Tag Archive for: CVD

Normal BMI but Still Too Fat

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Last week the health headlines shouted “Study Shows Over 90% of All Americans Are Overfat!” The rate of overweight as assessed by Body Mass Index (BMI) is already 70%; now scientists want to say even more people are too fat? What’s going on? I’ll explain what overfat means first and then tell you about the study behind it.

For the most part, the greater the BMI, the greater the risk for cardiovascular disease, prediabetes, and hypertension. For those of you who aren’t sure of your BMI, check out your BMI in the Health Info section of our website. And if you think you’re just big boned, we show you how to prove it.

But there are people who have a normal BMI under 25.0 but still may be overfat. Considering Waist Circumference in addition to BMI may help but that could still miss some people. How? They may have lost muscle mass; the subtle loss of lean muscle with a gain of fat could lead to overfatness. That increases their risk for the diseases I mentioned earlier.

Here’s the most common example of someone who has a normal BMI but is overfat: a very sedentary elderly person who looks slim, but has very little muscle. As the saying goes “use it or lose it” and they’ve lost it.

A clinician from Arizona has taken it upon himself to redefine the terminology associated with excess body fat. He claims that overfatness gets missed in too many people. The problem he sees is that people who could begin treatment with diet, exercise, and medication if necessary are being missed. He outlined his arguments in a paper published in January 2017 (1), but it was his paper published in July that lead to headlines (2).

He and his co-authors examined the BMIs of people in countries all over the world. Using prior studies that estimated the number of normal-weight people who are overfat, ranging from 9.7% to 20%, he then applied that to the normal-weight populations (as assessed by BMI) in the top 30 developed countries in the world. That’s how they derived the headlines of over 90% overfat—not just in the U.S. but also New Zealand, Iceland, and Greece as well. To be fair, this applied only to males. Don’t rest on your laurels, ladies. All the same countries were greater than 80% for females.

 

The Problems

There are three with his approach in my opinion. First, adding another definition to replace BMI doesn’t really help people or their physicians as he implies. Confirming a person with normal BMI is overfat would require a more advanced exam or assessment of body fat. I’m not sure that’s practical.

Second, I looked at his work from every direction and couldn’t get the numbers to work. If 70% of Americans are overweight or obese and you add 20% of the remaining 30%, it adds up to 76% not 90%. Even if the numbers worked, the statistic would apply to a physician’s total number of patients. There would be no way to identify who is overfat without additional testing.

Third, there’s another group that needs to be addressed, and that would be those who are overweight according to their BMI but are metabolically healthy. In fact, that’s a significant problem today. Even after losing over 30 pounds, my BMI is still in the overweight category. By every test of metabolic fitness—blood pressure, cholesterol, HbA1c, or insulin—I’m at no additional risk of heart disease, yet I’m still classified as “at risk” due to my BMI. I think that’s a greater issue and will be more so as healthcare gets debated. Is your BMI over 25? You’ll pay more, even if your test results are stellar.

 

The Bottom Line

I agree with the concept that the author put forth: there are people with normal BMIs that are overfat, and they’re at greater risk for CVD and metabolic diseases. But new definitions aren’t necessary. What is necessary is identifying who is at risk. That will only occur when doctor and patient meet face to face. When was your last doctor’s appointment?

What are you prepared to do today?

Dr. Chet

 

References:
1. Front. Public Health 4:279. doi: 10.3389/fpubh.2016.00279.
2. Front. Public Health 5:190. doi: 10.3389/fpubh.2017.00190.

 

Chelation Therapy: Too Soon to Judge

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The results of the study on chelation therapy in subjects with diabetes showed a reduction in cardiovascular incidents during the follow-up time. No single event dominated, ranging from heart attack to stroke to death, but overall there were fewer incidents. Subjects who did not have diabetes did not experience a benefit in v incidents during the same follow-up time.

That led the researchers to speculate why. They couldn’t come up with any specific reason other than the chelation must involve a mechanism that was not yet identified. They carefully suggested that while the results were positive, this study could only suggest that larger clinical trials were necessary and the findings do not constitute enough evidence to be recommended as a treatment.


Should You Do It?

Here a few more things to consider:

  • The cost: each session costs $90 to $150 and there should be at least 30-40 of them. Add office visits and the total price could be around $5,000; none of it is covered by insurance.
  • All the subjects continued to use their typical medications for diabetes, cholesterol, and blood pressure. This was not replacing traditional treatments, it was in addition to the treatments.
  • The investment of time was significant at three-plus hours once a week or on whatever schedule the patient and doctor agree upon.


The Bottom Line

This study demonstrated a small cardiovascular benefit to the patients, reducing the risk of a cardiovascular event from 35% to 25%. In my opinion, the results are too small to justify the cost of money or time.

I know people who swear by chelation therapy, and I’m happy it worked for them, but there’s too much we don’t know. Nobody tracks what is actually changed in the body during chelation. Where do the heavy metals go? What if someone doesn’t process metals the same way to eliminate them? At this point, there are more questions than answers.

Here’s an idea. Spend the money on more vegetables and fruit for your diet. Invest the three hours per week in additional exercise. Both of those things will give you a better return on your investment than chelation therapy.

Eat less. Eat better. Move more.

What are you prepared to do today?

Dr. Chet

 

Reference: Circ Cardiovasc Qual Outcomes. 2014;7:15-24

 

Update on Chelation Therapy

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One of the questions asked during Tuesday’s Conference Call was about chelation therapy for helping with memory. I didn’t find any research to support that outcome, but a couple of studies have been published on chelation therapy with cardiovascular disease (CVD). One paper was from the Trial to Assess Chelation Therapy or TACT study.

Chelation therapy is used to eliminate heavy metals with the goal of reducing the metals that can be toxic to the body. While it’s been used for decades, the research hasn’t demonstrated a clear benefit.

For the TACT trial, researchers recruited over 1,700 subjects. In this paper, they used a sub-group of subjects from the original study who had diagnosed diabetes and had a heart attack more than six months before the study began. Half the diabetic subjects received chelation with EDTA (ethylene diamine tetraacetic acid) as well as some vitamins and minerals. The other half were infused with just saline solution. All subjects were given low doses of vitamins and minerals.

Subjects were infused once per week for 30 weeks and then biweekly and bimonthly until 40 sessions were completed. Each chelation session lasted three hours. With the investment of time, did the chelation therapy result in fewer cardiovascular events over the next five years? We’ll see on Saturday.

What are you prepared to do today?

Dr. Chet

 

Reference: https://doi.org/10.1161/CIRCOUTCOMES.113.000663

 

Why I’ll Keep Using Coconut Oil

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The research that the authors of the American Heart Association Presidential Advisory on Dietary Fats and Cardiovascular Disease, specifically on coconut oil, seems to be in conflict. The authors suggested coconut oil is bad for us, but the research studies they used didn’t really seem to confirm that conclusion. What gives?

The criteria that the Advisory’s panel used were limited in scope. There’s no evidence that the regular use of coconut oil contributes to CVD, even in cultures that regularly use coconut oil. They used a part-equals-whole logic. As they reported, there were significant increases in LDL-cholesterol when subjects increased coconut oil in their diet in the studies they cited. Because a high LDL-cholesterol level contributes to CVD, therefore coconut oil must contribute to CVD. That’s why the Panel does not recommend its use.

I understand what they said. The data they used supported their conclusion. However, they used a very narrow use of the data on coconut oil to support their recommendation.

They are correct when they state that coconut oil is high in saturated fat; in fact, it has the highest percentage of saturated fat of all fats and oils including lard and butter. But it also has a very high percentage of short- and medium-chain saturated fatty acids as opposed to longer chain fatty acids. The advantage is that short- and medium-chain fatty acids can by-pass the liver and be used directly to produce energy in most organs of the body, which makes coconut oil an option for getting energy quickly.

Let’s examine the statement that LDL cholesterol increased when subjects were taking coconut oil (1). In one study, LDL rose from 166 to 171 mg/dl in men and 155 to 156 in women (2). In another study, LDL rose from 118 to 128 mg/dl in a study of men and women (3). These were studies that lasted six weeks and five weeks respectively. There’s no evidence it would continue to rise had the subjects continued to use coconut oil. An increase of 3–6% in LDL-cholesterol wasn’t translated into a risk for CVD. Statistically significant? Yes. Meaningful in the real world? No.

The panel did not recommend coconut oil because it has saturated fat and has no other health benefits, but that point is debatable. Research on other benefits of coconut oil is really just beginning. Too many health gurus are overstating the benefits, especially when it comes to Alzheimer’s disease, and that creates the hype and most likely, the reason the Panel singled out coconut oil to examine more closely.

 

The Bottom Line

The Panel suggested we keep fat intake to no more than 30% of dietary intake; of that, only 10% should be saturated fat. They recommend that we substitute poly-unsaturated and mono-unsaturated fats and oils for saturated fat. That’s not really controversial and it’s a good idea.

What they did not say was that we couldn’t use coconut oil as one of our sources of saturated fat. If we eat 2,000 calories per day, that would mean up to 200 calories per day can come from saturated fat; that’s about two tablespoons per day, and that seems to be a reasonable source of saturated fat consistent with their recommendation.

Here’s the real bottom line: if you’re going to use a sat fat as a source of immediate energy, coconut oil is a healthier choice than lard or butter. And that’s why I use coconut oil; I don’t use a lot, but it works for me and makes sense to me as a scientist.

My recommendations never change. Eat less. Eat better. Move more. And in my opinion, using coconut oil is eating better.

What are you prepared to do today?

Dr. Chet

 

Reference:
1. Circulation. 2017;135:00–00. DOI: 10.1161/CIR.0000000000000510
2. J Lipid Res. 1995;36:1787–1795.
3. Am J Clin Nutr. 2011;94:1451–1457

 

Coconut Oil Research vs. the AHA

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For this memo, I’ll print conclusions from the papers cited in the American Heart Association Presidential Advisory on Dietary Fats and Cardiovascular Disease and then print what the authors wrote about the research studies they used to assess coconut oil (1). I’ll confess, it’s hard to understand how they reached some of these conclusions.

The study:
The findings suggest that, in certain circumstances, coconut oil might be a useful alternative to butter and hydrogenated vegetable fats (2).

AHA:
“A carefully controlled experiment compared the effects of coconut oil, butter, and safflower oil supplying polyunsaturated linoleic acid. Both butter and coconut oil raised LDL cholesterol compared with safflower oil, butter more than coconut oil.”


The study:
In conclusion, the results of this study indicated that it may be premature to judge SFA-rich diets as contributing to CVD risk solely on the basis of their SFA (saturated fatty acid) content.

AHA:
“Another carefully controlled experiment found that coconut oil significantly increased LDL cholesterol compared with olive oil (3).”


The study:
There was no evidence that coconut oil acted consistently different from other saturated fats in terms of its effects on blood lipids and lipoproteins.

AHA:
“A recent systematic review found seven controlled trials, including the two just mentioned, that compared coconut oil with monounsaturated or polyunsaturated oils. Coconut oil raised LDL cholesterol in all seven of these trials, significantly in six of them.”

The Advisory’s conclusion: “Because coconut oil increases LDL cholesterol, a cause of CVD, and has no known offsetting favorable effects, we advise against the use of coconut oil.”

Significantly. That’s a meaningful word in statistics but how about in the real world? I’ll finish this up in Saturday’s memo.

What are you prepared to do today?

Dr. Chet

 

References:
1. Circulation. 2017;135:00–00. DOI: 10.1161/CIR.0000000000000510
2. J Lipid Res. 1995;36:1787–1795.
3. Am J Clin Nutr. 2011;94:1451–1457
4. Nutr Rev. 2016;74:267–280.

 

Coconut Oil: Healthy or Not?

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The headlines screamed “Coconut Oil is Alarmingly High in Saturated Fats!” News post after news post talked about how Americans have been sold a bill of goods on the health benefits of coconut oil. Now the American Heart Association says it’s harmful. They published a Presidential Advisory on Dietary Fats and Cardiovascular Disease, a review paper to examine one issue: does saturated fat contribute to cardiovascular disease? They state that both the public and healthcare professionals are confused over this issue. The reasons are complex but primarily due to recent research publications that questioned the role saturated fat plays in the development of CVD.

The paper is 19 pages long with six pages of references. I’m not going to cover the entire paper because for the most part, there’s nothing new in what they’ve said. I’m only going to address a single issue: coconut oil. They begin the section by citing a New York Times survey that looked at which foods nutritionists consider healthy and what a group of registered voters consider healthy; nutritionists say coconut oil is not healthy while the public believes it is. The authors speculate that this is the result of the marketing of coconut oil in the popular press. Evidently they don’t spend much time on the Internet, because that’s where the bulk of claims for coconut oil are made.

I’m a fan of coconut oil for one primary reason (other than the fact that I love coconut): it contains short- and medium-chain fatty acids that can by-pass the liver and be used as energy for most organs. Is it still a saturated fat? Absolutely. Does it cause an increase in your risk of CVD? I’ll review their research on Thursday.

What are you prepared to do today?

Dr. Chet

 

Reference: Circulation. 2017;135:00–00. DOI: 10.1161/CIR.0000000000000510

 

BMI, WHR, and Lifestyle

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The study we’ve been examining is interesting on so many levels: large numbers of subjects; new statistical techniques due in large part to progress in computing capabilities; genetic analysis that allows for rapid analysis and identification of polymorphisms. It’s all very exciting. You’re probably anticipating a “but” coming and you’d be correct.

This study demonstrated that when using genetic information, WHR is a risk for CVD and type 2 diabetes even with a normal BMI. But there’s still at least two factors to consider that are dependent on each other.

First, just because someone has a mutated gene or genes, it doesn’t mean it will ever express itself, i.e., turn on. More than likely, the second factor has a role to play and that’s the lifestyle of the individual. Some studies refer to it as environment, but they’re intertwined. Where you live may limit or provide you with easy access to healthier foods. It may be easier to exercise in the suburbs than in a large city, or just the opposite given the park systems in different areas of the countries.

Then there’s the home environment: what foods you ate growing up and what your diet is now. All these can impact whether some genes may be expressed. Others may express themselves only when you get to a specific weight or fat intake. The variables are too numerous to consider.

I’m not attempting to confuse the issue. I just want you to know that while this study provides insight that we didn’t have before, you don’t have to be overly concerned. If you keep to a normal BMI and WHR, less than 0.9 for men and less than 0.8 for women, your risk for CVD and type 2 diabetes will not be high.

When all is said and done, it still comes down to three things. Eat less. Eat better. Move more.

What are you prepared to do today?

Dr. Chet

 

Reference: JAMA. 2017;317(6):626-634.

 

Waist-Hip Ratio vs. BMI

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In Tuesday’s message, I said researchers used a unique approach to answering the question of whether waist-hip ratio (WHR) is associated with cardiovascular disease and type 2 diabetes regardless of BMI. They found 48 genes which were associated WHR, a unique approach using the genetic information with Mendelian randomization of epidemiological data. If that isn’t a brain-full, I don’t know what is. Let me see if I can break it down for you.

As I’ve said many times before, epidemiological data cannot show cause and effect; they’re just observations. By using the genetic information related to WHR, researchers can analyze the data by statistically removing the effect of BMI. Because the genetic traits follow some randomization based on Mendel’s genetic work, if the WHR is still associated with the increased risks of disease, that means that where you carry your body fat is important, whether your BMI says you’re overweight or not.

They found that WHR is an independent risk factor for CVD and type 2 diabetes, confirming that the location of your body fat is important regardless of your BMI. That may be why people with a high BMI but low WHR have normal blood pressure and cholesterol levels while others with a normal BMI but a high WHR may have high numbers.

What are you prepared to do today?

Dr. Chet

 

Reference: JAMA. 2017;317(6):626-634.

 

Redefining the Risks of Extra Weight

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Studies show that 70% of the population is overweight; by definition, that means that their body mass index (BMI) is greater than 25 or more. But are all overweight people at the same risk? Just because you’re overweight, are you automatically at greater risk for cardiovascular disease and type 2 diabetes?

That’s what a group of researchers in the U.S. attempted to find out. They had the benefit of access to the U.K. Biobank, an independently funded databank that has collected biometric data on over 500,000 subjects in the U.K. and contains accurate measures of BMI as well as the waist-hip ratio (WHR) on all subjects. They also had one more thing: the genetic information on a large sub-group of subjects. They identified 48 genes that seemed to be associated with WHR and used a unique approach to tease out the effects of WHR from BMI. I’ll cover that the rest of the week.

In the meantime, check out your BMI and measure your waist and hip to calculate your WHR. Measure your waist about an inch below your belly-button and your hips at the widest point; divide waist by hips and you have your ratio.

What are you prepared to do today?

Dr. Chet

 

Reference: JAMA. 2017;317(6):626-634.

 

Does Sitting Cancel Out Exercise?

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This past Friday, I ran 4.5 miles on a great running and biking trail in Grand Rapids; it was a great morning and with the canopy of trees, it was cooler than it would have been in the sun. The rest of the day, I recorded my radio show, read, wrote, and finished off the day watching some home improvement shows. I typically spend more than eight hours sitting while I do what I do.

Unfortunately, that run won’t reduce my risk of dying from cardiovascular disease—not based on the headlines for a scientific statement just released . . .

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