Saturday, July 31, 2010

Food Pyramids
Another good read from Mark.  I'd rather think about these pyramids than the new one the government published.  It's an improvement in many respects, but still scientifically indefensible.

Friday, July 30, 2010

Animals on Fructose

BLUF:  Fructose's role in the ancestral diet was to help us fatten up for the winter.  It did that by helping us to be insulin resistant, essentially setting up a metabolic balance which partitioned a larger percent of calories to storage.  Thus the prescription (courtesy  Eat meat and vegetables, nuts and seeds, some fruit little starch and no sugar.
"Studies in animals have documented that, compared with glucose, dietary fructose induces dyslipidemia and insulin resistance. To assess the relative effects of these dietary sugars during sustained consumption in humans, overweight and obese subjects consumed glucose- or fructose-sweetened beverages providing 25% of energy requirements for 10 weeks. Although both groups exhibited similar weight gain during the intervention, visceral adipose volume was significantly increased only in subjects consuming fructose. Fasting plasma triglyceride concentrations increased by approximately 10% during 10 weeks of glucose consumption but not after fructose consumption. In contrast, hepatic de novo lipogenesis (DNL) and the 23-hour postprandial triglyceride AUC were increased specifically during fructose consumption. Similarly, markers of altered lipid metabolism and lipoprotein remodeling, including fasting apoB, LDL, small dense LDL, oxidized LDL, and postprandial concentrations of remnant-like particle-triglyceride and -cholesterol significantly increased during fructose but not glucose consumption. In addition, fasting plasma glucose and insulin levels increased and insulin sensitivity decreased in subjects consuming fructose but not in those consuming glucose. These data suggest that dietary fructose specifically increases DNL, promotes dyslipidemia, decreases insulin sensitivity, and increases visceral adiposity in overweight/obese adults."

Thursday, July 29, 2010

Granny Smith 2
"Wheat elimination continues to yield explosive and unexpected health benefits. 
I initially asked patients in the office to eliminate wheat because I wanted to help them reduce blood sugar and pre-diabetic tendencies.
A patient would come to the office, for example, with a blood sugar of 118 mg/dl (in the pre-diabetic range) and the other phenomena of pre-diabetes or metabolic syndrome (high blood pressure, high inflammation/c-reactive protein, low HDL, high triglycerides, small LDL), and the characteristic wheat belly. Eliminate wheat and, within three months, they lose 30 lbs, blood sugar drops to normal, blood pressure drops, triglycerides drop by several hundred milligrams, HDL goes up, small LDL plummets, c-reactive protein drops.
People also felt better, with flat tummies and more energy. But they also developed benefits I did notanticipate:
--Improved rheumatoid arthritis--I have seen this time and time again. Eliminate wheat and the painful thumbs, fingers, and other joints clear up dramatically. Many former rheumatoid sufferers people tell me that one cracker or pretzel will trigger a painful throbbing reminder that lasts a couple of hours.
--Improved ulcerative colitis--People incapacitated with pain, cramping, and diarrhea of ulcerative colitis (who are negative for the antibodies for celiac disease) can experience marked improvement. I've seen people be able to stop all their nasty colitis medications just by eliminating wheat.
--Reduction or elimination of irritable bowel syndrome
--Reduction or elimination of gastroesophageal reflux
--Better mood--Eliminating wheat makes you happier and experience more stable moods. Just as wheat is responsible for a subset of schizophrenia and bipolar illness (this is fact), and wheat elimination generates dramatic improvement, when you or I eliminate wheat, we also experience a "smoothing" of mood swings.
--Better libido--I'm not sure whether this is a consequence of losing a belly the size of a watermelon or improvement in sex hormones (esp. testosterone) or endothelial responses, but more interest in sex typically develops.
--Better complexion--I'm not entirely sure why, but various rashes will often dissipate, bags under the eyes are reduced, itching in funny places stops.
It's also peculiar how, after someone eliminates wheat for several months, re-exposure of an errant cracker or sandwich results in cramping and diarrhea in about 30% of people.
Obviously, people with celiac disease, who can even die of exposure to wheat, are even worse. What other common food do you know of that makes us sick so often, even occasionally with fatal outcome?"

Wednesday, July 28, 2010

Granny Smith and Vitamin D
 "I was a little skeptical at first, having been disappointed by the failure of several nutritional agents like zinc, vitamin C (perhaps, at best, a minimal effect). Now, three years into my vitamin D experience, I am absolutely convinced that Dr. Cannells’ early observation was correct: Vitamin D enhances immunity enormously. Not only have I personally not had a virus in several years, the majority of my staff and patients have been happily free of viral infections. There have been a few, to be sure. But the usual winters of hacking, coughing, and sneezing in the office have become largely a memory. It is a rare person who comes to the office with viral symptoms.

With new lessons being learned every day, it is inevitable that other fascinating new vitamin D observations have yet to be made."

Tuesday, July 27, 2010

More On Omega 6 Fatty Acids

Interesting analysis by Dr. Sears.
"During the conference, his group presented more data on how excess omega-6 fatty acids double the production of endocannabinoids (the hormones that make you hungry). Furthermore, increasing the intake of omega-6 fatty acids from 1 percent of total calories (what it was in 1960 and apparently all the way back to 1900) to 8 percent of total calories (the current level in the American diet) causes massive genetic changes that result in greater obesity.
It should be noted that the American Heart Association recommends 5-10 percent of total calories should be omega-6 fats. Let’s put this into perspective. One percent of total calories represents about 20 calories or about 2 grams of omega-6 fatty acids. That’s the amount to fill about one-half teaspoon. Eight percent of the total calories (assuming a 2,000-calorie-per-day intake) represent 16 grams of omega-6 fatty acids. That’s the amount that would fill a tablespoon.
There it is. The difference between being lean and fat may be determined by a very small amount of the same fats being pushed by agribusiness and the American Heart Association. These fats are ubiquitous as they also represent the cheapest form of calories and are the foundation of American agribusiness.
The only good news from the conference is that if you take 2.5 grams of EPA and DHA per day, you can reduce the inflammatory damage done by the increase in omega-6 fatty acid consumption. So maybe our obesity epidemic started the day that mothers stopped giving their children a daily tablespoon of cod liver oil that would have contained 2.5 grams of EPA and DHA. "

Monday, July 26, 2010

"Wheat Hell"

Another "read the whole post"er.
"If we define hell on earth as constant, nagging pain and discomfort; energy depleted sufficient to impair daily function; chronic bloating and diarrhea; leg swelling, peculiar rashes; progression of a multitude of diseases ranging from annoying all the way to fatal . . . well, that’s a pretty bleak picture.

I have indeed witnessed it all. Inclusion of wheat products in the human diet in many (not all--I'd estimate 70% of people) yields devastating health effects. In a few, it shortens life. In the majority, it leads to a slow, miserable hell of inflammatory diseases like arthritis, coronary disease, and cancer.

I have also witnessed dramatic reversal of these phenomena with complete removal of wheat from the diet.

(For clarity, I am not only referring to gluten sensitivity, the immune reaction gone haywire that plagues people with celiac disease. Celiac disease is indeed another variety of wheat-induced hell on earth, but there’s far more to it than that.) "

Sunday, July 25, 2010

Have You Ever Met a Slender Dietician?
"Hospital dietitians are essentially forced to adhere to nutritional guidelines of "official" organizations, such as the American Heart Association and the USDA. There is some reason behind this. Imagine a rogue dietitian decides to advocate some crazy diet that yields dangerous effects, e.g., high-potassium diets in people with kidney disease. There is a role for oversite on the information any hospital staff member dispenses. 

The problem, of course, doesn't lie with the dietitian, but with the organizations drafting the guidelines. For years, the mantra of hospital diets was "low-fat." More recently, this dated message has begun--only begun--to falter, but now replaced with the "healthy, whole grain" mantra. And that is the advice the hapless dietitian follows herself, unwittingly indulging in foods that make us fat.

Sadly, the "healthy, whole grain" message also contributes to heart disease via drop in HDL, increased triglycerides, a huge surge in small LDL, rise in blood sugar, increased resistance to insulin, tummy fat, and diabetes. Yes, the diet provided to survivors of heart attack increases risk.

The "healthy, whole grain" message also enjoys apparent "validation" through the enormous proliferation of commercial products cleverly disguised as healthy: Cheerios, Raisin Bran, whole grain bread, whole wheat pasta, etc. The "healthy, whole grain" message, while a health disaster, is undoubtedly a commercial success.

I'll bet that our fat dietitian friend enjoys a breakfast of healthy, whole grains in skim milk, followed by a lunch of low-fat chicken breast on two slices of whole grain bread, and ends her day with a healthy meal of whole wheat pasta. She then ascribes her continually climbing weight and size 16 figure to slow metabolism, lack of exercise, or the once-a-week piece of chocolate. "

Saturday, July 24, 2010

WOD 22 Jul

3RM Shoulder Press

Cash out:  10 minutes of row/bike/run/etc.  30 seconds, as hard as you can go, 30 seconds recover.

Post results to comments.

Wheat - It's a Mental

Read the whole post - well worth it.
Dr. Christine Zioudrou and colleagues at the National Institutes of Mental Health got this conversation going back in 1979 with their paper, Opioid peptides derived from food proteins: The exorphins.
Exorphins are exogenously-derived peptides (i.e., short amino acid sequences obtained from outside the body) that exert morphine-like properties. Mimicking the digestive process that occurs in the gastrointestinal tract using the gastric enzyme, pepsin, and hydrochloric acid (stomach acid), Zioudrou et al isolated peptides from wheat gluten with morphine-like activity. They followed this research path because of the apparent association of wheat and mental illness.
In the bioassays used, wheat-derived exorphins competed successfully with the endogenous opiate, met-enkephalin. Interestingly, casein-derived (i.e., casein milk protein) exorphins were also identified that also displayed opiate-binding activity, though less powerfully. The morphine-like activity was also blocked by the drug, naloxone (the same stuff given to people exposed to morphine overdose).
Among the many devastating effects of celiac disease , the immune disease that develops from wheat gluten exposure, are mental and emotional effects, such as anxiety, fatigue, mental "fog," depression, bipolar illness, and schizophrenia, that disappear with removal of gluten. Many parents of autistic children also advocate wheat-free diets for similar reasons. 

Friday, July 23, 2010

Wheat - Top to Bottom
This will take you to a list of Dr. Davis' posts on wheat. I would consider this required reading for anyone sorting out what to eat or what not to eat.
In each post, you might consider this query: What can I do to validate the perspective Dr. Davis presents?
In most cases, the answer is you could evaluate changes in your fasting lipid profile, your post-prandial blood sugars, your abdominal fat, and or your weight. In other words, MOST of what he's saying can be evaluated if you follow his recommendations - complete elimination of wheat from your diet - for a month.
That's an exceeding cheap and easy way to make a significant impact on your health.

Thursday, July 22, 2010

Heart Scan on Oatmeal

This is why Dr. Davis' method is so powerful.  He measures the result of his patients' actions to find out what really happens - which is far better than just speculating on results based on this or that study.  This is how medicine should be done!
"You've heard it before: oatmeal reduces cholesterol. Oatmeal producers have obtained permission from the FDA to use a cholesterol-reducing claim. The American Heart Association provides a (paid) endorsement of Quaker Oats.
I've lost count of the times I've asked someone whether they ate a healthy breakfast and the answer was "Sure. I had oatmeal."
Is this true? Is oatmeal heart healthy because it reduces LDL cholesterol?
I don't think so. Try this: Have a serving of slow-cooked (e.g., steel-cut, Irish, etc.) oatmeal. Most people will consume oatmeal with skim or 1% milk and some dried or fresh fruit. Wait an hour, then check your blood sugar.
If you are not diabetic and have a fasting blood sugar in the "normal" range (~100 mg/dl), you will typically have a 1-hour blood glucose of 150-180 mg/dl--very high. If you have mildly increased fasting blood sugars between 100 and 126 mg/dl, postprandial (after-eating) blood sugars will easily exceed 180 mg/dl. If you have diabetes, hold onto your hat because, even if you take medications, blood sugar one hour after oatmeal will usually be between 200 and 300 mg/dl.
This is because oatmeal is converted rapidly to sugar, and a lot of it. Even if you were to repeat the experiment with no dried or fresh fruit, you will still witness high blood sugars in these ranges. Do like some people and pile on the raisins, dried cranberries, or brown sugar, and you will see blood sugars go even higher.
Blood sugars this high, experienced repetitively, will damage the delicate insulin-producing beta cells of your pancreas (glucose toxicity). It also glycates proteins of the eyes and vascular walls. The blood glucose effects of oatmeal really don't differ much from a large Snickers bar or bowl of jelly beans.
If you are like most people, you too will show high blood sugars after oatmeal. It's easy to find out . . . check your postprandial blood sugar.
...I now no longer recommend any oat product due to its blood sugar-increasing effects.
Better choices: eggs, ground flaxseed as a hot cereal, cheese (the one dairy product that does not excessively trigger insulin), raw nuts, salads, leftovers from last evening's dinner."

Wednesday, July 21, 2010

Think You Are Low Carb, Or Know It?

More from this magnificent blog:

"I last discussed the concept of postprandial glucose checks in To get low-carb right, you need to check blood sugars.
Here are some important lessons that many people--NON-diabetic people, most with normal blood glucoses or just mildly increased--are learning:
Oatmeal yields high blood sugars. Even if your fasting blood sugar is 90 mg/dl, a bowl of oatmeal with skim milk, walnuts, and some berries will yield blood sugars of 150-200 mg/dl in many people.
Cheerios yields shocking blood sugars. 200+ mg/dl is not uncommon in non-diabetics. (Diabetics have 250-350 mg/dl.)
Fruits like apples and bananas increase blood sugar to 130 mg/dl or higher.
Odd symptoms, such as mental "fog," fatigue, and a fullness in the head, are often attributable to high blood sugars.
A subset of people with lipoprotein(a) can have wildly increased blood sugars despite their slender build and high aerobic exercise habits.
Once you identify the high blood sugar problem, you can do something about it. The best place to start is to reduce or eliminate the sugar-provoking food."

Tuesday, July 20, 2010

Want Less

Interesting book on sustainability.  I think present methods of agriculture are in fact unsustainable, even if we don't run out of oil.  I think some of the problem may be prevented if salt tolerant crops are developed - salinization is inevitable with irrigation.  Strangely, we can only grow enough food to feed us all by using oil to make fertilizer, and using that to produce corn and soy beans.  This generates about 85% of the calories we make.  Our lives depend on this production by 'industrial agriculture.'  At the same time, the government's intervention into this industrial model creates many negative eventualities which distort the markets which drive the industry.  This is why we grow so much food that is essentially toxic to the human body.  And yet, you can provide the calories necessary to keep a poor person alive for a lower cost (at the point of sale - this cost analysis goes south when you consider the environmental impact, the higher taxes that sustain the industry, etc) than at any other time in history.

I don't know how humankind will stumble across the solution to all of this, but doubt that this author's suggestion will get us through.
"More food but also disease, craziness, and anomie resulted from the agricultural revolution, according to this diffuse meditation on progress and its discontents. Wells (The Journey of Man), a geneticist, anthropologist, and National Geographic Society explorer-in-residence, voices misgivings about the breakthrough to farming 10,000 years ago, spurred by climate change. The food supply was more stable, but caused populations to explode; epidemics flourished because of overcrowding and proximity to farm animals; despotic governments emerged to organize agricultural production; and warfare erupted over farming settlements. Then came urbanism and modernity, which clashed even more intensely with our nomadic hunter-gatherer nature. Nowadays, Wells contends, we are both stultified and overstimulated, cut off from the land and alienated from one other, resulting in mental illness and violent fundamentalism. Wells gives readers an engaging rundown of the science that reconstructs the prehistoric past, but he loses focus in trying to connect that past to every contemporary issue from obesity to global warming, and his solution is unconvincingly simple: Want less."

Monday, July 19, 2010

Vitamin D Toxicity

First thing I've found that analyzes the toxicity risk with this kind of specificity.

Any benefit of vitamin D needs to be balanced against the risk of toxicity, which is characterized by hypercalcemia. Daily brief, suberythemal exposure of a substantial area of the skin to ultraviolet light, climate allowing, provides adults with a safe, physiologic amount of vitamin D, equivalent to an oral intake of about 10,000 IU vitamin D(3) per day, with the plasma 25-hydroxyvitamin D (25(OH)D) concentration potentially reaching 220 nmol/L (88 ng/mL). The incremental consumption of 40 IU/d of vitamin D(3) raises plasma 25(OH)D by about 1 nmol/L (0.4 ng/mL). High doses of vitamin D may cause hypercalcemia once the 25(OH)D concentration is well above the top of the physiologic range. The physiological buffer for vitamin D safety is the capacity of plasma vitamin D-binding protein to bind the total of circulating 25(OH)D, vitamin D, and 1,25-dihydroxyvitamin D [1,25(OH)2D]. Hypercalcemia occurs when the free concentration is inappropriately high because vitamin D and its other metabolites have displaced 1,25(OH)2D from vitamin D-binding protein. Evidence from clinical trials shows, with a wide margin of confidence, that a prolonged intake of 10,000 IU/d of vitamin D(3) poses no risk of adverse effects for adults, even if this is added to a rather high physiologic background level of vitamin D.

Sunday, July 18, 2010

A "Prescription" Alternative to Statins

This is powerful medicine.  All the side effects are GOOD!
"In the world of conventional healthcare, in which you are instructed to follow a diet that increases risk for heart disease and not advised to correct nutrient deficiencies like vitamin D and omega-3 fatty acids, then a drug like Lipitor may indeed provide benefit.
But when you are provided genuinely effective information on diet, along with correction of nutrient deficiencies, then the "need" and apparent benefits of Lipitor largely dissolve. While there are occasional genetic anomalies that can improve with use of Lipitor and other statins, many, perhaps most, people taking these drugs really would not have to if they were just provided the right information."
Dr. Davis' Rx:
-eliminate wheat and sugar
-supplement vitamin D, measuring the result to achieve the right level
-measure and regulate iodine/thyroid function
Compare that prescription to the cost of a $3/day drug (typical statin cost), and consider the former has no negative 'side effects' (the main side effects are you lose weight and feel better), whereas statin side effects are significant. I am not the person to say whether you should or should not use statins, of course, as legally and morally, that's the realm of a board approved medical doctor. But it doesn't take an MD to figure out that the first prescription is superior and should be pursued prior to considering other interventions."

Saturday, July 17, 2010

Carbs Equal Small Dense LDL
"Measuring the number of small LDL particles is the best index of carbohydrate intake I know of, better than even blood sugar and triglycerides.
In other words, increase carbohydrate intake and small LDL particles increase. Decrease carbohydrates and small LDL particles decrease.
Carbohydrates increase small LDL via a multistep process:
First step: Increased fatty acid and apoprotein B production in the liver, which leads to increased VLDL production. (Apoprotein B is the principal protein of VLDL and LDL)
Second step: Greater VLDL availability causes triglyceride-rich VLDL to interact with other particles, namely LDL and HDL, enriching them in triglycerides (via the action of cholesteryl-ester transfer protein, or CETP). Much VLDL is converted to LDL.
Third step: Triglyceride-rich LDL is "remodeled" by enzymes like hepatic lipase, which create small LDL.
Carbohydrates, especially if they contain fructose, also prolong the period of time that triglyceride-rich VLDL particles persist in the blood, allowing more time for VLDL to interact with LDL.
Many people are confused by this. "You mean to tell me that reducing carbohydrates reduces LDL cholesterol?" Yes, absolutely. ""

Friday, July 16, 2010

Attacking Small Dense LDL

Dr. Davis does awesome work.

"Lee had suffered a stroke due to an atherosclerotic plaque in a brain artery. She also had plenty of coronary plaque with a heart scan score of 322.

Lee began with an LDL particle number (the "gold standard" for measuring LDL, far superior to conventional calculated LDL) of 2234 nmol/L. This is exceptionally high, the equivalent of an LDL cholesterol of 223 mg/dl (drop the last digit). Of this 2234 nmol/L, 90% were abnormally small, with 1998 nmol/L of small LDL particles.

Lee eliminated wheat products from her diet, as well as cutting out sugars and cornstarch. Six months later, her results:

LDL particle number: 1082 nmol/L--a 52% reduction from the starting value and equivalent to an LDL of 108 mg/dl. Small LDL: zero--yes, zero. "

Thursday, July 15, 2010

Robb Wolf

I did not start listening when Robb started his podcast last year, but I've downloaded every episode to my iTouch and most commuting time is spent processing all the info he offers (FOR FREE!) in those podcasts.  Now that his book is available on Amazon, I look forward to devouring a copy on my Kindle.  I have found his mix of big brain biochem being related to the tales he tells well of his trials and errors applying what he knows to clients has expanded what I know significantly. 

What interests me most is being able to hold a full contstruct of 'some thing' in my head, and relate it to others in a coherent fashion.  In other words, knowing this fact or that fact is nice, but it's twice as nice if I can associate that fact to other facts in a conceptually congruent way.  Robb has also pursued that end, at least, it seems that way to me.  I'll be very interested to see how he's pulled together and organized what he knows via this book.  I think it will be a potent tool for those seeking a deeper knowledge of how to eat for health and performance.

Just as significantly, Robb does a nice job in helping to cut through all the crap that's out there.  It's as much about learning what to eat as it is about learning how to see through the marketing and hype in the food industry so you don't waste your money and time on unneeded foods and supplements.

WOD Thursday 15 July

Buy in: 4x50m sprint

Deadlift, heaviest set of 3 with solid technique

Post results to comments

Profile: CrossFit Endurance

"Gone are the days of two-plus hour runs or six hour block sessions. With this program you can safely train for an Ironman or ultra marathon on less than eight hours a week, so imagine what you can do if all you want to do is a marathon or less. All you have to be willing to give is, well, everything you’ve got for the Workout of the Day (WOD) for four (to no more than six) days a week. You will be taxed, you will be sore, but also true to CrossFit form, you will reduce the chances for over use injuries and burnout, and you will see measurable results fast."

Wednesday, July 14, 2010

WOD Wednesday, 14 July

Perform the maximum number of burpees (defined as dropping entire body to the deck, then stand and jump with a clap overhead) as possible in 15 minutes.  Challenge: for the first five minutes, execute your goal number of burpees as fast as possible, recover for the remainder of the minute, repeat after 60s.  Example, if the goal is 150 burpees in 15 minutes, start with 10 burpees executed at fastest possible speed, rest until 60s is complete, repeat for a total of five rounds of "burping speed".

Lipoprotein Lesson

From Dr. Davis at

Why haven't you heard about lipoprotein(a)?

Lipoprotein(a), or Lp(a), is the combined product of a low-density lipoprotein (LDL) particle joined with the liver-produced protein, apoprotein(a).
Apoprotein(a)'s characteristics are genetically-determined: If your Mom gave the gene to you, you will have the same type of apoprotein(a) as she did. You will also share her risk for heart disease and stroke.
When apoprotein(a) joins with LDL, the combined Lp(a) particle is among the most aggressive known causes for coronary and carotid plaque. If apoprotein(a) joins with a small LDL, the Lp(a) particle that results is especially aggressive. This is the pattern I see, for instance, in people who have heart attacks or have high heart scan scores in their 40s or 50s.
Lp(a) is not rare. Estimates of incidence vary from population to population. In the population I see, who often come to me because they have positive heart scan scores or existing coronary disease (in other words, a "skewed" or "selected" population), approximately 30% express substantial blood levels of Lp(a).
Then why haven't you heard about Lp(a)? If it is an aggressive, perhaps the MOST aggressive known cause for heart disease and stroke, why isn't Lp(a)featured in news reports, Oprah, or The Health Channel?
Easy: Because the treatments are nutritional and inexpensive.
The expression of Lp(a), despite being a genetically-programmed characteristic, can be modified; it can be reduced. In fact, of the five people who have reduced their coronary calcium (heart scan) score the most in the Track Your Plaque program, four have Lp(a). While sometimes difficult to gain control over, people with Lp(a) represent some of the biggest success stories in the Track Your Plaque program.
Treatments for Lp(a) include (in order of my current preference):
1) High-dose fish oil--We currently use 6000 mg EPA + DHA per day
2) Niacin
4) Thyroid normalization--especially T3
Hormonal strategies beyond DHEA can exert a small Lp(a)-reducing effect: testosterone for men, estrogens (human, no horse!) for women.
In other words, there is no high-ticket pharmaceutical treatment for Lp(a). All the treatments are either nutritional, like high-dose fish oil, or low-cost generic drugs, like liothyronine (T3) or Armour thyroid.
That is the sad state of affairs in healthcare today: If there is no money to be made by the pharmaceutical industry, then there are no sexy sales representatives to promote a new drug to the gullible practicing physician. Because most education for physicians is provided by the drug industry today, no drug marketing means no awareness of this aggressive cause for heart disease and stroke called Lp(a). (When a drug manufacturer finally releases a prescription agent effective for reducing Lp(a), such as eprotirome, then you'll see TV ads, magazine stories, and TV talk show discussions about the importance of Lp(a). That's how the world works.)
Now you know better.

Tuesday, July 13, 2010

Cordain, More

Robert Crayhon: Did we move from a hunter-gatherer lifestyle by choice, or were we forced into the shift due to animal extinction?
Loren Cordain: If we examine the fossil record, it suggests that a number of environmental pressures may have forced humans to adopt agriculture, including increases in human population densities and the depletion of easily hunted game. The extinction of large mammals all over Northern Europe, Asia, and North America coincide with the adoption of agriculture.
It is quite likely that pre-agricultural man had sufficient knowledge of his environment to know the life cycle of plants, to be able to sow seeds and grow plants. However, ecologically, it was not necessary, nor energetically efficient to do so when human population numbers were low and game was plentiful. Although agriculture is a vast science and can encompass numerous disciplines, early agriculture essentially involved the domestication, growing and harvesting of cereal grains.
Robert Crayhon: Is there enough evidence to suggest that a diet that includes a large amount of grains is a step down nutritionally, and one that is far from optimal for humans? And how much of the prehistoric diet was animal, and how much was vegetable?
Loren Cordain: The fossil evidence as well as the ethnographic evidence from groups of hunter-gatherers studied in historical times suggests that the diet of pre-agricultural humans was derived primarily from animal based foods.
It is difficult to quantitatively determine from the fossil record the proportion of plant to animal food that was included in the diet of prehistoric humans. However, we do know that hunting of game was an important part of all pre-agricultural societies. Most prehistoric humans followed large game herds, and manufactured tools and weapons which were used to regularly kill and butcher these animals.
Ethnographic studies of living hunter-gatherer societies represent the best surrogate we have for estimating quantitatively the plant to animal subsistence ratios of stone-age humans. We have recently compiled ethnographic data from 181 worldwide societies of hunter-gatherers showing that the mean plant to animal subsistence ratio in terms of energy was 35% plant and 65% animal.
Thus, the fossil and ethnographic data suggests that humans evolved on a diet that was primarily animal based and consequently low to moderate in carbohydrate, high in protein and low to moderate in fat. This is in contrast to the low fat, high carbohydrate, plant based diet which is almost universally recommended by modern day nutritionists.
Clearly, humans can adapt to many types of diets involving multiple macronutrient combinations with varying amounts of fat, protein and carbohydrate. However, our genetic constitutions, including our nutritional requirements were established in the remote past over eons of evolutionary experience.
Human health and well being can be optimized when we use the evolutionary paradigm as the starting point for present day nutrition. 
Obviously, humans have had little evolutionary experience with the modern high carbohydrate, high fat, cereal based diet which is omnipresent in western, industrialized countries, and there is considerable evidence to suggest that these types of diets have the potential for creating health problems in some, but not all people.

Monday, July 12, 2010

Mercola with Cordain

"Further, the USDA food pyramid places breads, cereals, rice and pasta at its base and recommends that we consume 6-11 servings of these items daily. Nutritionists at the Harvard School of Public Health (Willett WC. The dietary pyramid: does the foundation need repair? Am J Clin Nutr. 1998;68: 218-219) have recently publicly criticized this recommendation.
It fails to distinguish between refined and complex carbohydrates and their relative glycemic responses. Dr. Willett further pointed out that there was little empirical evidence to support the dominant nutritional message that diets high in complex carbohydrate promote good health.
Both the fossil record and ethnological studies of hunter-gatherers (the closest surrogates we have to stone age humans) indicate that humans rarely if ever ate cereal grains nor did they eat diets high in carbohydrates.
Because cereal grains are virtually indigestible by the human gastrointestinal tract without milling (grinding) and cooking, the appearance of grinding stones in the fossil record generally heralds the inclusion of grains in the diet.
The first appearance of milling stones was in the Middle East roughly 10-15,000 years ago. 
These early milling stones were likely used to grind wild wheat which grew naturally in certain areas of the Middle East. Wheat was first domesticated in the Middle East about 10,000 years ago and slowly spread to Europe by about 5,000 years ago. Rice was domesticated approximately 7,000 years ago in SE Asia, India and China, and maize (corn) was domesticated in Mexico and Central America roughly 7,000 years ago.
Consequently, diets high in carbohydrate derived from cereal grains were not part of the human evolutionary experience until only quite recent times.
Because the human genome has changed relatively little in the past 40,000 years since the appearance of behaviorally modern humans, our nutritional requirements remain almost identical to those requirements which were originally selected for stone age humans living before the advent of agriculture.
Robert Crayhon: What happened to our health when we switched from a hunter-gatherer diet to a grain-based one?
Loren Cordain: The fossil record indicates that early farmers, compared to their hunter-gatherer predecessors had a characteristic reduction in stature, an increase in infant mortality, a reduction in life span, an increased incidence of infectious diseases, an increase in iron deficiency anemia, an increased incidence of osteomalacia, porotic hyperostosis and other bone mineral disorders and an increase in the number of dental caries and enamel defects.
Early agriculture did not bring about increases in health, but rather the opposite. It has only been in the past 100 years or so with the advent of high tech, mechanized farming and animal husbandry that the trend has changed. "

Sunday, July 11, 2010

More China DeBunking

China fiction?

I found the link that follows via Dr. Davis' post (see above).

I'm looking forward to digging in to this lady's posts.  The China Study claims to stand in contrast to the carbohydrate hypothesis, but the more one looks the study and the book Dr. Campbell produced from the study, the less water it seems to hold.

One Look At Statin Cost Benefit, Part 4

"The full report looks at both primary prevention against heart disease in men and women under the age of 65 and over the age of 65. And it looks at secondary prevention for men and women who already have heart disease. (Primary prevention is prevention against the development of heart disease in the first place; secondary prevention is prevention against having a heart attack in someone who already has heart disease.)
This post has dragged on long enough, so I’m going to briefly summarize the findings.
In men under 65 with no known heart disease but with risk factors, i.e. LDL of 130 mg/dL or greater, the studies cited showed no difference in all cause mortality. For those men under 65 who had very high LDL levels, the evidence showed that these men might have a slight benefit from taking a statin, but nothing to write home about. Certainly nothing that would justify putting a third of the population on statins.
In women who are under 65 there is virtually no evidence that statins do squat. In fact, the report doesn’t even produce evidence that cholesterol lowering does anything for women. The report states that it bases its rationale for treatment of women on an extrapolation of data from men.
In men and women over 65 the studies cited show no evidence that cholesterol lowering brings about any significant decrease in risk for heart disease. (Remember the 34% of subjects, average age 66.9, in the control group of the PD study mentioned at the start of this post who were on statins. According to the papers cited in this full report, none of those subjects could expect a decreased risk for CHD by taking the statins, but based on this report’s false reporting of the conclusions of these papers, a third of these folks are on statins.)
Men of all ages with diagnosed heart disease were the only group that the studies used in this report show receive an actual benefit from taking statins. And even that is slight.
Women who have heart disease and who take statins have a reduced death rate from heart disease but no decrease in all-cause mortality.
So there you have it. The giant report that, thanks to the executive summary, has driven most physicians in America to prescribe statins to practically everyone who walks through the door shows, when the data is examined, that statins are only really indicated in men who already have heart disease. They don’t do much for anyone else but put them at risk for a host of other problems while running health care costs through the roof for the rest of us.
Who could possibly benefit from this situation? How about the underwriters of the whole scheme: the drug companies and the ‘experts’ on their payroll.
We’ve got a situation where ‘experts’ paid by the drug companies write an executive summary about a report written by ‘experts’ paid by the drug companies, a report that misinterprets (purposefully?) the underlying data to make the case that the drugs made by the drug companies paying the ‘experts’ are under prescribed. Others jump on the bandwagon, making pronouncements, based on this faulty reporting, that almost everyone should be taking these drugs made by the drug companies that underwrote the entire enterprise. One buffoon, cloaked in all the trappings of academia, even made the comment that since statins are so wonderful perhaps they should be added to the drinking water. As a consequence, we’re paying billions of dollars for drugs that don’t particularly work and that cause a number of pretty bad side effects to prevent a disease that can be prevented by fairly simple lifestyle changes. Pitiful.
Is it any wonder that Dr. Weissberg got his panties in a wad when he thought a study might persuade people not to take statins. Based on what you know now, go back and read his comments to the BBC. And get mad."

Saturday, July 10, 2010

One Look At Statin Cost Benefit, Part 3

"The executive summary is 12 pages long and was published in JAMA, which is sent to every physician in America free of charge. The real report is 284 pages long and has to be pulled down from online or ordered from the government. (If you go to the website referenced in the executive summary to get the full report, you are sent here. See how much time it takes you to find it) Which of the two do you think most physicians read? Why should they read the full report when the prestigious authors of the executive summary assure them that
The full ATP III document is an evidence-based and extensively referenced report that provides the scientific rationale for the recommendations contained in the executive summary.
That says it all. According to the executive summary, the full report is like Fox News purports to be: fair and balanced. And the executive summary is then a fair and balanced report of a fair and balanced report.
What do we find when we read the full 284 page report (which you can get here)?
We find that the full report presents a totally biased misrepresentation of the underlying scientific material and seems intent on promoting the use of statin drugs despite any evidence to the contrary. Not the “evidence-based and extensively referenced report that provides the scientific rationale” for statin therapy that the executive report would have us believe.
Before we get into some of the specifics of this full report, let’s recall that the Framingham data, the Queen Mother of all dietary cholesterol studies, didn’t show a correlation between diet and cholesterol, cholesterol and heart disease, nor diet and heart disease. And we need to remember that, despite all the hoopla about statins and lowering cholesterol levels, that cholesterol is an extremely important molecule. The brain is rich in cholesterol, the sex hormones are made on a cholesterol structure, and even vitamin D is built on cholesterol. Consequently, statin drug use has been associated with decreased cognitive ability and sexual dysfunction. Statins can cause liver damage and the breakdown of muscle tissue, both of which can lead to death. In my opinion, these drugs would have to lead to huge reductions in risk for death from all causes to overcome the risk one accepts by taking them.
Let’s digress for a moment and discuss all-cause mortality. Let’s say we’ve got a drug that studies show decreases the risk of death from heart disease by 50%. Let’s say that the only half the subjects in study who are taking that drug die of heart disease as compared to those subjects in the control group. At first blush, it appears that we’ve got a great drug on our hands. But, what if the same number of subjects die in both groups? The study group has way fewer deaths from heart disease but has a lot more deaths from cancer so that the total number of deaths in both groups is the same. This would mean that the people taking the drug traded their decreased risk for death from heart disease for an increased risk for death from cancer. The all-cause mortality didn’t change. All that changed was the cause of death. If we had a drug that brought about the 50% decrease in heart disease deaths in the study group and no increased death from other causes, giving a big decrease in all-cause mortality, then we have something."

Friday, July 9, 2010

One Look At Statin Cost Benefit, Part 2

"So, why should we as a society spend over $100,000 per year to prevent one self inflicted death from heart disease? And remember, that figure is only good if we prevent every single death from heart disease. What if we only prevent half? Then the price goes up to $200,000 per year per death prevented. What if we only prevent 25% of deaths, then the price goes to $400,000. It would be nice to know how many deaths we prevent if we give a third of the population statins. Let’s take a look.
We can look in a couple of places. First we can look in the executive summary of the full 2001 report. This 12 page summary, published in the May 16, 2001 issue of Journal of the American Medical Association (JAMA), gets right to the point. The recommendations of the full report
expands the indications for intensive cholesterol-lowering therapy in clinical practice.
In other words, the recommendations increase the number of people and conditions that need statin-driven cholesterol-lowering therapy. As you go through this executive summary it becomes clear that the authorities believe that cholesterol-lowering is extremely important in both the primary and secondary prevention of CHD and that statins are the way to lower cholesterol.
Who wrote this executive summary? A long list of esteemed experts in the field of cholesterol study. Do they have any conflicts of interest? Let’s take a look. Here is the list of members on the panel that produced the summary:
Scott M. Grundy, MD, PhD (Chair of the panel), Diane Becker, RN, MPH, ScD, Luther T. Clark, MD, Richard S. Cooper, MD, Margo A. Denke, MD, Wm. James Howard, MD, Donald B. Hunninghake, MD, D. Roger Illingworth, MD, PhD, Russell V. Luepker, MD, MS, Patrick McBride, MD, MPH, James M. McKenney, PharmD, Richard C. Pasternak, MD, Neil J. Stone, MD, Linda Van Horn, PhD, RD
Here is the financial disclosure:
Dr Grundy has received honoraria from Merck, Pfizer, Sankyo, Bayer, and Bristol-Myers Squibb. Dr Hunninghake has current grants from Merck, Pfizer, Kos Pharmaceuticals, Schering Plough, Wyeth Ayerst, Sankyo, Bayer, AstraZeneca, Bristol-Myers Squibb, and G. D. Searle; he has also received consulting honoraria from Merck, Pfizer, Kos Pharmaceuticals, Sankyo, AstraZeneca, and Bayer. Dr McBride has received grants and/or research support from Pfizer, Merck, Parke-Davis, and AstraZeneca; has served as a consultant for Kos Pharmaceuticals, Abbott, and Merck; and has received honoraria from Abbott, Bristol-Myers Squibb, Novartis, Merck, Kos Pharmaceuticals, Parke-Davis, Pfizer, and DuPont. Dr Pasternak has served as a consultant for and received honoraria from Merck, Pfizer, and Kos Pharmaceuticals, and has received grants from Merck and Pfizer. Dr Stone has served as a consultant and/or received honoraria for lectures from Abbott, Bayer, Bristol-Myers Squibb, Kos Pharmaceuticals, Merck, Novartis, Parke-Davis/Pfizer, and Sankyo.Dr Schwartz has served as a consultant for and/or conducted research funded by Bristol-Myers Squibb, AstraZeneca, Merck, Johnson & Johnson-Merck, and Pfizer. [My bold type]
So, you’ve got about half the panel – including the Chair – who are, like so much lint, buried deep in the pockets of the pharmaceutical companies that make statin drugs. Do you think these folks might have a motivation to promote the products of the companies that are paying them a lot of money?
But, you say, these people are only summarizing the contents of the real report as an executive summary. They don’t have any say in the data that the report contains. True, but this is where the plot thickens."

Thursday, July 8, 2010

WOD Thursday 8 July

Back squat (low bar, to a 12-14 inch box), 5 rep sets to new 5 rep PR.

Press, 5 rep sets to 5 rep PR

Post results to comments

One Look At Statin Cost Benefit

"In 2001 probably the most momentous publication in medical history occurred. It was momentous not because it was of astounding importance like Einstein’s four papers in 1905, but momentous because it has ended up affecting so many people. The document is the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, produced as part of the National Cholesterol Education Program. The goal of these guidelines is to markedly decrease the incidence of coronary heart disease (CHD). How is this goal to be accomplished? First, by a regimen of low-fat dieting combined with exercise. But if this regimen should fail to lower LDL levels to below 130 mg/dL (more than half of adults over age 35 have LDL levels of 130 mg/dL or higher), then the guidelines recommend treatment with statin drugs to prevent CHD. Readers of this blog know how great the chances are of a low-fat, high-carb diet lowering the LDL to sub 130 mg/dL levels, so these recommendations are tantamount to recommending the use of statins to more than 50% of adults over the age of 35.
I don’t know the exact number of people over age 35 in the United States right now, but I think it would be safe to say that there are at least 100 million. Half that number is 50 million, which would represent the population of adults over 35 with LDL levels of 130 mg/dL or greater. Now, let’s make a big assumption and say that a third of that 50 million can lower their LDL levels with a combination of diet and exercise (highly unlikely, but lets say it just for grins), that leaves us with about 34 million people who–according to the recommendations–should go on statin drugs. Statin drugs cost, depending upon the brand, somewhere between $2.66 and $4.86 a day, so let’s average it out to $3.75 per day. If we multiply $3.75 per day times 365 days per year times 34 million people we end up with $46.537 billion per year, a tidy little sum that will find it’s way into the pockets of Big Pharma should these recommendations be carried out. (Of interest is the fact that in the paper on low LDL and PD that started this post, the average age of the control subjects was 66.7 and 34% of them were taking statins, so the numbers I’m postulating on numbers of people taking statins are pretty much right on the money.)
If you divide this $46+ billion by 453,189 (the number of people who died from CHD in 2004 from the last available statistics) you come up with a cost of $101,923, which would be the cost per year per person saved by statin drugs if those drugs could somehow prevent every single death from CHD. Now multiply this $101,923 times the number of years the average person would have to take these drugs to prevent death, and you come up with some hefty figures. Probably well over a million dollars per person saved. Is it worth it to society to pay that much? Remember, we all pay for this either directly if we take statins or through increased insurance premiums because of others who do. And we really have to ask that question because most of the deaths from heart disease are self inflicted.
Why self inflicted? Because by far the major cause of CHD is smoking with high blood pressure running a close second. I’ve thought back on all the people I know who have had heart attacks and on all the patients I’ve cared for who have had heart attacks, and all of them – 100% – were smokers. I’ve called a couple of colleagues and asked the same question and have gotten the same answer: people who have never smoked and who have heart attacks are scarce as hens teeth. They exist, to be sure, but they are in the minority. Think back about the people you know who have had heart attacks, and I suspect you will realize the same thing. There is a correlation for you. Smoking equals heart disease. Not cholesterol equals heart disease. Michael DeBakey, the Houston heart surgeon who pioneered bypass surgery,once famously remarked that at least half the patients he operated on had low cholesterol levels."

Wednesday, July 7, 2010

Wheatless Tour (de France)

Not sure how this team is doing, but it's a good read and good advice anyway.
"Besides people who suffer from wheat allergies and celiac disease — an autoimmune condition triggered by exposure to gluten that affects about one in 133 Americans, causing everything from diarrhea to fatigue — doctors and nutritionists frequently see patients who simply feel healthier and more energetic when they’re eating wheat-free."

Do Statins Work?

"The appearance of conflict of interest is "very important to organizations like ours, and we are all taking it seriously," responds NIH official and NCEP coordinator Dr. James I. Cleeman. "But the facts of the science were entirely correct.""
More excerpts follow:

"Martin Winn's cholesterol level was inching up. Cycling up hills, he felt chest pain that might have been angina. So he and his doctor decided he should be on a cholesterol-lowering medication called a statin. Statins certainly performed as they should for Winn, dropping his cholesterol level by 20%. "I assumed I'd get a longer life," says the retired machinist in Vancouver, B.C., now 71. But here the story takes a twist. Winn's doctor, James M. Wright, is no ordinary family physician. A professor at the University of British Columbia, he is also director of the government-funded Therapeutics Initiative, whose purpose is to pore over the data on particular drugs and figure out how well they work. Just as Winn started on his treatment, Wright's team was analyzing evidence from years of trials with statins and not liking what it found.
"Yes, Wright saw, the drugs can be life-saving in patients who already have suffered heart attacks, somewhat reducing the chances of a recurrence that could lead to an early death. But Wright had a surprise when he looked at the data for the majority of patients, like Winn, who don't have heart disease. He found no benefit in people over the age of 65, no matter how much their cholesterol declines, and no benefit in women of any age. He did see a small reduction in the number of heart attacks for middle-aged men taking statins in clinical trials. But even for these men, there was no overall reduction in total deaths or illnesses requiring hospitalization—despite big reductions in "bad" cholesterol. "Most people are taking something with no chance of benefit and a risk of harm," says Wright. Based on the evidence, and the fact that Winn didn't actually have angina, Wright changed his mind about treating him with statins—and Winn, too, was persuaded. "Because there's no apparent benefit," he says, "I don't take them anymore."
"A current TV and newspaper campaign by Pfizer, for instance, stars artificial heart inventor and Lipitor user Dr. Robert Jarvik. The printed ad proclaims that "Lipitor reduces the risk of heart attack by patients with multiple risk factors for heart disease.""
"For one thing, many researchers harbor doubts about the need to drive down cholesterol levels in the first place. Those doubts were strengthened on Jan. 14, when Merck and Schering-Plough (SGP) revealed results of a trial in which one popular cholesterol-lowering drug, a statin, was fortified by another, Zetia, which operates by a different mechanism. The combination did succeed in forcing down patients' cholesterol further than with just the statin alone. But even with two years of treatment, the further reductions brought no health benefit."
____________________________________________________________________________ "The second crucial point is hiding in plain sight in Pfizer's own Lipitor newspaper ad. The dramatic 36% figure has an asterisk. Read the smaller type. It says: "That means in a large clinical study, 3% of patients taking a sugar pill or placebo had a heart attack compared to 2% of patients taking Lipitor."  Now do some simple math. The numbers in that sentence mean that for every 100 people in the trial, which lasted 3 1/3 years, three people on placebos and two people on Lipitor had heart attacks. The difference credited to the drug? One fewer heart attack per 100 people. So to spare one person a heart attack, 100 people had to take Lipitor for more than three years. The other 99 got no measurable benefit. Or to put it in terms of a little-known but useful statistic, the number needed to treat (or NNT) for one person to benefit is 100. 
____________________________________________________________________________ "Compare that with, say, today's standard antibiotic therapy to eradicate ulcer-causing H. pylori stomach bacteria. The NNT is 1.1. Give the drugs to 11 people, and 10 will be cured."
"Plus, there are reasons to believe the overall benefit for many patients is even less than what the NNT score of 100 suggests. That NNT was determined in an industry-sponsored trial using carefully selected patients with multiple risk factors, which include high blood pressure or smoking. In contrast, the only large clinical trial funded by the government, rather than companies, found no statistically significant benefit at all. And because clinical trials themselves suffer from potential biases, results claiming small benefits are always uncertain, says Dr. Nortin M. Hadler, professor of medicine at the University of North Carolina at Chapel Hill and a longtime drug industry critic. "Anything over an NNT of 50 is worse than a lottery ticket; there may be no winners," he argues. Several recent scientific papers peg the NNT for statins at 250 and up for lower-risk patients, even if they take it for five years or more. "What if you put 250 people in a room and told them they would each pay $1,000 a year for a drug they would have to take every day, that many would get diarrhea and muscle pain, and that 249 would have no benefit? And that they could do just as well by exercising? How many would take that?" asks drug industry critic Dr. Jerome R. Hoffman, professor of clinical medicine at the University of California at Los Angeles.
"Drug companies and other statin proponents readily concede that the number needed to treat is high. "As you calculated, the NNT does come out to about 100 for this study," said Pfizer representatives in a written response to questions. But statin promoters have several counterarguments. First, they insist that a high NNT doesn't always mean a drug shouldn't be widely used. After all, if millions of people are taking statins, even the small benefit represented by an NNT over 100 would mean thousands of heart attacks are prevented.
"That's a legitimate point, and it raises a tough question about health policy. How much should we spend on preventative steps, such as the use of statins or screening for prostate cancer, that end up benefiting only a small percentage of people? "It's all about whether we think the population is what matters, in which case we should all be on statins, or the individual, in which case we should not be," says Dr. Peter Trewby, consultant physician at Darlington Memorial Hospital in Britain. "What is of great value to the population can be of little benefit to the individual." Think about buying a raffle ticket for a community charity. It's for a good cause, but you are unlikely to win the prize.
"Statin proponents also argue that when NNTs are calculated after the drugs have been taken for just three or five years, they're misleadingly high. Pfizer says that even though only one heart attack was prevented per 100 people in its trial, "it may be a possibility that several or even all [100] benefit" by reducing their risk of a future heart attack. And the benefit grows when the drugs are taken for more years, backers believe. "It does not make sense to take a statin for five years," says Dr. Scott M. Grundy, chair of the NCEP committee that called for more aggressive statin treatment and director of the Center for Human Nutrition at the University of Texas Southwestern Medical Center at Dallas. "When you take a cholesterol-lowering drug, it is a huge commitment," he says. "You take it for life." "Grundy figures the chances of having a heart attack over the course of a lifetime are about 30% to 50% (higher for men than women). Statins, he argues, reduce that risk by about 30%. As a result, taking the drugs for 30 years or more would bring 9 to 15 fewer heart attacks for every 100 people. So only 7 to 11 people would have to take the drugs for life for one to benefit.
Critics reply that this rosier picture requires several leaps of faith. A 30% reduction in heart attacks "is the best-case scenario and not found in many of the studies," says Wright. What's more, statins have been in use now for 20 years, and there's little evidence yet that the NNT decreases the longer people take the drug.
____________________________________________________________________________ "Most important, the statin trials of people without existing heart disease showed no reduction in deaths or serious health events, despite the small drop in heart attacks. "We should tell patients that the reduced cardiovascular risk will be replaced by other serious illnesses," says Dr. John Abramson, clinical instructor at Harvard Medical School and author of Overdosed America.
"In its written response, Pfizer did not challenge this key assertion: that the drugs do not reduce deaths or serious illness in those without heart disease. Instead, the company repeated that statins reduce the "risk of death from coronary events" and added that Wright's analysis was not published in a peer-reviewed scientific journal.
"If we knew for sure that a medicine was completely safe and inexpensive, then its widespread use would be a no-brainer, even with a high NNT of 100. But an estimated 10% to 15% of statin users suffer side effects, including muscle pain, cognitive impairments, and sexual dysfunction. And the widespread use of statins comes at the cost of billions of dollars a year, not just for the drugs but also for doctors' visits, cholesterol screening, and other tests. Since health-care dollars are finite, "resources are not going to interventions that might be of benefit," says Dr. Beatrice A. Golomb, associate professor of medicine at the University of California at San Diego School of Medicine.
"What would work better? Perhaps urging people to switch to a Mediterranean diet or simply to eat more fish. In several studies, both lifestyle changes brought greater declines in heart attacks than statins, though the trials were too small to be completely persuasive. Being physically fit is also important. "The things that really work are lifestyle, exercise, diet, and weight reduction," says UCLA's Hoffman. "They still have a big NNT, but the cost is much less than drugs and they have benefits for quality of life."
"Yes, Avandia is very good at lowering blood sugar, just as statins lower cholesterol levels. But that doesn't translate into preventing the dire consequences of diabetes, including heart disease, strokes, and kidney failure. Clinical trials "failed to find a significant reduction in cardiovascular events even with excellent glucose control," wrote Dr. Clifford J. Rosen, chair of the Food & Drug Administration committee that evaluated Avandia, in a recent commentary in The New England Journal of Medicine. "Avandia is almost the poster child for everything wrong with our system," says UCLA's Hoffman. "Its NNT is close to infinite."
"Regarding Avandia, Dr. Murray Stewart, Glaxo's vice-president for clinical development, says that the evidence of its benefits against heart disease and other major complications of diabetes "is still inconclusive." But the drug has other benefits, he argues, such as delaying the need to take insulin."
""It was pseudo-science, never telling you the bottom-line truth, [which is] that the drugs don't help unless you have pre-existing cardiovascular disease." The marketing worked, Liang says, "even in the face of studies and people screaming and yelling, myself included, that it is not based on evidence."
"Drugmakers, however, do make sure that the researchers and doctors who extol the benefits of medications are well compensated. "It's almost impossible to find someone who believes strongly in statins who does not get a lot of money from industry," says Dr. Rodney A. Hayward, professor of internal medicine at the University of Michigan Medical School. The NCEP's 2004 guideline update garnered headlines by recommending lower targets for bad cholesterol, which would put more Americans on the drugs. But there was also a heated controversy in the medical community over the fact that 8 of the 9 experts on the panel had financial ties to industry. "The guideline process went awry," says Michigan State's Barry. He and 34 other experts sent a petition of protest to the National Institutes of Health, saying the evidence was weak and the panel members were biased by their ties to companies."
"I bought into it," Brody says. Not to do so is almost impossible, he adds. "If a physician suggested not checking a cholesterol level, many patients would stomp out of the office claiming the guy was a quack."
____________________________________________________________________________ "Yet Brody changed his mind. "I now see it as myth that everyone should have their cholesterol checked," he says. "In hindsight it was obvious. Duh! Why didn't I see it before?"
____________________________________________________________________________ "Cholesterol is just one of the risk factors for coronary disease. Dr. Ronald M. Krauss, director of atherosclerosis research at the Oakland Research Institute, explains that higher LDL levels do help set the stage for heart disease by contributing to the buildup of plaque in arteries. But something else has to happen before people get heart disease. "When you look at patients with heart disease, their cholesterol levels are not that [much] higher than those without heart disease," he says.
____________________________________________________________________________ "Compare countries, for example. Spaniards have LDL levels similar to Americans', but less than half the rate of heart disease. The Swiss have even higher cholesterol levels, but their rates of heart disease are also lower. Australian aborigines have low cholesterol but high rates of heart disease.
____________________________________________________________________________ "Moreover, says MSU's Barry, cholesterol-lowering medications other than statins "do not prevent heart attacks or strokes." Take Zetia, which blocks absorption of cholesterol from the intestines. In an eagerly awaited trial completed in 2006, the companies compared Zetia plus a statin with a statin alone in patients with genetically high cholesterol. But the drugmakers delayed announcing the results, prompting scientific outrage and the threat of a congressional investigation. The results, finally revealed on Jan. 14, showed the combination of Zetia and a statin reduced LDL levels more than the statin alone. But that didn't bring added benefits. In fact, the patients' arteries thickened more when taking the combination than with the statin alone."
"If cholesterol lowering itself isn't a panacea, why is it that statins do work for people with existing heart disease? In his laboratory at the Vascular Medicine unit of Brigham & Women's Hospital in Cambridge, Mass., Dr. James K. Liao began pondering this question more than a decade ago. The answer, he suspected, was that statins have other biological effects.
Since then, Liao and his team have proved this theory. First, a bit of biochemistry. Statin drugs work by bollixing up the production of a substance that gets turned into cholesterol in the liver, thus reducing levels in the blood. But the same substance turns out to be a building block for other key chemicals as well. Think of a toy factory in which the same plastic is fashioned into toy cars, trucks, and trains. Reducing production of the plastic cuts not only the output of toy cars (cholesterol) but also trucks and trains. In the body, these additional products are signaling molecules that tell genes to turn on or off, causing both side effects and benefits.
"Liao has charted some of these biochemical pathways. His recent work shows that one of the trucks, as it were—a molecule called Rho-kinase—is key. By reducing the amount of this enzyme, statins dial back damaging inflammation in arteries. When Liao knocks down the level of Rho-kinase in rats, they don't get heart disease. "Cholesterol lowering is not the reason for the benefit of statins," he concludes.
"The work also offers a possible explanation of why that benefit is mainly seen in people with existing heart disease and not in those who only have elevated cholesterol. Being relatively healthy, their Rho-kinase levels are normal, so there is little inflammation. But when people smoke or get high blood pressure, their Rho-kinase levels rise. Statins would return those levels closer to normal, counteracting the bad stuff.
"Add it all together, and "current evidence supports ignoring LDL cholesterol altogether," says the University of Michigan's Hayward. In a country where cholesterol lowering is usually seen as a matter of life and death, these are fighting words. A prominent heart disease physician and statin booster fumed at a recent meeting that "Hayward should be held accountable in a court of law for doing things to kill people," Hayward recounts. NECP's Cleeman adds that, in his view, the evidence against Hayward is overwhelming.
"But while the new analyses may rile those who have built careers around the need to reduce LDL, they also point the way to using statins more effectively. Surprisingly, both sides in the debate agree on the general approach. For anyone worried about heart disease, the first step should always be a better diet and increased physical activity. Do that, and "we would cut the number of people at risk so dramatically" that far fewer drugs would be needed, says Krauss. For those people who still might benefit from treatment, a recent analysis by Hayward shows that statins might better be prescribed based on patients' risk of heart disease, not on their LDL cholesterol levels. The higher the risk, the better the drugs seem to work. "If two patients have the same risk, the evidence says they get the same benefit from statins, whatever their LDL levels," Hayward says.
"Ways to fine-tune this approach may be coming soon. The company that first sequenced the human genome, Celera Group (CRA), has found a genetic variation that predicts who benefits from the drugs. Perhaps 60% of the population has it, says Dr. John Sninsky, vice-president of discovery research, and for everyone else, the NNT is sky-high. "It does not relate at all to your cholesterol level," Sninsky adds.
"If the drugs were used more rationally, drugmakers would take a hit. But the nation's health and pocketbook might be better off. Could it happen? Will data on NNTs, the weak link to cholesterol, and knowledge of genetic variations change what doctors do and what patients believe? Not until the country changes the incentives in health care, says UCLA's Hoffman. "The way our health-care system runs, it is not based on data, it is based on what makes money."