Author Archives: Bob Hansen MD

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About Bob Hansen MD

I am a practicing physician, board certified in Anesthesiology and Internal Medicine with Certificate of Special Qualifications in Critical Care. My interests include the effects of lifestyle on health and health care policy.

Polyunsaturated fat, Saturated fat and the AHA

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The present paradigm among physicians and cardiologists presents saturated fat as a disease producing component of animal foods. Dietary recommendations include the reduction of saturated fat and replacement with carbohydrates and/or monounsaturated and polyunsaturated fats. In fact, the American Heart Association (AHA) updated its recommendations to increase the consumption of polyunsaturated fats as a percentage of total caloric intake in January 2009.

This was met by protests from three NIH scientists who had done extensive research in the area of fat consumption and health. Those scientists wrote letters to the editor of Circulation, the scientific journal of the AHA. Those protest letters were not published in print but were published on-line (where only geeks like me would find them,  the vast majority of physicians would never lay eyes on them)

The authors of those letters subsequently produced a brilliant study that involved forensic research. They conducted interviews with principal investigators who directed the studies upon which the AHA had based it’s recommendations. They discovered important data that had been collected but not mentioned in those study publications by painstakingly sleuthing multiple sources. They then produced a meta-analysis of the data from the studies. Their meta-analysis was published in the British Journal of Nutrition Dec 2010.

http://www.ncbi.nlm.nih.gov/pubmed/21118617

What they found was astonishing. The AHA had based it’s recommendations on faulty data. A major point of refutation involved  omega 3 fatty acids (fish oil which is arguably cardio- protective) vs omega 6 fatty acids. Both are poly-unsaturated fatty acids (PUFA). The AHA paradigm has been that replacing saturated fat with omega 6 PUFA results in reduction of cholesterol (short term studies) and therefore should reduce heart attacks and stroke. But the studies they used to support their recommendations were not “clean”.

Only three of the nine studies were “pure” omega 6 interventions, which increased omega-6 FA without a concurrent rise in omega-3.

Four of the studies increased both omega 3 and omega 6 PUFA. In one of those four studies the patients were given the equivalent of 16 fish oil capsules per day.

The control diets had an estimated 3% manufactured trans fats in the diet. This unquestionably increases risk of heart attack and creates a confounding factor.

The Omega 6 diets increased the risk of heart disease and death compared to the mixed omega 3 and omega 6 studies. The risk of cardiac death was increased by 28% in the omega 6 diets compared to the mixed diets.

The mixed omega 6 omega 3 diets showed an 8% risk reduction of death from all causes and a 22% risk reduction from cardiac death.

So the AHA had made recommendations that could possibly be harmful and certainly not helpful. Despite this great piece of investigative science, the AHA did not change it’s recommendations.

Since that time Christopher Ramsden and colleagues have published a sequel “to evaluate the effectiveness of replacing dietary saturated fat with omega 6 linoleic acid, for the secondary prevention of coronary heart disease and death”.

http://www.ncbi.nlm.nih.gov/pubmed/23386268

In their summary they stated:

“substituting dietary linoleic acid in place of saturated fats increased the rates of death from all causes, coronary heart disease, and cardiovascular disease. “

There you have it. The AHA has not withdrawn it’s dietary recommendations to increase n-6 fat despite the compelling evidence to the contrary. This is unfortunately a consistent pattern.

Why would an increase in omega 6 fats and a reduction in saturated fat increase cardiovascular events?

Here is one explanation which is supported by basic science. Omega 6 fats are PUFA (polyunsaturated). PUFA are easily oxidized but saturated fat is not. When PUFA sit in the membrane (outer wall) of LDL particles they become oxidized and the oxidized LDL particle stimulates macrophages (white blood cells) to become foam cells and create plaque in the walls of your arteries. Saturated fats are not easily oxidized. Saturated fats do not contribute to the formation of oxidized LDL.

The AHA encourages us to consume “vegetable oils” (oils made from corn, soy, cottonseed, safflower, etc) instead of saturated fat. The predominant fat in “vegetable oil” is linoleic acid, the major omega 6 fat in the American diet. Linoleic acid is not the hero in this story and saturated fat is not the villain that the AHA portrays it to be.

Having said that, one might ask the following. If PUFA are easily oxidized and omega 3 fats are are also PUFA, then how could omega 3 fats be “cardio-protective” while omega 6 fats are damaging?

Good question. That will be addressed in  future posts.

But before we get to that, there are other data on saturated fats that must be discussed in order to dispel the fear of saturated fat.  That data and discusion will come in the next post.

Go in peace, the post is ended.

Bob Hansen MD

Breastfeeding and Medications

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I promised to write my next post about saturated fat but I just read an excellent Medscape report about breastfeeding and mothers taking drugs. Here is the introduction.

“Many breastfeeding women are advised to stop taking necessary medications or to discontinue nursing because of potential harmful effects on their infants. The reality is that few medications are contraindicated in breastfeeding mothers.

The American Academy of Pediatrics (AAP) has just released a new clinical report, The Transfer of Drugs and Therapeutics Into Human Breast Milk: An Update on Selected Topics, to provide guidance on drug exposure and reaffirm the recommendation that most medications and immunizations are safe during lactation. Medscape spoke with lead author and pediatrician Hari Cheryl Sachs, MD, the US Food and Drug Administration (FDA) liaison to the AAP Committee on Drugs, about the key recommendations from the report and resources to assist clinicians in obtaining current information on specific drugs to help guide their advice to breastfeeding women.”

Here is the URL to the article and some other URLs you might want to click if you are a breastfeeding mother or parent.


Drugs and the Breastfeeding Mother: A New Clinical Report

The Transfer of Drugs and Therapeutics Into Human Breast Milk: An Update on Selected Topics,

LactMed

 

mobile app

FDA’s Adverse Event Reporting System.

The post has ended, go in peace.

BOB Hansen MD

Number Needed to Treat (NNT) website and Statin Drugs

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My 85 year old mother-in-law was placed on a statin drug two years ago by her primary care physician. She had no risk factors for coronary disease other than age, she had a prior completely normal cardiac catheterization (coronary angiogram) and was totally without symptoms before being placed on the statin. Within weeks she developed muscle pain and weakness, suffered fatigue and overall felt poorly. I convinced her to stop the statin and within a few weeks she felt great. I see similar scenarios frequently in the pain clinic. I personally suffered severe statin induced myopathy pain from two different statins (in the days before enlightenment) and gratefully recovered when I stopped the drug each time. I have since learned more about coronary artery disease, cholesterol metabolism, statins, and related topics.

There is a great website that analyzes data from multiple studies to estimate the number of patients needed to treat in order to help and/or harm a patient. Two such analyses on this website are the NNT with statin drugs for five years to achieve certain results. They analyze data  in patients without known coronary artery disease (primary prophylaxis) and in patients with known coronary artery disease (secondary prophylaxis).

Here is the website:

TheNNT

Here is the page for primary prophylaxis:

Statins for Heart Disease Prevention (Without Prior Heart Disease) | TheNNT

Here is the link to the page on secondary prophylaxis:

Statins for Heart Disease Prevention (With Known Heart Disease) | TheNNT

Here are the results for primary prophylaxis.

“In Summary, for those who took the statin for 5 years:

  • 98% saw no benefit
  • 0% were helped by being saved from death
  • 1.6% were helped by preventing a heart attack
  • 0.4% were helped by preventing a stroke
  • 1.5% were harmed by developing diabetes*
  • 10% were harmed by muscle damage

In Other Words:

  • None were helped (life saved)
  • 1 in 60 were helped (preventing heart attack)
  • 1 in 268 were helped (preventing stroke)
  • 1 in 67 were harmed (develop diabetes*)
  • 1 in 10 were harmed (muscle damage)”

Here are the results for secondary prophylaxis.

“In Summary, for those who took the statin for 5 years:

  • 96% saw no benefit
  • 1.2% were helped by being saved from death
  • 2.6% were helped by preventing a repeat heart attack
  • 0.8% were helped by preventing a stroke
  • 0.6% were harmed by developing diabetes*

In Other Words:

  • 1 in 83 were helped (life saved)
  • 1 in 39 were helped (preventing non-fatal heart attack)
  • 1 in 125 were helped (preventing stroke)
  • 1 in 167 were harmed (develop diabetes*)”

If anything, the side effects (harm) are understated and the authors acknowledge this because many of the studies do not adequately report side effects and complications. (The studies were funded in part or in totality by the pharmaceutical company that makes the drug and that is a problem as discussed below)

Association of funding and conclusions in randomized dr… [JAMA. 2003] – PubMed – NCBI

It is rare that this sort of analysis would be presented to a patient in the physician’s office to help a patient decide whether the risks and benefits are acceptable. (I provide patients with this data on a multi-page handout with significant narrative and explanation when I diagnose statin myopathy.)

The obsession that American physicians have with cholesterol (another topic to be addressed in future posts) creates a knee-jerk reaction to a lab value that results too often in muscle damage and pain and sometimes cognitive impairment.

My experience in the pain clinic has been that the % of elderly with statin induced muscle damage and/or muscle pain is much higher. When I suggest that the patient stop the statin drug because they are suffering disabling pain and possibly permanent muscle damage they often return at the next visit to tell me they were started on a different statin drug. Most patients who suffer this complication will have a repeat of the same complication when placed on a different statin drug. This complication can cause permanent damage.

In the medical literature, many studies presented as “primary prophylaxis” are not truly primary prophylaxis because there are some patients included that have known diagnosed coronary disease. This tainted data is then presented as if it were a true primary prophylaxis study.

A more recent study purported to demonstrate once and for all that statins in primary prophylaxis can save lives. Unfortunately, there were problems with this study as well. Here is an excerpt from a commentary in the publishing journal:

“There are reasons to be cautious about the findings of the meta-analysis by Taylor and colleagues. As the authors note, all but 1 of the trials were partly or fully funded by pharmaceutical companies. Trials funded by for-profit organizations are more likely to recommend the experimental drug than are trials funded by nonprofit organizations (4). Further, adverse event reporting in the original trials was poor, with few details about type or severity, and quality of life was rarely assessed. Some adverse events, such as cognitive impairment, are rarer and not assessed.”

Disappointingly, the commentary failed to point out that the study data again included some patients with diagnosed coronary artery disease. (up to 10%).

Here are the authors own words.

“We included randomized controlled trials of statins versus placebo or usual care control with minimum treatment duration of one year and follow-up of six months, in adults with no restrictions on total, low density lipoprotein (LDL) or high density lipoprotein (HDL) cholesterol levels, and where 10% or less had a history of CVD.”

Once again we have a “primary prophylaxis” meta-analysis that is not really a primary prophylaxis study. It never seems to end.

When drug companies fund studies the conclusions often overstate the benefit and understate the risks. If you do not look for a side effect or complication, you will not find one. Here is an excerpt from a large study that look at the issue of bias in drug company sponsored research.

“CONTEXT:

Previous studies indicate that industry-sponsored trials tend to draw proindustry conclusions.

OBJECTIVE:

To explore whether the association between funding and conclusions in randomized drug trials reflects treatment effects or adverse events.

CONCLUSIONS:

Conclusions in trials funded by for-profit organizations may be more positive due to biased interpretation of trial results. Readers should carefully evaluate whether conclusions in randomized trials are supported by data.”

Association of funding and conclusions in randomized dr… [JAMA. 2003] – PubMed – NCBI

There are many ways that authors can present data to give the appearance of success. A more recent study published in Lancet alleged to demonstrate benefit (death prevention) for statins in primary prophylaxis.

Here it is.

The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials : The Lancet

But when you drill down into the data you  discover a mechanism of deception. The benefits reported in the paper applied only to patients whose cholesterol dropped significantly. Looking at all patients in the study who took the statin did not result in decreased death rates. Selecting those whose cholesterol dropped 40 points did show death prevention benefit. They presented risk reduction per unit of cholesterol reduction. From a scientific point of view this is less than honest. The authors simply demonstrated that patients who responded to the drug benefited.

DUH***All previous studies that simply compared patients on statins vs. those not on statins (primary prophylaxis) showed no prevention of death. This is an important distinction, The cost implications of putting low risk individuals on statins are enormous. Statins also rarely can cause death (from rhabdomyalysis) and frequently caused harm.  One comment about this studies’ conclusions was titled “Statins for all by the age of 50 years?” That frightens me.

The mechanism of statin drug benefits are likely related to many known potentially beneficial physiologic effects, not from a reduction of cholesterol. As you will learn in future posts, cholesterol reduction in and of itself is almost meaningless. The amount of circulating cholesterol in your blood is not the problem. The problem is much more complex and relates in part to the oxidation of LDL particles, which has little to do with the amount of cholesterol carried in those particles. Other important factors include systemic inflammation and the response of the innate immune system to factors such as circulating LPS which in turn reflects intestinal permeability. I apologize for the sudden onslaught of abbreviations and medical terms but stay tuned and you will learn what they all mean.

Finally, in the secondary prophylaxis group, the benefits of statin drug use are equivalent to the benefits achieved with exercise-based cardiac rehabilitation following a heart attack. Cardiac rehab offers many benefits in addition to saving lives, produces no significant negative side effects, and improves quality of life and sense of well-being. Many patients on statins feel lousy.

Efficacy of exercise-based cardiac rehabilitation… [Am Heart J. 2011] – PubMed – NCBI

In my next post I will discuss saturated fat  and coronary artery disease. This issue represents the crux of controversy in the heart-healthy diet debate which most physicians and the AHA consider clarified (eat less saturated fat). You already know generally what I have to say about that if you have read my Manifesto page. The next post will expand on the saturated fat section in the Manifesto. Subsequent posts will discuss cholesterol, LDL cholesterol, LDL particle number, oxidized LDL and glycated LDL (the last two are referred to as modified LDL)

Bob Hansen MD

Introduction

Practical Evolutionary Health

Americans spend almost twice as much per person on health care than the rest of the developed world yet we rank between 20 and 30 on most measures of public health. Why is that? The answer lies in our cultural habits, shaped in no small part by the marketing departments and sales forces of corporate America. Lifestyle and personal habits, in the broadest sense, determine our longevity and functional status (both physical and mental) as we age more than any drug or surgery. Dissecting how corporate America shapes and affects our health requires us to explore several layers. The first layer includes the food, pharmaceutical and medical device industries. But looking deeper at what shapes our culture and therefore our health, we must recognize the way our consumer driven economy shapes our culture with regard to the essential ingredients of health and disease.

This blog will explore the science and economics of health in an attempt to answer the “why is that?” above. The framework of this exploration will utilize a practical evolutionary-medicine perspective.

For a few million years our ancestors lived as hunter-gatherers. That period represents more than 99% of our evolutionary history. During that period our sleep habits cycled with the sun, we exercised regularly to obtain food, we ate fresh foods that included wild game and seafood, berries, nuts, tubers and  some wild plants, we rested allot, and enjoyed the benefits of small intimate social networks. After a few million years evolving in that manner we introduced agriculture, bred grass seeds into grains, bred wild fruits and vegetables into a variety of agricultural products with very different nutritional profiles as compared to the wild predecessors, and domesticated animals. Beyond that, we entered a period of industrialization that  has altered our eating, sleeping, social and exercise habits in a profound and  detrimental manner.

Convenience foods have been engineered in human laboratories to present flavors, textures, appearances and just the right mix of sugar-salt-fat to stimulate excessive consumption of nutritionally deplete calories. Mono-agriculture has depleted our soil both quantitatively and qualitatively. Corporate farming and animal husbandry have introduced the unnecessary and harmful use of antibiotics, hormones, insecticides and pesticides in the name of efficiency. Shift factory work has disrupted the circadian rhythm of millions of workers, increasing the risk of cancer, diabetes, obesity, depression and accidents to name a few. Artificial light has interfered with the procurement of adequate restorative sleep so essential for health. And  modern society has depleted our social network of meaningful supportive relationships and meaningful work.

That is the big picture, but what is the scientific data to support these statements? And what can we do to recapture the essential ingredients of healthy living while bringing home a paycheck? That is what this blog is about.

The Manifesto page represents a summary opinion of important topics related to health.

My posts will generally address topics covered in the Manifesto.

Bob Hansen MD