Grandpa Harry and Grandma Louise

Tuesday, June 30, 2009
Word from all those town hall meetings members of Congress are having back home this week is that lots of seniors are showing up scared that all the talk of health care reform in Washington, DC might just hurt them.The seniors’ reasoning goes that Congress is getting ready to cut Medicare in order to pay for the uninsured grandkids' newfound access to a health insurance policy of their own.Watch

LDL Calculator

Monday, June 29, 2009
Commenter Kiwi Geoff kindly wrote a program that calculates LDL using the Friedewald equation and the equation from this paper, which may be more accurate for people with a total cholesterol over 250 and triglycerides under 100. For people whose triglycerides are over 100, the Friedewald equation should be relatively accurate. You can plug your total cholesterol, HDL and triglycerides into the program (in mg/dL), and it gives you both LDL values side-by side. Here it is:

LDL Cholesterol Calculator

Thanks, Geoff.

Will Eliminating Medical Underwriting and Merging the Small Group and Individual Market Into a New Insurance Exchange Work? Lessons From Massachusetts

Creating a universal system of health insurance is everyone’s objective. But even if we pass an expensive health care bill in 2009 we won’t achieve it. We just don’t have enough money to cover everyone. Maybe, in the most expensive proposals, we would make it possible for 90% to be covered. In others, far less.The problem is that without an absolutely seamless system there will still be people

Another Fatty Liver Reversal

Sunday, June 28, 2009
Just to show it wasn't a fluke, reader "Steve" replicates the experiment:
I had a similar problem as what Sam described, and it just happened to coincide with my discovery of and commitment to a new eating plan (based on low/good carb, high in good fat and omega 3, and good protein--basically a mix of paleo, primal, low carb, whatever they call it). I consider myself lucky to have had great fortune in my timing of finding out about my fatty liver.

My ALT and AST [markers of liver damage] had been at 124 and 43 respectively, and then still at 80 and 30 in a follow up a few months later. I weighed in at about 205 (I'm 6'1.5" on a slimmish frame), which was my heaviest. I had been on a basic American (bad) diet. The whole thing shocked me, especially after a CT with contrast showed the fatty deposits on my liver (and prior to that, when the muddy ultrasound revealed a fatty liver and a possible pancreatic mass, later ruled out by the CT). Like Sam, though I was surely overweight, I was not fat or heavy. (Most people have noticed I look leaner, but are shocked when I disclose how much weight I have lost since they say "I cannot believe you had that much to lose.")

At about the same time I found out about my liver issue, I had been getting into reading about diet and health (something I had done once when I read the Zone stuff from Sears many years ago). I practically dove through Taubes, Eades, Cordain, and a bunch of blogs (including yours), and I made a commitment to fix my problem.

I started a pretty severe regimen at first, which included only protein and good fats with a minimal amount of non-starchy fruits and vegetables. Almost immediately, I started losing weight and body fat (as measured by an electrical impedance scale). I have always supplemented with fish oil, but I added krill oil and I also started eating grass-fed beef and pastured eggs and pastured pork as much as possible. I have added some coconut oil and pastured butter to my diet as well. I have dropped almost 40 pounds, I am down to about 10-11% body fat (from 24%), and my ALT/AST on my last test was 24/14 [normal]. I am getting another test soon, and I expect similar results.
And a later comment:
I can add to the story that I first found out about the fatty liver on a routine new patient blood screening when I moved to a new town. I can also add that it took a bit of initiative on my part to get to the right diagnosis. The first doctor suspected hepatitis, but when blood work ruled that out, he ordered the imagining tests. Once I was referred to a GI specialist, it was a quick diagnosis. Still, I had to undertake myself to figure out the best diet. The GI recommended eliminating white bread, rice, pasta, starches, etc. but also recommended lowering fat intake. Having done some of my reading on diet and health, I knew to follow the former advice and to modify the latter to be "get plenty of fat, but make sure its the right kind."
Steve took the initiative and fixed his damaged liver. He modified his GI doctor's advice based on what he had read about nutrition, with excellent results. I suspect his doctor will be all ears next time Steve comes into his office.

The liver is a remarkable organ. Besides being your "metabolic grand central station", it's the only organ in the human body that can regenerate almost completely. It can be 75% obliterated, and it will grow back over time. Fatty liver and NASH are largely reversible.

Wyden-Bennett Touted as an Alternative

I have to say I was a bit surprised watching Meet the Press this morning to hear the pundits on both sides of the political spectrum discussing the Wyden-Bennett Healthy Americans Act as an alternative to the more partisan Democratic health care reform bills already on the table in the House and Senate HELP Committee.The Republican spin seemed to be that, "We've always been for Wyden-Bennett,

Unions May Get a Pass on Health Care Benefits Tax

There is a major bipartisan effort going on in the Senate Finance Committee to reform the health care system.Reportedly, one of the elements of that effort may be a tax on "gold plated" health insurance benefits above a certain threshold--$17,000 for family coverage is one option being discussed. The new tax could raise close to $300 billion over ten years to help pay for a health care

When Friedewald Attacks

Friday, June 26, 2009
I don't get very excited about nitpicking blood lipids. That's not to say they're not useful. There's definitely an association between blood lipids and certain health outcomes such as cardiovascular disease. The thing that tires me is when people uncritically interpret those associations as evidence that lipids are actually causing the problem.

Low-density lipoprotein, or LDL, is the cholesterol fraction that typically gets the most attention. High LDL associates with heart attack risk in Americans and some other groups. Statins reduce LDL and reduce heart attack risk in a subset of the population, and this has been used to support the idea that elevated LDL causes heart attacks. This is despite the fact that lowering LDL via diet doesn't seem to reduce heart attack risk (typically by reducing total fat and/or saturated fat). Statins may in fact work because they're anti-inflammatory, rather than because they reduce LDL. But both explanations are speculative at this point.

The fact remains that if you want to know if Mr. Jones is going to have a heart attack in the next five years, measuring his LDL will give you more information than not measuring his LDL. This association doesn't seem to apply to all cultures or to Americans eating atypical diets. Then you can get into the fractions that associate more tightly with heart attack risk, such as low HDL, high triglycerides, small dense LDL, etc. Triglycerides vary with HDL (that is, when trigs go up, HDL generally goes down) and the ratio also happens to be a predictor of insulin sensitivity. Total cholesterol is virtually useless for predicting heart attack risk in the general population. This is something I'll discuss in more detail at another time.

When you walk into the doctor's office and ask him to measure your cholesterol, the numbers you get back will generally be total cholesterol, LDL, HDL and triglycerides. All of those except LDL are measured directly. LDL is calculated using the Friedewald equation, which is (in mg/dL):
LDL = TC - HDL - (TG/5)
Low-carb advocates have known for quite some time that this equation fails to accurately predict LDL concentration outside certain triglyceride ranges. Dr. Michael Eades put up a post about this recently, and Richard Nikoley has written about it before as well. The reason low-carb advocates know this is that reducing carbohydrate generally reduces triglycerides, often below 100 mg/dL. This is the range at which the Friedewald equation becomes unreliable, resulting in artificially inflated LDL numbers that make you have a heart attack just by reading them.

I had a
lipid panel done a while back, just for kicks. My LDL, calculated by the Friedewald equation, was 131 mg/dL. Over 130 is considered high. Pass the statins! But wait, my triglycerides were 48 mg/dL, which is quite low. I found a paper through Dr. Eades' post that contains an equation for accurately calculating LDL in people whose triglycerides are below 100 mg/dL*. Here it is (mg/dL):
LDL = TC/1.19 + TG/1.9 - HDL/1.1 - 38
I ran my numbers through this equation. My new, accurate calculated LDL? 98 mg/dL. Even the U.S. National Cholesterol Education Panel wouldn't put me on statins with an LDL like that. I managed to shave 33 mg/dL off my LDL in 2 minutes. Isn't math fun?

*This equation was designed for individuals with a total cholesterol over 250 mg/dL.

Letter to the Editor

Wednesday, June 24, 2009
I just got a letter to the editor published in the journal Obesity. It's a comment on an article published in October titled "Efficiency of Intermittent Exercise on Adiposity and Fatty Liver in Rats Fed With High-fat Diet."

In the study, they placed rats on a diet composed of "commercial rat chow plus peanuts, milk chocolate, and sweet biscuit in a proportion of 3:2:2:1," and then proceeded to simply call it a "high-fat diet" in the title and text body, with no reference to its actual composition outside the methods section. We can't tolerate this kind of fudging if we want real answers from nutrition science. Rats eating the "high-fat diet" developed abdominal obesity, fatty liver and hyperphagia, but this was attenuated by exercise.

As I like to say, the problem isn't usually in the data, it's in the interpretation of the data. The result is interesting and highly relevant. But you can't use terminology that tars and feathers all fat when your diet was in fact high in linoleic acid (omega-6), low in omega-3 and high in sugar and refined grains. Especially when butter and coconut oil don't cause the same pathology. I pointed out in the letter that we need to be more precise about how we define "high-fat diets". I also pointed out that the study is highly relevant to the modern U.S., because it supports the hypothesis that a junk food diet high in linoleic acid and sugar causes metabolic disturbances and fatty liver, and exercise may be protective.

The Co-op Version of the Public Plan—It’s a Camel!

Tuesday, June 23, 2009
I am sure you have heard the story about the committee that was charged with designing a horse but, because of the bureaucratic ways of the committee process, instead ended up creating a camel.We will not see a Medicare-like public health plan as part of any health care reform bill in 2009. I know proponents don’t want to hear that but it is crystal clear to me there simply are not the Democratic

Fatty Liver Reversal

Monday, June 22, 2009
On April 15th, I received an e-mail from a reader who I'll call Sam. Sam told me that he had elevated levels of the liver enzyme ALT (alanine transaminase) in his blood, which indicates liver damage. ALT is an enzyme contained in liver cells that's released into the bloodstream when they rupture. Sam also had fatty liver confirmed by biopsy.

Liver damage with fat accumulation is very common in the United States. According to the NHANES health and nutrition surveys, in the time period 1999-2002, 8.9% of Americans had elevated ALT. Just 10 years earlier (1988-1994), the number was 4.0%. Fatty liver is a growing epidemic that currently affects roughly a quarter of Americans.
Sam told me he had been trying to reverse his fatty liver for nearly a decade without success, and asked if I had any thoughts. He was not overweight, and from what I could gather, his diet was already better than most. I believe Sam knew intuitively that the right diet would improve his condition. With the usual caveats that this is not advice and I'm not a doctor, here's what I told him:
The quality of fat you eat has a very large influence on health, and especially on the liver. Excess omega-6 is damaging to the liver. This type of fat is found primarily in refined seed oils such as corn oil, soybean oil, and safflower oil... Sugar is also a primary contributor to fatty liver. Reducing your sugar intake will go a long way toward reversing it. Omega-3 fats also help reverse fatty liver if an excess of omega-6 is present. There was a clinical trial using fish oil that was quite effective. You might try taking 1/2 teaspoon of fish oil per day.
On May 11, I received another e-mail from him:
The day after your recommendations, less than a month ago, I started a regimen of 1200 mg/day of fish oil concentrate.

At the same time, I significantly reduced or even eliminated all forms of sugar from my diet. I did have a half glass of orange juice for breakfast every few days or so, and some fruits, and maybe a taste of dessert or a small candy bar here and there. I never exceeded the 30 g/day sugar limit you suggested.

I completely eliminated any and all fried foods and avoided most oils. I also avoided high glycemic index foods to some degree, e.g. white bread and potatoes. I did eat quite a bit more protein, including red meat, eggs, fish, chicken, and pork.

The balance of my diet and lifestyle was largely unchanged. I do drink a couple of beers every two to three weeks, but never more than three drinks in day. I have been doing more yard work, simply because of the season. Other than that, I don't get much more exercise than a typical inactive office worker.
In the same e-mail, he sent me his new ALT test results. He had been getting tested since 2002. The latest result, reflecting his progress since adopting the new diet, followed the previous test by less than a month. Here's a graph of his ALT levels. Below 50 is considered normal: The latest test was 52, just on the cusp of normal. That's nearly 50% lower than his next lowest result over the past 7 years, in less than one month of eating well. I suspect that his next ALT test will be well within the normal range, and the fat in his liver will gradually disappear, if he continues this diet. When I asked him how he was feeling, he said:
I did feel different after adjusting my diet. It's hard to describe, but overall I just felt better. I wasn't as tired when I woke up in the morning and I became a little slimmer, not a lot, maybe 3-5 pounds [note: he was not overweight to begin with]. I figured it was a placebo effect, but I think the fish oil has made a real difference.

Yesterday I had a few potato chips, corn chips, and some others. I didn't like it at all. Today I had half of a brownie for an afternoon snack and I completely crashed after an hour or so. I had a hard time keeping my eyes open. I no longer have much of a craving for snack food, I prefer to eat a full meal with more protein, e.g. beans, meat etc.
Fatty liver is a serious problem that responds readily to diet. I believe the main culprits are excess omega-6 from industrial vegetable oils; insufficient omega-3 from seafood, leafy greens and pastured animal foods; and excess sugar. The liver is your "metabolic gatekeeper", so it pays to take care of it.

How to Fatten Your Liver
Excess Omega-6 Fat Damages Infants' Livers
Health is Multi-Factorial

Time to Take Another Look at the Wyden-Bennett Healthy Americans Act?

Thursday, June 18, 2009
This from today's Kaiser Health News:"A bipartisan proposal from Sen. Ron Wyden, D-Ore., to replace the tax exclusion for employer-based health benefits with a standard deduction would do more to contain healthcare spending than Senate Finance Chairman Max Baucus' plan to cap the exclusion, according to a recent assessment by the Joint Committee on Taxation,' Congress Daily reports. 'The

A Little Tidbit

Wednesday, June 17, 2009
I'm gearing up for a new series of posts based on some fascinating reading I've been doing lately. I'm not going to spill the beans, but I will give you a little hint, from a paper written by Dr. Robert S. Corruccini, professor of anthropology at Southern Illinois university. I just came across this quote and it blew me away. It's so full of wisdom I can't even believe I just read it. The term "occlusion" refers to the way the upper and lower teeth come together, as in overbite or underbite.
Similar to heart disease and diabetes which are "diseases of civilization" or "Western diseases" (Trowell and Burkitt, 1981) that have attained high prevalence in urban society because of environmental factors rather than "genetic deterioration," an epidemiological transition (Omran, 1971) in occlusal health accompanies urbanization.

Western society has completely crossed this transition and now exists in a state of industrially buffered environmental homogeneity. The relatively constant environment both raises genetic variance estimates (since environmental variance is lessened) and renders epidemiological surveys largely meaningless because etiological factors are largely uniform. Nevertheless most occlusal epidemiology and heritability surveys are conducted in this population rather than in developing countries currently traversing the epidemiological transition.
In other words, the reason observational studies in affluent nations haven't been able to get to the bottom of dental/orthodontic problems and chronic disease is that everyone in their study population is doing the same thing! There isn't enough variability in the diets and lifestyles of modern populations to be able to determine what's causing the problem. So we study the genetics of problems that are not genetic in origin, and overestimate genetic contributions because we're studying populations whose diet and lifestyle are homogeneous. It's a wild goose chase.

That's why you have to study modernizing populations that are transitioning from good to poor health, which is exactly what Dr. Weston Price and many others have done. Only then can you see the true, non-genetic, nature of the problem.

The Lyon Diet-Heart Study: A Few More Thoughts

Although the degree of atherosclerosis (hardening/narrowing of the arteries) correlates with the risk of heat attack, the correlation isn't perfect. In fact, if you read my previous post on 20th century coronary heart disease trends in the U.K., you know that the frequency of heart attacks rose dramatically during the first half of the century, while the prevalence of severe atherosclerosis stayed the same or even declined.

If you accept the standard idea of how a heart attack occurs, first the coronary arteries become narrowed due to atherosclerosis. Then a clot forms, which lodges itself in a narrowed artery, blocking it and cutting off the blood supply to part of the heart muscle. The clot may be the result of a ruptured atherosclerotic plaque.

If you're unlucky, the loss of blood to your heart causes
arrhythmia, or a loss of coordination of the heart muscle. This can cause it to pump blood inefficiently, sometimes resulting in death. Arrhythmias are estimated to account for about half of all heart attack deaths in the U.S. Sometimes they occur without a coronary blockage as well.

Omega-3 fatty acids seem to affect all three parts of the process: the atherosclerosis, the clot formation and the arrhythmia. Supplementing fish oil, even in the absence of reduced omega-6, may
slow the progression of atherosclerosis according to a controlled trial.

Where omega-3 really shines is its ability to prevent clots and arrhythmias. In the
DART and Lyon trials, the benefits of improving omega-6:3 balance appeared much more quickly than would be possible if it were acting by reversing atherosclerosis. This may have involved the blood-thinning properties of omega-3. The most dramatic effects were on sudden cardiac death, often the result of arrhythmia. Omega-3 fatty acids potently suppress arrhythmias in animal models.

You can have severely narrowed and calcified arteries, but if a clot never shows up, you may never actually have a heart attack. The modern industrial diet is extremely thrombotic (clot-promoting), probably in large part due to the combination of excessive omega-6 and insufficient omega-3. If the artery blockage doesn't cause an arrhythmia, the heart attack may not be fatal.

Omega-3 fats seem to prevent heart attacks on multiple levels.

The Lyon Diet-Heart Study: Background
The Lyon Diet-Heart Study
The Lyon Diet-Heart Study: Implications
Polyunsaturated Fat Intake: What About Humans?

Senate Finance Scrambling to Find a Way to Pay for Health Care Reform While CBO Warns That the Congress Needs to Get Serious About Cost Containment

Toldjaso.As I have been posting, it has been my observation that the Democrats were headed for a health care bill that had a little cost containment window dressing, would take a little off the top in provider payments, and use lots of new taxes to pay for at least half of it. I also argued that would not be health care reform but just entitlement expansion.Apparently the CBO (God bless’em)

The Dumbest Thing I have Ever Seen a Health Insurance Company Do––And Three of Them Took Their Turn Doing It in Front of the United States Congress

And, I’ve been in the business for 37 years.First, let me stipulate we really need a system of universal care where everyone gets to have insurance. But we don’t yet so certain rules are unavoidable until we do.Here are a few separate clips from today's Los Angeles Times article, "Health Insurers Refuse to Limit Rescission of Coverage:""Executives of three of the nation's largest health insurers

Donations Gratefully Accepted

Monday, June 15, 2009
I've been incurring significant costs buying books and photocopying journal articles for the blog lately, so I've decided to add a donation button to the right sidebar. Anyone is still welcome to read posts and participate in the community, regardless of whether or not they donate. If you feel like you'd like to chip in, I'd appreciate it.

The button takes you to a PayPal webpage, where you can securely donate either with a PayPal account or using a credit card.

Just Which $2 Trillion Were They Talking About?

Just two weeks after putting $2 trillion in health care cost reductions on the table, the response to President Obama's plan to cut the health care providers by a total of $618 billion over the next ten years ($305 billion in his original budget and another $313 billion this week) is startling--if not in the final analysis predictable.Given that, at present trends, we are on our way to spending

It’s NOT the Prices Stupid!

Sunday, June 14, 2009
Out here on Kent Island, the federal government says that I like to watch the Baltimore TV stations and therefore forbids my satellite provider to give me access to the local DC channels. (We’re about an hour from both Baltimore and DC.)There is reason number one never to put the government in charge of any more than absolutely necessary.While my new digital converter box had been working just

The Lyon Diet-Heart Study: Implications

Saturday, June 13, 2009
There's something ironic about the Mediterranean diet used in the Lyon diet heart study, the one that dramatically reduced participants' risk of heart attack and all-cause mortality relative to the prudent diet control group: it wasn't actually a Mediterranean diet.

The concept of the Mediterranean diet as protective against heart disease may have originated in Dr. Ancel Keys' Seven Countries study, in which he compared the food habits and cardiovascular mortality statistics both between and within seven European countries. Countries surrounding the Mediterranean, and in particular the Greek island of Crete, had the lowest cardiovascular death rates. The Cretan diet is high in monounsaturated fat, relatively low in saturated fat, low in omega-6, and high in omega-3 fatty acids, including fat from seafood and the plant omega-3 alpha-linolenic acid. It also includes abundant green vegetables. This became the inspiration for the modern American concept of the "Mediterranean diet". The part about low omega-6 tends to be omitted.

Of course, if you look at modern heart attack mortality statistics by country, France is the lowest in Europe. France is a Mediterranean country, yet happens to have a very high intake of saturated fat per capita. So the cardiologist-approved version of the Mediterranean diet isn't exactly accurate.

The Lyon study departs even further from the traditional Mediterranean diet. Neither the Cretan nor the French diet are low in fat, yet participants were encouraged to reduce their fat intake. The Cretan diet includes some animal fat and eggs, while Lyon participants were encouraged to avoid these. And finally, the margarine. You could be guillotined for using margarine instead of butter in France, and I'm sure the Cretans aren't too fond of it either. Yet the margarine used in the Lyon study was rich in omega-3 alpha-linolenic acid, a critical factor.

Previous intervention trials such as MRFIT, the Women's Health Initiative (WHI) dietary modification trial, and others, exhaustively tested the hypothesis that reducing total fat intake reduces cardiovascular mortality. It doesn't. A dozen trials have also tested the idea that reducing saturated fat reduces cardiovascular mortality. It doesn't. Increasing fiber doesn't, according to the DART trial. Increasing fruit and vegetables modestly doesn't, according to WHI.

So what's left that's unique about the Lyon trial? It was the only trial to dramatically reduce omega-6 consumption, to below 4% of calories, while increasing omega-3 consumption from plant and seafood sources. In my opinion, that combination is the only plausible explanation for the large reduction in heart attacks and total mortality. That combination also happens to be a consistent feature of the real Mediterranean diet. In both Crete and France, omega-6 intake is relatively low, and omega-3 intake is relatively high. They also eat more real food than processed food in general, a factor that I don't underestimate.

Where do we go from here? Obviously I'm not going to recommend eating omega-3 enriched margarine. Mediterranean countries don't need industrial goop to avoid a heart attack, and neither do you. Anyone who's been to France knows they don't deprive themselves over there. They eat real food and they enjoy it.

The way to preserve the essential elements of the Mediterranean diet without becoming an ascetic is to eat fats that are low in omega-6, and find a modest source of omega-3. That means eating full-fat dairy if you tolerate it, fatty meat if you enjoy it, organs, seafood, olive oil in moderation, coconut oil, butter, lard, and tallow. Along with a diet that is dominated by real, homemade food rather than processed food. Some people may also wish to supplement with small doses of high-vitamin cod liver oil, fish oil or flax. I consider the latter to be inferior to animal sources of omega-3, but it can be useful for vegetarians.

Here's an Example of a Cooperative Not-For-Profit Health Plan--North Dakota Blue Cross

Friday, June 12, 2009
North Dakota Senator Kent Conrad has proposed establishing not-for-profit cooperative health plans as an alternative to the Medicare-like public health plan President Obama supports.I will suggest Senator Conrad take a look at this one:North Dakota Blue Cross Blue ShieldFrom their website:"More than 65 years ago, Blue Cross Blue Shield of North Dakota (BCBSND) began as two separate pre-paid

Health Care Cooperatives--An Old New Idea--So What's a Blue Cross Plan?

As opposition to a Medicare-like public health plan option grows, there has been a lot of talk about the compromise idea of creating not-for-profit health insurance cooperatives that would compete on a level playing field with existing private insurers. The reasoning goes they would keep the existing insurers "honest" by introducing a new element of competition.That's a great idea.And it was a

Raising Taxes to Pay for a Health Care Bill--Apparently the Congress Wouldn't Be Able to Find a John Deere in a Hay Stack

Wednesday, June 10, 2009
Why Do We Need to Raise Taxes to Pay For a Health Care Bill in a System That Has $10 Trillion in Waste?White House Budget Director Peter Orszag has promised in the next few days to detail just how the administration would like to see health care reform paid for.There are some people who question whether he will play it straight or play games with those numbers—will the list really be scoreable?He

The Health Industry's Achilles Heel

by BRIAN KLEPPER and DAVID C. KIBBE"You never want a serious crisis to go to waste." - Rahm Emanuel, White House Chief of Staff.Timing matters. The health industry has demonstrated steadfast resistance to reforms, but its recently diminished fortunes offer the Obama Administration an unprecedented opportunity to achieve meaningful change. The stakes are high, though. The Administration's health

The House Tri-Committee Bill—The Playing Field Just Moved Back to the Middle

Tuesday, June 9, 2009
Just when people were getting ready to write-off the Baucus bipartisan approach to a health bill the debate has swung back to the middle on a number of critical issues.For a longtime I have been telling you two things:The final health bill will be more moderate than liberal—for example, no Medicare-like public plan, only a soft individual mandate, but including insurance exchanges and

Public Plan Option: Sustainable Growth Rate Formula On Steroids?

Everyone in the health care debate seems to agree that the biggest problem is costs and that the best way to control costs is to get at the waste in the system. To raise the money needed to cover everyone and to make the system sustainable, goes the argument, we need to convert the upwards of 30% in excess costs now in the system to savings. I think that’s right. Many of my friends in the health

Beware of Tax Increases Disguised as Good Health Policy

Monday, June 8, 2009
Many believe we need to use the tax system as a way of reforming the health care system.The idea is to use tax policy to encourage more efficient benefit plans. It seems to me such proposals make a great deal of sense as part of a more comprehensive reform.However, I am worried that the Congress will simply raise taxes to pay for health care reform--perhaps as much as half the cost of a new

The Lyon Diet-Heart Study

Sunday, June 7, 2009
Now that we have the proper context, it's time to dig into the Lyon Diet-Heart trial, one of the most important and misunderstood diet trials of all time.

The trial enrolled 605 middle-aged French men and women who had previously suffered a heart attack. This is called a "secondary prevention" trial because it's designed to prevent a second heart attack. The advantage of secondary prevention trials is that they can be smaller, because men who have already had a heart attack are at a much higher risk of having another. This increases your statistical power. The disadvantage is that the participants aren't necessarily representative of the population at large.

Participants were divided into a control group and an intervention group. The control group "received no dietary advice from the investigators but nonetheless were advised to follow a
prudent diet by their attending physicians". Ah, the prudent diet rears its ugly head once again. In a later paper, they describe the prudent diet they used in a bit more detail:
[The control subjects] were expected to follow the dietary advice given by their attending physicians, similar to that of step I of the prudent diet of the American Heart Association.
And what exactly is this prudent diet? It was created by the National Cholesterol Education Panel, that very conflicted organization I've written about before. Step I is now defunct, having given way to the next generation of NCEP guidelines in 2000. Here's a summary of the old Step I from the American Heart Association's website:
The Step I diet restricted total fat to no more than 30 percent of total calories, saturated fat to no more than 10 percent of total calories, and cholesterol to less than 300 mg/day. It was intended as the starting point for patients who had high cholesterol levels.
This is an important point: the Lyon Diet-Heart trial wasn't an ordinary trial comparing the average person's diet to a different diet. It was a bare-knuckle showdown between the prudent diet and a modified version of the Mediterranean diet! I believe that's part of the reason it was rejected by the prestigious New England Journal of Medicine, although there's another reason I'll get to later. The intervention group received different advice:
Patients in the experimental group were advised by the research cardiologist and dietician, during a one-hour-long session, to adopt a Mediterranean-type diet: more bread, more root vegetables and green vegetables, more fish, less meat (beef, lamb, and pork to be replaced with poultry), no day without fruit, and butter and cream to be replaced with margarine supplied by the study.

Because the patients would not accept olive oil- traditional to the Mediterranean diet- as the only fat [because French people use more butter than olive oil- SG], a rapeseed (canola) oil-based margarine (Astra-Calve, Paris, France) was supplied free for the whole family to experimental subjects. This margarine had a composition comparable to olive oil [mon oeil- SG] with 15% saturated fatty acids, 48% oleic acid but 5.4% 18:1 trans. However, it was slightly higher in linoleic [omega-6- SG] (16.4 vs 8.6%) and more so in alpha-linolenic acid [omega-3- SG] (4.8 vs 0.6%), a fatty acid markedly higher (3 fold) in the plasma of the Cretan cohort in the Seven Country study compared to that of Zutphen (Netherlands).

The oils recommended for salads and food preparation were rapeseed and olive oils exclusively. Moderate alcohol consumption in the form of wine was allowed at meals. At each subsequent visit of the experimental patients, a dietary survey and further counseling were done by the research dietician.
After five long years of these brutal diets, participants in the intervention ("Mediterranean") group were eating slightly less total fat, 29% less saturated fat, 32% less cholesterol, a bit more bread, legumes, fruit, vegetables and fish, compared to the control (prudent diet) group. They were also eating less meat and much less butter and cream, although cheese consumption was the same between groups. French people know better than to give up their cheese!

So far, these changes are not unique. They're similar to the interventions in the ineffective MRFIT and WHI trials in the last post. Here's where it gets interesting. The intervention group ate three times as much omega-3 alpha-linolenic acid as the control group, and 32% less omega-6 linoleic acid. The ratio was 20 : 1 linoleic acid : alpha-linoleic acid in the control group, and 4.4 : 1 in the intervention group. This was due to the combination of a low-fat diet and the canola oil goop they were provided free of charge.

But it gets even better. The intervention group reduced their omega-6 linoleic acid intake to 3.6% of calories, below the critical threshold of 4%. As I described in my
recent post on eicosanoid signaling, reducing linoleic acid to below 4% of calories inhibits inflammation, while increasing it more after it has already exceeded 4% has very little effect if omega-3 is kept low*. This is a very important point: the intervention group didn't just increase omega-3. They decreased omega-6 to below 4% of calories. That's what sets the Lyon Diet-Heart trial apart from all the other failed diet trials.

After five years on their respective diets, 3.4% of the control (prudent diet) group and 1.3% of the intervention ("Mediterranean") group had died, a 70% reduction in deaths. Cardiovascular deaths were reduced by 76%. Stroke, angina, pulmonary embolism and heart failure were also much lower in the intervention group. A stunning victory for this Mediterranean-inspired diet, and a crushing defeat for the prudent diet!

There's a little gem buried in this study that I believe is the other reason it didn't get accepted to the New England Journal of Medicine: there was no difference in total cholesterol or LDL values between the control and experimental groups. The American scientific consensus was so cholesterol-centric that it couldn't accept the possibility that an intervention had reduced heart attack mortality without reducing LDL. The paper was accepted to the British journal The Lancet, another well-respected medical journal.

In the next post, I'll describe how we can benefit from the findings of the Lyon trial, and even surpass it, without having to resort to canola oil margarine.

*I admit 4% is somewhat arbitrary, but I think it's a good reference point based on the shape of the HUFA curve in this post.

$2 Trillion Sure Doesn't Buy You a Lot These Days

Friday, June 5, 2009
I know that we talk in terms of trillions and not billions in Washington these days but even by that new standard the way the Democrats are dissing the "$2 trillion stakeholders" is amazing.Not two days after the big stakeholder trade associations offered their "$2 trillion in health care savings," President Obama called on Congress to pass a health care reform bill that included the dreaded

The Lyon Diet-Heart Study: Background

Thursday, June 4, 2009
To appreciate the full significance of the Lyon diet-heart study, we have to go back in time a bit. We're off to 1982, the year the U.S. National Heart, Lung and Blood Institute published the results of their massive study, the Multiple Risk Factor Intervention Trail (MRFIT).

By 1982, the idea of the "prudent diet" was well ingrained in American medicine, despite a lack of direct evidence to support it, and even a certain amount of evidence at odds with it (such as the ill-fated Anti-Coronary Club trial). The prudent diet was designed to reduce the risk of heart attack, and suggests reducing total fat, saturated fat and cholesterol intake, while increasing consumption of vegetables, whole grains, fruit and fiber. Some versions of the diet replace saturated fat with polyunsaturated vegetable oils.

MRFIT involved 12,866 men at high risk of heart attack, making it one of the largest controlled trials of all time. Half of the group were told to keep doing what they were doing, under medical supervision, and the other half were given intense diet and lifestyle counseling. The intervention group was counseled to quit smoking and reduce their consumption of saturated fat and cholesterol, and increase polyunsaturated vegetable oil consumption.

After 6 years, 46% of the intervention group had quit smoking, compared to 29% in the control group. The intervention group reduced their cholesterol intake by 40% and their saturated fat intake by more than one-fourth, and increased their consumption of polyunsaturated fat (omega-6) by one third relative to the control group (source).

The results? After seven years, total mortality was 41.2 per 1,000 in the intervention group and 40.4 in the control group, a difference that was not even close to statistically significant. There were also no significant differences in heart attack rate or heart attack death rate. The authors and their apologists tried to wiggle out of the obvious conclusion through an avalanche of slippery math and editorials.

The results were mirrored by a later intervention trial published in 2006, the Women's Health Initiative dietary modification trial. This one was even larger, involving 48,835 postmenopausal women! This was another test of the prudent diet, in which participants were intensively counseled to
reduce total fat intake to 20% of calories and increase intakes of vegetables/fruits to 5 servings/d and grains to at least 6 servings/d.
After 6 years, the intervention group was eating 22% less fat, 23% less saturated fat, 20% less cholesterol, 15% more carbohydrate, 22% more fruits and vegetables, and slightly more fiber and whole grains than the control group. LDL dropped a bit in the intervention group.

I think you know what's coming...
Over a mean of 8.1 years, a dietary intervention that reduced total fat intake and increased intakes of vegetables, fruits, and grains did not significantly reduce the risk of CHD, stroke, or CVD in postmenopausal women...
Oh and you forgot to mention, 4.9% of women died in the intervention group as opposed to 5.0% in the control group. A "minor detail" that I couldn't find in the paper so I had to look up elsewhere. The study also showed that the diet modifications didn't reduce the incidence of breast or colorectal cancer, two of the most common cancers. RIP, prudent diet. Although it still seems to be struggling along, despite the beating. Another set of editorials appeared claiming that the diet didn't work because it wasn't extreme enough. How far do we have to move the goalposts before we give up?

There was one interesting finding that came out of MRFIT, which foreshadowed the result of the Lyon trial. MRFIT participants eating the most omega-3 from fish were at a 40% lower risk of coronary heart disease and a 22% lower risk of dying of any cause. This was not part of the intervention, so it doesn't necessarily reflect cause and effect. For that, we'll have to look at the Lyon trial.

The Health Care Reform Meter--Do the Dems Have the Money to Pay for It?

If I knew anything about computer graphics I'd post this really neat picture of a meter--sort of like a your car's gas gauge.The full point would represent the cost of a health care bill--somewhere in the $1.2 trillion to $1.5 trillion range.Each time someone put up scoreable savings I'd post it toward achieving the ultimate objective.So, you will have to imagine my meter.Here's where I think we

How to Use Comparative Research to Manage Health Care Costs

Recent proposals from the American Medical Association (AMA) to voluntarily use comparative research information ring hollow without their having any teeth to assure the information is in fact used.I thought Gail Wilensky had some thoughtful comments on the issue of using comparative research to control health care costs in today's Kaiser Health News.An excerpt from her interview with Christopher

The Health Care Affordability Model—A Plan That Will Control Costs and Improve Quality

Monday, June 1, 2009
The Health Care Affordability ModelHealth plan networks made up of insurers and providers would be required to first begin to stabilize and then control their costs. Failure to do so would mean the loss of their federal tax qualification. Premiums for a non-qualified health plan would no longer be tax deductible for individuals or plan sponsors who used these unqualified plans.The Affordability

Stakeholders Provide 28 Pages of Detail on How to Save $2 Trillion Dollars--And They Did it With a Straight Face!

America's Health Plans (AHP), the American Medical Association (AMA), the American Hospital Association (AHA), The Pharmaceutical Research and Manufacturers Association (PhRMA), the Advanced Medical Technology Association (AdvaMed), and the Service Employees International Union (SEIU) have detailed their plans to "do our part" toward achieving the administration's goal of saving $2 trillion in

Kaiser Health News Debuts Today and Features an Important Insight Into a Likely Health Care Bill

Kaiser Health News (KHN) debuted today and is a critically important addition to America's debate over health care reform.As the media has downsized in recent years, we have lost many reporters who were health care specialists. KHN will provide news outlets across the country with an important specialized source of solid reporting from an organization that has come to be known as uniquely expert