Currently browsing posts about: Heart-disease

Every year, CA–A Cancer Journal for Clinicians publishes an annual review of cancer statistics.

The report has some good news: trends in the overall death rates from cancer show significant declines, for both men and women.

The overall incidence (new case) rates are holding steady or a down a little since 1990,but are still above the rates in 1975.

The incidence patterns differ for cancers at different sites:

In men, lung cancers are down undoubtedly due to less cigarette smoking.  Prostate and colorectal cancers are down, perhaps due to favorable dietary changes.

In women, lung cancers have leveled off and colorectal cancers are down, but breast cancers don’t seem to budge.

As for the comparison to heart disease, that’s interesting too.  In 2005, cancer surpassed heart disease as the leading cause of death in people younger than age 85.

Plenty of good news here, but plenty more to be done.

Last week, a Feedback comment from a reader, Judith Rice-Jones, inspired me to try to understand what’s going on with the new heart disease prevention guidelines (I can’t say I’m succeeding very well).

Looking forward to your response to the recent recommendations for more people to take statins. Don’t see anything in the new recommendations about changing lifestyle or diet to reduce risks of stroke or heart attack.

Yes, there are lifestyle recommendations.   But lifestyle changes do not make money for drug companies, and they don’t get press attention.

The American College of Cardiology (ACC) and American Heart Association (AHA) issued four sets of guidelines:

1. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults
2. 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults
3. 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk
4. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk

These organizations say:

AHA and ACC are pleased to announce a series of new cardiovascular prevention guidelines for the assessment of cardiovascular risk, lifestyle modifications that reduce risk, management of elevated blood cholesterol, and management of increased body weight in adults. These guidelines are based on rigorous, comprehensive, systematic evidence reviews originally sponsored by the NHLBI. The ACC and AHA collaborated with professional organizations to finalize these AHA/ACC cardiovascular prevention guidelines, and stakeholder organizations were invited to review and endorse the final documents.

So these guidelines are a major big deal.  The New York Times said you need to know three things about them:

• You don’t need to know your cholesterol number (unless it is very high).
• You do need to know your risk (for this you need to use the risk calculator and, therefore, to know your LDL and HDL levels and blood pressure).
• If you are at risk, take a statin (most, at least, are generics).

But wait!

As the New York Times also suggested, the new guidelines have taken many by surprise.

This is an understatement.

Problem #1: Authoritative clinicians say more patients should not be taking statins

This announcement is not a result of a sudden epidemic of heart disease, nor is it based on new data showing the benefits of lower cholesterol. Instead, it is a consequence of simply expanding the definition of who should take the drugs — a decision that will benefit the pharmaceutical industry more than anyone else.

This opinion piece points out that members of the group writing the recommendations have financial ties to drug makers, as do both the AHA and ACC.

The guidelines might make sense, they say, if statins

actually offered meaningful protection from our No. 1 killer, heart disease; if they helped people live longer or better; and if they had minimal adverse side effects. However, none of these are the case…as shown in a recent BMJ article co-written by one of us.

Perhaps more dangerous, statins provide false reassurances that may discourage patients from taking the steps that actually reduce cardiovascular disease…80 percent of cardiovascular disease is caused by smoking, lack of exercise, an unhealthy diet, and other lifestyle factors. Statins give the illusion of protection to many people, who would be much better served, for example, by simply walking an extra 10 minutes per day.

Problem #2: The risk calculator greatly overestimates risk

The lead article in today’s Times summarizes studies to be published in The Lancet tomorrow concluding that the risk calculator makes the risks seem greater than they really are.

It will lead many doctors to prescribe statin drugs to people who do not need to take them (from the standpoint of drug companies, that’s the point).

The calculator overpredicted risk by 75 to 150 percent, depending on the population. A man whose risk was 4 percent, for example, might show up as having an 8 percent risk. With a 4 percent risk, he would not warrant treatment — the guidelines that say treatment is advised for those with at least a 7.5 percent risk and that treatment can be considered for those whose risk is 5 percent.

What to do?

• Best to discuss this one with your doctor.
• For sure, eat your veggies and be active.
• If you still smoke cigarettes, stop.
• Stay tuned for further developments.

Just for fun

Let’s let Brian McFadden (Sunday’s New York Times Week in Review) have the last word for today.

I had no idea scientists were taking CT scans of mummies, and was riveted by a paper in the April 6-12 issue of The Lancet.  The investigators acquired or took CT scans of 137 mummies collected from various museums, the Brooklyn Museum among them (this photo is from the British Museum).

The mummies originated from four different parts of the world.

• Ancient Egypt
• Ancient Peru
• Southwest America (ancient Pueblo Indians)
• The Aleutian Islands

Their deaths occurred over nearly a 6000-year span, from perhaps 3800 BCE to 1900 CE.

The CT scans revealed calcifications in the arteries of 34% of the mummies.  The older the mummies were at the time of death, the more calcifications they displayed (average age at death was about 43).

The authors’ conclusion:

Atherosclerosis was common in four preindustrial populations including preagricultural hunter-gatherers. Although commonly assumed to be a modern disease, the presence of atherosclerosis in premodern human beings raises the possibility of a more basic predisposition to the disease.

The most fun is the table itemizing details about each of the 137 mummies.  For example, #57 was a male mummy from Egypt, age 40-45, from the Middle Kingdom Dynasty 12, around 1981-1802 BCE, with definite calcifications of the iliac, femoral, popliteal, and tibial arteries.  

The authors say that the presence of calcifications in the arteries of four preindustrial populations across a wide span of human history argues that “the disease is an inherent component of human ageing and not characteristic of any specific diet or lifestyle.”

Maybe, but we don’t know whether the calcifications caused the death of these individuals.  The paper assumes that calcifications seen on the CT scans indicate atherosclerosis.  Even if they do, it’s not clear whether or under what circumstances they might lead to coronary heart disease or stroke. 

The accompanying editorial doubts that dietary cholesterol and cigarette smoking were responsible for atherosclerosis in antiquity.  Instead, “infection is likely to provide the unifying explanation” (via inflammation).

More research needed!  But this is an entertaining example of the use of modern medical technology to explore interesting questions in human anthropology, physiology, and health.

Reference:  Thompson RC, et al.  Atherosclerosis across 4000 years of human history: the Horus study of four ancient populations.  The Lancet 2013;381:1211-1222, and editorial on pages 1165-1166.

As I mentioned in a previous post, the United Nations General Assembly met this month to consider resolutions about doing something to address rising rates of “non-communicable” diseases (i.e., chronic as opposed to infectious diseases such as obesity-related coronary heart disease, type 2 diabetes, and cancers).

The Declaration adopted by the Assembly disappointed a consortium of 140 non-profit public health advocacy groups who issued a statement noting the conflicts of interest that occur when international agencies “partner” with companies that make products that contribute to an increase in disease risks.”

The consortium suggested actions that they hoped the U.N. would recommend, such as:

• Realign food policies for food and agricultural subsidies with sound nutrition science
• Mandate easy-to-understand front-of-pack nutrition labeling
• Ban the promotion of breast-milk substitutes and high-fat, -sugar and -salt foods to children and young people
• Prohibit advertising and brand sponsorship for alcohol beverages
• Increase taxes on alcohol beverages
• Expand nutritious school meal programs

The group also said that the U.N. should still work on:

• Developing tools to navigate the trade law barriers to health policy innovation,
•  Establishing disease-reduction targets and policy implementation schedules
• Instituting mechanisms to keep commercially self-interested parties at arms-length and public-interest groups constructively involved

Food companies and trade associations are actively involved in lobbying the U.N. not to do any of these things.  This consortium has much work to do.

 

 

In what Bloomberg News terms an “epidemic battle,” food companies are doing everything they can to prevent the United Nations from issuing a statement that says anything about how food marketing promotes obesity and related chronic diseases.

The U.N. General Assembly meets in New York on September 19 and 20 to develop a global response to the obesity-related increase in non-communicable, chronic diseases (cancer, cardiovascular disease, respiratory disease, type 2 diabetes) now experienced by both rich and poor countries throughout the world.

As the Bloomberg account explains,

Company officials join political leaders and health groups to come up with a plan to reverse the rising tide of non- communicable diseases….On the table are proposals to fight obesity, cut tobacco and alcohol use and expand access to lifesaving drugs in an effort to tackle unhealthy diets and lifestyles that drive three of every five deaths worldwide. At stake for the makers of snacks, drinks, cigarettes and drugs is a market with combined sales of more than $2 trillion worldwide last year.

Commenting on the collaboration of food companies in this effort:

“It’s kind of like letting Dracula advise on blood bank security,” said Jorge Alday, associate director of policy with World Lung Foundation, which lobbies for tobacco control.

The lobbying, to understate the matter, is intense.  On one side are food corporations with a heavy financial stake in selling products in developing countries.  Derek Yach, for example, a senior executive of PepsiCo, argues in the British Medical Journal that it’s too simplistic to recommend nutritional changes to reduce chronic disease risk.  [Of course it is, but surely cutting down on fast food, junk food, and sodas ought to be a good first step?]

On the other side are public health advocates concerned about conflicts of interest in the World Health Organization.  So is the United Nations’ special rapporteur for  the right to food, Olivier De Schutter.  Mr. De Schutter writes that the “chance to crack down on bad diets must not be missed.”

On the basis of several investigative visits to developing countries,  De Schutter calls for “the adoption of a host of initiatives, such as taxing unhealthy products and regulating harmful food marketing practices…Voluntary guidelines are not enough. World leaders must not bow to industry pressure.”

If we are serious about tackling the rise of cancer and heart disease, we need to make ambitious, binding commitments to tackle one of the root causes – the food that we eat.

The World Health Organization’s (WHO) 2004 Global Strategy on Diet, Physical Activity and Health must be translated into concrete action: it is unacceptable that when lives are at stake, we go no further than soft, promotional measures that ultimately rely on consumer choice, without addressing the supply side of the food chain.

It is crucial for world leaders to counter food industry efforts to sell unbalanced processed products and ready-to-serve meals too rich in trans fats and saturated fats, salt and sugars. Food advertising is proven to have a strong impact on children, and must be strictly regulated in order to avoid the development of bad eating habits early in life.

A comprehensive strategy on combating bad diets should also address the farm policies which make some types of food more available than others…Currently, agricultural policies encourage the production of grains, rich in carbohydrates but relatively poor in micronutrients, at the expense of the production of fruits and vegetables.

We need to question how subsidies are targeted and improve access to markets for the most nutritious foods.…The public health consequences are dramatic, and they affect disproportionately those with the lowest incomes.

In 2004, the U.N. caved in to pressures from food companies and weakened its guidelines and recommendations.  The health situation is worse now and affects people in developing as well as industrialized countries.  Let’s hope the General Assembly puts health above politics this time.

 

I keep getting questions about saturated fat.  Does it really pose a health risk?  If so, how serious a risk?  And isn’t eating real food OK even if it contains saturated fat?  Good questions.  Here are a couple of recent examples:

Reader #1: I think that the idea that saturated fats in meat and dairy are unhealthful is errant, based on correlative – not causative – scientific studies…I propose that instead of demonizing one nutrient over another, we favor whole, high-quality foods of both animal and plant origin…designed by nature (and thousands of years of trial and error) to meet the needs of their respective populations. What do you say?

Reader #2: I wonder how the government can be so focused on low-fat milk. Is that really such a huge problem? Isn’t the bigger problem that the state of NY is telling people pretzels make a healthy snack? Isn’t it soda and cheese doodles and eating every dinner from a box that is the problem? Whole milk, really? I’d appreciate your clarity on this… we are full fat milk and cheese people, and all of this perplexes me.

I can understand why anyone might be confused about saturated fat.  Food fats are complicated and it helps to be a biochemist (as I once was) to sort out the issues related to degree of saturation and whether the omegas are 3, 6, or 9 (I explain all this in the chapter on fats and in an appendix to What to Eat).

And yes, the science is complex and sometimes seems contradictory but scientific committees for the past 50 years have concluded one after another that substituting other kinds of fatty acids for saturated fatty acids would reduce levels of blood cholesterol and the risk for coronary heart disease.

And no, those scientists cannot have all be delusional or paid off by the meat or dairy industries.  They—like scientists today—mostly call the science the way they see it.

What makes the research especially hard to sort out is that all food fats—no exceptions—are mixtures of saturated, unsaturated, and polyunsaturated fatty acids (just the proportions differ), that some saturated fatty acids raise blood cholesterol levels more than others do, and that one kind—stearic acid—seems neutral with respect to blood cholesterol.

But overall, the vast majority of expert committees typically conclude that we would reduce our heart disease risks if we kept intake of saturated fat below 10% of calories, and preferably at or below 7%.   On average, Americans consume 11-12% of calories from saturated fat, which doesn’t sound too far off but the average means that many people consume much more.

As is often the case with studies of single nutrients, research sometimes comes to different conclusions.  Several studies—all quite well done—have appeared just in the last year or so.

One of these is a meta-analysis (a review of multiple studies). It concludes:

…there is no significant evidence for concluding that dietary saturated fat is associated with an increased risk of CHD [coronary heart disease] or CVD [cardiovascular disease]. More data are needed to elucidate whether CVD risks are likely to be influenced by the specific nutrients used to replace saturated fat [my emphasis].

What saturated fat gets replaced with is the subject of three other well conducted studies that come to a different—the mainstream—conclusion.  One, another recent meta-analysis, confirms decades of previous observations (sorry about the annoying abbreviations):

These findings provide evidence that consuming PUFA [polyunsaturated fatty acids] in place of SFA [saturated fatty acids] reduces CHD events in RCTs [randomized clinical trials]. This suggests that rather than trying to lower PUFA consumption, a shift toward greater population PUFA consumption in place of SFA would significantly reduce rates of CHD.

Translation: replacing saturated fats with polyunsaturated fats would be healthier.

Another meta-analysis comes to the same conclusion:

The associations suggest that replacing SFAs with PUFAs rather than MUFAs [monounsaturated fatty acids] or carbohydrates prevents CHD over a wide range of intakes.

A very recent consensus statement concludes:

the evidence from epidemiologic, clinical, and mechanistic studies is consistent in finding that the risk of CHD is reduced when SFAs are replaced with polyunsaturated fatty acids (PUFAs). In populations who consume a Western diet, the replacement of 1% of energy from SFAs with PUFAs lowers LDL cholesterol [the “bad” kind] and is likely to produce a reduction in CHD incidence of ≥2–3%. No clear benefit of substituting carbohydrates for SFAs has been shown, although there might be a benefit if the carbohydrate is unrefined and has a low glycemic index.

The advisory committee to the 2010 Dietary Guidelines for Americans reviewed this and other research relating saturated fatty acids to heart disease risk and concluded:

Cholesterol-raising SFAs, considered SFA minus stearic acid…down-regulate the low density lipoprotein (LDL) receptor by increasing intracellular cholesterol pools and decreasing LDL cholesterol uptake by the liver.

The committee’s research review addressed the question, “What is the Effect of Saturated Fat Intake on Increased Risk of Cardiovascular Disease or Type 2 Diabetes, Including Effects on Intermediate Markers such as Serum Lipid and Lipoprotein Levels?”  It judged the evidence strong

that intake of dietary SFA is positively associated with intermediate markers and end point health outcomes for two distinct metabolic pathways:

1) increased serum total and LDL cholesterol and increased risk of CVD and

2) increased markers of insulin resistance and increased risk of T2D [type-2 diabetes]. Conversely, decreased SFA intake improves measures of both CVD and T2D risk.

The evidence shows that 5 percent energy decrease in SFA, replaced by MUFA or PUFA, decreases risk of CVD and T2D in healthy adults and improves insulin responsiveness in insulin resistant and T2D individuals.

How much saturated fat might increase the risk of heart disease or type-2 diabetes depends on how much you eat as well as what you eat.

What to do to reduce your dietary risks for heart disease?  Take a look at the top 15 sources of saturated fats in U.S. diets:

• Regular cheese
• Pizza
• Grain-based desserts (cakes, cookies, pies, pop-tarts, donuts, etc)
• Dairy desserts
• Chicken and chicken mixed dishes (e.g. fingers)
• Sausage, franks, bacon, and ribs
• Burgers
• Mexican mixed dishes
• Beef and beef mixed dishes
• Reduced fat (not skim) milk
• Pasta and pasta dishes
• Whole milk
• Eggs and egg mixed dishes
• Candy
• Butter
• Potato/corn/other chips
• Nuts/seeds and nut/seed mixed dishes
• Fried white potatoes

Explanation: These foods do not necessarily have the most saturated fat.  If the list surprises you, recall that all food fats have some saturated fats.  These foods are leading sources because they contain some saturated fat and many Americans eat them.

It is surely no coincidence that these foods are also among the leading sources of calories in U.S. diets.  The health effects of diets, let me repeat, have to do with quantity as well as quality.

If you do not habitually eat most of the foods on this list, and are not gaining weight, saturated fatty acids are much less likely to be a problem for you.

And just because saturated fats raise the risk of heart disease does not mean they are poisons.   Eat fats.  Just not too much.

 

 

 

I went to the reception last week for Diet Coke’s red dress event,:

Diet Coke and the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health have joined forces to raise awareness about women’s risk of heart disease — in support of NHLBI’s The Heart Truth campaign — with a multi-faceted program that will reach consumers across the nation.

To celebrate American Heart Month in February, Diet Coke’s Red Dress Program will take center stage at high-profile events, including sponsorship of The Heart Truth’s, Red Dress Collection fashion show at Fashion Week 2008. Diet Coke will also unveil new packaging and programs featuring The Heart Truth and Red Dress logos and messages on heart health.

The Center for Science in the Public Interest points out that Coca-Cola, whose products are not exactly heart healthy, is a strange partner for the NHLBI.  The agency should reconsider.  It wrote NHLBI to say so.

New York Times reporter Tara Parker-Pope asks: “Should Coke talk about heart health?”

I don’t know how long Diet Coke and NHLBI have been engaged in this partnership but it is surely more than five years.  From NHLBI’s point of view, the partnership publicizes the risk of heart disease to women.  For Coca-Cola, the benefits are obvious.

Are such partnerships a benign win-win?  History suggests otherwise.  In 1984, Kellogg cooked up a partnership with the National Cancer Institute to put health claims for fiber on the boxes of All-Bran cereals (I discuss this incident in Food Politics).  In doing so, Kellogg (and NCI) went around the FDA and undermined that agency’s control over health claims on food packages.  This let to the current mess over health claims, which the FDA is now trying to clean up.

Update March 3: The Public Health Advocacy Institute at Northeastern University has filed a petition to NHLBI to give up the partnership.

I’ve just received the latest cancer statistics from CA–A Cancer Journal for Clinicians. The good news is that overall cancer death rates are down from their peak in the 1990s and rates of specific cancers are stable or decreasing.  None seems to be increasing.

Look at what is happening with heart disease (page 15).   Its rates have fallen by half since the mid-1970s for people under age 85.  Even for people over 85, heart disease death rates are falling rapidly.

Obesity is a risk factor for both cancer and heart disease.  So ideas about its effects on health need to take these statistics into consideration.  But before dismissing obesity as a risk factor, note that both heart disease and cancer remain leading causes of death, and both disproportionately affect low-income groups.   Groups with low income and education tend to have many risk factors for these diseases, among them high rates of obesity.

Public health still has plenty of work to do.