strength of evidence that their conviction conveys.

 

What Do We Do???

 

Be wary of anyone who claims they have the “answer” and the “conclusive” evidence. Try not to get caught up in all the debate if you don’t want. You can keep it simple and keep it healthy.

 

Eat real food. Mostly vegetables and some fruits with healthy fats such as extra virgin olive oil, avocados, nuts and seeds. Add smaller portions of high quality animal sources and smaller portions of minimally processed whole grains and legumes.

 

If you enjoy the debate, by all means participate. It’s good for science. But here is the one and only thing I can say with absolute certainty.

 

I can’t prove anything that I recommended in this article.

 

There has never been a randomized study to prove my personal nutritional consensus. No one has done their middle school science fair project to prove my hypothesis.

 

Sometimes, we need to take a leap and say, “this makes sense.” We need to integrate all the evidence, combine it with clinical experience, and come up with our best solution.

 

That is why experts can be so passionate and so resolute in their position, and yet the positions can be so variable.

 

And that is why we need to find reliable voices we can trust. 

 

My voice? Keep it simple.

 

Eat real food. Mostly vegetables and some fruits with healthy fats such as extra virgin olive oil, avocados, nuts and seeds. Add smaller portions of high quality animal sources and smaller portions of minimally processed whole grains and legumes. Take away the stress, be mindful in your eating, and enjoy!

 

Action Item:

Identify a belief you hold to be true about nutrition. Something that is ingrained in your core that must be true. Saturated fat is a perfect example, but there are plenty others. Salt? Carbs? Juicing? Whatever you feel is undoubtedly healthy or unhealthy. Next, search online for the exact opposite position. Keep an open mind and explore what the opposing side says. This will hopefully help you understand the complexities and uncertain nature of nutritional science.

 

Then, get back to the basics and (say it with me now….) eat real food. Mostly vegetables and some fruits with healthy fats. Add smaller portions of high quality animal sources and smaller portions of minimally processed whole grains and legumes. Take away the stress, be mindful in your eating, and enjoy!

 

Thanks for reading.

 

Bret Scher, MD FACC

Cardiologist, author, founder of Boundless Health

www.DrBretScher.com

 

 

 

 

 

 

 

 

 

 

 

Dessert- Who Needs it? Not Me and Not You!

I just had the most incredible family Passover Seder. We travelled to the east coast to see our cousins, and they treated us to a wonderful evening. We always have a fantastic time when we see them, which is not often enough.

 

Their company makes eating flattened cardboard (a.k.a matzah) almost worthwhile.

 

They also know how to feed us. A beautiful salad, matzah ball soup, steamed green beans, butternut squash “rice,” salmon, roasted chicken…my mouth is watering all over again just thinking about it. It was delicious and plentiful.

 

When dinner concluded, we pushed ourselves away from the table nicely fed, likely fuller than we needed to be (these things can happen when we get distracted by great conversation and connecting with our loved ones). If the evening had ended here, we would all have been more than satisfied.

                     

Trust me when I say no one would have gone home hungry.

 

But then it happened.

 

They brought out dessert.

 

We figured this would happen and tried to plan in advance by bringing a beautiful fruit tray that we picked up from a local grocer. Everyone remarked how lovely it was. Then they would sample one or two pieces of fruit and immediately turn their attention to the not one, not two, but three cakes that were beautifully displayed next to it.

 

Why three? Excellent question. I’m not sure as to the answer, but I noticed that most people felt compelled to take a piece of each one.

 

I was immediately struck by the complete lack of necessity for the cakes.

 

Was anyone still hungry or lacking for calories? No way. Dinner was more than enough.

 

Were we lacking in conversation and socializing so we needed an excuse to extend the evening? No way. The kids were getting restless and the adults were starting to yawn as it was getting late in the evening. We had all had a wonderful time, but it was clear the end was drawing near.

 

Our well-meaning hosts provided the array of desserts because that is what people do.

 

That is our unconscious action and belief about what a dinner party should entail.

 

I am sure (or at least I hope) that if we logically think about the need for dessert, we would see that it is almost always unnecessary. When we act in an unconscious manner, however, we simply provide dessert because it is what we do and what we feel our guests expect.

 

It turns out, studies have shown that we make 200 food and beverage decisions every day. 200! When I first heard that my initial reaction was, “No way. It doesn’t feel like that many at all.” 

 

That is true. It doesn’t feel like we make 200 decisions because most of them are unconscious decisions. They are habit, routine, automatic. They are less decisions and more natural reactions.

 

Our health usually suffers from those decisions. On the one hand, we could say it isn’t really our fault. Society inundates us with unhealthy junk food.

 

A prime example was on our flight home from the east coast. It is a minor miracle to get any food on an airplane nowadays. Our flight attendants were happy to announce that they provided free snacks for the flight. They proudly walked down the aisle holding their trays full of packaged cookies, chips, fake cheese and crackers, and the healthiest option….pretzels.

 

It was no surprise that all the kids on the flight immediately wanted one or two of everything. I was struck, however, by how many adults wanted to partake in the junk fest as well.  Was it their fault? There were no other options available. What else could they have done?

 

Plan ahead. My wife is the master at plan ahead food. We had a Tupperware of carrots, almonds, cashews, sweet potato, broccoli and cauliflower. We even had PB&J for the kids.

 

What if you can’t pack ahead? Just say no. Nancy Regan would be proud of you. If you have read my posts on intermittent fasting, you understand the importance of knowing that we are in control of our hunger, not the other way around. Going without snacks on a four-hour flight should not be a major challenge in our lives.

 

The problem once again lies in our unconscious decisions. We don’t actively think about our nutrition and don’t plan ahead to provide healthy choices. Until society does it for us (which seems unlikely on a mass scale in the immediate future), it is up to us as individuals to make the unconscious become conscious.

 

It isn’t always easy to question the automatic decisions. Trust me, I wanted to discuss the dessert issue with our host. I chickened out. She was incredibly gracious and warm to welcome us into her home and provide a wonderful meal. The last thing I wanted to do was insult her or make her feel badly about her decisions.

 

So, I let it go. In a way, I am an enabler for the next time. I admit that it is not always an easy thing to point out to others.

 

But it is an important thing to do. Our health depends on us taking responsibility for what we put in our bodies, what we make available for us and others, and how we make our 200 food and drink decisions.

 

We can start by reframing how we make our own decisions, and then can help others see how they make theirs. One by one, we can make the unconscious become conscious. Then we can give our health the priority it deserves.

 

ACTION ITEM:

At your next dinner party, birthday party, or other social gathering, do not serve dessert. Simply don’t have it. Don’t apologize for not having it. Don’t make a big deal about it. Don’t even mention it. Just go about as usual as if nothing was different. Over the course of the next week, ask those who attended if they noticed anything different or if they felt anything was missing. You may be surprised about what you find!

 

Thanks for reading.

 

Bret Scher, MD FACC

Cardiologist, author, founder of Boundless Health

www.DrBretScher.com

 

Stevia- Sweetness for free, or same story different chemicals?

“I love your book but I have a big problem and a question for you.” Since this was coming from my favorite cousin, I knew she was obligated to say she loved the book. But she had a “big problem.” Was she about to attack a major premise? I braced for the question.

 

“Do I have to give up Stevia? I’m just not sure that I can.”

 

First off, I love this question. It is a very specific question. She can focus on this level of detail because she already eats predominately real foods, vegetables first with healthy fats, and with appropriate quantities of high quality animal sources. She already commits to regular exercise and physical activity and does her best with stress reduction and sleep.

 

Check. She gets the big picture. That’s 90% of my job when it comes to advising clients how to reframe their nutrition and lifestyle. The details may be harder to answer completely, but they are easier in the sense that the big picture is taken care of.

 

So, what about Stevia?

 

Stevia comes from the stevia plant, Stevia rebaudiana, and has naturally occurring glycosides which are extracted from the plant to concentrate the sweet flavor. Sounds great, right? It is a natural plant, what could be wrong?

 

It is the best of the sweeteners as it has no calories or absorbable carbohydrates.

 

It has been shown to have minimal effect of on glucose, a claim that artificial sweeteners cannot make. In fact, stevia proponents market it specifically for those with diabetes.  

 

Interestingly, stevia does increase insulin levels. Some promote this as a benefit. If it increases insulin without increasing glucose, then it could help treat hyperglycemia seen in diabetes. That assumes, however, that higher insulin levels are beneficial.

 

That is likely an incorrect assumption. Insulin is a pro-inflammatory fat storage hormone. Therefore, more insulin in the body can cause increased fat mass and increased inflammation. How much insulin is too much? That is very difficult to say. But it makes sense that we should all strive for optimal blood glucose control with the lowest possible amount of insulin in our bodies.

 

Stevia’s effect on insulin is small, especially when compared to sugar and artificial sweeteners, so it is unclear if this is “harmful” or not. As with most things, it is not a black or white answer. Shades of grey predominate.

 

In addition, some stevia products, such as Truvia, are highly processed versions of stevia that contain very little pure stevia extract. Remember, stevia has to survive on the store shelf, so manufacturers add chemical such as erythitriol or dextrose, plus added flavors.

 

Other versions, like Green leaf stevia, are less processed and more pure.

 

Stevia extract is much sweeter than sugar, so a little goes a long way.

 

Many have claimed even greater health benefits from stevia. However, claims for weight loss, cholesterol reduction, improved blood pressure, and even anti-cancer benefits are poorly researched and far from proven.

 

The Real Issue

 

The real problem with stevia is not with its chemical structure or its physiological effects on our blood sugar. The real problem is that Stevia reinforces our dependency on sweet tastes.

 

We can train our taste buds, for better or for worse. I see it time and time again. One sweetener becomes two, which then becomes three. Yet we don’t find the increased sweetener increasing the “sweetness.” That is because our taste buds adapt to the sweetness and require more.

 

As a society, sugar and sweet flavors have become an epidemic. We need to train our taste buds and our brains to not require sweeter and sweeter foods. That is where I see the big problem with stevia. It is too sweet and is a slippery slope to seeking sweetness in other aspects of our food and drink.

 

If you need a sweetener, and I encourage you to explore your definition of need, then stevia is likely your best choice.  If you can minimize the amount you use, even better. Remember, we can train our taste buds. We can require less sweet taste and can still enjoy our meals.

 

ACTION ITEM:

Go for a whole week without sugar or artificial sweeteners. That includes even the “natural” sugars like real maple syrup, honey and others. It’s just 7-days. You can do it. At the end of the week, if you feel the need to go back to your sugar or sugar substitute, cut it in half. You may find that your taste buds have adapted and half your usual amount is now just right.

 

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!

Bret Scher, MD FACC

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