Here you can find Boundless’ Health, Fitness, and general Wellness articles.

bret

The Statin Debate and Our Health

Thank goodness. We finally have the last word on statins that will forever lay the risk/benefit debate to rest. At least that is according to the authors of a recent review titled “Interpretation of the evidence for the efficacy and safety of statin therapy.” (DOI: http://dx.doi.org/10.1016/S0140-6736(16)31357-5)

 

This review study was touted as the end-all, be-all word on statins. It concluded that the benefits of statins have been underplayed while the adverse events have been overplayed.

 

The study quoted a 15% benefit from statins with only a 2% risk of side effects. According to the main author, this was supposed to silence all statin naysayers, end all debate and finally prove for good that the benefits of statins far outweigh the risks, even for those at low risk for cardiovascular disease.

 

Did it work? Of course not. If it did, I wouldn’t likely be writing about it.

 

 

Let The Debates Rage

 

For starters, when should the debate about anything be over? When should we ever stop questioning the status quo? When should we stop looking for new scientific findings to help promote our health? I hope we can all agree the answer is a resounding NEVER.

 

The day we stop questioning things is the day robots take over and deliver cookbook style healthcare to the masses. No thanks.

 

Debates are healthy. Debates are educational. Debates are built on free speech. Let’s agree to not stop that please. We can talk about the responsibility of the media in reporting scientific findings, but let’s keep the science free of censorship.

 

40 Million Statin Prescriptions

 

Statins are no strangers to debates. The pro vs. con statin debate has waged for decades. Statins have been used with less controversy in secondary prevention (in people who have already had heart attacks, stents or bypass surgery), but their use in primary prevention (those who have never had a cardiovascular event) has appropriately met with much more controversy.

 

The controversy intensified in 2013 when the revised ACC/AHA guidelines dramatically increased the number of low-risk patients who were now “statin eligible.” Prior guidelines stated statins were not beneficial for anyone with less than a 20% risk of developing cardiovascular disease over the next 10 years.

 

The new guideline lowered the statin threshold to anyone with a 10-yer risk of developing cardiovascular disease of 5% or more. There are now an estimated 40 million Americans without cardiovascular disease should consider taking statins.

 

Why the change? Was there new data that made the committee change the guidelines? Surprisingly, there was not. Instead, it was a review of old data.

 

The 2012 meta-analysis by the Cholesterol Treatment Trialists (CTT) Collaboration (Lancet 2012;380:581-590) reviewed trials involving over 170,000 participants. By statistically crunching the data, they concluded that statins were indeed beneficial even in those at low risk for cardiovascular disease. They concluded that statin benefits “greatly exceed any known hazards of statin therapy.”

 

Not So Fast

 

An independent analysis of the same data concluded that there was absolutely no mortality benefit for those with <10% 10-year risk, and in order to prevent 1 heart attack, you would need to treat 140 people for 5 years.

 

In addition, the incidence of adverse events was drastically minimized in the clinical trials.  Almost all of the studies were pre-designed with a run-in period.

 

Run-in periods work like this. Say we recruit 200 people for a drug trial. We give all 200 of them the drug for 3 months. This isn’t part of the trial yet. This is the “run-in period.” If 100 of them get side effects, those 100 are disqualified from the trial. The remaining 100 people who did not get side effects are now the trial subjects. 50 get a placebo, and 50 get the drug. We follow them for the duration of the trial.

 

The trial purposely excludes anyone who might have side effects.

 

As a real word example, the TNT trial (a trial popularly used to promote statins) excluded 35% of all participants during their run in period because they had side effects from the statins.

 

So when the CCT trial claims statin side effects are far less than 1%, that is the best case scenario from trials designed to limit the reported side effects. In real world estimates, the adverse events range closer to 30-40%.

 

Now reexamine Dr. Collins’ clams that the benefits far outweigh any risk. Suddenly it is not as clear, is it?

 

The Bigger Picture:

 

Statins are a hot-topic example of a larger debate in medicine, the debate between the less-is-more camp and the more-is-better camp. It applies to statins, to chemotherapy, to CT scans, to cancer screening, and almost every aspect of medicine.

 

The less-is-more camp tends to focus more on lifestyle and non-prescription therapies. They value “do no harm” above a small possibility for benefit. They are disturbed by the over-involvement of pharmaceutical companies in funding and designing drug trials and sponsoring the physicians who create the guidelines.

 

The more-is-better camp believes in the limitless potential for medicine. They are willing to risk adverse events to ensure no potential benefit is left unexplored. They believe cost to the individual or society should not deter even the smallest chance for benefit.

 

Both factions are right and both are wrong. Both use the scientific literature to back their approach, and both believe they are doing what is best for their patients. That is what makes this debate so difficult. For the most part, they both feel they are doing “the right thing.”

 

The Art vs. The Science of Medicine

 

Sure, some healthcare providers are financially motivated. Some do more to get paid more, and some promote treatments from whatever company pays them the most.

 

But the overwhelming majority of physicians are simply trying to do their best for their patients. They simply weigh the trade-offs with differing levels of importance.

 

This is where the “art” of medicine becomes more important that the science. P-values can only tell us so much. It is how we interpret them for our patients that matters most.

 

Said another way, a statistically significant finding may not always mean a clinically significant finding for you. That is for you decide with the guidance of your healthcare provider. It is not for your doctor to decide for you.

 

Despite Dr. Collin’s wishes, the statin debate is far from over. The benefit vs. risk balance in people without cardiovascular disease is suspect at best.

 

If your doctor has prescribed a statin, make sure you have a good understanding of your risk of heart disease, how much the statin can reduce that risk, how much it reduces your risk of death, and what are the real world risk of side effects.

 

In the end, you may feel it is worth taking. In many cases you may not. That is for you to decide, not your doctor.

 

Who Wins the Statin Debate?

 

Twenty years from now when medical historians look back, who will they declare the winner of the great statin debate of the 2010’s?

 

Hopefully the winner will be the patients’ health.

 

Hopefully the open debate will help patients and providers alike realize that healthcare is not always about statistics and p-values.

 

Healthcare is about human interactions, about understanding the wants and fears of each individual, and about using the totality of evidence to help make the correct decision for each person in that moment.

 

As of now, there is still no role for robots in delivering this style of healthcare.

shutterstock_136073105

Activity Monitors and Our Health- Don’t Throw Them Out Yet!

Time to Throw Out your FitBit?

 

A recent JAMA study questioned the efficacy of activity trackers for weight loss. In this study, those wearing an activity tracker lost 7.7 pounds over 2 years. Those without it lost 13 pounds over two years.  There has been a resulting social media storm questioning if the devices on our wrists are nothing more than just jewelry.

 

This was a surprise to the authors who were “fairly confident” at the start of the study that they would see the opposite results. Why the unexpected difference?

 

One potential explanation is that activity monitors are an adjunct to an otherwise healthy lifestyle. If we see them as the key to health and weight loss by themselves, we will likely neglect the real work that needs to be done with nutrition, intensity of exercise, sleep hygiene and other healthy living habits. After all, “you can’t out run a bad diet.”

 

Also, was there an issue with immediate feedback and immediate rewards? Did the activity tracker group feel like they were doing so well exercising, as evidenced by their tracker results, that they deserved a reward and ate more calories, more sugar, more sweets, etc.?

 

Or were they more interested in the number of steps and less interested in increasing the intensity of their exercise? Low intensity exercise is better than none, but increasing the intensity is very helpful for weight loss and overall health goals.

 

All of these are potential pitfalls with activity trackers. They work best when they are one piece of an overall health program.

 

What I see as the most likely explanation, however, is that the research staff was still involved in the care of the control group, providing feedback and encouragement based on the nutrition and exercise logs. To understand this, it helps to know the details of the study.

 

The study, (JAMA 2016;316:1161-1171) looked at 470 overweight 18-35 year olds. For 6 months all subjects adhered to a low calorie diet and an exercise program, after which time both groups had lost 17.5 pounds.

 

Pretty good results for a 6-month program! To me that shows the quality of engagement and encouragement that the staff provided. This is not the “usual care” seen in most clinical practices, it was a much more involved program with impressive results. But wait, the trial hasn’t even started yet!

 

The subjects were then encouraged to continue with the diet and exercise program but half were assigned an arm-band activity monitor and the other half were the “control” group.

 

18 months after randomization, the activity tracker group had regained approximately 10 pounds for a total 24-month weight loss of 7.7 pounds. The group without the activity tracker regained only 4.5 pounds for a total 24-month loss of 13 pounds, 5.3 pounds better than the activity monitor group.

 

A glaring difference between the groups is that the activity tracker group did not have the same human interaction. They were instructed simply to rely on their devices for feedback. Since we know the success the research staff had in the initial 6-moths, it is not surprising that things would deteriorate when that support was withdrawn.

 

It would have a better study if the activity monitor group still had feedback from the research staff, or if the control group was left on their own without external support. That would have been a better study to focus more on the effect of device itself.

 

Compounding this point further, the activity monitors used in the study did not have the important community building and social interaction components that modern-day Fitbits, Garmin vivos, Apple watches etc. have.

 

So in essence, the study compared an activity tracker with no social support network to a very effective and organized weight loss support system. The support system won.

 

Unfortunately, most people do not have immediate access to such a support system. Interestingly, modern day activity monitors try to provide such a support system by virtually connecting their users. So don’t throw out your Fitbits yet!

 

Another important consideration is that weight loss may not be the best outcome to follow. Instead, overall health and reduction of death and disease should be the ultimate goal. You may be thinking, aren’t they one in the same? Not necessarily.

 

There is no question that being overweight and in poor physical condition is a perfect storm for poor health. However, even if you are overweight, being physically fit dramatically reduces your risk of disease.

 

A study published back in 1999 (Am J Clin Nurtr 1999;69:373-380) found that unfit lean men had a higher risk of death than fit obese men. Since then other studies have confirmed that technically overweight individuals who meet criteria for being “fit” have similar health benefits as those who are “normal weight.” Also, in most cases, skinny but sedentary people had much worse health outcomes than fit overweight individuals.  (J Am Coll Cardiol. 2014;63(14):1345-1354. doi:10.1016/j.jacc.2014.01.022 J Am Coll Cardiol. 2012;59(7):665-672. doi:10.1016/j.jacc.2011.11.013 http://dx.doi.org/10.1016/j.pcad.2013.09.002)

 

So maybe we shouldn’t throw out our Fitbits quite yet (or sell the company stock?). Instead, we need to realize that activity trackers are one piece of a complicated puzzle that is our health.

 

We still need to focus on our nutrition, on the intensity of our exercise, and most importantly, on building a community and support system to help keep us motivated towards our overall health goals.

 

Thanks for reading, and thank you for prioritizing your heath.

 

Take care of ourselves, take care of others, and take care of the earth!

 

Bret Scher, MD FACC

Boundless Health

shutterstock_251592922

The Mediterranean Diet- What it Means to Me

As I have mentioned in previous posts, nutritional science can be difficult and messy. It frequently can only prove an association but falls short of proving cause and effect. This is most popularly noted in the Seven Countries Study, which noted an association between those who ate a higher fat diet and the incidence of heart disease. The study did nothing to prove that one caused the other, it merely identified a potential association. On the other hand, nutritional science can focus on a single food component and prove what effects it may have on our bodies. An example of this was a recent study that investigated the effects of increasing fat intake in a very controlled environment inside a metabolic ward. Unfortunately, that approach frequently has little practical application to how we eat in real life.  We do not live in controlled environments where all our food is supplied for us. That may be helpful from a physiology standpoint, it is less helpful from a real world perspective.

The majority of nutritional research focuses on specific macronutrients (i.e. fat, carbohydrate or protein), or it focuses on specific food types (i.e. meat, sugar, vegetables, etc.).  One of the main concerns with that style of research is that we do not eat only protein, or only fat, or only sugar. We eat food. Food is a complicated combination of ingredients and macronutrients that makes it challenging to apply specific research to the food we eat on a daily basis. Macronutrient research is still valuable knowledge to have, and it can help us make better choices for more nourishing and healthy food. For instance, we now know that we do not have to be afraid of high quality fats, but we should avoid industrialized trans-fats. We should avoid added refined sugar, but carbohydrates in the form of vegetables and some fruits are very beneficial to our health. That evidence came from macronutrient research. More helpful, however, would be real food research with strong clinical outcomes.

Research with the “Mediterranean Diet” fits the criteria perfectly; real world food and eating patterns with strong clinical outcomes. Initially, researchers noted that populations living along the Mediterranean Sea (Greece, Spain, Italy etc.) had a lower incidence of cardiovascular diseases despite nutritional patterns that were higher in fat. That drew attention from nutritional scientists to try to understand how this could be true. Subsequent studies as detailed below have shown that a Mediterranean style diet can reduce the risk of death (Circ 1999;99:779-85), reduce the risk of cardiovascular diseases (NEJM 2013;368:1279-1290), reduce the risk of diabetes (diabetes care 2011;34:14-19), and reduce the oxidation of cholesterol (JAMA int med 2007;167:1195-1203).  That is a pretty impressive resume for a particular intervention. If it was a pharmaceutical medication showing those results, there would be a multi-million-dollar marketing campaign designed to promote the drug to physicians and consumers alike.  Instead, it was not a drug, but rather a pattern of eating. Nobody owns Mediterranean eating, and therefore companies cannot patent it and profit from it. So instead of the media blitz, the promotion of this diet depends on well-meaning individuals focused on promoting a lifestyle over medications.

What exactly is a Mediterranean diet? In the trials, the Mediterranean diet was described as a diet with “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 consumed with meals.” (NEJM 2013;368:1279-1290.) This diet has greater than 40% fat and strongly discouraged soda, bakery goods, and processed foods. In the PREDIMED study (NEJM 2013;368:1279-1290.), this diet was compared to a low-fat diet that was likewise low in bakery goods and processed foods. Interestingly, this “control diet” was already an improvement over the standard American diet that tends to be full of processed foods and simple carbohydrates.  In addition, the individuals in the trial were being aggressively managed for their medical conditions; 40% were on statins and 50% were on blood pressure medications.  Despite the medical therapy and the improved baseline diet, the Mediterranean diet intervention group still had a 3% reduced risk of cardiovascular disease over 5 years. The investigators set a very high bar to show any significant improvement, and the diet intervention convincingly showed a significant benefit.  If it were compared to the standard American diet in patients less aggressively managed, I would expect it would have shown an even greater benefit.

The other major trial investigating the Mediterranean diet that preceded the PREDIMED study was the Lyon Heart Study (circ 1999;99:779-85). This study examined a higher-risk population compared to PREDIMED as they only enrolled subjects who had already had a heart attack. In contrast to the PREDIMED study, the control group received no dietary intervention. Therefore, they were following a less healthy diet at baseline. The results were astounding with significant reductions (70% relative risk reduction) in heart attack, cardiac death, and overall deaths after 2 years of follow-up. A single intervention focusing on diet reduced the risk of death in less than 2 years! A longer term analysis showed that the beneficial results were maintained at 4 years as well (circulation 1999;99:779-785). Also important to note, the reduction in heart attack and death all took place without any significant change in the LDL-C levels. Again, it becomes clear that LDL is not the only “culprit” in causing cardiovascular disease.

You can see how this research did not focus on a single nutrient or a single food type. Instead, it investigated a cultural style of eating. That cultural style went beyond just the categories of food they ate or did not eat. It also included appropriate portion sizes, it included the freshness and quality of the ingredients, and it included the social environment and mindset of the individuals as they ate. That point is worth reiterating. The Mediterranean diet pattern that reduced cardiovascular death and heart attacks included high quality real foods, but it also included the culture of eating; appropriate portion sizes, and presumably a relaxed and more mindful approach to eating. That makes it difficult to say exactly what component of the Mediterranean diet was the one element that reduced cardiovascular risk. It also makes it difficult to say that we can replicate the benefits simply by changing what we eat. I would argue that we need to change how we eat as well.

Combining the Mediterranean diet research with macronutrient-centered research creates a powerful intersection of knowledge to help guide our nutritional choices.  The logical conclusion is to follow a Mediterranean style diet based on real foods. This diet is full of fish, avocados, nuts, olive oil, vegetables and fruit, and it avoids sweets, baked goods and processed meats and processed foods. It focuses on higher quality ingredients, it has controlled portion sizes especially for grains and simple carbohydrates, and it follows the rule of eating to nourish your body. The Mediterranean diet involves an entire culture of eating. That culture does not include an all-you-can-eat buffet, it does not include super-sized fast food. It does include a culture of enjoying high-quality food in appropriate portions, consumed in a relaxed and social environment.  The macronutrient research shows that we can welcome the added high quality fat involved in this nutritional pattern, and we should be vigilant to avoid the added sugars.

The last piece of the puzzle regarding nutritional health is our mindset.  We can only maintain healthy eating patterns if we are purposeful and mindful about our eating. We have to allow ourselves to rethink all of our assumptions and our individual and cultural traditions regarding food intake. Our tradition may involve eating the 16-ounce porterhouse steak with white potatoes on the side. That tradition needs a healthy update. We don’t have to forgo the steak, but rather we should eat 4-6 ounces of grass fed steak on top of a salad full of fresh vegetables and added fats with avocados, nuts and olive oil. We need to choose our food for the purpose it is intended; to nourish, to relieve hunger, and to provide energy.

In addition, by being mindful as we eat, by being present with our meal, we can control the urge to overeat. We eat to eliminate hunger, not to feel stuffed.  We have likely all experienced the situation where we are eating while watching TV, or on our computer, or distracted in some other way. Before we realize it, we ate the entire bowl of whatever was in front of us. No matter what we ate, overconsumption is deleterious to our health. Whether it was something relatively healthy like a bowl of raw almonds, or something not so healthy like a bowl of trail mix full of chocolate chips, craisins and dates; overconsumption still has negative effects on our bodies. Unfortunately, it is all too easy to do when we are distracted. It turns out, this doesn’t just make common sense.  Science also supports the claim that distracted eating leads to unhealthy overeating (Am J Clin Nutr 2013, 97:728-742).

Fortunately, the converse is also true. If we are mindful when we eat, and pay attention to being present, we tend to eat less. We still eat what we need. We don’t leave ourselves hungry. But we are able to avoid the mindless overconsumption of calories that our bodies do not need. It takes about 20 minutes for your brain to fully realize “I am full so I had better stop eating.” If you are distracted in that 20-minute period, you are likely to keep eating without even realizing it. Focus on the food you are eating, understand when you are no longer hungry, and stop when you have ingested your nourishment.

Following a Mediterranean style eating pattern and being mindful while you eat are two effective techniques to improve how you nourish your body. Nourishing your body is a vital component of taking control of your health and taking control of your life. NOW is always the best time to start your journey towards health! Contact us at Boundless Health today to see how we can help you on your journey.

Thanks for Reading

Bret Scher, MD FACC

www.myboundlesshealth.com

info@myboundlesshealth.com

shutterstock_252233521

A Brief History of Fat

A Brief History of fat

Our relationship with fat and dietary cholesterol has just gotten more complicated. Or has it gotten easier? I guess it depends on how you look at it. What we once thought was an absolute truth now no longer seems to be true at all. It was supposedly well known science that dietary fat and cholesterol are dangerous and need to be avoided. We now know, however, that science tells us the opposite. Dietary fat and cholesterol are not inherently unhealthy. How could this be? Let’s take a look at the history of what brought us to this point.

The evidence that convinced nutritional and health experts that dietary fat and cholesterol were dangerous to our health consisted of three main areas.

1- Studies showed that feeding animals very high levels of dietary cholesterol increased plasma cholesterol and vascular plaque. This started back in 1843, when researchers analyzed atherosclerotic plaque and found it to contain cholesterol.(Am J Clin Nutr 1974;27:403-422). After that, studies in the early 1900s showed that rabbits who were fed cholesterol developed more atherosclerosis (Cardiovasc pathology 1999;8:177-178). Then other studies followed in a similar vein. However, it should be pointed out, that rabbits and other herbivores that were tested have never adapted to eating cholesterol in their diet. They have forever been herbivores and their bodies are not evolutionarily adapted to eating cholesterol. In addition, they were given extreme amounts of cholesterol. Therefore, the correlation to humans eating cholesterol and fat in food is questionable at best.

2- Clinical studies in humans showed that increased fat and cholesterol consumption raised total cholesterol levels. Unfortunately, total cholesterol is a poor marker for cardiovascular risk and has very little to do with the fat and cholesterol you eat. Studies that investigated changes in specific lipid subtypes in response to fat intake showed that LDL and HDL increased proportionally, thus keeping the HDL:LDL ratio the same, and likely NOT increasing the risk of cardiovascular disease. More recent studies have confirmed this by showing that dietary cholesterol intake had no effect on cardiovascular risk (biochem biophys acta 200, 1529, 310-320)

3- Epidemiological studies subsequently showed that increased dietary cholesterol and fat intake was associated with an increase in cardiovascular disease. This was the main area of research that captivated the public and experts alike.

Let’s look a little deeper into the epidemiological studies and how they came to influence nutritional guidelines. The big push for the low-fat craze came in the 1950’s when Ancel Keys embarked on his Seven Countries Study, which was essentially his quest to prove that dietary fat and cholesterol led to heart disease. His timing was ideal for having a maximal impact as heart disease was fresh on peoples’ minds. President Dwight Eisenhower had just had a heart attack in 1955, and the rates of heart disease in the US were rapidly rising as the nation’s number one cause of death.

Everyone was primed to find a scapegoat. Society wanted to find the one thing that causes heart disease, eliminate it, and the go back to feeling safe and protected. It is an overly simplistic way of thinking, but at the same time it is part of human nature to want to simplify things into an easily answered question. Dr. Keys believed that the countries that ate cholesterol and fat-containing foods had higher rates of coronary heart disease, and those that ate less had lower rates. Therefore, based on his logic, dietary fat and cholesterol caused heart disease, and suddenly society had their scapegoat. This line of thinking provides absolutely no proof, but that did not stop him from promoting it as such.

In 1968 the AHA recommended that all individuals should limit their dietary cholesterol and fat intake (Dr. Keys was on the board of this committee), and the American Government incorporated the same into the official dietary guidelines in 1977. Acta Cardiol 1999;54:155–158 JAMA 1961;175:389-391. Based on these guidelines, the medical profession preached the dogma that dietary fat and cholesterol were dangerous and by definition, a healthy diet was a low fat, low cholesterol diet. Food companies raced to the market with “healthy” low fat food, and a multi-million dollar food industry was born.

However, the problem lay with the details of Dr. Keys’ study. Most importantly, his study was purely observational. There was no control group, no randomization, and no controlling for variables. Therefore it did nothing to prove causation. It merely pointed out an observed coincidence. In addition, there have been numerous debates about whether he handpicked his countries to fit his hypothesis. It has been suggested that he started with 22 countries and only kept the ones that supported his hypothesis, discarding the rest. In addition, the main example of beneficial effects of low cholesterol intake correlating with low CHD risk was extrapolated from peasants from the Greek Island Crete. These individuals performed hard manual labor for the majority of their lives. Therefore they were much more active then the other populations studied. But he did not control for this variable of increased physical activity and its beneficial effect of reducing the risk of heart disease. In addition, Dr. Keys sampled their dietary patterns during lent. The majority of them were avoiding meat and cheeses, thus underestimating their true average consumption of saturated fat.

All that being said, however, those details matter less since the study as a whole was plain and simply bad science. The study did not prove anything, and it should be considered an interesting finding that required more investigation, not a cause and effect result around which governmental guidelines should be based. The study did not accurately control for other behaviors such as level of physical activity, sugar intake, vegetable intake etc. It is very plausible that the people who ate more saturated fat ate more burgers, so they also ate more French fries, more simple carbs (buns), and were not eating as many vegetables (ketchup was their vegetable), and maybe even had more milkshakes and soda. It is very shortsighted to say with certainty that the fat was the culprit, (thus one of my favorite sayings, “Don’t blame the butter for what the bun did.”). A well-designed scientific study would control for all that, including physical activity, smoking, stress management, etc. Dr. Keys’ study did not, but he stated his results with authority as if it had.

Interestingly, there was a dissenting voice during that time frame that got drowned out by Ancel Keys. A British physiologist, John Yudkin asserted that fat was not the main culprit, but rather sugar was the main cause of CHD and death. Like Keys, his data was observational and not conclusive. His theory, however, was shunned and was not adopted like Keys’. It is fascinating to read reports as to why this may have been. Keys is described as aggressive, charismatic and combative. Yudkin, on the other hand, is described as calm, reserved and quiet. Some, therefore, believe the past 50 years of misguided dietary guidelines all started because of differences in personalities. That may be an over-simplification, but it is a fascinating theory none-the-less.

Although it would be unfair to say our country’s entire low-fat craze came from Ancel Keys, he certainly promoted his hypothesis with enthusiasm and a fervor that gained a tremendous amount of attention. The subsequent national recommendations started an entire industry of “low-fat” food products ranging from cookies and cakes, to meat alternatives and even “Healthy” hydrogenated vegetable oils to replace anything that had dietary fat and cholesterol. The word “fat” became one of the most loaded and charged words in our language. Think about it. Sugar is a term of affection. You can hear the waitress with her southern drawl, “Hey, sugar. What can I get you?” We frequently use “sweet” to mean nice, caring, kind. “She is so sweet.” Fat, on the other hand, is a word you have to whisper for fear someone will hear you. The word fat has become associated with ugly, unpleasant, or even worse, death.

Unfortunately, our dialect and misguided dogma make an implicit assumption that eating fat makes us become fat. If cholesterol and fat are in arterial plaques, then it must get there by eating cholesterol. That way of thinking, however, ignores the fascinating and complex physiology that occurs in our bodies when we ingest food. In fact, it turns out that our bodies convert sugar to fat. This causes us to gain weight and can lead to fatty plaques in our arteries. Sugar increases insulin levels, and insulin is a hormone that causes our bodies to store more fat. Low-fat, higher carbohydrate diets have consistently shown less weight loss than higher fat, low carbohydrate diets. It seems contradictory, but eating fat can actually help us burn fat! As an example, a ketogenic diet, which is up to 80% from fat and less than 20 grams of carbohydrates, is one of the best diets for fat loss. Our bodies preferentially burn fat despite eating a high percentage of calories from fat. After all, from an evolutionary standpoint, we have been eating animal fats for 200,000 years. Grains have only been introduced over the past 10,000 years, and refined sugar (stripped of any fiber or nutritional components) over the past 300 years, a mere blink of the eye in evolutionary terms.

A big question that was not addressed as much during the past 50 years has been what do we eat instead of the fat? Once the government recommended a low-fat and low-cholesterol diet, society as a whole was not as concerned with what we replaced the fats with, so long as we got rid of the fat. Therefore, the high sugar, high fructose, processed foods reigned unchecked and became the new “healthy” staple of the American diet. Eggs for breakfast were replaced by sugar cereals, bagels, muffins and the like. Whole milk was replaced by orange juice and fructose containing drinks. Meat and chicken were replaced by white bread and white flour noodles. Since that time, the incidence of obesity and diabetes has increased dramatically. In 1950, 12% of Americans were obese. In 1980 it increased a little to 15%, and then sky rocketed to 35% by 2000. At the same time, rates heart disease and other chronic illnesses have also continued to climb. Again, this does not prove that the low-fat craze was the cause, but it certainly shows that the low-fat shift did not achieve the intended results of improving our health. At best it failed to make us healthy. At worst, it was the direct cause of an explosion of obesity, diabetes, autoimmune disease, and other chronic diseases.

More than 50 years have passed since the low-fat craze began, and there are still no randomized controlled trials to support the hypothesis that dietary fat and cholesterol increase the risk for heart disease (Am j clin nutr. 2010;91:535-546). In fact, multiple epidemiological studies and meta-analysis have subsequently shown no correlation between dietary cholesterol intake and cardiovascular risk. The American College of Cardiology (ACC) finally reversed their ban on dietary cholesterol in 2014 saying, “There is insufficient evidence to determine whether lowering dietary cholesterol reduces LDL-C” (JACC 2014,63,2960-2984.). In 2015, the American government guidelines followed suit saying, “Available evidence shows no appreciable relationship between consumption of dietary cholesterol and serum cholesterol.” (http://www.health.gov/dietaryguidelines/science-report) Taking this one step further, new research now suggests much more clearly that John Yudkin had the more plausible hypothesis that sugar is the main culprit leading to obesity, diabetes and CHD. It is fascinating to think how things could have been different if the sugar hypothesis, rather than the fat hypothesis, was adopted in the 1960s.

There remains no doubt that real, from the earth vegetables in a variety of colors should make up the majority of every meal. However, nutritional science has entered a new frontier, and all that was known in the past has to be questioned. When it comes to fat and animal based foods, many of the previous experts and authority figures who followed the conventional dogma have now begun to rethink their positions. Additionally, the rise of social media has given a voice to dissenters and supporters of the low-fat hypothesis alike.

If you choose to not eat animal products based on a moral belief about the treatment of animals, then the science does not matter as much as that is a very personal decision and is a matter of principal. If you choose to not eat animals based on environmental sustainability, that likewise has little to do with the science of how it affects your body. Even here, the science can get murky, but I will stick to what I know best and focus on the effects on our bodies.

There is no high level evidence proving that we should avoid animal based foods. Nutritional science is complicated, with mostly observational and epidemiological studies as opposed to studies showing a causative proof. That being said, however, large meta-analysis of most dietary trials have shown that there is no direct relationship between fat intake and heart disease. Period.

I would suggest, however, that quality matters. One of the problems may be that the quality of our animal based foods have deteriorated as a result of mass production and the associated use of corn feed, antibiotics and hormones. Studies have shown higher nutrient and lower toxin content in grass-fed as opposed to grain-fed meat, wild as opposed to farmed fish, pasture-raised as opposed to pen-raised chicken and hens (Nutr J 2010;9:10; J Nutr, 2005;135(11),2639-2643; Environ Health Prospect 2005;113(5), 552-556). From an evolutionary perspective, our ancestors only ate grass fed meat. They only caught wild fish. They only ate eggs from hens freely grazing grass. Our bodies have evolved over thousands of years to eat this way. If we could get back to those basics, we would take a huge step towards restoring a healthier dietary pattern.

 

So what can we conclude from the research we have available, good, bad or otherwise?

  • Vegetables are the undisputed cornerstone of a healthy diet and should make up the majority of every meal. The debate over whether fats are “good” or “bad” should not overshadow the fact that all research points to the healthy power of fresh (preferably organic) vegetables. That is not synonymous with being vegetarian, but it holds true that veggies are king.
  • Dietary cholesterol has been exonerated and no longer needs to be avoided. Eggs are the primary example. Since they are a widely available and affordable source of protein, choline, xanthophylls, vitamin K2, and other vital nutrients, we should now focus on eggs for their health benefits rather than avoiding them.
  • Fat is not inherently unhealthy. All fat is not the same, and diets that have shown reduction in heart disease and strokes have had over 40% fat (Lyon heart study and PREDIMED study).
    1. Monounsaturated fats (avocado, nuts, olive oil etc.) are clearly beneficial to our health and help with reduction of chronic diseases.
    2. Trans-Fats (food made with hydrogenated oils like doughnuts, muffins, cookies, crackers etc.) are almost certainly associated with increased risk of CHD and cancer and should be avoided.
    3. Saturated fat is not as evil as initially thought. We may not have convincing evidence for its direct health benefits, but we also do not have any credible evidence for its health detriments. Therefore this one is “neutral,” and more controversial, but we can no longer say with certainty that it needs to be avoided. We can now start to explore its potential benefits and enjoyment.
    4. Polyunsaturated fats (mostly found in cooking oils such as soybean oil, corn oil, sunflower oil etc.) may not be as beneficial as initially thought. Risk of oil oxidation causing systemic inflammation may lead to potential deleterious health effects. Again, the science is mostly observational but certainly suggestive.
  • Simple carbohydrates, sugars and processed grains are the most likely foods to cause obesity, diabetes and heart disease, and therefore should be minimized.

Practical tips:

Cooking oils are a vey common way we encounter fats in our diet. There are many choices, and it can be confusing to know which are “healthy” oils and which are less healthy. Here is a quick primer:

You want to pick a cooking oil that has :

  • a higher amount of monounsaturated fatty acids (MUFAs)
  • a high smoke point (the point at which heat starts to change the structure of the fat and can cause it to oxidize),
  • it should be made with minimal processing and not be prone to toxin accumulation.
  • Lower Omega 6 to Omega 3 ratio. Simplistically you can think of omega 3 fatty acids as “anti-inflammatory” and omega 6 as “potentially inflammatory.” As with most things, it is more complicated than this, but it still helps to have a convenient way of thinking.

 

Whatever you choose, choosing organic is best as it avoids GMOs and contaminants. Also, look for oils that are labeled as “cold pressed” or “expeller pressed” as this ensures that the oil retains more nutrients and has fewer chemical contaminants.

Best oils: Avocado oil, almond oil, olive oil (be careful with high cooking heat), canola oil (important to be organic)

Second line: Butter, Ghee, coconut oil or other medium chain triglyceride (MCT) oil

Avoid: Processed oils such as corn, cottonseed, sunflower and soy based products. Avoid any partially hydrogenated oil. In addition, grapeseed oil is prone to contamination and has a high proportion of omega 6, thus unfavorable altering your omega 6 to omega 3 ratio.

 

Whether you are in the “low-fat” or the “low-carb” camp, one thing is clear beyond reproach. Focusing on real foods, avoiding processed or refined foods, and avoiding added sugar is a great place to start to improve your health. Improve the quality of what you use to nourish your body, and your heath will improve. If that is the only change you make, then you are well on your way.

 

shutterstock_195157802

How much exercise do we really need?

We all know exercise is important for our health. Just knowing that, however, does not always translate into appropriate implementation. Time, motivation, logistical barriers all can get in our way preventing us from getting the amount of exercise we want or need. But what if we could get significant health benefits from only a few minutes of exercise per day? Wouldn’t that make it much easier to achieve our exercise goals? In prior blogs, we wrote about the evidence behind exercise duration and mortality benefit, and also talked about the benefits of high intensity interval training (HIIT). You can go back and read the prior blogs here:

http://www.myboundlesshealth.com/exercise-is-the-new-medicine/ http://www.myboundlesshealth.com/hiit-right/

I have included the summary tables from those studies below.

 

Amount of exercise per weekCardiovascular/Mortality result
SedentaryHighest mortality and cardiovascular risk
Less than 150minReduced death by 20% over sedentary
150 minReduced death by 31%
450 minReduced death by 39%
More than 450 minNo additional benefit, but no increased harm either

 

 

Best Evidence Summary Table:

Minimum exercise needed for mortality benefit20min once per week, JUST MOVE
Official Recommendation for general population150min per week moderate exercise, 75 min per week high intensity
Maximal mortality benefit450 min per week of moderate exercise
POSSIBLE lack of mortality benefit>450 min per week
Increased risk of lifetime AFIntense exercise >5 days per week

 

Now, however, we have even more evidence suggesting that minimal amounts of vigorous exercise can reduce the risk of death. One study showed as little as 1 minute of intense exercise 3 days per week, and another as little as 5 minutes per day helped reduce mortality risk. Could this be true? It almost seems too good and too easy to be true. Let’s take a look at the studies to see if this is something we should all consider.

 

The first study (JACC 2014;64:472-81), is detailed below:

1-an observational (not randomized) study

2-followed over 55,000 subjects for 15 years (mean age 44, majority white men).

3-Based on activity journals, they specifically looked at the frequency, duration and intensity of running and correlated that to overall risk of death.

4-Using statistical methods, they attempted to adjust for other levels of activity and other cardiovascular risk factors.

5-Over the course of the study, non-runners had 17.8 deaths per 10,000 person years. Those who ran some but less than 51 minutes per week had only 8 deaths per 10,000 person years, and this death reduction remained relatively consistent for increasing durations of running.

6-Overall any amount of running was associated with a 30% mortality reduction.

 

The catchy headline associated with the study was that “As little as 5 minutes of running per day saves lives!” That type of conclusion is a bit of a stretch since this was an observational study and it is impossible to completely correct for all the co-variables (i.e. did the runners eat better, sleep better, have less stress response, etc.). It does not prove that the running was responsible for the reduced death rate. However, it does raise the question, how much exercise do we really need to benefit our health? If we can’t seem to exercise 30-60minutes most days of the week, would we still benefit from as little as 5 minutes of exercise? The answer would have significant implications on our lifestyle and the stress we put on ourselves to exercise. Based on this study, the suggestion is that it may be true, but more research is needed.

 

The second study I want to highlight (PLoS ONE 11(4):e0154075) provides some of the needed further research and is detailed here:

 

1-Randomized, controlled trial

2-25 sedentary participants were followed for 6 weeks.

3-They were randomized to a control group, Sprint Interval Training Group (SIT) or Medium Intensity Cardio Training (MICT)

4- Sprint Interval Training (SIT) group consisted of a 2-minute warm up, 3 sets of 20 seconds of maximal effort cycling separated by 2-minutes of low intensity cycling, and a 2 minute cool down. So only 1 minute total was high intensity, the rest was warm-up or recovery.

5- The medium intensity group did 45 minutes of moderate intensity (70% of max predicted heart rate) cycling,

6- The control group remained sedentary.

7- The SIT and MICT groups had an equal decrease in body fat, they both had a 19% gain in VO2Max, whereas the control group had no meaningful changes.

8- Insulin sensitivity had a greater improvement in the SIT group than the MICT group.

 

This study overcomes the shortcomings of the prior study in that it was completely randomized, and there was only 1 intervention. So we can be fairly certain that the difference in exercise caused the decrease body fat, increased VO2Max, and improved insulin sensitivity. The down side to this study was its short duration, small number of participants, and lack of clinical outcomes (i.e. it did not look at risk of death, heart attack etc.).

 

Taking these two studies together, it certainly seems reasonable that shorter, higher intensity bouts of exercise provide meaningful improvements in overall health. Current guidelines are for 150 minutes of moderate exercise per week, or 75 minutes of intense exercise per week. While setting a goal such as this is important for many, it can also serve as a roadblock to others. Too often we can fall prey to the thought: “If I can’t get the 150min, why should I bother?” If that is the case, we now have good evidence to suggest that we should at least make time for a short bout of higher intensity exercise.

 

However, there are some practical considerations. Higher intensity exercise is challenging to do safely and appropriately, especially in the beginning. The risk of injury is higher than with more moderate exercise, and it can be challenging to get to true maximal exercise intensity. Here are some helpful hints:

  • Biking is a great exercise to start with for high intensity exercise. There is less impact, and less risk of injury compared to running or interval circuit training. That doesn’t mean you have to only use cycling forever, but it is a safe and effective way to start out.
  • It is still a good idea to ease into high intensity training. The randomized study referenced above used 100% maximum effort. However, it would be reasonable and safe to start with 70%, then increase to 80%, 90% and finally 100% over the course of a few weeks. Not only does it allow the body to adjust, it also helps the individual learn what each intensity level feels like.
  • Heart rate training can be very helpful to gauge the intensity level. You can have your actual maximal heart rate measured, or you could use the short cut of 220-your age, which is good at getting you close. You can adjust it as needed as you get more experience.
  • Remember to always warm up and cool down. Don’t expect to sit behind a computer for 8 hours, drive a half an hour, then hop on a bike and give it 100% effort right off the bat. That is a recipe for disaster.

 

Exercise is a key pillar of health for us all. In our busy lives, however, we may not always find the time for 30-60 minutes of exercise most days of the week. Fortunately, we now know that shorter bouts of maximal intensity exercise can also provide us with significant health benefits. When done appropriately, Sprint Interval Training (SIT) is a vital component to any exercise program. Contact us today to learn more about how you can incorporate SIT into your life to help you on your health journey.

 

Thanks for reading

 

Bret Scher, MD FACC
Lead physician, Boundless Health

www.myboundlesshealth.com

 

shutterstock_251592922

Statins, cholesterol and fat, oh my!

What a week it was for primary prevention of cardiovascular disease. Three significant publications with varying implications were released roughly at the same time. If you go by the headlines, each study could dramatically change the way we live and the way doctors practice medicine. If you dig a little deeper, you may find that the three studies are interesting and add somewhat to our current knowledge, but they may not change much that we do. One of the hardest parts of trying to be healthy is deciphering for yourself what all the news really means. If a headline says “New Study Shows Statins Should Be Given To Everyone!”, you need to critically assess that claim. That is what we are here to do. In this blog, I try to cut through the sensationalism and get to the bottom line of what these studies mean to you.

 

1- HOPE 3: A study sponsored by the drug company Astra Zeneca to look at blood pressure and cholesterol lowering in 12,000 intermediate risk patients and the effect on composite cardiovascular outcomes (cardiac death, heart attack, stroke) over 5.5 years. It was a somewhat complicated 4-way design that looked at rosuvastatin (Crestor) alone vs antihypertensives alone, vs rosuvastatin plus antihypertensives vs “double placebo”. The LDL cholesterol was reduced from 127 to approximately 95 in the Crestor group, which is 30mg/dl lower than in the placebo group. There was a statistically significant 1% reduction in the composite outcome, 0.4% reduction in heart attacks, 0.5% reduction in stroked, 0.4% reduction in angioplasty/stents. There was no difference in overall mortality, cardiovascular deaths, cardiac arrest, heart failure or angina. Most medical communities and mainstream media presented this as an incredible success for Crestor. But was it really?

Potential Take Home Messages:

  • Rosuvastatin had a very small clinical benefit on intermediate risk subjects for the composite endpoint. Does statistically significant mean it is worth it for you to do? That is the harder question to answer. I would say in this case, probably not except in the most extreme circumstances.
  • There was no effect on mortality or cardiovascular mortality despite significant LDL reductions
  • The study was well designed to weed out anyone who might get side effects by having a “run in” period and eliminating anyone who reported side effects. So the side effect data they present is not representative of a real world sample. It is representative of the best possible outcome in highly selected individuals. With that caveat, there was still a 1 % increase in muscle symptoms in the rosuvastatin group.
  • The relatively short duration of the study may underestimate long term efficacy, but may also underestimate long term harm or side effects
  • Should statins be used in all “intermediate risk” patients? From a population standpoint, if you treat a million patients, you are going to save a significant number of heart attacks (although not deaths). But how does that apply to you as an individual? Given the very small benefit and the potential risks of the medications, I would say this is more evidence that we can do better with lifestyle changes than we can with drugs.

 

 

  • 2- Minnesota Coronary Experiment (MCE): This one wins the award for most interesting, detective style of science. The MCE was conducted from 1968-1973 and it studied the specific question: Does substituting saturated fat with vegetable oil (in the form of corn oil containing primarily linolenic acid) improve cardiovascular outcomes? The initial study was published in the journal Arteriosclerosis in 1989 and concluded there was no reduction in cardiovascular events (arteriosclerosis, 1989;9:129-35). But not all the data was released. The current authors did an investigation worthy or a TV show similar to Cold Case, opening up old cases to shed new light. What makes it even more interesting is that they did something similar for the Sydney Diet Heart Study and found a possible INCREASED risk of death by substituting saturated fat with vegetable oil. They claim that their current investigation of the MCE likewise shows an increased risk of death by reducing saturated fat and increasing vegetable oil. The study was performed on mental health inpatients or nursing home residents, so the dietary intervention had excellent compliance. The subjects had no personal control over their food intake. The investigators substituted liquid corn oil instead of the hospital cooking fats (butter, lard and even trans-fats), and even added corn oil to other foods being eaten (injecting it into their meat, yum). The study subjects had 9% saturated fat and 13% linolenic acid in their diet. The control diet had 18% saturated fat and 5% linolenic acid. Total cholesterol was lowered by 31mg/dl in the study group and only 5mg/dl in the controls. LDL and HDL sub fractioning was not measured. They reported an increased mortality in the study group despite the lowered cholesterol, especially in the group >65years old.

Potential Take Home Messages:

  • They deserve a round of applause for their efforts, but as far as the quality of the evidence goes, it is still pretty weak. Despite their best efforts, the data was still incomplete and under powered
  • It is unclear how this relates to contemporary dietary practices as it was a very specific intervention with a specific type of corn oil
  • Total cholesterol is an outdated tool for measuring cardiovascular risk. At a minimum we need LDL and HDL fractions. Did the total cholesterol go down because the HDL decreased more than the LDL? We will never know. What about Apo B, oxidation parameters, and density of the LDL? In my mind, studies are incomplete unless they address all these important variables.
  • Although this study does not prove saturated fats are “healthier” than corn oil, it is certainly more evidence to make us rethink the demonization of saturated fats, and more evidence that we need better studies in the future.
  • Nutritional studies are hard! Sticking with high quality real food is your best bet.

 

3- ACCELERATE. This trial was a study looking at evacetrapib, A CETP inhibitor and its effects on cardiovascular disease events. CETP inhibitors increase HDL and lower LDL, presumably a powerful combination for preventing cardiovascular disease. The trial was concluded in Oct 2015, but the data were not presented until now. This trial enrolled 12000 high risk participants, was a randomized placebo controlled study (high quality evidence) and showed Evacetrapib had dramatic changes in lipids with increased HDL to 104 vs. 46 on placebo, and reduced LDL to 55 vs. 88 on placebo. Despite these improvements in the lipid panel, there was no decrease of cardiovascular event. Prior CTEP inhibitor trials have likewise shown no clinical benefits despite LDL lowering and HDL raising properties

 

Potential Take Home Messages:

  • CETP inhibitors are not beneficial for reduction of CVD risk despite raising HDL and lowering LDL. Could this be due to a drug specific effect that increases risk in some other way?
  • There is something beyond LDL and HDL at play in the development of cardiovascular disease. The LDL hypothesis is not an end all solution. We have to be very careful using surrogate markers such a lipids to “prove” benefit.
  • HDL is less important when LDL is already reduced
  • This is likely the last we will hear of CTEP trials.

 

I hope that helps summarize the three recent trials that you have likely seen in the lay press. As you can see, the science is messy. Yet the media and some health experts like to make it sound simple, sexy and dramatic. Don’t fall for the headlines. Step back and keep asking the question: what does the trial really show that I can practically use in my life? Also, be wary of study bias. A drug company sponsored trial (like HOPE) is going to be designed as well as possible to show the smallest benefits for the drug and minimize any reported side effects. Statistically significant does NOT necessarily mean significant for your life and your health. On the other hand, the authors of the MCE revision study clearly had a bias that vegetable oils could cause harm, and they set out to show that end. It doesn’t make either one wrong, but it may make the results seem more robust than are practically relevant.

At Boundless Health we are constantly surveying the medical literature to make sure we keep you up to date on the latest studies that affect your health. We help you see through the sensational journalism to help you answer the most important question, “What does this mean for my health today and in the future?” Contact us today to see how we can help you on your path to health, today and in the future.

 

Bret Scher MD FACC

 

 

shutterstock_234495904

Sleep as if your health depends on it!

We all need more sleep, right? YAWN! We have said it or heard it hundreds of times. Get more sleep for better health. Yet despite the prevalence of the advice, there is a clear disconnect between hearing it and implementing it. For one, there is a positive stigma or bragging rights associated with “I only need 5 hours of sleep per night.” Secondly, our lives have become so busy, over scheduled, and over stressed, that it is easy to prioritize everything else before sleep. And lastly, even when we want to get more sleep, many of us are unable to do so for a variety of reasons that we will address.

 

As with many areas of health, the first step is educating ourselves about the importance of sleep. Only once we understand the real importance of sleep can we prioritize sleep adequately, thus committing to the sleep hygiene practices that help us achieve better health. Without education, the rest never follows.

 

The scientific literature is saturated with evidence that sleep is important for health. It would be overwhelming to try to summarize all the literature here, but here are some of the highlights. Poor sleep has been linked to :

 

Depression

Anxiety

Hypertension

Diabetes

Weight gain

Poor job performance

Poor athletic performance

Car Accidents

Coronary artery disease

Strokes

And more

 

One of the most common associations is the connection between poor sleep and poor performance in life. What does that mean? It means not achieving your goals. Whether it is athletic performance, work performance, or improving your overall health, inadequate sleep dramatically reduces the chances of success.

 

Let’s look at one of the most frustrating failures of lack of sleep- inability to lose weight. Numerous studies have shown that poor sleep habits lead to increased hunger, increased snacking and poor nutritional choices. Not only is there a proven relationship, but there is also a biological reason for this. Ghrelin is a hormone in our body called the “hunger hormone.” It signals to your body that you are hungry and need to eat. Leptin has the opposite effect. It says to your body that you are full and don’t need to eat. When we do not get adequate sleep, our ghrelin levels spike and our leptin levels are inhibited. Thus we have a biological reason for feeling hungry and snacking more. Plus, since our mental clarity is reduced and our emotional control is inhibited by poor sleep, we tend to make impulse decisions in reaction to the feeling of hunger. Impulse decisions rarely end in preparing a well-balanced meal of veggies with high quality fats and proteins. Instead, they may result in standing in front of the freezer eating the Ben and Jerry’s right from the carton with no end in sight. I’d be lying if I said I have never been there before. But I can also say that I will never be there again.

 

The next concept I want to address is our perception of how much sleep we need. Many people with inadequate sleep may feel like they are doing just fine. But a fascinating study published in the journal Sleep in 2003 showed that people who got no more than 6 hours of sleep for 10 days had a similar decline in cognitive function and physical reaction time as those who were completely deprived of sleep for 2 whole days. The amazing part, however, was that they had no idea how bad their performance was. They felt they were thinking clearly and performing well on all the required tests, and they did not feel tired. That makes it even more dangerous! To perform so poorly and not even realize it is a recipe for disaster. At least those who were deprived of sleep for two whole days knew they were exhausted, and they could change their lives accordingly. The same cannot be said for the group who got less than 6 hours of sleep per night. So it is clear that we frequently need more sleep than we realize.

 

Yet another incredible study was recently published looking at the sleep patterns of traditional hunter-gatherer tribes. Sleep problems were so rare in their cultures that the three tribes studied did not even have words for insomnia in their language.

The study showed that they averaged 7.5-8 hours in bed per night. In addition, they had an absolutely consistent sleep-wake schedule thus maintaining a stable diurnal rhythm. Couple that with their lack of distractions from computers and phones, and it is no wonder their society had no concept of sleep problems.

 

What about those who say “Sleep is a waste of time. It is unproductive time I could spend accomplishing things.” This couldn’t be further from the truth. “Restorative Sleep” is a combination of Stage 3 sleep and REM sleep. It is appropriately named because your body literally restores itself while you sleep. Learning, memory and concentration are improved while you are in REM sleep, and your body is able to heal and restore physical energy when you are in Stage 3 sleep (deep sleep or delta wave sleep). Without adequate time spent in each stage of sleep, the body is not able to perform its essential “reboot” functions. Lack of sleep robs your body of these restorative functions. In addition, alcohol and sleep medications can disrupt the balance of sleep stages, thus resulting in less restorative sleep. Part of the importance of maintaining a steady sleep schedule is that it allows your body to cycle through the stages of sleep consistently, ensuring that you get adequate time in the deep and restorative stages.

 

Lastly, part of the problem is that even those who want to sleep more find they cannot. Insomnia is a growing problem in our society with prescriptions for sleeping medications increasing over 50% since 2008. As with many things in medicine, prescription drugs are simply Band-Aids. They treat the symptom without addressing the underlying cause. Sleeping medications come with their own risks of developing dependence, rebound insomnia, potential short-term memory loss, and distorting the stages of sleep so that the sleep you do get does not have the full restorative power of naturally achieved sleep.

 

Once you have made sleep a priority for your health, there are a number of specifics to consider. Here are some tips to incorporate into your life for better sleep:

 

  • Reduce exposure to screens and artificial light– they disrupt the circadian rhythm and fool your brain into not being tired. Avoid screens 60 min prior to sleep or if that is not possible, consider using blue blocker glasses which help filter out the blue light from your devices. You should also maintain a very dark room for sleeping. Use black out shades, cover your clocks (or if you need them keep them more than 3 feet away from your head), if you need light use low wattage yellow, orange or red lights, not standard white lights
  • Maintain a consistent schedule– this can be difficult for many, but going to bed and waking up at the same time every day has been scientifically shown to improve sleep performance and allow for consistent deep, restorative sleep
  • Meditation-A study comparing individuals engaging in a mindfulness meditation practice vs. those who were given general sleep hygiene education showed significant improvements in sleep quality as well as less depression and fatigue in the mindfulness group. This does not mean you need to meditate for an hour a day. Just 10 minutes of mindfulness meditation has proven results.
  • Avoid caffeine in the afternoon. Caffeine is a stimulant that can keep you from falling asleep. Even those who say caffeine has no effect on them have demonstrated reduced sleep performance than those who do not drink caffeine
  • Limit alcohol or any liquid for that matter. The more you drink, the more likely you are to wake up to urinate, thus giving your brain a chance to wake up and start spinning and reducing the chance of going back to sleep. Although alcohol may make you feel tired and help you “get to sleep,” it can dramatically alter the stages of sleep and prevent you from getting fully restorative sleep
  • Get outside and get light exposure during the day- This helps your circadian rhythm stay in sync with proper sleep-wake patterns. Studies in Hunter Gatherer societies have highlighted the importance of daytime light exposure. This may also help with your vitamin D levels, which are also linked, to better sleep performance.
  • Exercise during the day, but not within an hour before going to bed.
  • Keep your room cool, between 60-68 degrees
  • Bed is for sleeping and sex only, no TV books or phone use
  • Journaling to clear your mind before bed. This helps you get your thoughts out on paper so your mind is not ruminating on them and keeping you from falling asleep.
  • Low carb diet increases slow wave sleep, but fat can increase GERD, very individualized
  • Magnesium supplements (usually in the form of magnesium glycinate or malate) has been shown to help with falling and staying asleep
  • Melatonin is beneficial for short-term use when natural timing is disrupted, such as with travel or when your sleep cycle has been disrupted for other reasons. It is not meant to be used long term
  • Get checked for sleep apnea – This is a very common cause of poor sleep and now there are easily accessible home screening tests that can be ordered by your physician. Keep in mind that sleep apnea is more common in overweight people, as well as those who drink alcohol or take sedatives

 

The list is long, but hopefully you will notice that most of these are actions that are easy to implement. Once we understand the importance of restorative sleep, and we prioritize sleep as a pillar of our health, then the above list becomes an easy “to do list”. If we still don’t truly believe that sleep is important, then the same list appears like an intrusive and ridiculous list of demands.

 

At Boundless Health, we hope we can all be in the former category and realize that sleep is a powerful tool in the promotion and maintenance of our heath. Please contact us today to see how we can help you on your path to better sleep, better health, and a better life.

 

Fitness. Health. Life

BOUNDLESS HEALTH

 

 

Bret Scher, MD FACC

www.myboundlesshealth.com

858-799-0980

shutterstock_129797939

PPIs and Dementia- Cause for alarm?

A recent study popularized in the mainstream media claims that a class of popular heartburn drugs called proton pump inhibitors (PPIs) such as Prilosec, Nexium, Protonix and others, may be linked to a higher risk of dementia. On the surface this sounds very concerning. But lets look a little deeper to see how concerned we really need to be.

 

A study in Germany followed over 73,000 people 75 years old or older between 2004 and 2011 and found that those subjects who took PPIs had a 44% increased risk of dementia compared with those who were not taking PPIs. This is in addition to a previous study showing a “20-50%” increased risk of kidney disease in PPI users compared to non-users. To put all this into context, 15 million Americans currently take PPIs accounting for a $10 billion industry. After reading the headlines, I could see how there could be 15 million people throwing away their PPI pill bottles. While that might not be a bad idea in many cases, it is likely not necessary just based on this study.

 

Remember, an association does not prove causation. These two studies do nothing to prove that PPIs cause dementia or kidney disease. People take PPIs because they have GERD or heartburn. Could it be something about the heartburn that is the cause of dementia or kidney disease rather than the medication? People with heartburn tend to be heavier, eat worse diets, exercise less, or do one of a myriad of other unhealthy habits. Based on these studies, we still do not know if it was the medication or the underlying habits that caused the dementia and kidney trouble. So if you take a PPI for heartburn, don’t stop just because of this study. But there may be other reasons that you should consider stopping anyway.

 

Lets look for a second at what PPIs do. They reduce the amount of acid that your stomach produces. GERD symptoms are presumed to be due to the presence of acid refluxing from the stomach into the esophagus. So if you can reduce the acid content, the reflux will not cause as much symptoms and will not cause harm to the esophageal mucosa (the lining of the esophagus). As with many instances in medicine, PPIs are a band aid that masks the symptoms, but they do not attempt to address the underlying cause. Even worse, for some it makes them feel as if they have a license to eat whatever they want since they no longer have to worry about suffering with reflux symptoms.

 

When these medications first came out, it was recommended that you not take them for more than 6-8 weeks. They were never meant for long-term use. They are very good at helping repair the esophagus from damage that has been done by acid (a condition called erosive esophagitis). But the assumption is that an attempt is being made to find and eliminate the cause of the reflux. Why would we continue to mask the symptoms, without trying to address the root cause and reduce the reflux?

 

What we need to do is to keep the acid in the stomach where it belongs and prevent it from going into the esophagus where it does not belong. After all, stomach acid is there for a reason. You need it to digest food, activate digestive enzymes in your small intestine, and help you absorb vitamins and nutrients (B12, calcium, magnesium). Reducing stomach acid it is not necessarily harmless. It has been linked to higher risk of infections (C. diff, pneumonia), vitamin deficiencies, and now dementia and kidney disease.

 

Sometimes the cause is a physical issue that needs aggressive medical care, such as a hiatal hernia (where part of the stomach slips into the chest), H. Pylori infection or a rare condition where the stomach aggressively overproduces acid. The majority of the time, however, simple lifestyle adjustments can help reduce reflux from the stomach to the esophagus. The following 6 steps are a must to help reduce the cause of reflux:

 

1-Not eating too late at night (a full stomach when you lie down is more likely to reflux)

2-Eating smaller meals

3-Avoiding alcohol, caffeine, fried foods and chocolate (these can relax the lower esophageal sphincter and allow the reflux to occur)

4-Don’t lie down within 2 hours of eating (gravity is your friend)

5- Stop smoking

6- Maintain an ideal body weight (especially reducing abdominal and visceral fat).

 

One other common cause that does not get enough attention is stress. Practicing stress management and relaxation techniques has been shown to reduce GERD symptoms. In addition, stress leads to obesity, poor nutritional choices, and increased risk of all 6 of the above GERD causes. Interestingly, magnesium supplementation has been shown to reduce GERD symptoms, and it has also been used to reduce stress reactions and anxiety. Could there be a causal relationship there? Possibly, and it certainly deserves some attention.

 

The most likely cause of GERD, however, is the food we eat. Not just the greasy food, chocolate etc., but actual food sensitivities. If our bodies cannot digest our food efficiently, it sits in our stomach longer and can cause reflux. Food intolerances are different for everyone, but the two most common are gluten and dairy. Others common intolerances are tomatoes or legumes. The best way to identify the culprit is to start with an elimination diet and then slowly introduce specific classes of food back into the diet. It is a slow, logistically challenging endeavor, but it is the best way to find the true cause of GERD. You can see why some prefer to simply write a prescription rather than go down the road of becoming a diet detective. It is so much easier. But you deserve to have someone spend the time to get to the bottom of your true causes rather than masking the symptoms with medications that have their own problems. Don’t trade a problem for another problem. Get to the root cause and eliminate it.

 

Lastly, and counter-intuitively, one cause of GERD could be too little stomach acid. That’s right! Too little. If you do not have enough stomach acid, digestion can be impaired, thus causing food to sit in your stomach longer. This increases the risk of reflux. One approach for treating GERD, therefore, can be GIVING acid (HCL) as a supplement. This is contrary to the pharmaceutical industry driven solutions, so is rarely discussed in mainstream medicine. In addition, the future will likely show a connection with the gut biome and small intestinal bacteria overgrowth. This again is taking shape outside of mainstream medicine. That doesn’t make it wrong, it just makes it harder to gain popular acceptance.

 

In conclusion, although a study can be presented in a dramatic headline, it may still be far from proving a true cause and effect relationship, as is the case with PPIs and dementia and kidney disease. Despite that, however, these studies are a welcome reminder that medications such as PPIs simply mask the symptoms of an underlying issue, and they may cause significant problems of their own. They do not address the root cause, and they cannot be assumed to be harmless. You deserve to prioritize your health, and have a thorough evaluation and detailed treatment plan aimed at the underlying cause of your heartburn.

 

At Boundless Health, we feel You deserve this level of attention and commitment. To find out more about how you can prioritize and take control of your health, please contact us today.

 

Bret Scher, MD FACC

info@myboundlesshealth.com

www.myboundlesshealth.com

858-799-0980

shutterstock_99130316

How much do we really know about statins?

How much do we really know about statins?

Statins are one of the most prescribed medications in the U.S., and they are becoming more popular given the recent revision to the cholesterol treatment guidelines. The new guidelines technically make 45 million Americans without evidence of coronary artery disease (CAD) candidates for statins (JACC 2014;63:2889-934). Statins are also one of the most researched medications with hundreds of studies looking at their effects both good and bad. Most of those studies have lasted less than 5-years. In fact, one recent study reported on the “long-term” kidney side effects of statins (Am J Cardiol 2015;doi:10.1016). That trial was only 6 years long, yet they considered it “long-term”. That does not seem comforting when we are starting 30- and 40-year olds on statins who will likely be taking them for decades. As with most research, the devil is in the details, and what we read in the newspapers may not always be the “truth.”

 

It is very important to note that the major statin trials were essentially all cholesterol drug trials and not cholesterol lifestyle trials. There was minimal, if any, exercise intervention and only a token of nutritional guidance. All of these trials were done either with a specific recommendation for following a low fat diet or no dietary intervention at all. Therefore, the vast majority of people in these trials were following a high carbohydrate, low fat diet.

 

When a doctor prescribes a statin because someone meets the guideline, it is crucial to realize that if the individual is following a low carbohydrate diet, they were by definition not represented in the major trials, and therefore are not represented by the guidelines.

 

To make sense of this, we need to understand the effects that a high carbohydrate and low-fat diet can have on our bodies. Such diets can increase inflammation, worsen diabetes, worsen insulin resistance and promote the metabolic syndrome, all of which may make cholesterol more harmful (more on this later). Would a different diet have lead to different results regarding the efficacy of statins?

 

We can’t blame the researchers for recommending a low fat diet since at the time there was still a widely held belief that dietary fat caused heart disease. We now know, however, the evidence liking dietary fat as the cause of heart disease was incorrect and has been disproven (JAMA 2006;295(6):655-666). In addition, fat cannot be lumped into one category (as is the same for carbohydrates) as trans-fats act much differently in our bodies than mono-unsaturated fats, and even saturated fats are not all the same (grass-fed beef acts differently from grain-fed beef, coconut oil acts differently from sunflower oil, etc.). This opens up a whole array of questions regarding nutritional and other lifestyles choices and how they affect cardiovascular risk and the subsequent effects of statin therapy.

 

There has been a growing wave of popularity for variations of a high-fat, low-carbohydrate diet (ketogenic diet, Paleo nutrition, ancestral nutrition etc.). And for good reason. Low carb, high fat (LCHF) diets result in improved weight loss, specifically fat loss, when compared to low fat diets. In addition they raise HDL, lower triglycerides, decrease fasting glucose and decrease insulin levels, thereby improving insulin resistance and the metabolic syndrome. The literature also shows that LDL on average goes down despite eating the higher fat diet.

 

More intriguing is how these nutritional choices effect the overall environment of the body from an inflammatory and metabolic standpoint. Low carbohydrate, higher fat diets are anti-inflammatory. They can change the structure of the LDL particles, making them less likely to invade the arterial wall, less inflammatory and thus less likely to cause heart attacks. This suggests that LDL in an individual following a higher fat, lower carbohydrate diet might not be as potentially harmful as LDL in a higher carbohydrate diet. If the major statin studies had recommended a low carbohydrate diet, would they have had the same results? Would statins have had the same benefits? This is unproven and unexplored.

 

What diet someone is eating is not the only reason to exclude him or her from requiring a statin. A recent trial (JACC 2015;66:1657-68) showed that by using coronary calcium scores, approximately 50% of statin eligible patients had a score of 0 and therefore would no longer meet the threshold for statin therapy. HALF! That’s a lot of statin prescriptions that can be avoided, thus reducing the cost and risk to the patient.

 

Lastly, it is important to ask, what treatment result are we expecting to get from statin therapy? Are we reducing the mortality risk? Are we reducing the risk of a heart attack but not reducing the mortality risk? What are we doing to the quality of life? A physician prescribing statins for primary prevention (no pre-existing cardiovascular disease) will hopefully realize that a pooled analysis of the biggest trials showed that there is no proven mortality benefit, and there is only a very small reduction in the risk of heart attack (only in men, there is no such benefit in women). Yet the risk of side effects is actually greater than the beneficial effects. To me, that means there is little harm (and likely a greater benefit) to exhausting all other options before committing to taking a statin.

 

I hope this gives you the idea that prescribing a medication is rarely cut and dry. This is despite the fact that the industry-led media, both medical and lay-press, would like us to believe that it so. Instead, there are multiple factors to weigh for each individual. If your doctor does recommend you start a statin(or any medication for that matter), take a second to ask WHY they are prescribing it. What outcome are they expecting to prevent? Are you going to take it for the rest of your life? What are the potential long-term effects? Also, consider if you can do more with your lifestyle to reduce your risk, and based on your lifestyle, do they feel you were represented ton the major trials?

 

If they still feel a statin is indicated, ask if you would benefit from further risk stratification such as a coronary calcium score before committing to a potential lifetime of a medication. Would calcium score of zero change their mind?

 

This approach takes longer than writing a prescription, but you deserve to be treated like an individual, and you deserve the extra attention to make sure you are receiving the most appropriate care. At Boundless Health, we take the time to review all the potential options, and we use evidence-based decisions to help you reach the best decision for your health. Contact us today to learn more about how we can help you achieve your optimal health.

 

Fitness. Health. Life. Boundless Health

 

 

 

Select references:

 

Meta Analysis:

Arch Intern Med 2004;164:1427-1436

JAMA 2004;219:2243-2252

Lancet 2005;366:1267-78

Arch Interb Med 2010;170(12):1024-1031

 

Secondary prevention trials:

4S- Lancet 1994;344(8934):1383-1389

LIPID- Amer H J, 2003;145:643-651

CARE NEJM 1996;335:1001-1009

 

Primary Prevention trials:

AFCAPS- JAMA 1998;279:1615-22

ALLHAT- JAMA 2002;288:2998-3007

ASCOT-LLA- Lancet 2003;361:1159-58

PROSPER- Lancet 2002;360:1623-30

JUPITER- NEJM 2008;359:2195-207, also Circ 2010;121:1069-1077

WOSCOPS- NEJM 1995;333:1301-07

shutterstock_252233521

Thoughts on Nuts and Omega-3s

I saw a client last week who ignited the light bulb for this blog. He is a 55 year old man, 5ft 10in, 230 pounds, not very active but trying to improve his exercise. He has never really paid much attention to his nutrition and was a big snacker on chips, pretzels, cookies etc. With guidance from his physician he started to make positive changes in terms of his nutritional choices. But he was frustrated with his lack of weight loss. When he came to see us, one thing that struck me the most was that he was eating 4-5 handfuls of nuts (mostly peanuts) 4 times per day. That’s a lot of nuts! All of a sudden it made perfect sense why he wasn’t losing weight. Here are some thoughts on how to avoid this situation.

Nuts are a fantastic snack. They are:

1-packed with nutrients

2- they are filling,

3-they provide good fats, and

4-they are free of simple carbs and sugars that frequently plague our snack choices.

However simply saying “Snack on nuts” without more specific guidance is inadequate advice, and can frequently do more harm than good.

Nuts are calorie dense foods, they taste good, and are easy to eat while you are distracted doing other things. Therefore they are easy to over-consume. Overconsumption can lead to unrecognized calorie intake and weight gain. In addition, too many nuts can distort one’s omega 6: omega 3 ratio. More on this later. Thirdly, nuts contain phytic acid. Humans cannot adequately digest phytic acid (herbivores like cows and sheep can), and thus phytic acid can bind to iron and zinc in your gut leading to inadequate absorption and resulting mineral deficiencies.

Therefore it is important to specify a serving size of nuts to help prevent over consumption. A serving size usually equates to 1 oz. of nuts once or twice per day. But we do not all know what 1 oz. of nuts looks like, so we frequently say “a handful.” A 100 pound woman has a very different size handful than a 250 pound male. So it is also important to know quantity as well. For instance, 1 oz. is approximately 18 cashews (160kcal, 4g protein, 13g fat), 23 almonds (160kcal, 6g protein, 14g fat), 6 Brazil nuts (190 kcal, 4g protein, 19g fat), 10 macadamia nuts (200kcal, 2g protein, 22g fat), 45 pistachio nuts (160 kcal, 6g protein, 13g fat).

Another consideration is raw vs roasted. Many people prefer roasted for taste reasons, but studies have shown a significant decrease in nutrient availability once the nut is roasted. As with most foods, the less handling and processing the better. We definitely recommend the raw nuts whenever possible. If someone won’t eat the raw nuts because the taste, we suggest a combination of raw nuts and roasted nuts mixed together. To take it a step further, studies have shown that soaking raw nuts for 8hours increased nutrient bioavailability. It’s not the easiest thing to do, but it can help.

What types of nuts are best? Taste definitely plays a big role in determining what nuts we eat. But below are descriptions of some of the more nutrient dense nuts and they’re beneficial properties.

Walnuts- 1/4cup has 100% of the daily recommended amount of omega 3 FAs and have been associated with anti-inflammatory properties, “brain health,” among other benefits (Br J Nutr, 2012 May;107(9):1393-401).

Almonds– Rich in antioxidants including flavonoids and phenolic acids, and has been associated with mild LDL reductions.

Pistachios- high in lutein, beta carotene and Vitamin E. Pistachios have been shown to lower the amount of oxidized LDL (J Nutr 2010, Jun;140(6):1093-8)

Also consider pecans, cashews, Brazil nuts. Try to avoid simple peanuts as they are less nutrient dense.

And don’t forget the seeds– Pumpkin and sunflower seeds, which are also rich in vitamin E, magnesium, antioxidants and others.

I mentioned earlier how nuts can change the Omega 6 and omega 3 ratio. What is that about? This is an entire blog or two in itself. But here is my attempt at a quick summary (it gets a little technical, so I apologize in advance)

  • Not all omega 3s are created equal. Most of the beneficial effects of omega 3 FAs are felt to be from DHA and EPA and not from other versions of omega 3s. DHA and EPA are the longer chain FAs found exclusively in seafood and marine algae. Alpha-linolenic acid (ALA) is a shorter chain omega 3 FA that is found in plant foods such as flax, hemp and pumpkin seeds as well as walnuts. ALA can be converted in the body to EPA and DHA but only at about 5% efficiency. In addition, this process depends on zinc, iron and pyridoxine. Non-fish eaters can therefore have a very difficult time maintaining adequate DHA and EPA levels, especially if they have co-existing nutrient deficiencies.
  • Omega 6 fatty acids, such as linoleic acid (LA), are essential fatty acids meaning our body cannot produce them and we need to consume them. They are required for multiple functions including building cell membranes, helping in cell repair and other fatty acid functions. However, omega 6 FAs have also been implicated in many deleterious functions such as promoting inflammation, and can inhibit the conversion of n-3 ALA to DHA and EPA.
  • The general assumption is that although we need omega 6 FAs for normal cell functions, we need to balance the amount of the more beneficial omega 3s with the potententially harmful (at higher doses) omega 6s.
  • Research of hunter-gatherer societies has shown that the omega 6 to omega 3 ratio averages 1:1 up to a maximum of 3:1. In the traditional western diet, our ratio of omega 6 to omega 3 has ballooned to 20:1 predominately due to the excessive use of safflower oil, sunflower oil, corn oil and soybean oils as well as soy and grain fed livestock. It is estimated that our intake of omega-6 fatty acids is up to 20 times higher that “evolutionary norms.” The assumption is that since hunter-gatherer societies have fewer inflammatory diseases, it may be related to the lower ratio of the proinflammatory omega 6s compared to the anti-inflammatory omega 3s.
  • The next natural question is, “So what? What does this mean for our health?” Observational evidence suggest increasing the proimflammatory omega 6s at the expense of anti-inflammatory omega 3s MAY be related to the increased prevalence of inflammatory diseases, i.e. heart disease, diabetes, cancer, auto-immune disease. For instance, why do traditional Japanese men and women have lower rates of inflammatory diseases despite higher rates of smoking and hypertension? Studies have shown, on average, their population’s omega 6 to omega 3 ratios is more in line with hunter-gatherer societies. There are other observational data to suggest a link, although no direct causative

The way I look at it, although there is no direct proven link, it is certainly plausible that higher omega 6 to omega 3 ratios promote inflammatory disease. However, more importantly, the key is that you correct the ratio by eating less vegetable oil, less cereal grains and less processed foods, and eating more omega 3 dense foods like fish and flax, and more grass fed livestock, pastured eggs etc. This has multiple other health benefits and we recommend it to most people anyway! I would go one step further and say if you are not a fish eater, we would suggest a high quality Omega 3 DHA/EPA supplement (high quality meaning one that gives you at least 400mg of DHA/EPA, and one that has a detailed distillation process to remove mercury, and other heavy metals and toxins).

In summary, we highly recommend healthy snack options that are low in simple carbs and sugars; snacks that provide beneficial nutrients, are easy to fit into our busy daily lives, and help us feel full. Nuts definitely fit all those requirements. But please make sure you limit your nut intake to 1 ounce once or twice daily.

In addition, we strongly suggest reducing the consumption of vegetable oils and processed carbs, and we encourage fresh (preferably wild) fish consumption and higher quality pastured and grass fed meat and eggs to promote adequate omega 3 levels and reduced omega 6 levels.

At Boundless Health, we are not just here to check off the boxes that we “did our job” and made the recommendations we are supposed to make. We are here to ensure that you get the information and guidance you need to safely incorporate our suggestions into your healthy lifestyle. Contact us today to learn more about our programs to help you achieve your health and wellness goals.

 

Health. Fitness. Life. Boundless Health

shutterstock_129797939

SPRINT trial revisited

Last month I wrote a brief blog about the SPRINT trial and the “earth shattering” results that were presented in the lay press (http://www.myboundlesshealth.com/what-is-your-ideal-blood-pressure/) . My main theme was to urge caution until the actual study details were released. I still feel it was somewhat irresponsible to publish dramatic headlines before any study details were released, but now we finally have the study itself, presented at the AHA and published simultaneously online in the NEJM. This is a very important trial as it seeks to answer the question of, what is the optimal target for the treatment of blood pressure? For the background of this, please see my prior post. For this post, I will talk about some of the study details and how that relates to changes in our clinical practice.

 

The overall finding was that having a target systolic blood pressure of <120 significantly reduced the composite outcome of myocardial infarction, acute coronary syndrome, stroke, heart failure, or cardiovascular death when compared to the target group <140. That in and of itself is a “game changer” result. As with any study, it pays to look at the details. I will do my best to summarize the pertinent details below.

 

  • Who was included? Participants OLDER than 50yo with baseline SBP between 130-180 and with at least 1 cardiovascular risk factor defined as subclinical cardiovascular disease, chronic renal insufficiency, age >75, or a Framingham 10 year risk >15%. This is now a similar fashion to treating lipids, the other risk factors count. In patients with none of these risk factors, the trial would not apply.

 

  • Who was EXCLUDED- People with diabetes, prior stroke, under age 50. This is important as the ACCORD trial showed NO benefit to a more intensive BP target in the diabetic population. So these trial results should not be extrapolated to diabetics.

 

  • What was the structure? Participants were followed monthly for the first 3 months, and the every 3 months with an average overall follow up of 3.2 years. This shows the labor-intensive aspect to treating BP aggressively and making the necessary changes. In the “real world,” over 50% of hypertensive patients do not reach the goal of <140. To expect medical practices to be able to now treat to <120 shows the need for dedicated blood pressure clinics with very close follow up. Also, there was an increase in serious adverse events in the <120 group, thus highlighting even further the need for close monitoring.

 

  • My biggest problem with the study is the word “Lifestyle” is mentioned exactly ONCE in the whole trial. All patients were given lifestyle counseling on enrollment. However, there was no mention of following up on lifestyle changes at any subsequent visits, no data on what changes, if any, were made. This was a hypertension drug study and only a drug study. A true blood pressure control study would absolutely prioritize diet, exercise, weight management, stress reduction, sleep patterns and restricting alcohol at a minimum. It is disappointing that this trial prioritized medicines and largely ignored lifestyle. As a result, they needed almost 3 drugs per patient to get their BP to goal.

 

  • The trial was stopped early due to the significant benefit seen. Many have criticized the investigators and DMSB for terminating the trial early. As it stands, we know the risks and benefits of aggressively treating SBP for 3 years. We do not know the detail beyond that time frame. However, due to the large number of participants and the large number of outcome events, it is unlikely that stopping the trial early impacted the significance of the results

 

  • How significant were the reductions? The news publications always seem to prefer relative risk reductions, as they sound more dramatic. I like the absolute risk reductions as I feel they are easier to relate to patients and they are more germane to helping patients decide how they want to proceed.

 

  1. Primary outcome was reduced by 1.6%, so we need to treat 62 patients to save 1 outcome over 3.2 years
  2. There was no significant difference in the rates of myocardial infarction, acute coronary syndrome or stroke (was this related to the short time frame of the follow up?)
  3. Heart failure was reduced by 0.8% and this was the main driver of the composite endpoint.
  4. Cardiovascular deaths was reduced by 0.6% so the number needed to treat (NNT) was 167 to prevent 1 death
  5. Overall death was reduced by 1.2 %, NNT 83. It was surprising that the total death reduction was greater than the CV death. What other types of death were prevented?

 

  • What were the adverse results? The intensive BP lowering group had severe adverse events 1.2% more than the lower intense group. Number needed to harm 83. These included, symptomatic hypotension, syncope, severe electrolyte abnormalities, and acute kidney injury.

 

  • Was there a difference in quality of life in the elderly population? This question was not addressed. With the higher incidence of adverse effects, the question I would like to answer is if it was worth it. In other words, were the adverse events tolerable enough that it was worth it for the end benefit? That is going to be an individualized decision, and that will be our charge as clinicians to have that conversation with our patients.

 

I could go on, but by the time I hit 9 points, I have probably already lost half the readers. Hopefully this helps sum up the trial, helps cut through the sensational press releases, and help determine if it applies to you. The outcome differences are small but real. They come at a potential side effect cost, but reducing death is as good as an outcome can be. If you have high blood pressure, your goal should now be to get SBP< 120, and it is our job at Boundless Health to make sure we can get you there safely.

 

First and foremost, however, please, PLEASE, remember that this was a hypertension DRUG trial. In the real world, drugs are only part of the equation and they should never be a stand-alone first line treatment. First line treatment is, without a doubt, lifestyle changes! You deserve to have a practitioner who is just as interested, if not more interested, in your lifestyle choices as they are in your prescriptions. Where have you succeeded? Where do you need more support, or maybe to change directions? I would venture to say that with more attention to lifestyle changes, the researchers in this trial could have saved at least 1 if not more BP meds per patient. That doesn’t make the drug manufactures happy, but it sure would have made the patients happy!

 

Contact us today at Boundless Health to learn more about how we can use cutting edge research and highly individualized programs to help you reach your health goals.

shutterstock_138284549

Intermittent Fasting

Intermittent Fasting- A Revolutionary Concept Making a Comeback

“Fasting?! Are you crazy?! I need to eat every 3-4 hours to keep from getting hungry and to regulate my blood sugar!”

For some people this statement may be true. However for many it may not actually be the case. The theory of frequent small meals has been popularized so much (even with a lack of scientific evidence) that many people feel it is an absolute must do. As with most things regarding your health, there are no absolutes and there is no one strategy that works for all of us.

Intermittent fasting goes directly against the theory of frequent small meals, yet it has very good evidence showing that it helps promote fat loss while maintaining lean body mass and athletic performance. It’s important to point out that this is not a specific diet, but rather a pattern of eating. It doesn’t change what you eat, it changes when you eat. The concept certainly makes sense. When our bodies are in a true fasting state, we begin to utilize fat as a fuel source, breaking it down into ketones for use for energy. However we only reach the fasting state when we have completely digested and absorbed our entire food intake, and our insulin levels are low enough that we switch from glucose metabolism to fat metabolism. That usually doesn’t happen until about 10 or 12 hours after our last meal. If you stopped eating at 8 PM and had breakfast at 6 AM; you only went 10 hours between meals and you never reached the fasting state and therefore never started to burn fat.

Intermittent fasting proposes that you have an eating window, for example from 12 PM to 7 PM, and then a fasting window for the remainder of the time. With this schedule, you have approximately 6 hours in the morning (starting around 5-7am, which is 10-12 hours after your last food intake) when your body is preferentially using fat as a fuel source and therefore improving fat loss. There are other variations to the schedule such as fasting for an entire day once or twice a week, or even 2-day fasts twice a month and every variation in between. However the most common and easiest to implement is the 6-8 hour eating window.

In addition to fat loss, intermittent fasting has shown improved longevity in mice and it’s thought to also apply to humans. It’s been reported to increase insulin sensitivity as well as reduce oxidative stress and to resist the processes of disease and aging. There is not yet solid scientific evidence to support this in humans, but theories abound and research is quickly being done.

In addition:

1-Intermittent fasting requires very little behavior change, just simply changing the timing of your meals and is therefore simple enough that people actually do it and powerful enough that it will actually make a difference

2- intermittent fasting takes away one extra thing to worry about. There is no thinking what’s for breakfast? There is no worrying about shopping for breakfast or preparing it.

3-Intermittent fasting provides the psychological benefit of realizing “I am in control of food and hunger, it is not in control me. “

.

Intermittent fasting certainly makes sense from a physiological standpoint, and has been shown to work well for fat loss. However it is not without its potential drawbacks.

1-There is a significant psychological barrier when committing to not eating until lunch. Interestingly, it’s been said that “diets are easy in the contemplation, difficult in the execution. Intermittent fasting is just the opposite; it’s difficult in the contemplation but easy in the execution.” Most people report that once they get over the initial psychological barrier, it is very easy to keep to the schedule

2- You still need to get adequate calories and nutrients during the day. For some people this can be difficult to do in only a 7-hour window. Therefore it works best in people who can control their food intake during the day. People may have trouble maintaining an adequate caloric intake if they have to “grab whatever they can on the run” or those who are restricted to eating only during certain times. But if you can find the structure to eat whole, nutrient rich foods throughout that 7-hour window and get adequate caloric intake, then intermittent fasting can be huge success

In the end, is Intermittent fasting right for you? If your goal is fat loss, and you can control your food intake enough to consume adequate calories and nutrition in a 6-8 hour window during the day, and you don’t have legitimate issues with low blood sugar (as in patients on hypoglycemic medications), then it may be worth a try. Keep in mind, it does not have to be done every day. So if you have a big morning meeting, you are travelling, or you have a long endurance work out, you may want to skip that day (although some have reported excellent exercise performance when fasting for shorter workouts).

At Boundless Health, we are dedicated to finding the ideal approach to help you reach your goals. Intermittent fasting is one more tool we have to promote healthy fat loss. Remember, there is no one size fits all approach, so it is crucial to know all the various options that exist to find out what works best for you. Contact us today to learn more about how we can help you find your boundless.

Fitness. Health. Life. Boundless Health.

shutterstock_14936848

The Fat Fallacy continues….

More on the Fat Fallacy

 

There has been plenty of attention to the fact that fat is not as “bad” or “dangerous” as was once thought. The data that suggested dietary intake of cholesterol and fat directly caused cardiovascular disease has now been discredited.

 

In fact, the Mediterranean diet with 41% of calories from fat has been shown to reduce cardiovascular outcomes compared to a more standard European diet. So in essence, fat may actually have a protective effect. This was truly seen as science turned upside down.

 

However, when something that has been ingrained in our society for so many years has been reversed, most of us are slow to change our thoughts and actions. And who could blame us! It makes sense that we should now be skeptical of any nutritional recommendations, and it makes sense that our old beliefs may continue to linger.

 

One thing that I find helpful is to show the differences with an objective breakdown of what a full fat breakfast/snack may look like compared to a non-fat one. If you are lactose intolerant, I apologize, but the following example may still be helpful as an illustration.

 

Nonfat fruit yogurt 8ozLow fat Vanilla yogurt

8oz

Whole milk plain yogurt 8oz plus 1 cup berries
230 calories230 calories208 calories
0.5 gram fat3gm fat7 g fat
46 gram carbohydrates33g carbs20 g carbs
10 gram protein12g protein9 g protein
46 gram sugar33g sugar20 g sugar
0 gram fiber0 fiber5 g fiber

 

The big differences that should stand out are that the whole milk option has overall FEWER calories, markedly LOWER sugar content, and the addition of fiber with adding the berries. Not to mention that the fat from the whole milk with provide more satiety and decrease the snacking urge, and the lower sugar content will lessen blood sugar swings and insulin spikes.

 

The last thing to mention is that now there is actually evidence suggesting that dairy fat may actually be PROTECTIVE for developing cardiovascular disease. I will admit that this involves observational studies, and observational science is what got us into trouble with the “fat causes cardiovascular disease” hypothesis to begin with. So I wouldn’t say it is proven that dairy fat is protective, but I can say with certainty that there is no good evidence to suggest it is dangerous.

 

It makes me wonder, where is the debate?

 

At Boundless Health, we take pride in helping optimize your health and vitality by presenting you with the latest research on lifestyle interventions. We aim to be your partner in navigating the vast array of recommendations and warnings. Contact us today to see how we can help you on your journey to health.

 

Fitness. Health. Life.

Boundless Health

info@myboundlesshealth.com

858-799-0980

 

 

 

shutterstock_98521079

What is your ideal blood pressure?

Can you believe that “we” as a medical community do not know with certainty what your goal blood pressure should be on medications? There was a time where blood pressure was treated to “100 plus your age,” so if you were 70 years old, your goal would be 170. Luckily those days are long gone, but for evidence-based guidelines, it is still murky what that goal should be. Of course I am quick to point out that the first line treatment for blood pressure has NOTHING TO DO WITH A PRESCRIPTION! Lifestyle choices with nutrition, exercise, daily activity, relaxation, sleep etc. are far more important and with no side effects. But I do have to admit that there are times when lifestyle cannot overcome the powers of genetics, and then medications are required.

Let’s look at the hypothesis of what an ideal blood pressure should be:

1: A normal blood pressure is 120/80 or less, and epidemiological studies show that those with blood pressures naturally in this range have lower incidence of cardiovascular complications and death in the long term. Therefore, for some it makes sense that we should target <120 /80 with medications

2: It is unknown if naturally having blood pressure <120/80 is different than artificially achieving it with medications. A prime example is that of HDL cholesterol. A high level of naturally occurring HDL is protective for cardiovascular disease in epidemiological studies. However, artificially raising HDL with medications not only lacks benefit, but also has actually been shown to increase the risk of stroke and death! Could the same be true with blood pressure? (No such “side effects” are seen with diet and exercise of course)

3: Blood vessels stiffen as we age and therefore we need a higher blood pressure to adequately perfuse our organs such as the brain and kidney. It is possible that lowering blood pressure too much in the elderly can lead to worsening cognitive function, renal insufficiency, or other complications.

Three fairly reasonable hypotheses, all without a clear answer.

If you read the New York Times, you would think this question is now finally answered and everybody should have a blood pressure less than 120/80. A number of press releases regarding the SPRINT trial have been published in non-scientific publications touting this study as “groundbreaking” and “completely reframing the way we treat hypertension.” Briefly the SPRINT trial was a trial that randomly assigned more than 9000 men and women over age 50 to one of two systolic blood pressure targets; less than 120 or less than 140. The study was stopped over a year early by the safety monitoring board because of a significant improvement in cardiovascular events and mortality in the lower target blood pressure group. Therefore there is no shortage of articles now proclaiming that <120/80 should be the target BP for everyone. This may end up being true, and that absolutely would revolutionize the way we treat blood pressure.

However, as with most scientific evidence, the proof is in the pudding; and unfortunately we’ve yet to see the pudding come out of the fridge. There has been no release of any specific data, and as a result we should proceed with caution regarding how we view blood pressure management.

For instance, we know the targets were less than 120 or less than 140, but we don’t know what was actually achieved. In addition we know an average of 3 medications were needed in the goal less than 120 group. THREE MEDICATIONS!! Were patients living longer but not able to get off the couch without getting dizzy or falling over? This may be a bit of a dramatic example, but hopefully you get my point.

Furthermore, what type of lifestyle intervention or advice did they provide? As with treating cholesterol, the goal is not a lower blood pressure or lower cholesterol number. The goal is helping you live better, healthier and longer. Moving your body, exercising, making good nutritional choices, and managing your body’s sleep and stress response add dramatically to the overall goal and reduce the need for medications.

 

So as you can see, the SPRINT trial has the potential to turn upside down the way we approach and treat blood pressure. But we all have to remember that the first-line treatment for high blood pressure has nothing to do with your prescription pad and has everything to do with getting moving, exercising, maintaining an adequate body weight, and focusing on real whole foods and making proper nutritional choices. As for the target of pharmacotherapy, I eagerly anticipate the publication of the specifics of the SPRINT trial. But I caution all of us to resist drawing conclusions until all the evidence is revealed.

 

At boundless Health, we pride ourselves at critically examining health and medical scientific studies, and most importantly, realizing how those studies apply to you as an individual. Not as a population or a number, but as YOU. Contact us today to learn more.

Fitness. Health. Life. Boundless Health

shutterstock_129797939

Is Advanced Lipid Testing Right For Me?

It is hard to read an article or have a discussion about lifestyle choices for promoting health without also talking about cholesterol. Even though cholesterol levels should never be our ultimate goal, they are much easier to measure than the true ultimate goal of reducing heart attacks, strokes or even death. Therefore cholesterol dominates the discussion as a surrogate for what is “healthy.”

 

But cholesterol is not a single entity, and the association between cholesterol and cardiovascular disease (heart attacks, strokes, or heart related death) is murky at best. We should never again think of cholesterol as a single entity. In the old days, we used to talk about the total cholesterol level. The higher it was, the higher your risk of cardiovascular disease. Or so we thought. Then we learned that total cholesterol is not nearly as important as the individual cholesterol levels of LDL (commonly called the “bad cholesterol”), HDL (good cholesterol) and triglycerides. Low LDL and high HDL was protective and the reverse was harmful. But wait, there is more. People with “normal” LDL levels were still having strokes or heart attacks. What were we missing? Since there are other cholesterol varieties (such as IDLs and VLDLs), we started to shift to “non-HDL levels” which is simply total cholesterol minus the HDL (trying to capture all the “bad cholesterol” levels without having to measure them individually) or the total cholesterol to HDL ratio. But is that good enough?

 

Cholesterol is no longer the only player in town. We are also starting to focus on markers of inflammation, glucose utilization, insulin levels, and hormonal changes and have found strong associations between these and cardiovascular disease.

 

How can we make sense of it all and boil it down to what really matters: What is YOUR risk for cardiovascular disease? Not a whole population’s risk, but your individual risk. That is one of the hopes for “advanced lipid testing.”

 

Advanced lipid testing assumes that all LDL and HDL are not created equal. Some versions of LDL may be more dangerous, or atherogenic, than others. Without getting too technical, LDL is carried by lipoproteins, with ApoB being the most common one. So higher ApoB levels predict a higher cardiovascular risk. In addition, the LDL can be densely packed with cholesterol (bad), or can be lighter and less densely packed (better). In addition, HDL comes in different subsets with HDL 2 being more protective than HDL 3. None of these factors are measured by standard lipid testing. So theoretically, measuring ApoB levels, LDL size, or LDL and HDL sub-fractions should tell us more about our risk than traditional blood tests.

 

The hope is that knowing the specifics of LDL and HDL will help identify those at higher risk of cardiovascular disease, and allow us to target our more aggressive treatments to them. As new, more effective, and much more expensive treatments become available (like the newly approved PCSK9 inhibitors), it becomes even more important to accurately identify those at risk.

 

Despite potential impact of these tests, many health insurance carriers will not cover advance lipid testing. Many of the large organizations, such as the American College of Cardiology and the American Heart Association, are on record saying that the evidence does not support routine advanced lipid testing. They feel it has not been shown to provide greater benefit than standard lipid testing. That may be true at this time, but it brings me back to my previous point. I am not nearly as interested in a population’s risk as I am interested in YOUR risk. I want to know what your risk is, and how certain interventions can reduce that risk. Do you respond to a low fat diet? Or do you respond better to a high fat, low carb diet? Does a long cardio workout improve your risk profile, or does a shorter, higher intensity workout benefit your risk profile more?

 

Remember, when it comes to the “best diet” for cardiovascular health, the times they are a-changin’. The low fat, high carb diet was founded on faulty evidence, and in retrospect did not help reduce the incidence of diabetes, heart disease and stroke. Now we have made an about face. The high fat, low carb diet has been shown to reduce inflammation, reduce diabetes, and may eventually reduce cardiovascular disease. It can do that despite RAISING total cholesterol and even on occasion raising LDL. But we also have to be aware that one size does not fit all. Some individuals on this diet may reduce their cardiovascular risk and some may not. We do know that traditional cholesterol tests frequently will not be able to differentiate between those who lower their risk and those who do not. Instead, we may need the more advanced testing to learn whether our lifestyle changes are meaningfully impacting our health. Not everyone needs the advanced tests, but if you do, they can be very helpful.

 

In summary, if you want to dig deeper to know more about your cardiovascular risk, and find the optimal diet and exercise program to reduce that risk, consider advanced lipid testing. At Boundless Health, we specialize in the cutting edge analysis and treatment of cardiovascular risk. We work with our clients as individuals to find the best approach to help each one achieve their health and lifestyle goals. Contact us today so we can help you on your quest for a healthy and vibrant lifestyle.

 

Bret Scher, MD FACC

Lead Physician, Boundless Health

bret@myboundlesshealth.com

shutterstock_245163073

Meditation: Now it’s for everyone

Meditation: Now it’s for everyone

 

What do you think of when you hear the word MEDITATION? Monks in a remote mountain village, sworn to silence, sitting for hours trying to free their minds, trying to clear all thoughts and then levitating above the ground? Or do you think of Steve Jobs, one of the most creative and innovative humans ever to start a business?

 

What was once felt to be only for deeply pious individuals who dedicated their life to mindfulness, has now become mainstream and nearly a requirement for creativity, innovation and productivity. Steve Jobs was a devout practitioner of Zen mindful meditation. He saw the benefits of reduced stress, increased creativity and enhanced clarity in life. In his biography, Mr. Jobs is quoted as saying:

 

“If you just sit and observe, you will see how restless your mind is. If you try to calm it, it only makes it worse, but over time it does calm, and when it does, there’s room to hear more subtle things- that’s when your intuition starts to blossom and you start to see things more clearly and be in the present more. Your mind just slows down, and you see a tremendous expanse in the moment. You see so much more than you could see before.”

 

Sounds pretty good, doesn’t it? There is no question that having time to ourselves, slowing down our pace and our breathing, can work wonders to help us relax after a stressful day. But now there is evidence that meditation, or mindfulness, can do much more.

 

A recent study out of Harvard analyzed MRI images of participants before and after an 8-week meditation practice. They also analyzed MRIs on control subjects who did not participate in meditation. The treatment group averaged 27minutes each day of mindfulness exercises. Amazingly, the MRIs showed a significant increase in the hippocampus and other areas related to memory, self-awareness and compassion. There was decreased size in the amygdala, which is linked to anxiety and stress. None of these changes were seen in the control group. This was the first study to show in a prospective, randomized manner that less than 30 minutes of daily mindfulness practice can actually have direct effects on the brain size and composition.

 

They still didn’t levitate, but they did change their brains. Sounds pretty impressive to me.

 

In addition to actually changing your brain, mindfulness (defined by some as the “non-judgemental awareness of experiences in the present moment”) has been shown to reduce stress, relieve anxiety, reduce blood pressure, and improve overall well being. It doesn’t eliminate external stressors, of course, but it can dramatically alter how your body and mind react to them. Some would argue, what good is it if it only works when you are doing it or shortly thereafter? It is important to point out that meditation is like exercise. If you exercise one week, and then not again for 3 months, you will no longer have the beneficial effects of that one-week of exercising. But if you maintain your workouts 4 days per week, week in and week out, you will see dramatic short and long-term benefits. The same applies for mindful practice.

 

Plus, it isn’t very hard to do. Like anything it takes practice, and you actually do get “better” at it with time. Here is how to start:

 

  • Sit in a quiet place with few distractions. Just be comfortable. You don’t need to sit cross-legged and hold your fingers in funny positions. You just need to be comfortable.
  • Close your eyes and notice your thoughts. Don’t try to stop or control the thoughts, just observe them like a third party observer looking in from the outside.
  • Yes, this may sound cliché, but a big part of mindfulness is focusing on your breath. Feel the breath as it comes in and out through your nose. As you focus on your breath, thoughts will come in to interrupt you, and that’s okay. Don’t judge your thoughts, don’t try to control them. Simply observe and acknowledge them, and then move your focus back to your breath.
  • Become aware of how your body feels. The heaviness of your head, the feeling of your hands resting on your legs, your feet touching the ground, the air moving in and out of your nose as you focus on your breath.

 

 

And that’s it, the basics of being mindful. Be in the present, focus on your breathing, and allow the world to continue without reacting to it. Allow your thoughts to come and go without trying to control them or react to them. You can start with as little as 5 minutes, then progress to 10, 15 even 20 minutes.

 

I can’t promise that a regular mindfulness practice will make you as brilliant and creative as Steve Jobs. But I can promise you that it will help you think more clearly, feel more balanced, and help you unleash the true potential within yourself.

 

At Boundless Health, we are committed to helping you achieve your health and performance goals. We believe in evaluating every aspect of your life to help find the right approach for you, as an individual, to help you reach your goals. Does mindfulness or meditation fit into this approach for you? We would love to help you find out. Please contact us today to learn more.

 

Bret Scher MD FACC

President, Boundless Health

bret@myboundlesshealth.com

shutterstock_252233521

Is A Ketogenic Diet Right For ME?

Is a Ketogenic Diet right for me?

Now more than ever we have learned that we need to question all accepted dogma and assumed medical truths. None is more obvious than the previous belief that dietary fat causes heart disease. In fact, we now know that there may be just as much evidence that carbohydrates and sugar cause heart disease. Because of this, there has been a newfound interest in high fat low carbohydrate diets, sometimes referred to as ketogenic diets. Versions of these diets have been around since the beginning days of Atkins and South Beach. To truly have a ketogenic diet, however, you need to be able to measure ketones in your blood or urine, and not all low carbohydrate diets achieve that. Now we have readily available ketone supplements and ketone tests, thus allowing ketogenic diets to evolve into their own science and develop a very strong following.

By definition, a high fat low carbohydrate (HFLC) diet is approximately 60% fat, 30% protein and <50g carbohydrates (for a 2000 kcal diet that is 1200 kcal or 130 gram fat, 600 kcal or 150 gm protein, 200kcal or 50 g carbs). For the most part, the goal of a high fat low carbohydrate is to get your body into a state of “keto-adaptation” where your body changes from relying on glucose as the main source of energy, and instead turns to fat, thus relying on the liver’s ability to convert fat into the ketone beta hydroxybutyrate (BHB). This improving fat weight loss without a loss of energy.

Without getting too technical, the body in general, and the brain specifically, can adapt to using ketones very efficiently for energy, which makes sense from an evolutionary standpoint. If you are in a period of starvation your body will need to get energy by breaking down fat. BHB is that source of energy. This then equates to using fat as an efficient fuel source

A quick review:

1- A high carbohydrate diet Increases glucose in the bloodstream, which increases pancreatic insulin secretion, thus shuttling glucose into cells for use for energy.

2- A ketogenic diet decreases glucose levels. Your body then breaks down fat tissue into fatty acids, which are then taken up by the liver and metabolized into ketones for energy

Interestingly this diet has had the most success and scientific documentation in terms of treating epilepsy in children. Part of it has to do with the brain’s efficiency in using ketones as a fuel source. Now that the ketogenic diet has been popularized, more research has been done with the following proposed benefits:

  • Studies have shown very good results with weight loss. Part of this is from water loss by reducing glucose and glycogen stores. However another big part of this is decreased fat stores. More long-term studies are needed. However, it does appear that if the diet can be maintained over the long-term, it has shown very good results.

 

  • High fat low carb diet is very good at reducing hunger. A big drawback to “diets” and weight loss attempts is increased hunger, binge eating and mood swings. The ketogenic diet has been shown to not have these effects (in fact, it has the opposite effects).
  • Improved insulin sensitivity. The ketogenic diet has been shown to be an effective treatment for metabolic syndrome and insulin resistance. As an aside, one of the biggest proponents of the ketogenic diet is Dr Peter Attia, a former surgical resident and a local here in San Diego who has started the Eating Academy, eatingacademy.com. He is a wealth of information on the topic. He became interested because he treated his own metabolic syndrome by changing to a ketogenic diet.
  • A ketogenic diet is very good for reducing visceral fat (the fat that likes to accumulate in your gut). This one ties into its improvement on the metabolic syndrome
  • Reduced inflammatory markers such as CRP, which has been proposed as a possible mechanism that may lead to better cardiovascular outcomes.
  • Possible improved athletic performance. This is a vey active area of research. Ketones have been proposed as a “more efficient” fuel for athletic performance and many runners, triathletes, weight lifters, golfers, and other swear by the increased performance they get with a ketogenic diet.

What about cholesterol? As a cardiologist, this is the topic that is near and dear to my heart (pun intended). The world has changed since we know dietary fat does not “cause” heart disease. We now know the data to support that claim was woefully inadequate, so it is fair that we should re-examine the topic from all angles. A high fat low carbohydrate diet does raise total cholesterol. But is that important? When you break it down, HFLC diet also raises HDL (the good cholesterol) and lowers triglycerides. The data on LDL is mixed. Even when the lab value LDL-C increases, a ketogenic diet can reduce the actual LDL particle number. In addition, the LDL size increases with reduced density, thus potentially reducing the harmful effect of LDL. I know that was technical, but it is important to emphasize how one simple lab value does not tell the whole story. Will this lead to any increase or decrease in heart disease? That remains to be scientifically proven. But we can say for sure that we can no longer automatically assume that eating fat and increasing total cholesterol will lead to heart disease. There are more pieces of the puzzle that need to be re-examined.

What about potential drawbacks to a ketogenic diet:

  • Micronutrient deficiency. Thiamine, folate, calcium, iron, potassium, magnesium can all be deficient in a very low (<50gm) carbohydrate diet. If you maintain a strict HFLC diet, you should take a daily multivitamin.
  • Transition phase- There have been reports of a difficult “transition phase” as the body learns to become keto-adaptive. This can cause decreased energy and concentration. But the same reports state once the body has passed the transition phase, then patients report improved energy and concentration. Ketone supplements have helped dramatically with this transition phase, and anyone wanting to reach a ketogenic state should consider starting a ketone supplement.
  • Since much of the early weight loss is from water loss, it has been proposed that you could become dehydrated with this diet. Pay close attention to drinking half your body weight in ounces of water.
  • Is there a risk of “ketoacidosis”? Ketoacidosis is a life threatening condition that happens in diabetics where the ketone levels reaches a high enough to cause their blood to turn acidic. If you measure the concentration of BHB, acidosis occurs at a level of 20-25mM. In a ketogenic diet, levels generally approach 0.5-3mM. As long as someone has adequate pancreatic insulin production, they cannot physically reach high enough levels of BHB. But if a diabetic tried a ketogenic diet, they could definitely get into trouble with acidosis.
  • It can be challenging to eat that much fat! Some people struggle to get the appropriate amount of fat to maintain a ketogenic state. Tips include using medium chain triglyceride (MCT) oil, lots of avocados, nuts, meat and ketone supplements (which is a booming market in the supplement industry right now)

 

In summary, the ketogenic diet is a high fat, low carbohydrate diet that has beneficial effects of fat and weight loss, improved satiety, improved metabolic syndrome and reduced inflammation. The diet is at the forefront of the reanalysis of the relationship between dietary fat, carbohydrates and heart disease. It also likely has beneficial effects on athletic performance, mental clarity, and even Alzheimer’s disease. It can be a challenging diet to maintain, it can be associated with micronutrient deficiencies, it can be dangerous in diabetics, and it may have a problematic “transition phase” as one becomes keto-adaptive. But for the right person, it can have a profound positive impact.

If you remember from my previous posts, I am not a fan of “diets” at all. Lifestyle changes tend to be much more effective over the long term than “diets” do. However, in order to properly maintain a state of ketosis, it does have to be a lifestyle choice since it is arduous to keep up with. For one who is motivated enough to do it, they will be well rewarded with the results.

We are now entering a brave new world where all we were taught about fat and cholesterol are being questioned more than ever before. It is our job to stay as educated and open-minded as we can. Question all assumptions all the time. At Boundless Health, we are at the forefront of the scientific evidence regarding nutritional practices. It is our passion to find the right approach to help you reach your goals. Is a ketogenic lifestyle right for you? We would love to help you find out the answer. Contact us to today to learn more.

 

Bret Scher, MD FACC

President, Boundless Health

858-799-0980

bret@myboundlesshealth.com

slide1bg

Exercise is the new Medicine

“Walking is man’s best medicine”- Hippocrates (Greek physician 460 BC-377BC). How did he know that? For one, he didn’t have scientific studies to reach that conclusion (at least I assume he didn’t). He didn’t even have fitness trackers to monitor how many steps people took (how did they survive in such prehistoric times??) I guess it all came down to common sense. Even “back then” Hippocrates could understand the physical and psychological benefits from an activity as simple as walking. Today, we have the research to support his claims.

 

We also have information from one of the best and healthiest trends of the past decades–the flood of activity trackers and step counters that keep us moving and motivate us to get off the couch. As a society, we have gone through the running and marathon trend, the gym trend, and now the “JUST MOVE” trend. What I love about the “just move” trend is the simplicity of it. No driving to the gym, no finding a parking space, no changing clothes, and it doesn’t have to take 3 hours to do. Don’t get me wrong, the gym is a great place to exercise, be healthy, and develop strength and power. Running a marathon is a fantastic motivator and a very worthwhile goal. But when it comes to reaching the masses and improving health for an entire population, nothing works better than a free activity that requires only a pair of shoes. And on top of that, the roads and sidewalks are open 24/7/365, and side effects may include increased work productivity and better moods to name only two.

 

As is frequently the case, however, there exists a disconnect between what we know is good for us and what we actually end up doing. Why doesn’t everyone get out and walk? Why doesn’t everyone get the magic 10,000 steps every day? Motivation and free time are the most often sited factors. Plus, it appears as if part of society is determined to force us to walk less. Long work hours behind a computer screen, moving walkways, escalators, the culture of fighting for the closest parking space, all are societal “forces” that cause us to move as little as possible. Recently, however, there has been a flood of research showing that exercise and being active can help us live longer! No only can physical activity reduce your risk of diabetes, hypertension, depression, but it can reduce your risk of DEATH!

 

However, unlike prescription medications, exercise does not come with dosing instructions and overdose precautions. So what is the optimal level of exercise? Current guidelines suggest 150min per week of moderate intensity or 75 minutes of high intensity exercise. This recommendation came from a combination of outcome data, and an assumption of what people will actually do. As you will see, the best data supports more exercise for maximal mortality benefit. But what does the data say about “overdosing” on exercise, or the toxic/therapeutic index? Read on for more.

 

A recent large study (JAMA Internal Medicine April 6 2015) followed 661,000 Middle Aged adults over 14 years investigating their risk of death. The highest risk was in those who did not exercise. Even a “little amount” of exercise (less than the official guidelines but more than no exercise) reduced the risk of death by 20%. The benefit continued to increase linearly with increasing exercise duration until it plateaued at 450 min per week. The following table summarizes the results.

 

Amount of exercise per weekCardiovascular/Mortality result
SedentaryHighest mortality and cardiovascular risk
Less than 150minReduced death by 20% over sedentary
150 minReduced death by 31%
450 minReduced death by 39%
More than 450 minNo additional benefit, but no increased harm either

 

In the same journal, an Australian study followed 200,000 adults and concluded that vigorous and frequent exercise had an additional 13% death reduction over more moderate exercise. These are important findings because they suggest there is no “over dose” or “toxic limit” to exercise, which seems contrary to other studies that suggested “extreme” or “excessive” exercise can actually worsen cardiovascular and/or mortality risk.

 

Perhaps the best-publicized recent study on the subject of exercise benefits and risks has been the Copenhagen City Heart Study (JACC 2015;65:411-9). Again it was shown that “light” running even just once per week resulted in reduced mortality benefits, with the maximal benefit in those who jogged at a slow or average pace between 1-2.5 hours per week. However, contrary to the above studies, they also showed there was a U shaped curve, meaning running at faster paces >3 days per week did not have a mortality advantage over sedentary non-runners (there may have been other benefits, but death prevention was not one of them).

 

On the surface this seems contradictory to what has been conventional wisdom that when it comes to exercise “more is better.” Although it is far from definitive, some research does suggest that there is a maximal beneficial amount of exercise, beyond which there are diminishing health returns. For instance, it is now well documented that there appears to be a association between exercise and atrial fibrillation. Moderate intensity exercise is beneficial and REDUCES the lifetime risk of atrial fibrillation, but intense exercise more than 5 days per week can actually INCREASE the risk of atrial fibrillation (Heart 2014:100;1037-42). We are starting to see more of this as the first generation of Ironman Triathletes, ultra-marathon runners, and others endurance athletes are now reaching their 50s or older and are starting to show higher rates of atrial fibrillation than we would have otherwise expected.

 

So how do we sum this all up? It appears Hippocrates was right on when he said “Everything in excess is opposed to nature.” Once again, we see that we all need to exercise with a purpose. The key is defining that purpose and tailoring an individualized exercise program or philosophy to achieve that purpose.

 

If your goal is optimizing cardiovascular health and mortality, the most efficient goal should be 450 minutes per week of moderate cardiovascular exercise. That is clearly a difficult goal to reach for many of us. So it is crucial to remember that we still gain benefit from performing any amount of exercise even 20min of walking. And we get increasing health benefits for any amount of exercise up to 450 minutes per week. However, performing more than 450 minutes per week, or frequent higher intensity exercise, may blunt the mortality benefit and may increase the risk for atrial fibrillation. We often see that those who perform high intensity endurance exercise frequently do so for reasons other than just cardiovascular benefit. They love the challenge, the thrill of accomplishment, the competition, the structure, and the community just to name a few. By defining their purpose, we can design their exercise program accordingly.

 

Best Evidence Summary Table:

Minimum exercise needed for mortality benefit20min once per week, JUST MOVE
Official Recommendation for general population150min per week moderate exercise, 75 min per week high intensity
Maximal mortality benefit450 min per week of moderate exercise
POSSIBLE lack of mortality benefit>450 min per week
Increased risk of lifetime AFIntense exercise >5 days per week

 

At Boundless Health, our expert team of cardiologists, health coaches and physical therapists help identify your specific goals, and we work with you to safely achieve those goals. If your goal is to compete in an Ironman Triathlon, or play 18 holes of golf without pain, or reduce your risk of diabetes and heart disease, we are here to help you accomplish your goal. We help you train hard, and we help you train smart. We make you sweat, but we also emphasize the importance of rest, nutrition and overall health. We apply the latest research and science to you as an individual, and customize a program just for you. And along the way, we will help you move better, feel better, and live a healthier and more purposeful life.

 

Please contact us today to learn how together, we can build your path to a healthy future.

 

Bret Scher, MD FACC

President, Boundless Health

TPI Fitness Level 2, NASM CPT FNS

bret@myboundlesshealth.com

slide4bg

The #1 Guaranteed Weight Loss plan!

The Number One Guaranteed Weight Loss plan!!

 

My Weight loss plan is proven to help you easily lose weight and keep it off!

Well…..actually that isn’t exactly true.

Well…OK, it isn’t true at all. But it might work!!

 

It seems we cannot turn on the TV, open a magazine, look at Facebook or twitter now a days without someone guaranteeing you will lose weight with their new and proven method of weight loss. The problem is, there really is no research to prove any of it actually works, and now we have the evidence to PROVE THAT!

 

There was a study published in the April 7th issue of The Annals of Internal Medicine that looked at dozens of commercial weight loss programs focusing on if they had hard evidence to back their claims of weight loss. Only Jenny Craig and Weight Watchers actually had long term (1 year) evidence to support their claims that their programs helped people lose weight and maintain the weight loss. I have to point out that this doesn’t necessarily mean that the others have been shown to not work, but it does highlight the dearth of evidence despite the preponderance of impressive claims.

 

What did the evidence show? Jenny Craig showed a 5% greater weight loss at 1 yr. compared to those who dieted on their own (for a 200 pound person that equals a 10 pound weight loss, certainly a change but still lacking in impressive results). Weight Watchers was less impressive at 2.6% at 1 year. Nutrisystems had good evidence of 3.8% weight loss compared to controls at 3 months, but no longer-term evidence was available. Not surprisingly, very low calorie programs such as Medifast and Optifast showed 4% weight loss over counseling alone in the short term, but those numbers slipped significantly beyond 6 months.

 

What can we learn for this data? The obvious lesson is that we can ignore the majority of claims that one method or another has been proven to be successful. But more importantly, why were Jenny Craig and Weight Watchers the “successful ones?” There may not be one absolute reason. But for one, they are not “no fat” or “no carb” diets. They avoid the “all or none” fad or “the good and the evil” foods, and instead they strive for balanced and healthy nutritional choices. And they do so in a structured and supportive environment with goal setting, frequent “check-ins” and attempts to build a community. We have seen time and time again that restrictive diets (no fat, no carb, severe calories restriction) can be successful in the short term, but they have poor long-term success due to the difficulty in maintaining the restrictive choices and incorporating them into your lifestyle.

 

This brings up the issue of a “diet” vs a “lifestyle change”. Diets are quick and easy in the short term, but difficult to maintain and largely ineffective in the long run. Lifestyle changes are slower and more difficult in the short run, but by definition they become part of who you are and are therefore much more effective in the long run. Our society as a whole tends to focus on the quick and easy and shun the long and difficult, thus the hundreds of weight loss programs and diets that promise quick short-term success. But to truly make a long lasting change, change has to be part of who you are, and it has to be compatible with your life. Try to make a “meat and potatoes” guy a Vegan and I wish you luck. The same holds true on selling a vegetarian on Paleo. Different structures work for different people. Our charge at Boundless Health is to find out what will work for YOU. Not for the next 6 weeks or 6 months, but for YOUR LIFE. We wont try to sell you a diet. Instead we work together as a team to help you adopt a healthier lifestyle.

 

A big component of making lasting lifestyle changes revolves around keeping our choices enjoyable. We all enjoy eating flavorful food. There is no arguing against that. So we shouldn’t shun flavor in lieu of restrictions. A recent WSJ article argued that flavor should be the main driver of our food choices. The author suggested that in the past, flavor was linked to nutritious foods. Our bodies sought out nutrition based on our “tastes and needs”. Now, however, flavor comes more from additives packed with sugar and hidden calories. One way to adopt a healthy and tasty lifestyle change is not to avoid flavorful foods, but rather to focus more on natural flavors. Put another way, don’t deprive yourself of what tastes good, just achieve it naturally. Add strawberries to your salad, not a strawberry flavored dressing. Or put slices of peaches in your yogurt instead of eating the sugary pre-mixed peach flavored yogurt. Start with a high quality 6oz grass fed steak and grill it with flavorful seasoning rather than getting the huge porterhouse smothered in butter from Donovan’s. Simple concepts that we may not think about on a regular basis can make a significant difference in making meaningful change enjoyable.

 

What are some other “tricks of the trade” for success with healthy lifestyle modifications? The marketing sector would like to convince you there are 3 tips that will change your life! In reality, there are too many to list, and they are too individualized to generalize. Some resonate more than others depending on individual personalities. But some crucial concepts are listed below:

 

1-Set realistic goals for both the short and long term. A frequent term used is to develop SMART goals

 

Specific“Feel better” “Look better” are vague and hard to quantify. “Shrink my waist from a 45 to a 38” is specific
MeasureableSimilar to above, a specific goal that can be measured provides a hard end point for success
AchievableIf the initial goal is to lose 50 pounds in 3 months, we can modify the goal into something more achievable, i.e. lose 10 pounds in the first 2 months and then reset for a second goal
Realistic“Run a marathon next month” for someone who does not exercise at all is not very realistic. “Do my cardio 3 days per week and 1 HIIT workout per week” is ambitious, but much more realistic.
TimelyHave short and long term time frames. If your only goal is 1 year away, you miss out on checkpoints to reinforce success or encourage a change to improve your progress.

 

 

 

2-Reinforce small victories– we all love and are motivated by success. By setting short and long term goals, we can reinforce successes along the way thereby increasing motivation

 

3- Don’t adopt a diet in isolation. Exercise, sleep, happiness, stress etc. are all connected and all play a crucial role in lifestyle modification and ultimate weight loss and healthy living

 

4- Know what works for you. Some of us do better with absolutes, i.e. never eat X, only eat Y. Others do better with quantification such as calorie counting. Many will likely do better with balanced guidelines and with frequent reinforcements. We need to establish what will work best for us as individuals, then come up with a game plan.

 

5- Become Educated about how small gains still having significant benefits. The goal may be losing 50 pounds, but even if you only lose 10, celebrate that success and realize it can still improve blood pressure, blood sugar, pant size, or other metrics that will encourage and motivate you to achieve more

 

6- Expect setbacks and plan for them in advance. If you plan in advance you wont be surprised by the first bump in the road and want to quit. Instead, you will be armed and ready to regroup and try again. The goal is not perfection, but rather long term progress despite the bumps in the road.

 

7- Engage in community and support, either with an in person group, or an online community, or fitness monitor like Fitbit, etc.

 

8- Know that Will Power is Weak! Controlling our environment is of utmost importance. It is well proven that buffet style eating and eating on larger plates increases potion size even when people are specifically told to reduce their portion size. Another example that I love: In one study, 74% of subjects said they would eat fruit over chocolate for a snack. However, when actually confronted with the food, 70% ate the chocolate! Will power is weak!

 

9- Attach an emotion to the goal– Visualize achieving your goal, and talk about the emotions you feel once you have achieved the goal. Psychological research has shown that education is insufficient to make lasting change. Emotion is the missing piece. Talking about your emotions makes it more powerful, and makes us more accountable

 

As you can see, behavior change is not easy and has many caveats. In fact, there are many other tips that I could have listed. But by keeping these above tips in mind and developing your own style of incorporating them into your life, together we can increase your chances for real, meaningful, long term lifestyle change that will help you on your path to health and wellness.

 

So the next time you hear about the “Miracle Diet Guaranteed to Fix Everything!!!”, sit back and smile, and know that the tortoise who eventually gets to the finish line always beats the hare who sprints out of the gate and never finishes.

 

Thank you for reading. Please contact us today to find out more ways Boundless Health can work with you to achieve your health and wellness goals.

 

Bret Scher, MD FACC

President, Boundless Health

Board Certified Cardiologist

TPI Fitness Level 2, NASM CPT

info@myboundlesshealth.com

shutterstock_101231881

Nutritional advice doesn’t have to be so hard!

Dietary and nutritional research is hard! How can you eliminate every variable?? But just because the research is hard, doesn’t mean nutritional advice has to be hard. Here are my rules to follow to make it simpler:

  • Don’t focus so much on the macronutrients. We don’t eat proteins, fats and carbs. We eat food!
    1. Grilled salmon with lemon sauce and olive oil is vastly different than fried cod fish tacos on flour tortillas and creamy “special sauce.” Yet both are “fish” and both are “protein.” We don’t eat nutrients, we eat food!

 

  • We can’t focus on what NOT to eat unless we also focus on what TO eat instead. One explanation for the variable results in nutritional studies is that some studies focus on what to avoid, while others focus on what TO EAT.
    1. You can avoid saturated fats, but if you replace it with crackers, pretzels, white bread, cereal, “low fat” cookies….have you done your body any good? Unlikely. To me, it is much more important to focus on what actually goes into our bodies!

 

  • Look at the full effect of a food, not just the effect on one parameter. Or even better, focus on a food’s effect on our life, not our blood tests.
    1. For decades measuring the number of LDL particles in our blood was the key parameter, and we had to try to avoid an increase in our LDL. We now know that if a food causes the LDL to go up, but it also raises HDL and makes LDL “less dense,” then the cardiac risk does NOT go up. One marker doesn’t tell the whole story.

 

  • All fats aren’t created equal. This is similar to #1, but it is so important, I will say it again. We need to focus on specific foods and not generalize classes of foods
    1. Saturated fat from grass fed steak has different properties than trans fats from fried foods. Saturated fats from dairy sources may be protective from heart disease. Polyunsaturated fats from fish are tremendously beneficial to our health, and monounsaturated fats from avocados or olive oil are crucial to a healthy diet. Not all fats are created equal.

 

  • Healthy dietary choices are only part of the overall health puzzle.
  1. To obtain the best health results, nutrition has to be combined with an exercise program and a commitment to a healthy lifestyle. Our bodies are too complex to achieve meaningful results with a “quick and easy” fix.

 

At Boundless Health, we focus on you as an individual, not as a population study. We would never assume a nutritional pattern that works for someone else would automatically “work” for you. We celebrate all that makes us unique, and we work together with you to devise an individualized plan to help you on your lifelong journey of health and fitness. Please contact us today to find out more.

 

Bret Scher, MD, FACC

Titleist Level 1 Certified

NASM Certified Personal Trainer