Vol. 226 February 1, 2020 Current Controversies . . . other than impeachment.

February 1, 2020

The Battle of the Best Diets
Low-carb? Low fat? Keto? Intermittent fasting? Paleo? Gluten-free?
“The science of nutrition is confusing and contradictory. How are we supposed to figure out what to eat?”

A Stanford nutritionist’s study of 600 people, half on low carb diet and half on low fat diet for a whole year, not only found no difference in weight loss between the two groups, but also revealed wide variations in weight change in individuals within each group. Some members in each group actually gained 10 to 20 pounds! Furthermore the researches had no success in predicting which individuals would do better on one or the other diet.

“With diets, there are too many dry drunks around – people who have found a way to drop some weight and now want to force everyone else to see the light.” The only consensus about the best diet is:
reduce or eliminate added sugar.
2. reduce or eliminate refined grains, processed carbs, and processed meats.
eat as many green, leafy vegetables as possible (avoid white potatoes).
(Neil Swidey, Boston Globe magazine, August25, 2019, pg. 17-20)

Vaping Illness Epidemic
“In 2019 so far there have been six deaths in the U.S. connected to vaping, as compared with more than 10,000 gun-related deaths. That can mean only one thing: EXPECT IMMEDIATE LEGISLATION RESTRICTING VAPING.”
Brian Pomodore, Letter to the Editor, Bos Globe September 13, 2019)

Nap for Heart Health
A Swiss study tracked 3,462 healthy adults for five years and found that those who took a nap once or twice a week had about half the risk of a heart attack or stroke. More frequent naps and naps over an hour provided no additional protection. The researchers admit they have no idea how napping provides that benefit, but speculate that it might be “stress relief”.
(Nadine Hauser, NBCNews, September 2019)

Vitamin D Supplement Does Not Strengthen Bones
Canadian researchers studied 311 healthy adults from the “land of lesser sun” (Calgary and Alaska) taking vitamin D supplements daily for three years and discovered that supplemental Vitamin D actually was associated with a decline in bone density: 1.2% decrease in those taking 400 units daily, 2.4% in those taking 4,000 units, and 3.5 % in the 10,000 units a day group. (The official Canadian recommendation for Vitamin D is 600 units a day)
(Burt, JAMA 2019 August 27;322)

Is Dark Chocolate Good For Your Heart?
The Mayo Clinic says that the beneficial ingredient in chocolate is flavanol which which acts as “an antioxidant that can reduce cell damage implicated in heart disease, helps lower blood pressure, and improve vascular function.” The problem, of course, is to get the flavanol benefit you would have to eat about seven average chocolate bars a day! The flavanol in cocoa is actually bitter and has to be masked with fats and sugar to make delicious-tasting  commercially available chocolate; consumption of which can lead to weight gain  and increased risk of associated diseases. Many of the “favorable studies” of the effect of chocolate have been industry-funded so “should be taken with a grain of salt, , , and not another square of chocolate.”
(Unsavory Truth: How Food Companies Skew the Science of What We Eat, Marion Nestle, NYU Professor of Nutrition and no relation to the candy maker, Bos Globe 10/27/19, A28)

Does Smartphone Screen Time Effect the Sense of Well Being?
Not really. A rigorous meta-analysis of 226 studies involving 275,000 people showed no significant link between depression and suicide and increased screen time. There was a tiny effect; about the same effect as wearing glasses. Many studies were based only on “time spent onscreen” with no data on “screen content”. It seems clear that heavy use of social media can be associated with harmful effects, but concern over average use of social media technology is overblown. One must remember that “association” does not prove “cause and effect”. Radio, video games, television, and even comics have caused consternation in the past about the harmful effects of technological innovation. in fact, Socrates bemoaned the new tradition of writing for fear it would diminish the power of memory. He was wrong about writing, but was prophetically correct about cell phones and our memory of phone numbers.
(Lydia Denworth, Scientific  American, November 2019, pg. 49)

Is Reading Printed Books with Children Better Than Reading Digital Books?
Yes. Reading printed books with children increased the mutual, reciprocal interactions between parental reader and the child when compared with reading digital, tablet-based books. Control and intrusive behavior on the part of both parent and child were decreased when reading printed books.

Is Red Meat Bad For You?
The Annals of Internal Medicine just “ corrected” (retracted) its publication of a 2019 study saying that most people could continue eating red and processed meat at their average consumption level without bad health effects. That report went against the prevailing scientific view that red or processed meat consumption is bad for you because of high amounts of saturated fat. The retraction was caused by the discovery that the principal author failed to disclose that he had received a sizable grant from Texas A&M AgriLife. It raised questions about conflict of interest and the researchers’ agenda “to make saturated fat look benign or beneficial”.

Benefits of Probiotics?







Enuff said.

Vol. 219 October 1, 2019 Vitamin D Supplement; Take It or Leave It?

October 1, 2019

Ever since the French sailors, weakened by scurvy, lost control of the seas to the British navy which was scurvy-free by vitamin C in the lime juice added to their daily ration of grog (hence the name “Limeys”), vitamins have been a subject of great interest and, even now, a lot of mystery. Everyone agrees that a little bit of them is essential for good health, but even two-time Nobel Prize winner Linus Pauling couldn’t convince all of us that a lot of vitamin C  could cure a cold. (1)

Vitamin D is currently the most popular vitamin to study because of some past research suggesting that vitamin D protects us from heart disease, particularly the elderly. A 2012 survey reported that about 20% of respondents were taking vitamin D supplements (multivitamin supplements were not included).  Supplemental vitamin D AND supplemental calcium have long been touted for preventing loss of bone density, or osteoporosis, especially in post-menopausal women. 

It is clear that Vitamin D deficiency can cause growth retardation and bone disease, particularly in the first years of life. It is a bit unclear as to how much of vitamin D we need. The American Academy of Pediatrics recommends vitamin D supplements of 400 units a day for breast-fed babies. Recommendations for minimum doses in other than infants range from 400 units to 2000 units a day. It is said to be almost impossible to be “vitamin deficient” on a normal diet nowadays, but certain very restricted vegan diets can cause some problems in rare cases.  Also, studies of Northern urban  children (less sun exposure) revealed “low” Vitamin D blood levels which stirred up a lot of discussion about its significance and about “what level was normal”. Too much of most vitamins can’t really hurt you too much. Most “excess” of vitamins ingested ( the amount over the minimum required to prevent a deficiency disease)  just ends up in the toilet via your urine.

A recent systematic review of a large number of peer-reviewed research studies on the use of supplemental Vitamin D to reduce the risk of cardiovascular disease was recently published. (2) This meta-analysis (our trade name for such huge reviews) of 21 randomized clinical trials with over 83,000 participants (mean age, 65) followed for 1 to 12 years showed that using a variety of Vitamin D supplements did NOT lower the risk for myocardial infarction, stroke, cardiovascular-related deaths, or all-cause deaths. This is “the best evidence to date that fails to support use of vitamin D supplementation for lowering cardiovascular risk.” (3)

Of course, the results of that meta analysis was muddied just a bit by another meta analysis of 52 clinical trials with over 75,000 participants (mean age, 74) with 1 year follow-up which showed that Vitamin D supplements was associated with 4 per 1000 persons fewer deaths from cancer in a small sub-group of participants. (4)  To further confuse the issue, it was noted that this small but significant difference occurred in only those people taking the D³ form of oral Vitamin D, not those taking the D² form. But, this review also revealed no cardiovascular benefits.

What about effects of vitamin D supplements on bone-density? If the recommended daily dose of vitamin D is from 400 to 2000 units, what if we took twice that? About 3% of U.S. adults take over 4000 units of vitamin D daily. A Canadian randomized study of 311 adults with pre-study normal vitamin D blood levels took either 400, 4000, or 10,000 units per day of supplemental vitamin D for three years.  Bone density actually DECREASED in those taking the higher doses. Also, the vitamin D blood levels in those taking the 400 units (recommended minimum) did not increase above normal. “The findings point to no benefit for bone integrity—and even harm—with high dose vitamin D supplementation in patients with adequate vitamin D blood levels.” (5) 

In today’s blog I offer evidence-based skepticism about the benefits of both vitamin C and vitamin D supplements. In my last blog I cautioned against vitamin E . . .at least the inhaled form. Is there a vitamin F supplement to continue my progression? Yes, there is! Vitamin F is an outdated term for omega-3 and omega-6 fatty acids,  but I think I’ll let that subject “sleep with the fishes” for the moment.

1. “Vitamin C and The Common Cold”, Linus Pauling, 1970 and 1976.
2. JAMA Cardiology 2019 Aug; 4:765
3. NEJM Journal Watch cardiology,vol.39, Oct. 2019)
4. NEJM 2019;380:33
5. JAMA 2019Aug27;322:736


Vol. 207 February 1, 2019 Things That Threaten

February 1, 2019

With our President and our own intelligence agencies currently in public disagreement about our greatest threats (Southern border migrants {Tweets} VS China, Russia, and North Korea {“Worldwide Threat Assessment”} ), it seems an appropriate time to list again some of the things that might threaten us from a medical point of view.  I last did this on February 1, 2010.

Repeats from 2010:

Watching TV – increase chance of a cardiac death by 18%, increase chance of obesity in children by 5%. 

Tanning Booths – Increase chance of malignant melanoma by 75%; 20 minutes in the booth equals 5 hours in the sun.

Cell phone use in cars – Increase risk of accident by 400%

Toys – 13,663 head injuries in children from toys seen in an ER in 2005; 251,000 toy injuries seen in ERs in 2018; 41% (102,910) were injuries of face or head.

Sleep apnea in truck drivers – Sleep apnea increases the chance of a driving accident by about 100%; 17% of truck drivers have sleep apnea

Brain cancer from cell phones– no evidence for it in 2010; “maybe” in 2019; very heavy users over 10 years in Sweden had an increased incidence of acoustic neuroma (non-cancerous growth on hearing nerve).

Contaminated herbal supplements – more studies continue to find supplements with incorrectly labeled ingredients and/or unlabeled contaminants. Most of these supplements are for sexual enhancements, body building, or weight loss.  

Vaping of nicotine products – “Unknown risks” noted in August 1, 2009; Still unknown over the long term, but of more concern because of the alarming explosion of use by junior high students and 21% of twelfth-graders.( an increase of 1.3 million teens just since 2017) (NEJM 2018 Dec 17)

New threats:

Gun Violence – I am surprised that this wasn’t in my 2010 list since it seems like we have been talking about this threat for years, but it was before the Sandy Hook and Stoneman Douglas school massacres . Wikipedia has a handy list of 122 world-wide school massacres by country, dates, number killed, etc. Do you remember what the auto industry said in the past regarding proposed laws requiring seat belts? – “Cars don’t kill people; people kill people.” I don’t either. Someone must have made that up to make a point. Check my two previous blogs (2015 and 2018) for the comparison of “the frog sitting in the gradually heating up water” with our pace of achieving gun safety. (“By Degrees”, Markerelli.com)

Climate Change – Extreme weather events and raging wildfires in California have caused some to label climate change as a “Health Emergency”. Accompanying an article describing the stress on emergency medical care resources and the significant contribution to air pollution caused by the California wildfires, a lead editorial in the New England Journal of Medicine stated: “Climate change is already adversely affecting human health and health systems, and projected climate change is expected to alter the geographic range and burden of a variety of climate-sensitive health outcomes and to affect the functioning of public health and health care systems.”  

Large Gathering in Any Public Place – During a break in the interminable Boston TV coverage of the Patriots prior to Super Bowl LIII one channel showed a segment on the security planned for the Mercedes Benz Stadium in Atlanta. It was impressive; ten miles of fencing, prohibition of drones, helicopter fly-overs, fully-armed policemen, and more-fully-armed soldiers (always shown walking in pairs). Nothing new to us since September 11th. Just another reminder, but now at least we realize it is not actually foreign “terrorists” that have caused the most havoc in our country.

Enough about threats. Any good news?

Salt-free diet not necessary for heart failure patients- A review of 9 studies showed “a paucity of evidence supporting low-sodium diets for patients with heart failure”. The recommended first step is to “… retreat from an unbridled and potentially harmful insistence on rigorous sodium restriction” in these patients. (JAMA Internal Med 2018 Dec; 178)

Vitamin D supplements of no benefit to preventing cancer or cardiovascular disease –A study of 25,800 participants over 50 years old followed for 5 years showed that daily 2000 IU of Vitamin D “did not keep the doctor away” compared to placebo. This is good news for people spending money on vitamin D supplements for this purpose. (NEJM January 3, 2019:380;1)

Omega-3 Fatty Acids (“fish oil”) of no benefit in preventing cardiovascular disease – Ditto  (JAMA Cardiology March 2018; 3)

Stand-up desks at work reduces sitting times – See “Watching TV” above, but unfortunately there are no studies that standing does anything but improve psychological well being of the worker with some work-related benefits.  When arising from the sitting position, the authors recommended doing some physical activity. Standing alone is not any healthier. (BMJ 2018 Oct10:363)

Vol. 201 October 15, 2018 Medical Facts and Fantasies?

October 15, 2018

Hub thumbnail 2015A baby aspirin a day does not necessarily keep the doctor away.
Daily low dose (81 mg. or a baby tablet) aspirin protects you from having your SECOND heart attack, not your first one. Another recent study confirmed that aspirin gives no such protection to someone who has a normal heart history. A baby aspirin is of NO benefit for primary cardiovascular disease prevention. (Despite these repeated studies many of us continue on our merry way of taking a daily baby aspirin in hopes of preventing “the big one.” )

Ritalin is apparently better than nothing . . . and lots of other things.
ADHD (Attention-Deficit-Hyperactivity-Disorder) in school children is not helped much by non-drug therapy. A 2011 review of 54 studies showed little lasting effectiveness of neurofeedback, child behavioral training, parent training, cognitive behavioral (“talk”) therapy, dietary changes, or herbal and Omega fatty acid supplements when compared to the usual psychostimulant drugs like Ritalin. (This lack of evidence of any benefits from non-drug treatment of this common condition is disappointing. The reviewers themselves call for additional studies.)

There’s An App For It – Among things that your smartphone can do are:

  • Record and transmit a electrocardiogram of your heart rate and rhythm.
  • Ask questions to determine whether you are slipping into a depression, and send a text message to your therapist.
  • Have a trained counselor call you within an hour of you opening up a bluetooth equipped HIV self-test kit to interpret the results for you.
  • Adjust the volume and sound characteristics of the hearing aid in your ear.
  • Operate an automatic pill dispenser filled with your daily medications.
  • Give you a “text neck”. The 60 degree angle of your neck as you text puts about 60 pounds of strain on your spine. (That’s the equivalent of 4 bowling balls).
  • Measure, record, and transmit your blood pressure or blood glucose level.
  • Give you an inaccurate pulse oximetry reading if using a non-FDA approved monitoring app. (In fact, the FDA faced with the existence of about 400,000 health and wellness apps has decided to review 20 apps a year that are directly related to gathering and transmitting clinical data. – FitBits are not included in that category)

Got your flu shot yet?
This year the CDC is recommending the quadrivalent flu vaccine for everyone over 6 months old who does not have a medical contraindication. No particular vaccine brand is recommended over the others. People with egg allergies can safely receive any of the vaccines. ( The Bill and Melinda Gates Foundation is pouring money into research efforts to reduce the potential effects of one of their greatest fear, another flu pandemic.)

Parents know best.
Children sleep better if fed earlier in life. Official pediatric policy used be to start solids at 6 months. Many parents think that starting at 3 months causes longer sleep periods and less sleep problems. A study of 1300 breast-fed infants in England and Wales showed that the parents are right. Duh! (Pediatricians used to recommend starting certain solid foods at even a later age because of potential food allergies. That is no longer true.)

The “other shoe” on probiotics.
The current wisdom that “probiotics are harmless and can benefit everyone” is not necessarily true. The exploding volume of research on our “microbiome” (the bacteria in our intestines) reveals that the bacterial mix in our intestines is unique to each individual (like a fingerprint) and is “good” for us in its natural state. Probiotics can change that mix, and one study shows that some of us have guts that are not only “resistant” to probiotics, but that alteration of our natural mix by probiotics could delay recovery from some illnesses.

Why your visit to your doctor’s office isn’t the same as the “old days”.
It is estimated that a typical primary care physician needs 22 hours a day to address all of the preventive, acute, and chronic needs of an average patient panel of 2,500 patients. This includes all of the insurance-prescribed, electronically embedded (in the electronic medical record – EMR) quality measures tied to the reimbursement of the physician. (This is one reason we patients are filling out more questionnaires, clicking on more boxes on a screen, and spending more time with nurse practitioners and physician assistants when we go to the doctor’s office. “The doc can’t do it all any more.”)

Watch out. More un-immunized children are on their way to school.
A 2017 CDC telephone survey indicates that about 100,000 children in the U.S. born in 2015 and 2016 have not received vaccination against the 14 disease for which shots are recommended. This is an increase from a similar study of children born in 2011.

Too fat? Just take a pill. . . A new kind of pill.
A capsule with a long thin plastic tube is swallowed by the patient. Once in the stomach air is pushed down the thin plastic tube, the capsule expands into a balloon filling 1/3 of the stomach, the patient has sensation of having a full stomach, and the thin tube breaks off and is withdrawn. In about three months the stomach balloon disintegrates, deflates, and is passed out in the stool. It has been approved in Europe and is being tested in the U.S. hoping for FDA approval in 2020. Another start-up company is hoping that their capsule filled with gel that expands in the stomach juices and accomplishes the same thing will also be approved. ( The gel-filled capsule is a bit of deja vu for me. As a chubby pre-teen trying to lose weight, I remember taking a tablespoon of “weight-loss powder” a half-hour before a meal, waiting to let it expand in my stomach, and feeling less hungry  so I ate less. I forget its name, but I do clearly remember the time I was in a particular hurry, ate too soon after the dose, and promptly emptied my over-filling stomach onto my shoes.)

A timely tip for women.
With all the surprise disclosures of “good men” exhibiting past sexual harassment acts and even sexual assaults, how can a woman feel confident that the man she is with is not the aggressive type? A recent study suggests you can just look at his hands. The shorter the index finger is compared to the ring finger, the more aggressive the man may be. This is from a study of 300 Canadian men and women. No correlation of personality to finger lengths was found in women. Researchers associate this finding with “the amount of testosterone that babies are exposed to in utero”. ( Or could it be related to being born North of the 49th parallel?! )

Vol. 199 September 15, 2018 Nature vs. Nurture . . . an update

September 15, 2018

Hub thumbnail 2015

“The closer scientists get to understanding the impact of individual genes,
the smaller that impact seems to be.”
– Evan Horowitz, Boston Globe, 9/11/18,C1

The discussion about what influences our upbringing the most, the environment (“nurture”) or our genes (“nature”), has been going on for decades. Sets of twins, particularly comparison of fraternal twins (two genetically different people born at the same time) and identical twins (two genetically identical people born at the same time), have been the subjects of much research trying to tease out the answer to which has the most influence. Why is one twin smarter than the other? Why does one love football and the other the violin? Why do they have the same walk, the same tastes in clothing, and the same gestures, but one has no sense of humor and the other is the class clown?

Despite the revelations in the recent movie, “Three Identical Strangers, many ethical and scientifically-rigorous twin studies have added a great deal of insight into the nature vs. nurture conundrum, and the discussion continues in the absence of consensus. The completion of the human genome project in 2003 was heralded as an historic step in finally settling this question. The hope was that, at last, we would be able to correlate a specific gene, or maybe just two or three genes, with a human characteristic, a human condition, and even a human disease.

In a recent study of the human genome, researchers found 1,271 different genes that seemed to improve educational outcomes. However, the cumulative effect of these educationally significant genes explained only about 11-13% of real world, actual educational attainment. (1) In a separate study by other researchers, the role of inherited genes in height, obesity, and education seemed to have much less influence than previously estimated . . . and a drastically much smaller role than suggested by twin studies. The influence of genes was highest for height (55%) and lowest for years of schooling (17%). The gene effect on cholesterol level was about 31% and the gene effect on determining your body mass index (BMI) was 29%.(2) There is no single “fat gene.”

One group of researchers suggested that perhaps the genes of the parents that are NOT passed to their offspring are important. What if the parents’ genes made them “slightly more attentive to kids and more willing to sacrifice their own happiness for the benefit of the kids”? Perhaps that could result in those children receiving a richer education. They suggested calling this influence of the parents’ genes on the children’s environment “genetic nurture”. (Thanks a lot for mudding the waters some more!)

There is no doubt that the genes we inherit from our parents influence our health and longevity. The adage, “To enjoy a long life, pick your parents right”, was dramatically brought home to me one day in the hospital cafeteria many years ago. A dozen of us physicians were discussing over lunch the pros and cons of a new study that daily baby aspirin could prevent some heart attacks, and different opinions about this brand new data were being voiced. A cardiologist espousing the strong genetic influence on heart disease interrupted our lively discussion with the question, “How many of you can call your father on the phone right now?” Only three could.

So the discussion of nature vs. nurture continues despite our growing knowledge of the human genome, but we have nothing to worry about as long as we have picked our parents right.

1. Nature Genetics, July 2018, as reported in Boston Globe, September 11, 2018
2. Ibid

Vol. 186 February 1, 2018 Good News For Dieters, and Some Others Who Ingest

February 1, 2018

Hub thumbnail 2015

“The only time to eat diet food is while you’re waiting for the steak to cook.”  — Julia Child

Pizza, even bad pizza, makes you feel good.
A recent study of 10 men in Finland (there’s the Finns again!) found evidence of high level of natural painkillers in their brains after eating a pizza. Their opioid receptors literally lit right up after the pizza! Even more surprising, the pizza did not have to be good to show that opioid receptor activity. If the same nutritional value was ingested in a “nutritional goo” form, the brains had even more opioid-like activity. So, the pleasurable feeling after eating pizza has nothing to do with how good it was. Speculations abound about a “full stomach feeling” or a “return of energy” as being the cause of the source of release of this endogenous opioid-like substance. (Journal of Neuroscience, November 2017)

Coffee can be part of a healthy diet.
A mega-review of over 200 studies of coffee consumption revealed that coffee consumption was associated with more benefit than harm, at all levels of consumption. Coffee contains more than 1000 bioactive compounds, including antioxidants, so this review was timely. The largest risk reduction of adverse health outcomes was found in those people who drank 3 to 4 daily cups of coffee (caffeinated OR decaffeinated!).  Death rates from any cause,  death rates from heart disease, and death rates from associated cardiovascular diseases were 15-19% lower in coffee drinkers. High coffee consumers had a 18% lower risk for cancer while lower consumers still had a 13% lower risk compared to non-coffee drinkers. The only adverse effects of coffee consumption were found in women: some higher risks for pregnancy loss, more preterm births, more low birth weight infants, and more bone fractures. The editor of the journal, anticipating our excitement at this news, counselled that “clinicians should not recommend coffee consumption on the basis of this review.”  And, oh yeah . . . this mega-review only included studies of black coffee. If you add sugar, milk, or any other ingredient to your coffee . . . “never mind”. (BMJ 2017)

Fecal transplants now come in pill form.
Selected cases of intractable diarrhea caused by recurrent infection with C. difficile (a bacteria that overgrows in the intestine after multiple courses of antibiotics) have been treated successfully by “transplanting” other people’s normal feces (material that contains normal symbiotic bacteria) into the patient’s intestines by infusing liquid fecal material either through a nasogastric tube or a colonoscope. In a study of 116 participants with recurrent, intractable diarrhea 96% were cured by the administration of the fecal material in a pill form. That is good news, but I hope that I won’t ever have to take that pill. (JAMA, Nov. 2017)

Low-dose aspirin does not raise your risk for intracranial bleeding.
A whole lot of people take daily low-dose aspirin (83 mg. – a baby aspirin) in the belief that it will reduce their risk of a fatal heart attack. The evidence actually shows that the preventative effect of low-dose aspirin is true only if you are trying to prevent your second heart attack; i.e.. the data supports its preventive effect in those people who already have clinical heart disease. Much of the general population, including me, is taking low dose aspirin in hope that it will work similarly for them. The only problem is that aspirin is an anti-thrombotic agent (it makes platelets “slippery” so that platelets don’t clump to start a clot). Such an effect raises a concern about spontaneous bleeding, particularly in the brain. A study of 400,000 people over 5 years in an established U.K. database showed that the incidence of brain hemorrhage was not significantly higher in those on the low-dose aspirin compared to those who took none. Remember also that if you have been taking low-dose aspirin for some time and decide to stop, your risk of spontaneous adverse clotting events may increase over the next 6-12 months. (Neurology, Nov. 2017)

Pasta is back!. . .  sort of.
An Italian study (no conflict of interest there I’m sure)  of 23,000 Italians revealed that the pasta lover had lower BMIs, the gold standard for definition of overweight. The researchers tout that pasta is not “just empty carbs”, but contains protein (6.7 grams per cup) and, if whole wheat pasta, it has iron, folic acid, and several B vitamins. The Italian study results are similar to a U.S. study of about 1,800 middle-aged adults, but there are a couple of caveats to consider. Italians eat much less pasta than we do in a meal because they consider it a first course, not the whole meal. The participants in the Italian study consumed an average of 3 oz. (86 grams) of pasta each meal. The study researchers did not name the “ideal amount” of pasta to eat per meal, but did note that those Italians who ate more pasta than the average tended to be obese. As we have said before, losing weight usually comes down to (no pun intended) taking in fewer calories rather than picking different kinds of calories to eat.

Vol. 182 December 1, 2017 “This Is Not Your Father’s Heart Attack”

December 1, 2017

The remarkable facts, that the paroxysm, or indeed the disease itself, is excited more especially upon walking up hill, and after a meal; that thus excited, it is accompanied with a sensation, which threatens instant death if the motion is persisted in; and, that on stopping, the distress immediately abates, or altogether subsides; have . . . formed a constituent part of the character of Angina Pectoris. – “Remarks on Angina Pectoris” by John Warren, M.D., appeared in 1812 as the first article in the first issue of The New England Journal of Medicine and Surgery.

About this time of year in 1958 my father had a heart attack in Toronto.
He awoke in the morning with some chest pain that didn’t get better after a cold, brisk shower “to make it subside” (“De’Nile ain’t just a river in Egypt”).Then he walked up a flight of stairs to a physician’s office (more water down De’Nile), almost left the waiting room when the pain went away (ditto again), but immediately impressed the doctor with how pale and clammy he looked. He spent three (3) weeks on his back in a Toronto hospital bed with the diagnosis of “heart attack.:” He was allowed to return home to suburban New York City by train. I don’t remember why the train, but I think it had something to do with him traveling in a wheelchair (“activity still restricted”).

Things sure have changed. (NEJM 376:21 May 25, 2017)
The rate of hospitalization in the U.S.for a heart attack (acute myocardial infarction or AMI) has decreased by 5% PER YEAR since 1987. The rates of major complications have dramatically decreased during the same period. Deaths from acute MI have declined slowly since 1980, but 50% of the AMI deaths occur before the patient arrives at the hospital. Hence the push in recent years to teach CPR to everyone and distribute portable cardiac defibrillators/ automatic external defribillators (AED) as widely as possible.

There are now at least six types of heart attack.
The big divide is between those patients that have a specific change in their EKG, an elevation of the ST segment (STEMI) and those that do not (non-STEMI). STEMI implies significantly more heart damage and is treated more aggressively. Branching down off of these two big categories are 5 other distinct types of MI based on modern diagnostic modalities, both EKG findings and blood sample biomarkers, and therapies. I won’t bore you with all those details. Just remember that a “heart attack” is not just a “heart attack” anymore. It all depends…

There is distinctly different therapy for each type of AMI.
Today there is a lot more than “bedrest for three weeks.” Each AMI type has a best practice timeline which varies considerably, except that everyone arriving in the ER with chest pain gets an aspirin within 5 minutes (makes platelets “slippery” to reduce clotting of blood in small coronary arteries). After that:

  • you may be whipped into the cardiac cath lab within 90 minutes for percutaneous cardiac intervention (PCI – a catheter in a radial (wrist) artery) to stent your coronary artery(s);
  • or you may be given a stress test and be sent to the cardiac cath lab for a diagnostic catherization and then maybe scheduled for open heart surgery (CABG) that day or days/week later;
  • or you may be admitted to a CCU/ICU bed;
  • or you may be admitted to an “observation bed” or “step down unit” which have outcomes as good as a CCU or ICU.
  • or you could even be sent home.
    You will probably be anti-coagulated as well. Most admitted non-CABG patients stay in the hospital for no more than 3-4 days.

Some studies credit the declining death rate from cardiovascular disease to better prevention (Public health and primary care interventions). Others credit better, more timely diagnosis and treatment (scientific advances). Both are correct.


Decline of cardiovascular deaths due to scientific advances.
(NEJM 366:1, January 5, 2012)

Decline of cardiovascular deaths due to public health and primary care interventions.
(NEJM 366:13 March29,2012)

Numerous studies have shown that the biggest influence on your chance of having a heart attack is genetics; what you inherit from your parents. The good news is that if you have NOT picked your parents well, life style changes like no smoking, exercise, no obesity, and a healthy diet can reduce even the high risk for coronary disease by nearly 50%. (NEJM 375:24 December 15, 2016)


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