Does a Little Extra Weight Keep You Alive?

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The Rotterdam Study was begun in 1991 to investigate the risk factors of cardiovascular, neurological, ophthalmological, and endocrine diseases in people 55 and older (1). The study is still ongoing, but periodically subsets of subjects are examined to find out which characteristics are associated with these diseases. In a study published in 2001, researchers reported on a group of subjects who were diagnosed with heart failure at the beginning of the study and followed for an average of six years—181 out of over 5,000 subjects. By the end of five years, 85 subjects had died. One of the observations that researchers noted was that a higher BMI was associated with reduced mortality; in plain terms, the heavier people were more likely to stay alive.

It didn’t stop there. In 2013, a study was published that directly examined the relationship between BMI and mortality (2). This meta-analysis included 97 studies and examined more than 2.88 million participants and more than 270,000 deaths. They reported that while grades 2 and 3 obesity (grade 2: BMI of 35-39.9; grade 3: BMI more than 40) were associated with increased mortality, grade 1 (BMI of 30-34.9) was not, and the overweight category (BMI of 25-29.9) actually showed a reduced risk of dying. (How do you rate? Check your BMI here.)

Is this true? Is body weight not associated with an increased risk of death? Have we been trying to lose weight for no reason? I’ll finish this on Saturday.

What are you prepared to do today?

Dr. Chet

 

References:
1. European Heart Journal (2001) 22, 1318–1327.
2. JAMA. 2013 January 2; 309(1): 71–82.

 

What Is the Obesity Paradox?

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Did you ever hear something that didn’t seem to make sense? That seemed to go against everything you thought to be true? One example of this is something called “The Obesity Paradox.” I’ve seen a few headlines this week that have talked about it, so it’s time to address it in the Memo.

One of the variables that we would think is related to the development of cardiovascular disease would be body weight. It seems logical: as weight increases, so does the strain on pumping the blood through the additional blood vessels required to feed the extra fat and muscle. People who are overweight may eat the wrong foods, consume too much food, and move too little.

But since the early 2000s, several studies have been published seeming to show that body weight wasn’t necessarily a risk factor for CVD or an early death. They showed that those who were overweight, a BMI between 25.0 and 29.9, had lower mortality rates than those who were normal weight. Some showed that stage-one obesity, a BMI between 30.0 and 34.9, was also not related to mortality. Thus the term “The Obesity Paradox” was coined. But is it true? We’ll take a look at the research the rest of the week.

What are you prepared to do today?

Dr. Chet

 

Special Memo: 28 Years!

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Paula and I are celebrating our 28th wedding anniversary today. Yep, the photo is our wedding picture from 1990—a couple of crazy kids (in their late 30s) vowing to tackle life together. It’s been a great experience, through more good times than not. In the movie As Good as It Gets, Jack Nicholson says one of the great lines in cinema: “You make me want to be a better man.” I can’t say that I would ever come up with something as profound as that, but I can say that you want a partner who can help you be better than you are. I am, and it’s due to sharing the past 28 years with Paula.

Paula adds: “We’ve always accepted each other as we are. That makes marriage a lot less ‘work’ than if you go into it wanting to remake each other—although I did get him to change his hairstyle.”

 

Thanks for being a regular reader and for sharing our celebration of 28 years together.

What are you prepared to do today?

Dr. Chet

 

Research Update on Vaping

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Tin, aluminum, lead, and zinc: those are the metals that were found in the aerosol generated by various e-cigarette devices in a recently published study. Sounds like exactly what you want to inhale deep into your lungs, right?

Researchers in Maryland recruited volunteer vapers to test the liquid in the tank, the aerosol, and the remaining fluid in their e-cigarette tanks; 56 subjects provided their e-cigarette for analysis. Testing these metals is no easy task. All samples were collected in sterile conditions, and all tests were compared to samples known to be pure and also with calibrating liquids. The objective was to see what contributions the heating coil might have made to the metals in the aerosol.

Levels of tin, aluminum, lead, and zinc increased after exposure to the coil and the heat it generates, and that’s being distributed into the lungs. Did the metals all come from the coil? No, the e-liquid already had the metals, but the amounts increased after conversion to aerosol.

This adds to the growing body of research that suggests vaping is not benign and is potentially harmful. We won’t know how harmful for years, possibly decades, when those who began vaping years ago are tested and found to have higher rates of lung disorders. If you continue to vape, you may look forward to being one of those subjects. It’s your body. It’s your choice.

What are you prepared to do today?

Dr. Chet

 

Reference: Environ Res 159:313–320, PMID: 28837903, 10.1016/j.envres.2017.08.014.

 

Do Calcium Supplements Harm Your Heart?

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Over the past few years, concern has grown about the relationship between heart disease and calcium intake. A couple of studies have shown a possible association between calcium intake and cardiovascular disease. In an article also published this month in the Journal of Women’s Health (1), two clinicians reported on a number of studies including one that examined calcium intake and heart disease. Their purpose was to update clinical guidelines for physicians and internists who regularly treat women and heart disease.

They selected a study that included a meta-analysis of studies on calcium intake from food and supplements (2). You know my position on meta-analysis and its overuse and limitations, but in this case, the researchers wanted to establish positions for both the National Osteoporosis Foundation and the American Society for Preventive Cardiology on calcium intake and heart disease. I think the use of this statistical method was warranted.

After an exhaustive review of the studies and re-analysis of the data, researchers found that calcium intake, from either food or supplements, at levels up to 2,000–2,500 mg per day are not associated with CVD risks in generally healthy adults. Although they found a few trials that reported increased risks with higher calcium intake, the risks were small and not considered to be clinically important even though they were statistically significant. The results applied to women and men.

At this point, with data from tens of thousands of subject, taking calcium from food or supplements will not harm your heart if you’re healthy. Does that mean you should limit calcium if you’re not healthy? No. There just isn’t sufficient data to know. In my opinion, if you take 800–1,000 mg of calcium per day, I think you’ll be fine but you should always check with your physician. You need calcium for many reasons, including bone and blood health and conducting signals between nerves. Especially if you don’t consume a lot of dairy, take your calcium supplement.

What are you prepared to do today?

Dr. Chet

 

References:
1. J Women’s Health DOI: 10.1089/jwh.2018.6932
2. Ann Intern Med 2016;165:856–866.

Treating a Woman’s Heart Disease

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The paper I’ve been using as a primary source for this week’s Memos is titled “Sex Differences in Ischemic Heart Disease. Advances, Obstacles, and Next Steps”; the purpose of this paper is to provide the current state of the science to clinicians when it comes to preventing and treating heart disease in women. A team of experts combed the medical literature to let their colleagues know where we stand in treatment and where future research should go, and you could look at it as a roadmap for improving prevention and treatment. You could also look at this as an indictment for less-than-quality care for women with heart disease.

There were seven categories of treatment options for various phases of heart disease, from diagnosing heart disease to mortality. I’m going to talk about just two but understand that even though the mortality from heart disease has decreased over the past 30 years, there are still gaps in treatment between men and women.

The first was a 30-minute delay in restoring the flow of blood to the heart in women who were having a heart attack with ST- segment elevation, a distinct change in the EKG. The time from the onset of symptoms and arrival at the hospital as well as time from arrival at the hospital to needle insertion for a percutaneous coronary intervention was 30 minutes or longer compared to men. That means women don’t get to the hospital early enough, so that’s on them. Ladies, you need to make that 911 call a little quicker. But it also means that once they’re there, it takes longer to get the arteries open again. That creates the possibility of more damage.

One of the problems is getting the correct diagnosis. There are 11 other conditions that can cause ST-segment elevation including takotsubo syndrome also known as broken heart syndrome. Still, 30 minutes seems way too long and needs to be improved.

The second is the one that really stunned me: fewer women are given recommendations for cardiac rehabilitation after a heart attack. Not only that but fewer women register to take part in cardiac rehab. They also attend fewer sessions than men do. When I read that, I was almost apoplectic. The heart is a muscle that can be damaged by a heart attack. When it’s time to rehabilitate that muscle, it’s not like restoring range of motion after knee surgery. If this muscle isn’t rehabbed and then trained for the rest of a women’s life, the death rate increases for those women.

That has to change today. If you have any type of coronary event, from atrial fibrillation to a full blown heart attack, the first question you ask is “When can I begin cardiac rehab?” I understand that every insurance plan may be different but you need to understand any limitations, how to exercise after a heart attack, and how to progress. That’s important, not just for the muscle, but also for the nervous system, the lungs, increasing the number of blood vessels, and even to reduce the depression that occurs after a heart attack.

And then you’re going to do it until you get every session you qualify for and get a plan to take home with you to keep improving. When that’s done, you’re going to get a plan from your physician as to how to progress from that point. These are non-negotiable. This has to change and it has to change today. The quality of your life depends on it.

Next Tuesday I’ll finish American Heart Month with a question I get a lot: does taking my calcium supplements increase calcification in my coronary arteries? I’ll let you know on Tuesday.

What are you prepared to do today?

Dr. Chet

 

Reference: Circ Cardiovasc Qual Outcomes. 2018;11:e004437.

 

Emerging CVD Risk Factors for Women

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The paper I referred to in Tuesday’s Memo provided a list of emerging risk factors for heart disease that apply only to women. But first, I wanted to define exactly what a risk factor is and what it means.

As defined by the World Health Organization, a risk factor is any attribute, characteristic, or exposure of an individual that increases the likelihood of developing a disease or injury. The key word is likelihood. It does not mean cause and effect, and that includes genetic tendencies. Lifestyle contributes close to 80% when it comes to raising or lowering risk. You’re not doomed; you just have to be aware and take action.

There were several emerging risk factors for cardiovascular disease (CVD):

  • Gestational diabetes: your risk of getting type 2 diabetes increases four-fold later in life; type 2 diabetes is a risk factor for heart disease.
  • Hypertension during pregnancy: hypertension and preeclampsia increase the risk of heart disease three-fold.
  • Early menopause: women’s hormones are protective against heart disease. When they change during menopause, the risk of heart disease begins to increase; the earlier that happens, the sooner the risk rises.
  • Autoimmune disease: diseases such as rheumatoid arthritis and lupus increase the risk of heart disease. Autoimmune diseases increase inflammation, and that may partially explain this connection.

You can see why these emerging risk factors are primarily associated with women. While depression is also associated with an increased risk in women, it may be that women seek help more than men.

Keep in mind that these conditions don’t make heart disease a given, just a risk. But if that gives you the oomph you need to get to the gym today or skip that sweet roll, I’m okay with that.

What happens after a woman has heart disease or a heart attack? We’ll take a look at that on Saturday including one thing that stunned me and has to change.

What are you prepared to do today?

Dr. Chet

 

Reference: Circ Cardiovasc Qual Outcomes. 2018;11:e004437.

 

It’s American Heart Month

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February was declared American Heart Month by President Lyndon Johnson in December 1963. As I’m searching the recent research in preparing to update the Women’s Heart Health audio, I’ve found new research on women’s hearts. I’m not ignoring men, but the research on women has lagged behind what we know about the risk of heart disease in men, because women’s bodies react differently to heart issues. Now we’re starting to catch up on women’s hearts.

Let’s look at the same risk factors for heart disease and see the differences between men and women. In a paper published this month, researchers looked at the differences in how risk factors for heart disease are managed in women. Here’s what they found:

  • Blood lipids: after menopause, women are less likely to achieve goals in reducing triglycerides and LDL-cholesterol and increasing HDL-cholesterol.
  • Blood pressure: as women get older, those with hypertension are less likely to lower blood pressure; only 29% achieve healthy blood pressures.
  • Exercise: 25% of all women get no regular exercise.
  • Obesity: carrying extra weight impacts the risk of heart disease more in women than men—64% compared to 46%.

There are more risk factors, but what makes these four important is that they can be improved through changes in lifestyle. Eating less. Eating better. Moving more. Even a 10% change can help reduce a women’s risk of getting heart disease.

Some new risk factors are emerging that are unique to women. I’ll cover those on Thursday.

What are you prepared to do today?

Dr. Chet

 

Reference: Circ Cardiovasc Qual Outcomes. 2018;11:e004437.

 

What Happens Inside When You Quit Drinking?

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Beer, wine, hard cider, whiskey, vodka, bourbon—that’s a partial list of alcohol-based drinks we consume. The amount of alcohol that’s recommended is no more than two drinks per day for men and one drink per day for women. Many people exceed that amount on a regular basis. While alcohol, especially wine, has some reported health benefits, even just a little more alcohol has consequences.

Alcohol is a toxin. The liver can handle and detoxify small amounts, but it can take several hours to process one drink. Alcohol is a diuretic, which means it will lead to dehydration when too much is consumed. While alcohol is a central nervous system depressant, it can interfere with sleep patterns. The next day fogginess is a result of the dehydration and nervous system effects. Alcohol is converted to fat and then stored. However, it may not store fat normally and overfill the livers fat storage ability. That results in a fatty liver. And then there’s the weight gain that comes with too much alcohol intake.

What happens if you give up alcohol for 40 days? Researchers in the United Kingdom found out by tracking over 100 people for over a month. Without any change in diet, the subjects lost two to four pounds. Cholesterol levels and blood pressure dropped as well. In addition to that, a marker of prediabetes and insulin resistance dropped as well. Researchers suggested that if those types of results could be put into a pill, it would create a $250 million industry overnight. And all people did was abstain from alcohol.

Is there a substitute? In trying to put a blend together that might have the calming effects of alcohol on the nervous system, I think a decaffeinated chai with its blend of herbs or a chamomile tea might have a similar benefit to the nervous system without the stimulant effects of caffeine.
 

The Bottom Line

Sugar. Salt. Alcohol. If you’re going to give up something during Lent, these deserve a try. There are some real benefits to your body if you do, even if you just reduce your intake. You might just find that you don’t need them at all. It’s worth a try.

What are you prepared to do today?

Dr. Chet

 

Reference: Hepatology. 2015. Volume 62, Issue Supplement S1. Abstract 113.

 

What Happens if You Give Up Salt?

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The next category of foods that you could give up for Lent is salt and sodium. Why do I mention both? Because they’re not exactly the same thing. Salt is sodium-chloride, a one to one proportion of sodium and chloride; sodium is just sodium. The typical American takes in over three grams or 3,000 mg of sodium per day. The upper limit is 2,300 mg and the goal is 1,500 mg. In past centuries, packing a food in salt was one way to preserve it, but with today’s refrigeration systems, we don’t need salt as a preservative. We just like it.

Where do we find sodium? Salt is added to all types of chips, nuts, processed meats, and deep-fried foods. But sodium is also added to many types of prepared foods. With the emphasis on reducing fat and carbohydrates, the flavor is often enhanced with sodium.

What could you expect to happen if you reduced your salt and sodium intake? You would probably lose some fluids. You body must keep sodium in a specific ionic balance, and reducing sodium would reduce the need for additional fluid. That could result in the reduction of blood pressure, something almost everyone could benefit from. That eases the strain on the heart, which won’t have to pump as hard because the resistance would not be as great.

As I’ve confessed before, I’m a salt-aholic so I’m going to work on reducing my sodium intake—no salty crunchy chips or roasted nuts, and no added salt to anything. I’ll also limit my intake of processed meats such as ham and bacon. We’ve become used to salt and sodium and it’s jaded our taste buds. No substitutions for this one. Time to retrain our taste.

What are you prepared to do today?

Dr. Chet