AHA Makes Headlines With Story That's Been in the News for Over Half a Century

The Story:
The number one killer of women in the US is heart disease, and we need to do something about it.

For as far back as I looked (1950), the CDC has records showing that women, and men, have been laying down their lives to cardiovascular disease (CVD).

You can click the chart to the right for a larger version. Or you can see the CDC's whole report here (pdf):

US Age-adjusted Death Rates, 1950-2001

You have to hand it to the American Heart Association (AHA) for pushing such a ho-hum story to the top of the news heap, if only for 2 hours on February 19th. It appeared briefly in the Health segments of news broadcasts and websites and was quickly superseded by the Salmonella-in-Peanut-Butter story and the Pregnant?-Eat-Fish story.

It's hard to care about a somber truth that's been with us day after day, year after year, for most of our recent history. But we would do well to care, not least because heart disease doesn't have to hold such a hallowed place. It is, in fact, preventable. And compared to the cost of dealing with cardiovascular problems once they rear their head, the actions needed for prevention are cheap, doable for most people, and they work.

You may now be asking, what are they?

Here's where the AHA earned their pat on the back. They just published a set of guidelines, not their first, in their peer-reviewed journal Circulation. Boy, did they do they homework.

Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women: 2007 Update

They identified thousands of CVD-pertinent studies (5774 to be exact) that were performed in the brief period between 2003 (the cut-off for their previous guidelines) and 2006. They whittled those down to 246 that had the best research designs, with study populations of at least 1000 - one meaty pile of evidence. They then extracted those studies' findings, ranked them, and whipped up a list of recommendations.

Here's their list:


________
The guidelines above might be condensed into another unfortunately lackluster message: Eat a healthful diet, exercise, don't smoke. But after raking through their paper, a few points stood out for me ... points that sometimes didn't make it into the news summaries, and sometimes contradicted them when they did:

1. They recommended "a minimum of 30 minutes of moderate-intensity physical activity" daily. They increased this time to 60-90 minutes to achieve or sustain weight loss. However, this increase was not backed by any evidence from their included trials, unlike the 30 minute recommendation. Rather, it was "based on expert opinion, case studies, or standard of care."

It seems intuitive that more would be better in this case. But if I'm going to set aside an hour and a half of my day to exercise, I'd prefer to see this lengthier time withstand more and better scientific scrutiny. Otherwise, one could easily rationalize it away as an example of the law of diminishing returns.

If 60 or 90 minutes/day is really the minimum required to stave off a heart attack, please don't tease me with 30 :)

2. The following was some guidance they gave for the use of aspirin in women. Pay close attention.

"Routine use of aspirin in healthy women <65 is not recommended to prevent MI."

There are three key words in that sentence: "healthy", "women", and "MI" (Myocardial Infarction = heart attack). Replace any one of those three terms, respectively, with "high-risk", "men", or "stroke", and aspirin therapy may be indicated.

We're only beginning to learn how men and women differ in their response to drugs and other therapies. Unfortunately, the bulk of studies upon which we depend for clinical guidance do not make gender distinctions. I intend to address some of these differences in a later post. For now, I'll just note that aspirin was found more useful in protecting women against strokes but not heart attacks, and protecting men against heart attacks but not strokes ... and it's always accompanied by risk of gastrointestinal bleeding.¹

3. They recommended that depression be treated.

For as much as omega-3 fatty acids have gained a reputation for lowering CVD risk, the AHA ranked treatment for depression higher, and for good reason:

• Depression treatment: "Weight of evidence/opinion is in favor of usefulness/efficacy."
  
• Omega 3 intake: "Usefulness/efficacy is less well established by evidence/opinion."

There's a complex relationship between depression and heart disease. (The same could be said for depression and other diseases - diabetes is one I'm familiar with in my line of work.) Depression could directly cause, indirectly cause, or result from CVD ... or any combination of the three. Also, depression exerts a range of effects, both physiological (release of stress hormones, activation of sympathetic nervous system - "fight or flight") and behavioral/emotional, which feed into the connections in the previous sentence.

What is known is that depression complicates CVD outcomes, and that the association between the two is more pronounced in women than in men.² This area of study is hot right now. However, while researchers are teasing this relationship apart, there is every reason (not least of which is quality of life) to treat depression.

4. They recommended women "limit intake of saturated fat to <10% of energy, and if possible <7%."

In my experience, there is an enormous chasm between this kind of recommendation and it's execution. Even if women have knowledge of foods that are high in saturated fat, they can't easily parlay that into knowledge of intake, and even if they have knowledge of intake, they can't easily parlay that into % of energy. To make a recommendation based on % of energy, let alone the distinction between 10% of energy and 7% of energy, however beneficial this distinction has proven in studies, seems pointless. Here's where a Pollanism would have been better: eat less meat and cheese.

5. The AHA expert panel declined from including "yoga/stress reduction" in their guidelines because they "determined the data were insufficient to make clinical recommendations." Another therapy that's been in the spotlight lately is vitamin D supplementation, a topic the AHA discusses readily on their site³ (as does Dr. Davis) but refrained from addressing here, again due to a paucity of research.

So there's more in store. These 2007 Guidelines aren't the be-all and end-all for ways to avoid CVD, but they're chock full of useful advice. And, at least for some people, they make a great conversation piece, as you might attest to if you've read my post this far :)

________¹ Aspirin for the Primary Prevention of Cardiovascular Events in Women and Men, JAMA, 2006.
² Depression and Cardiovascular Disease, Circulation, 2005.
Another good resource on depression and heart disease: Depression Can Break Your Heart, National Institute of Mental Health, 2001.
³ Vitamin D Gets an A+ for Treating Heart Disease, AHA, 2002.

How to Box at 60

Sylvester Stallone was born on July 6, 1946. This is what 60 years old looks like:



That's one motherload of protein powder and biceps curls if you ask me.

The photos were taken last Sunday at the Lakes Golf Course in Sydney. Mr. Stallone is in Australia to promote his latest Rocky movie. What would have been a benign, non-newsmaking trip slid into the headlines last Friday when ...

"... a routine luggage search at Sydney Airport detected a prohibited substance."

A few days later, Customs officials visited the buff actor at his hotel. The meeting ...

"... became a full-blown raid when people were allegedly seen throwing items from the windows and the balcony."

Oh, to have been a fly on that balcony. No one will come out with the straight dope. But a spokeswoman for Customs...

"... confirmed [that] importing "performance and image enhancing drugs" had a possible $110,000 fine and a five-year jail term."

For no particular reason let me bring your attention to a list of metabolic functions of a particular substance called growth hormone (GH) or somatotropin:¹

• It increases calcium retention, and strengthens and increases the mineralization of bone.
  
• It increases muscle mass through the creation of new muscle cells.
  
• It promotes lipolysis, which results in the reduction of adipose tissue (body fat).
  
• It increases protein synthesis and stimulates the growth of all internal organs excluding the brain.
  
• It plays a role in fuel homeostasis.
  
• It reduces liver uptake of glucose, an effect that opposes that of insulin.
  
• It also contributes to the maintenance and function of pancreatic islets.
  
• It stimulates the immune system.
  - Wikipedia: Growth_hormone.

________¹ I don't advise it for recreational use. There are a number of conditions GH is indicated for: AIDS, Turner Syn., Prader-Willi Syn., deficiencies, etc. But in a normal person it can up risk for diabetes (see item 6 in the post), atherosclerosis (and thus heart problems), joint problems, and others. It can also cause existing, and perhaps undetected, tumors to grow.

It must be injected, it's available only by prescription, and it's expensive. A more natural way to ensure a nice dose of endogenous growth hormone it to get a good night's sleep - GH is secreted in high amounts during sleep. Exercise, of high intensity, also stimulates its release.

One feedback mechanism for release of GH is glucose in the blood. The higher blood glucose, the less GH is secreted. The converse is also true - the lower blood glucose, the more GH secreted.

Lastly, it appears that although GH can change body composition, it may not improve function, i.e. you may have more muscle but not more strength. (See Growth Hormone and Sex Steroid Administration in Healthy Aged Women and Men.)

Photos via Just Jared, via Bauer-Griffin.

Trans Fat in Peanut Butter: Not So Much

I indicated in my last post that Peter Pan Peanut Butter could contain up to 0.5 grams of trans fat per serving (a serving is 2 tablespoons = 32 grams). Afterwards, out of curiosity, I went searching for an exact amount. What I found is good news.

In fact, it's such good news that Peter Pan (and Jif, and Skippy, etc.) would probably benefit from stating on their label the actual amount of trans fat per serving, instead of rounding the number to zero and having some fanatic make unflattering assumptions.

In 2001, the USDA sponsored a study¹ that measured the amount of trans-fatty acids in 11 brands of peanut butter, including Jif, Peter Pan, Skippy, Smuckers, and freshly ground peanuts. Their findings:

"No trans-fatty acids were detected in any of the samples in an analytical system with a detection threshold of 0.01% of the sample weight."
- Non-detectable levels of trans-fatty acids in peanut butter

Trans fats are very likely present since hydrogenated fat is present. What this study tells us is that the amount of trans fat in their samples was very small ... not more than 0.01% or 0.0032 grams in a 32 gram serving. Assuming they haven't changed their recipe much since 2001, you could eat the whole 1 lb. jar (actually 510 grams) and still only take in at most 0.05 grams of trans fat. (The whole jar provides about 3040 calories and 272 grams total fat.)

To make it up to them, I'll post a little Peter Pan trivia...

The brand Peter Pan emerged in 1928. It was one of the first companies to use a new process which churned peanuts into a smoother consistency than was widely available at the time, and which made the product "shelf-stable" or resistant to separation. The patent for that process was secured by Joseph L. Rosefield who, in 1932 had a falling out with Peter Pan and began selling his own product under the Skippy label the following year.²

Peter Pan peanut butter was originally packaged in a tin can with a turn key and re-closable lid. The packaging was changed to glass jars during World War II to save metal.³

________¹ The study was partially funded by the American Peanut Council.
² From PeanutButterLovers.com.
³ From Wikipedia: Peter Pan Peanut Butter.
Photo compliments of the American Package Museum.

FDA Pans Certain Nut Butters

Specifically ...

"The Food and Drug Administration (FDA) is warning consumers not to eat certain jars of Peter Pan peanut butter or Great Value peanut butter due to risk of contamination with Salmonella Tennessee (a bacterium that causes foodborne illness). The affected jars of Peter Pan and Great Value peanut butter have a product code located on the lid of the jar that begins with the number 2111."
- FDA Warns Consumers Not to Eat Certain Jars of Peter Pan Peanut Butter and Great Value Peanut Butter

Because I actually like peanut butter, I thought I'd make a few unsolicited recommendations to ConAgra Foods, Peter Pan's manufacturer.

Dear ConAgra,

First, I think a more accurate label on a product that contains at least 5 ingredients would be "Peanut Butter-Containing Spread", or to be even more disclosing to an increasingly distrustful citizenry, since the second most prevalent ingredient is sugar, I recommend "Sweetened Peanut Butter-Containing Spread". The more unaffected and natural-sounding "Peanut Butter" might be a little misleading.

Second, given that those 5 ingredients are ...

• Roasted peanuts
  
• Sugar
  
• Partially hydrogenated cottonseed oil
  
• Partially hydrogenated rapeseed oil
  
• Salt

... I personally would be embarrassed to promote such a spread in the present anti-partially-hydrogenated climate. But it's your call. I see you've managed to get your per serving amount of resulting trans fats down to something less than 0.5 grams which allows you to claim "Zero or No Trans Fat" on the label. If this lets you sleep better at night, so be it.

Third, and most importantly, I realize you find financial reward in embellishment of a food product which, in its basic form, need only contain one ingredient. But I'm going to wager that your latest addition of Salmonella, with its accompanying public relations fallout, may set your bottom line back a few digits. It's never a good idea to mess with a recipe when the resulting product prompts a biggety-big federal regulating agency to use the words "Do not eat" in reference to your profit-maker. Perhaps your latest ingredient appeared inadvertently, in which case I have a simply remedy : clean your grinders.

Sincerely,
Fanatic Cook, Team Chunky
________Photo from Bill Marler's blog. Mr. Marler is attorney who litigates foodborne illness cases and has some good running commentary on this latest outbreak.

It's Not the Diagnosis, It's What We Do With It

Constance and Melinda were discussing a recent article in the New York Times. It may have been this one:

What's Making Us Sick Is an Epidemic of Diagnoses

It's not surprising which side of the fence I fall, especially after my last few posts on blood pressure and blood sugar testing. (I believe in early diagnosis.)

I can understand how an article such as this is born, in a culture that embraces medical technology and pharmacological therapies. "Enough with the doctors and hospitals already!" But I thought the authors came down harder on the diagnosis end of the spectrum than was warranted. I don't see that diagnoses are harmful, or are "making us sick". I do however see abuse of pills and surgery ... that sickens me.

Nipping high blood pressure, high blood sugar, cancerous lesions, excess weight, etc. in the bud - through early diagnosis - can save lives, money, and most importantly, can improve quality of life.

However, where I agree with the article is:

"More diagnoses mean more money for drug manufacturers, hospitals, physicians and disease advocacy groups."

That's a shame because many conditions, if found early, respond to inexpensive lifestyle changes.

"First, Do No Harm"

A better argument the article could have made in defense of its diagnoses-are-harmful theme, one that would have won me over, is the possible risk to health involved in invasive screening technologies, especially those involving radiation and excision of healthy tissue, including blood. Let's not even discuss the humiliating ones. (If you're over 50 and haven't had a sigmoidoscopy yet, raise your hand.) It's enough to make one forego the test.

Happily, scientists are working on less invasive technologies, for example, viewing lungs without ionizing radiation (using sound) and testing blood glucose without drawing blood (using light) Stay tuned!

Sickness is in the Eye of the Beholder

As to people viewing themselves as "sick" when they have no symptoms, e.g. in hypertension, I think this lies in perspective. The article discussed one perspective, a negative one: "Simply labeling people as diseased can make them feel anxious and vulnerable." This assumes there's only one way to view a person with a condition. I don't know what these authors' healthcare backgrounds are, but I can speak for members of the diabetic community when I say they prefer to be regarded as people ... who happen to have diabetes, not as "diabetics", and certainly not "sick".

If you are someone with fair skin that benefits from protection in the sun, do you think of yourself as diseased? If you are someone whose blood pressure benefits from less sodium and more activity, do you think of yourself as diseased? Certainly there's a spectrum of illness, but people have a choice as to how they view chronic conditions that can be successfully managed. A more optimistic and empowering view of an early diagnosis might be, "Great! I found my blood pressure beginning to inch up and can work it down by cutting back on salt and following the dog around the block."

Curiously, these authors again took a negative stance by giving the impression that treatments for early-found conditions can be harmful, "Not all treatments have important benefits, but almost all can have harms." (I get the feeling the people who wrote this have a more intimate relationship with pills than I do.) What's harmful about a walk? What's harmful about ditching the donuts? Lifestyle changes such as these have been shown to be just as effective as drugs for a number of conditions.

As I see it, there's more harm in letting a disease go undiagnosed, and having to resort to more extreme therapies when the person lands in the emergency room.
________

Are You Insulin Resistant? Get Pricked

If you've reached your mid 30s; are carrying a few extra pounds that can't be explained by breast augmentation or steroid-induced muscle build-up; had a brother, sister, mother, father, or childhood mail carrier ... the last of which was rumored to have spent a little extra time delivering your family's weekly editions of Life magazine in the months prior to your mother making her own special delivery of you, and which aging mail carrier happens to share your same lumpy schnoz, taste for black support hose, and appetite for Desperate Housewives reruns ... or any other first-degree relative known to have diabetes; or you're a woman who battled high blood sugars during a pregnancy - I offer this advice: get your blood glucose (BG) tested.

The only way to determine if you are insulin resistant, or have full-blown diabetes, is through a blood test. You don't have to have vials of your valuable stuff drained, just a finger prick test can provide valuable feedback.

If that prick is done after an overnight fast and the number (mg/dl) on the meter reads:

• 126 or more - See a doc for confirmation: 126 mg/dl is the cutoff for a diagnosis of diabetes.
  
  
• 100 to 125 - You may have a prediabetes condition called Impaired Fasting Glucose (IFG) - your cells are likely becoming insulin resistant. IFG, by itself, raises the risk for heart attack, stroke, hypertension, atherosclerosis, polycystic ovary disease, some cancers, and more.

As your cells become resistant to insulin, more glucose (and insulin) roams the bloodstream. Those glucose molecules damage blood vessels over time. That's why insulin resistance, even without a diagnosis of diabetes, is harmful. The little vessels, the ones in the eye and kidney, are particularly vulnerable. In fact, the inability to metabolize glucose effectively, i.e. diabetes, is the leading cause of new-case blindness and kidney failure worldwide. It's also responsible for most lower extremity amputations, although with all the unexploded ordnance in the world, limb-loss cause has gotten pretty region specific.¹

What Are Your Odds

A survey of US adults (20 and older) published last May revealed:

• One-third of adults with diabetes didn't know they had it.
  
• One in 4 adults (26%) had IFG. (The rate for adults 40 and older is higher.)
  
• IFG and undiagnosed diabetes were 70% more common in men than in women.

You can find more trends in their report:
Prevalence of Diabetes and Impaired Fasting Glucose in Adults in the U.S. Population

Back to Testing

If screening for diabetes (or insulin resistance) was as easy as taking a body temperature or measuring blood pressure, there'd be a lot more people with a full-fledged diagnosis standing in pharmacy lines spending their way towards their Medicare Part D donut hole (that's not to say lifestyle treatments aren't effective, but drug companies have pull). But BG testing can be a pain in the ass (or finger). Ask anyone with diabetes, since daily pricking - preferably several times a day - is part of the therapy.

It amazes me how many people we find in a screening. People walking around with no overt symptoms whose sugars are in the 200s, 300s, 400s! Granted, they're not fasting, but if your body isn't getting your BG down to the low 100s several hours after a meal, those extra glucose molecules are wrecking havoc.

I wish there was an inexpensive, accessible, easy-to-administer test for measuring blood glucose. Aside from testing one's urine, which is a good indicator of urine glucose, but not a good indicator of blood glucose (or tasting urine for sweetness which was performed in the past), there isn't. A one-off test as part of a blood workup doesn't tell you what's going on daily, monthly, or yearly - given the frequency of those tests. (There is a time-lapse blood test, the glycosylated hemoglobin or HbA1c, but again, it fails to reveal daily peaks and valleys.)

For those with the financial means, and the proclivity, a blood glucose meter like the one shown (I make no endorsement of brand) can be had for under $100. Manufacturers often provide a coupon to cover the cost of the meter, which isn't the gift you might think after realizing the single-use test strips go for around $1.00 a pop ... or prick.

________¹ "In the aftermath of the 2006 Israel invasion of Lebanon, it is estimated that southern Lebanon is littered with one million undetonated cluster bombs - approximately 1 ½ bombs per Lebanese inhabitant of the region."
- Wikipedia, Unexploded Ordnance

Photo: Homegrown

The Fungus and the Ant

We know fungi don't belong to the Plant Kingdom, nor do they belong to the Animal Kingdom. But given that they intake oxygen instead of carbon dioxide (like we do), eat plants instead of photosynthesizing (like we do),¹ and can apparently, as evidenced in this video, tame some of the animals that walk the earth, they sure seem closer to the animal world.²

See what you think:



If you like text to accompany your viewing, Lawrence Weschler, in his book Mr. Wilson's Cabinet Of Wonder: Pronged Ants, Horned Humans, Mice on Toast, and Other Marvels of Jurassic Technology describes the ant and the fungus thusly:

"Deep in the Cameroonian rain forests of west-central Africa there lives a floor-dwelling ant known as Megaloponera foetens, or more commonly, the stink ant. This large ant - indeed, one of the very few capable of emitting a cry audible to the human ear - survives by foraging for food among the fallen leaves and undergrowth of the extraordinarily rich rain-forest floor.

On occasion, while thus foraging, one of these ants will become infected by inhaling the microscopic spore of a fungus from the genus Tomentella, millions of which rain down upon the forest floor from somewhere in the canopy above. Upon being inhaled, the spore lodges itself inside the ant’s tiny brain and immediately begins to grow, quickly fomenting bizarre behavioral changes in its ant host. The creature appears troubled and confused, and presently, for the first time in its life, it leaves the forest floor and begins an arduous climb up the stalks of vines and ferns.

Driven on and on by the still-growing fungus, the ant finally achieves a seemingly prescribed height whereupon, utterly spent, it impales the plant with its mandibles and, thus affixed, waits to die. Ants that have met their doom in this fashion are quite a common sight in certain sections of the rain forest.

The fungus, for its part, lives on. It continues to consume the brain, moving on through the rest of the nervous system and, eventually, through all the soft tissue that remains of the ant. After approximately two weeks, a spikelike protrusion erupts from out of what had once been the ant’s head. Growing to a length of about an inch and a half, the spike features a bright orange tip, heavy-laden with spores, which now begin to rain down onto the forest floor for other unsuspecting ants to inhale."

Is this blurring the lines of what it means to be a vegan?

________¹ A few other fungi feats include making vitamin D (like we do), stalking animals (yikes!), glowing in the dark, and a few others I've outlined in my post "The Earth is the Mushroom's Gut".

² Who was it that said only humans can tame animals? With all the raking, mowing, weeding, feeding, and pruning I do, I often feel like a slave to the flora in my backyard.

Slate on Pollan

The online magazine Slate has been reading our minds, maybe even our comments:

Survival of the Yummiest: Should we buy Michael Pollan's nutritional Darwinism?
________