Mediterranean Diet Archives

June 24, 2013May 11, 2021

Statins and Heart Disease – Do Women Differ From Men?

Recent studies have shown that the symptoms of heart disease may differ between men and women. For example, women are less likely than men to have chest pain while suffering an acute heart attack (acute myocardial infarction). This may delay diagnosis and may partly explain why women seem to fare worse than men under these circumstances. Furthermore, the role of risk factors for heart disease may be different between the two genders.

It has also been suggested that treatment with cholesterol lowering drugs, so-called statins may be less effective for women than men, in particular in primary prevention (individuals without known cardiovascular disease).

We had the pleasure to address these important issues recently in my hometown Reykjavik, Iceland, when visited by Barbara H. Roberts MD who is a prominent expert in this field. Dr. Roberts is director of the Women’s Cardiac Center at the Miriam Hospital in Providence, R.I. and associate clinical professor of medicine at the Alpert Medical School of Brown University. She has written two hugely interesting books, How to Keep From Breaking Your Heart: What Every Woman Needs to Know About Cardiovascular Disease and The Truth About Statins: Risks and Alternatives to Cholesterol-Lowering Drugs.

I ran across Dr. Roberts recent book on statins while visiting New York last December for a cardiovascular meeting. I became very fond of it because it is extremely well written and can easily be read both by laymen and professionals. Her discussion is objective, evidence based, and she does not jump to any conclusions. Although Dr. Roberts has a point to make, her writing is careful and unbiased. Of course, the book has a strong message which I know many of my cardiologist colleagues will not agree with.

The internet may affect our lives more than we sometimes realize. A few days after I finished reading Dr. Roberts book I mentioned it in one of my blog posts because I felt it had an important message to everyone interested in cardiovascular disease and modern-day health care. Statins are used by millions of people worldwide. Whether we like it or not, we have an obligation to look at both the positive and negative effects of this therapy.

By coincidence, Dr Roberts read my article and we became acquainted. Six months later she arrived in Reykjavik to give two talks, a public lecture on how women may reduce their risk of heart disease, and another lecture at aimed at professionals at our University Hospital on statin therapy.

How to Keep From Breaking Your Heart: What Every Woman Needs to Know About Cardiovascular Disease

Dr. Roberts gave her first talk on the evening June 18th 2013. It was attended by more than 300 people, mostly women. I was really proud by the huge interest. Thank you, Icelandic women for showing so much interest in how to improve your health and reduce the risk of heart disease. Dr. Roberts gave a fascinating overview of cardiovascular disease, risk factors, lifestyle and prevention. It was a memorable evening.

She started by addressing the anatomy of the normal heart, the coronary vessels and the blood circulation. She then discussed important symptoms and disease concepts such as angina pectoris, myocardial infarction or heart attack, congestive heart failure, and palpitations. She touched on the underlying pathology of cardiovascular disease and introduced important disease mechanisms like atherosclerosis, plaque rupture and clot formation.

Barbara H Roberts MD is director of the Women’s Cardiac Center at the Miriam Hospital in Providence, R.I. and Associate Clinical Professor of Medicine at the Alpert Medical School of Brown University

Dr. Roberts then went on to describe how the symptoms of an acute heart attack may differ between men and women. Men are more likely to experience chest pain than women. Women are more likely to have nausea, back, shoulder, abdominal or neck pain than men. Women are also more likely to have no chest pain, and just shortness of breath or sometimes fatigue.

Dr. Roberts went through most of the known modifiable risk factors for heart disease like smoking, high LDL cholesterol, low HDL cholesterol, high blood pressure, diabetes, obesity, sedentary lifestyle, the metabolic syndrome and inflammation.

Dr. Roberts dedicated a part of her talk to treatment with statin drugs. Statins are frequently used to lower cholesterol and to reduce the risk of heart disease. It is her opinion that the benefits of statins have been greatly exaggerated and that their dangers have been greatly downplayed. She mentioned the most common side effects of statin therapy like muscle pain, rhabdomyolysis, cognitive dysfunction, tendon and nerve damage, diabetes, liver and kidney damage, fatigue, cataracts and congenital defects in babies exposed before birth. She summarized the results from clinical trials addressing the effects of statins in women. She underlined that no study has ever shown that treating women who do not have established vascular disease or diabetes with a cholesterol lowering medicine lowers the risk of cardiac death or cardiac events.

Dr. Roberts concluded that high levels of LDL cholesterol appear less predictive of cardiovascular risk in women than in men. In women, HDL cholesterol appears more predictive of risk than any other lipid level. She emphasized that abnormal blood cholesterol is but one of many risk factors for cardiovascular disease and that it´s not all about the LDL-cholesterol.

After covering the health risks of diabetes, inflammation, obesity and the metabolic syndrome Dr. Roberts went on to talk about the influence of diets. She mentioned a few dietary fictions like “Eating foods high in cholesterol raises your cholesterol” and “Low fat diets are good for your heart“. She also mentioned a few dietary facts like “Low fat diets lower HDL cholesterol so they are NOT heart healthy. You need to eat heart healthy fats” and “You can eat your way through any cholesterol lowering medicine“. Finally she underlined the strong scientific evidence indicating that a Mediterranean type diet reduces cardiovascular risk.

Dr Roberts concluded her lecture with this message:

Prevention of Heart Disease Made Easy:

If you smoke, STOP

If your cholesterol is high, get it down

If your blood pressure is high, get it down

If your blood sugar is high, get it down

If your weight is high, get it down

Do moderate exercise 30 minutes/day

Eat a heart healthy diet

Pick your parents wisely

The Truth About Statins: Risks and Alternatives to Cholesterol-Lowering Drugs

Dr. Barbara Roberts gave her second lecture in Reykjavik on June 19th at Landspitali University Hospital. Again she did a wonderful job with a highly informative and provocative talk. Unfortunately, only about 40 people attended, among them only a handful of cardiologists. I know doctors are busy people, but I have to admit that I would have loved to see more colleagues. Statins are the most frequently prescribed drugs by cardiologists all over the world. Many of us believe they are our most important weapon when it comes to pharmacological treatment of cardiovascular disease. So, I can understand that it may be unpleasant to hear about their presumed bluntness.

Dr. Roberts started by going through many of the advantages and disadvantages of statin therapy. She quoted Doctor Rita Redberg: “There are millions of women on a drug with no known benefit and risks that are detrimental to their lifestyle — and no one is talking about it”. She also quoted Dr. Sidney Blumenthal: “The totality of the available biologic, observational and clinical-trial evidence strongly supports the selective use of statin therapy in adults demonstrated to be at high risk for heart disease”. So, “are statins angels or devils” she asked?

Next Dr. Roberts took us through the history of the lipid hypothesis, from the work of the German pathologist, Rudolph Virchow on atherosclerosis in 1856, to the modern day clinical trials. She underscored the difference between absolute and relative risk reduction. She summarized data from clinical trials on the use of statins in secondary prevention. The result was that statins significantly reduce the number of cardiac events among individuals with cardiovascular disease, although the effect appears less pronounced among women than men. Again, she underscored the fact that clinical trials have not shown that treating women who do not have established vascular disease or diabetes with a cholesterol-lowering medicine lowers the risk of cardiac death or cardiac events.

Dr. Roberts then went through all the most common side effects of statin therapy. Unfortunately, this list appears to be growing, not unsurprisingly though, considering the huge number of people taking these drugs. Recently the increased risk of diabetes and cognitive dysfunction associated with statin therapy has been highlighted. Finally, she talked about possible alternatives to statin therapy. Again she underscored the positive effects of the Mediterranean diet.
Dr. Roberts final conclusions were:

Statins confer a small reduction in the risk of heart attacks and in some studies of dying of heart disease in those with established disease. The benefit is less in women than men.

They confer much less benefit in men without disease and none at all in healthy women.

The Mediterranean Diet is more effective than statins in lowering risk, WITHOUT ANY SIDE EFFECTS.

The Bottom Line

We, cardiologists tend to focus on the positive effects of statins. This is completely reasonable because clinical trials have shown that these drugs are very effective under certain conditions, and they improve the prognosis of patients with cardiovascular disease. Statins may also be effective among individuals at high risk for developing cardiovascular disease, such as those with diabetes. Nobody doubts the important role of statins in patients with familial hypercholesterolemia (FH).

Sometimes it is much easier for doctors to prescribe a drug than not to do it. Furthermore, the positive effects of statins are highly emphasized by the medical community, and these drugs are generally considered well tolerated. I am much more likely to be criticized by my colleagues if I don´t put a patient on statin therapy who might benefit, than if I put someone on such therapy who will probably not benefit from it. Sometimes we forget the words of our ancestors: Primum non nocere; first do no harm.

Sooner or later we will have to face the fact that many people have side effects from statin therapy. Often, these effects are not obvious. As doctors, we have to be alert and monitor patients for such side effects.

It has been pointed out by some of my colleagues that highlighting the negative effects of statins may encourage some patients to stop taking their drugs. Obviously, if these are individuals who are benefitting from their therapy, this may cause harm. On the other hand, providing truthful unbiased information to our patients can never be ethically wrong. Indeed, such information is necessary for shared decision making. Otherwise, our patients will not be able to make a truly informed decision on whether they want a certain treatment or not.

Finally, I would like to sincerely thank Dr. Barbara Roberts for visiting Iceland and sharing her knowledge and experience. Again, I recommend everyone interested in cardiovascular disease and modern-day health care to read her book on statin drugs. It is a strong reminder of our limited knowledge of the long-term effects of drugs that are being prescribed to millions of people worldwide.

March 7, 2013May 11, 2021

What Is the Best Diet for Type 2 Diabetes?

An interesting scientific paper on the efficacy of different dietary approaches in type 2 diabetes recently caught my eye. The study has not received much media coverage although it certainly addresses a question of importance to millions of people worldwide.

More than 20 million people in the US have type 2 diabetes. According to the International Diabetes Foundation (IDF), the number of people diagnosed with diabetes in the last twenty years has risen from 30 million to over 246 million, or about 7.3% of the world population. Approximately 90% of those have type 2 diabetes. Diet and nutrition play a central role in the well-being of all those people.

The study, which is a systematic review, was published in a recent issue of the American Journal of Clinical Nutrition. A systematic review is an unbiased survey of all the scientific evidence available on a given question. In this case, Ajala and coworkers from Plymouth UK addressed the efficacy of different diets to induce weight loss and improve glycemic control and lipid profile among people with type 2 diabetes.

Type 2 Diabetes and Prediabetes

Before we go further, let me touch on few basic issues, just for the sake of clarification. Type 2 diabetes is a chronic condition that affects the way our body metabolizes sugar (glucose). Glucose is the body’s primary source of fuel. With type 2 diabetes, the body either resists the effects of insulin — a hormone that regulates the movement of sugar into our cells — or doesn’t produce enough insulin to maintain a normal glucose level.

Glucose comes from two major sources, food and the liver. Our liver produces and stores glucose. When glucose enters the blood stream, insulin is released from the pancreas. Insulin enables sugar to enter the cells of the body where it is used for energy production. Without insulin, or when insulin resistance is present, glucose builds up in the blood stream. This is what happens in diabetes. Elevated levels of blood glucose may cause a number of symptoms, and increase the risk of developing heart disease and stroke.

It is not fully understood why people develop type 2 diabetes, but certain factors increase the risk. Overweight is a risk factor. However, many overweight and obese individuals never have diabetes, and many people with type 2 diabetes are not overweight or obese. If our body stores fat primarily in the abdomen, the risk of diabetes is higher than if the body stores fat elsewhere such as on our hips and thighs. Family history and physical inactivity also increase the risk of diabetes.

The risk of type 2 diabetes increases with age. Lately, type 2 diabetes has become increasingly common in children, adolescents, and young adults. The main goals of therapy are to improve glucose metabolism and thereby reduce blood sugar levels and to mitigate the risk factors for the main complications of diabetes, heart disease, and stroke. Overweight often contributes significantly to the development of type 2 diabetes. Therefore weight loss often plays a large role in the treatment of the disorder.

Prediabetes is a condition in which blood sugar level is higher than normal, but not high enough to be classified as diabetes. Left untreated, prediabetes often progresses to type 2 diabetes. There is good evidence showing that dietary modification can prevent the progression from prediabetes to type 2 diabetes. Howvever, the optimal dietary approach to type 2 diabetes is less clear. Before I discuss the recent study by Ajala and coworkers, let’s have a look at the background stage.

What Is the Best Diet for Type 2 Diabetes?

For some years, experts and scientists have debated what dietary approach is best to control and treat type 2 diabetes. Most regulatory authorities, like the British Diabetic Association, European Association for the Study of Diabetes (EASD), American Diabetes Association (ADA), Canadian Diabetes Association and many more usually recommend a carbohydrate intake of 50-60% of total energy intake, total fat intake less than 30% of energy, with restriction of saturated and trans fat intake. Some experts believe there is insufficient evidence to justify these recommendations.

Almost five years ago, an international group of scientists and experts on diabetes, nutrition and carbohydrate metabolism published an overview paper suggesting a critical appraisal of the role of carbohydrate restriction in type 2 diabetes mellitus and the metabolic syndrome. The authors pointed out that current nutritional approaches often emphasized a reduction in dietary fat.

They believed that such approaches often were ineffective, leading to more reliance on drug therapy. They argued that carbohydrate restricted diets were at least as effective for weight-loss as low-fat diets and that the substitution of fat for carbohydrate was beneficial for the risk of cardiovascular disease. Furthermore, they provided evidence suggesting that carbohydrate restriction improved control of blood glucose and reduced insulin fluctuations. They believed the recommendation to reduce the intake of saturated fat in type 2 diabetes lacked scientific evidence.

The authors concluded: “Finally, while no systematic study of clinical practice has been done, anecdotal evidence suggests that carbohydrate restriction is a common clinical recommendation for diabetes. We believe that there is a need to codify these recommendations in light of current evidence.”

In the recent systematic review by Ajala and coworkers, data was collected from all studies published up to July 2011 that compared low carbohydrate, vegetarian, vegan, low glycemic index (GI), high fiber, Mediterranean, and high protein diets with control diets including low-fat, high-GI, ADA diet, EASD diet, and low-protein diets. Only randomized controlled trials with an intervention lasting longer than six months were selected. A total of 20 studies including 3073 individuals fulfilled the defined criteria and were selected for the metaanalysis. Measured outcomes were HbA1c (which reflects glucose control), difference in weight loss, and changes in HDL-cholesterol (“good cholesterol”), LDL-cholesterol (“bad cholesterol”) and triglycerides.

The low carbohydrate, low-GI, Mediterranean, and high protein diets all led to a greater improvement in blood glucose control (HbA1c) compared with their respective control diets, with the largest effect seen with the Mediterranean diet. Low-carbohydrate and Mediterranean diets led to a greater weight loss compared with their control diets. Low carbohydrate, low-GI, and Mediterranean diets all led to an elevation of HDL-cholesterol. Only the Mediterranean diet led to a significant reduction in triglycerides. High protein diets had no effects on markers of lipid profile. One study from their review compared the effects of a vegan diet to the low-fat ADA diet. The vegan arm had a significantly lower levels of total cholesterol, LDL-cholesterol, and HbA1c, indicating better glycemic control by the vegan diet. Similar results were obtained in one study that compared the effect of a vegan diet with the EASD diet, with more weight loss on the vegan diet.

Ajala and coworkers conclude that their review provides evidence that modifying the amount of macronutrients can improve glycemic control, weight, and lipids in type 2 diabetes. In their analysis, low carbohydrate diets appeared to provide superior weight loss, better control of blood glucose, and better lipid profile, compared with low-fat diets. The authors also conclude that vegan and vegetarian diet may improve glucose control and promote weight loss in type 2 diabetes.

The Mediterranean diet is rich in olive oil, legumes, unrefined cereals, fruit, and vegetables, low in meat and meat products, and with moderate contents of dairy products (mostly cheese and yogurt), fish and wine. The total fat in this diet is typically 25-35% of calories, with saturated fat less than 8% of calories. The meta-analysis indicates that a Mediterranean diet provides better control of blood glucose, greater weight loss, and a more favorable lipid profile compared with a conventional diet and ADA diet.

A meta-analysis of such widely different studies may be problematic. For example, the control diets differed significantly between studies and the duration of the studies ranged between six months and four years. The definition of a low carbohydrate diet varies between studies. While the authors acknowledge the limitations of their study, they believe that low carbohydrate, low-GI, Mediterranean and high-protein diets should be considered in the overall strategy of diabetes management.

What is the best diet for type 2 diabetes? Although there is probably not a simple answer, the question reflects one of the main challenges of modern medicine. It is likely that our dietary recommendations will have to be tailored to the needs of the individual. A one-size-fits-all approach is unrealistic. Although not providing any definitive answers, the study by Ajala and coworkers is an important contribution to our understanding of this highly important issue.

March 2, 2013May 11, 2021

Diet or Drugs to Prevent Heart Disease

The risk of heart disease has been associated with countless different things.

Smoking, diabetes, high blood pressure, overweight, obesity, sitting and watching TV, eating too much fat, eating too much sugar, not eating certain fats, eating meat, not eating fish, eating too much animal fat, eating cholesterol, eating saturated fat, eating trans fats, high blood cholesterol, high LDL-cholesterol, inflammation, family history of heart disease….

Is it really possible to avoid being hit by this dreadful disease, the most common cause of death and disability worldwide?Should we change our lifestyle? How can we improve our diet? Should we take drugs for prevention?

The risk of heart disease increases with age. So, if we become old enough, we will probably have heart disease sooner or later, and most likely die from it. But that is not necessarily a bad thing. We all have to die from something. Dying from something else is not a goal by itself.

So maybe we would be more accurate if, instead of aiming at preventing, our goal was to delay the onset of heart disease. However, defining our goal is probably less important than defining the methods to achieve it.

A huge number of healthy adults will have heart disease in the next ten years. Many will be treated with drugs, some will have angioplasty and stents, and some will have open heart surgery. Many will die from the disease. A substantial number will be left with severe disability. Many will not be able to work, and many will not enjoy the quality of life they had before the disease hit them. So, I presume we all agree that delaying the onset of heart disease is a worthwhile target.

Who should worry about getting heart disease? Probably everybody. But, who should worry the most? Who is most likely to be struck by heart disease in the next few years?

This is where it comes to the so-called risk factors. If you have many risk factors, the risk of having a heart attack or stroke becomes higher. The strongest risk factors are smoking, diabetes, high blood pressure, high levels of LDL-cholesterol, low levels of HDL-cholesterol, overweight or obesity, and family history of premature coronary artery disease. If you don’t have any risk factors, your aim should be to avoid them at all costs. But, if you have some of these risk factors, what can you do?

A Visit to Dr. Oxenhaler

Let’s assume you are a responsible person (you probably are by the way, because you are reading my blog), and you want to do everything you can to delay the onset of heart disease.

Maybe your father had a heart attack in his fifties. Maybe you have gained a bit of weight, and maybe your cholesterol level is a bit too high. So, you decide it’s time to have a chat with your general practitioner, Dr. Oxenhaler, the family doctor. Last year he put you on a drug to lower your blood pressure. This time, you are better prepared for your visit because you have been reading my blog.

You are sitting in front of Dr. Oxenhaler in his office. He just finished measuring your blood pressure, and now he is watching your blood work on his computer screen. This is how the conversation might evolve.

‘Is there a specific reason you decided to come to see me. Have you been having chest pain or discomfort of any kind?’
‘No Dr. Oxenhaler. I was just worried. I’ve been reading lots of stuff about heart disease on the internet. I was wondering what I should do to avoid having a heart attack.’
‘Well, I guess you should be a little bit worried, but I’m glad you care. That’s the first step. Your blood pressure is fine, thanks to the medication I prescribed for you last year. However, your cholesterol is 277 mg/dl (6.9 mmol/L), that’s way too high.’
‘How about my LDL cholesterol?’

Dr. Oxenhaler watches you carefully, his glasses sliding down on his nose. He takes a deep breath.

‘I see you’ve been reading. That’s good. Education is the key to better health. Your LDL cholesterol is 182 mg/dL (4.7 mmol/L), that’s also way too high. HDL-C, the good cholesterol is 40 mg/dL (1.0 mmol/L) which is too low. Considering your family history and your history of high blood pressure, the risk is quite high. By using the Framingham risk calculator, I can see that your risk of having a heart attack in the next ten years is about 17 percent.’

You feel a little numb like the blood is draining from your head. Dr. Oxenhaler notices your paleness and becomes a bit more sympathetic.

‘Don’t be scared though. We can take care of this. Treatment is available. By putting you on a cholesterol lowering drug, we can lower your risk substantially. Your cholesterol will go down and so will LDL-cholesterol. Your risk of heart attack will be much less’.
‘But I read that the effect of statin drugs is very small when they’re used for prevention in people who don’t have heart disease’.
‘That’s a misinterpretation. The risk reduction in the clinical trials is about 30 percent among high-risk individuals, which in my mind is quite substantial.’
‘You’re talking about relative reduction then Dr. Oxenhaler, aren’t you?´

There is a momentary pause. You catch a glimpse of surprise in his eyes. He looks at his watch and then back at you, a faint smile on his lips.

‘Yes, relative reduction, that’s correct’, he says.
‘I’ve read that statins have lots of side effects as well.’
‘Side effects are very uncommon. A small number of people have muscle pain, but it’s rare. Most people do not have any problems with cholesterol-lowering drugs.’
‘I read that some people have memory loss.’

He looks surprised.

‘I don’t recall any of my patients complaining of memory loss from statins.’

Now you can’t help wondering whether Dr. Oxenhaler is taking statins. You dismiss the thought immediately. You have to keep focus.

‘I’ve heard there is more risk of diabetes if you take statins,’ you say,

He loosens his tie a bit, and he has stopped smiling. You’re aware that you’re using up a lot of his time. There are more patients waiting for him.

‘Let me just tell you that the benefits of statins definitively outweigh the risks’, says Dr. Oxenhaler.

But you’re not giving up.

‘Isn’t there something I can do by myself, change may diet or exercise more?’, you ask.
‘Diet and exercise is fine. Cut down on fats, especially saturated fat and don’t eat too much cholesterol. That’s helpful. But it won’t replace statin treatment when it comes to reducing your risk.’
‘I heard about a study published recently in The New England Journal of Medicine showing that a Mediterranean diet could lower the risk of heart attack and stroke if you have risk factors like I do’
‘You’re right indeed, but the effect is very small. Besides, diets are usually hard to stick with.’
‘I read that the relative risk reduction was about 30 percent on the Mediterranean diet compared to a low-fat diet. Isn’t that about the same effect that statins have in a similar population?’ Could a Mediterranean diet be an alternative to statin therapy?

Dr. Oxenhaler does not answer right away. He stares at the computer screen.

‘Very well, why don’t you try the Mediterranean diet for six months and then come visit me again. We’ll measure your cholesterol and decide what to do. If it’s still high, I definitively recommend statin treatment to cut your risk’, he says eventually, still watching the computer screen.

‘Isn’t it possible that the diet is helpful, although my cholesterol stays the same?’

Now he is looking at you again, more seriously than before. You can’t really tell whether he is annoyed or not.

‘If we are to succeed in lowering your risk of heart disease, we must lower your LDL-cholesterol. That’s a fact.’
‘But, I just read about the Women’s Health Initiative showing that reducing the intake of fat lowered cholesterol, but did not cut the risk of heart disease’.

Now he is up on his feet and offering his hand. He shakes his head in disbelief, but he is smiling again.

‘Please come back to see me in six months. Good luck with the Mediterranean diet. Go easy on the wine though. And for God’s sake don’t believe everything you read on the internet….’