Deja vu all over again?

10. January 2009 William Davis (8)
HeartHawk brought a report and debate on The Heart.Org website to my attention:

Screening for risk factors or detecting disease? Debate divides the CV community. After landing on theheart.org, paste this onto your URL address:article/883239.do. (Full address: http://www.theheart.org/article/883239.do. I don't know why, but I couldn't go there directly.)

Some interesting comments:

Dr. Jay Cohn (University of Minnesota):

"They're saying that we can't identify disease very effectively so let's just stick with risk factors, which we know are very poorly predictive and nonspecific. It boggles my mind as to why they won't open up their minds to the importance of moving forward in finding better strategies to identify the disease that we are treating. It's very strange. They criticize these disease markers because they are not predictive of events, but they are looking at very short-term outcomes. We're interested in lifetime risk. We're screening people in their 40s who are concerned about morbid events in their 60s and 70s, and no trials are going to track them that long."

"You have to accept the pathophysiologic reality that heart attacks don't occur in the absence of coronary disease, and coronary disease doesn't occur in the absence of endothelial dysfunction and vascular disease, all of which now can be identified."

". . . Can we as a society and as a profession accept the idea that there is a link between the vascular abnormalities and the events? "And that that linkage is tight enough that it should allow us to accept slowing of progression of the vascular abnormalities as an adequate marker for slowing disease progression, without waiting for events to occur? As soon as you use the word surrogate, people jump up and say we have all these markers that we know don't work well—things like premature ventricular contractions [PVCs] on the electrocardiogram, LDL, HDL—but those are not the markers we're talking about. We're talking about structural and functional changes in the blood vessel and in the heart."


Wow. The idea may be starting to catch on.

As an interesting aside, Cohn et al use a 10-test panel to screen for vascular disease:

"Named for the center's benefactor, the Rasmussen score includes tests for large and small artery elasticity (compliance), resting blood pressure, blood-pressure response to moderate treadmill exercise, optic fundus photography, carotid intimal-media thickness (IMT), microalbuminuria, electrocardiography, left ventricular (LV) ultrasonography for LV volume and mass, and brain natriuretic peptide (BNP). Each test result is scored out of 10 for low, intermediate, or high risk, and the combined results yields a score that Cohn et al believe is more predictive than any of the existing standalone tests."


The counterarguments in this debate were provided by Dr. Philip Greenland (Northwestern University), who repeated his oft-used argument that, while he accepts that vascular disease can be identified, no one has proven that measuring it improves outcomes:

"We do have that evidence for risk-factor screening. Even though people criticize risk-factor assessment because it is not sensitive enough or not accurate enough, the interesting and curious thing is that we actually have evidence that if you go to the trouble of screening for risk factors and treating them, patients have better outcomes. We do not have that evidence for any of these other tests."


An interesting debate ensues that includes Track Your Plaque friend, Dr. William Blanchet, who characteristically argues persuasively in favor of broad screening for coronary disease with coronary calcium scoring:

"If we were doing our jobs in primary prevention, we would not need to look at improved intervention and secondary prevention to reduce coronary death."


Here's a shock: Dr. Melissa Shirley-Walton, the cardiologist who previously preached the "cath lab on every corner" argument seems to have undergone a change of heart:

"What if I walked up to a gentleman and said, "you are at risk for CAD, take a statin", to which he replies, "I'm afraid of those meds". BUT if he sees his calcium score........he is then convinced to be pro-active. What is so wrong with that? What is so wrong with allowing him to spend 250.00 US out of pocket in order to save the US 150,000.00 US later on?

No hard endpoints you say with intensive therapy for primary prevention? What about extrapolating from trials for secondary prevention like HATS? ARBITER2? And what exactly is the true definition of secondary prevention? Is it truly primary prevention if we already have intima thickness abnormalities, or fatty streaks? That would more likely fall under secondary prevention by today's new standards.

So, I'm all for any visual aid that will encourage compliance with life style change, necessary medical therapy and followup. If the patient is willing to spend 250.00$ to get a calcium score, so be it. Better yet, why not lower the price so everyone can have the option if they are motivated enough to seize an opportunity?"


I have to admit that I thought that Dr. Blanchet was wasting his time trying to persuade Shirley-Walton et al, but perhaps he is having an impact, though having hammered away at them for the last year or so.

These arguments, for me, eerily echo many previous debates I've heard. But I am encouraged by the more favorable treatment the notion of atherosclerosis screening is receiving. Just 5 years ago, all coronary calcium scoring would have received from the conventionalists is "more clinical studies are needed."

So perhaps the cardiology and medical worlds are inching slowly towards broad acceptance of screening for coronary and vascular disease.

BUT, screening is not sufficient. What do you do with the information?

Here is where the conventional-thinkers stop. The question that seems to occupy them: Perhaps we should screen people for hidden coronary and vascular atherosclerosis so we can better decide who needs a statin drug or a procedure.

I would pose a different challenge: We should screen people for hidden coronary and vascular atherosclerosis so we can better decide who needs to engage in an intensive program of disease reversal using natural means and as little medication and procedures as possible.

Well, perhaps in time.
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Comments (8) -

  • Jenny

    1/10/2009 3:17:00 PM |

    I've been mulling over that Veterans study published in NEJM that found lowering blood sugar had no impact on CVD in older veterans with diabetes. The conclusion from this seems to be that people shouldn't bother lowering blood sugar.

    That conclusion seemed to me to be just like saying, "Water does not put out fire" based on a study where a single pail of water was not able to make any difference in a raging house fire.

    Obviously some damage is irreversible and if you wait until someone is 65 and has had diabetes for a decade (many years of which the diabetes was undiagnosed) you are not going to be able to fix it in a year or two of doing even the correct things.

    This is probably true with all the other factors.

    OTOH, as I keep being reminded every time I visit the nursing home, there are times when a swift and fatal heart attack is a whole lot better than the alternatives. Without heart disease your old age likely to with years of cancer, COPD, or dementia.

  • JD

    1/10/2009 5:39:00 PM |

    http://www.sciencedaily.com/releases/2009/01/090106181731.htm

    More reasons not to take statins due to risk factors.

    "Results showed that 21% of the patients who were thought to need statin drugs before the scan (because of the Framingham and NCEP assessment tools) did not require them; “26% of the patients who were already taking statins (because of the risk factor assessment tools) had no detectable plaque at all,” said Kevin M. Johnson, MD, lead author of the study."

  • steve

    1/10/2009 6:46:00 PM |

    excellent post.  I fail to see why a calcium score is necessary if sub fraction testing of lipids is done.  Why isn't it enough to see that if you have tons of small LDL particles and little large fluffy ones, as well as low HDL then you need to take some lifestyle corrective action?

  • Anonymous

    1/10/2009 10:53:00 PM |

    Good blog Dr.D.

    FYI..In Torrance, they are doing a two for one calcium score test. So we are going for it. Costs a total of $400.00 for 2. Its the location on your website TYP.

    So thanks for sharing the testing locations.

    Stevie

  • pomeropd

    1/11/2009 12:57:00 PM |

    Good to hear someelse is attempting to develop a monitoring/early detection approach.

    BUT, the cost mentioned on their website $1800 is far more costly than a CT calcium score.

  • mark

    1/11/2009 11:28:00 PM |

    Dr. Davis, I did an archive search for Vitamin A and came to this entry:

    http://heartscanblog.blogspot.com/2008/06/vitamin-d-newsletter-autism-and-vitamin.html

    You wrote: "5) Vitamin A--Is vitamin A with vitamin D good or bad? This one I do not have an answer to. Reading the literature Dr. Cannell cites didn't help much. (Dr. BG--Any comments? Dr. BG is a vitamin A advocate.)"

    Chris Masterjohn wrote an article for the Weston Price Foundation on Vitamin D, and a sizeable segment deals with the relationship of intakes of  vitamin D AND A.  He provides some references, which will hopefully provide an answer to the question.

    The article is here:
    http://westonaprice.org/basicnutrition/vitamin-d-safety.html

    Mark.

  • Scott W

    1/12/2009 12:17:00 AM |

    One of my favorite quotes - Leo Tolstoy wrote:

    "I know that most men, including those at ease with problems of the greatest complexity, can seldom accept even the simplest and most obvious truth if it be such as would oblige them to admit the falsity of conclusions which they delighted in explaining to colleagues, which they have proudly taught to others, and which they have woven, thread by thread, into the fabric of their lives."

    It's about ego and losing face. Facts that disagree with their belief system are either incorrect or irrelevant.

    Scott W

  • Thomas

    1/12/2009 8:03:00 PM |

    Two points: science is about trying to improve our explanations, not searching for correlations (or 'risk factors', or 'links'). The role of experiment is to select between explanations.

    So we ought to be conjecturing and criticising/testing theories of heart disease.

    Treatment is a separate, medical, problem.

    On a philosophical level, I think we need to look at the individual: well-being and motives.

    It's probably correct to say that people need to cut back on carbs and alcohol, however, we need ask *why* people go after those things, and other addictions generally.

    If cutting carbs comes at the cost of self-coercion and misery, then we may have fixed somebody's CVS but we haven't solved the deeper problem. Which is a longterm recipe for relapse.

    Or are we afraid to venture near the intellectuals quagmires of subjectivity and spirituality?

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Do the math: 41.7 pounds per year

Do the math: 41.7 pounds per year

14. October 2011 William Davis (21)
Consumers of wheat take in, on average, 400 calories more per day. Conversely, people who eliminate wheat consume, on average, 400 calories less per day.

400 calories per day multiplied by 365 days per day equals 146,000 additional calories over the course of one year. 146,000 calories over a year equals 41.7 pounds gained per year. Over a decade, that's 417 pounds. Of course, few people actually gain this much weight over 10 years.

But this is the battle most people who follow conventional advice to "cut your fat and eat more healthy whole grains" are fighting, the constant struggle to subdue the appetite-increasing effects of the gliadin protein of wheat, pushing your appetite buttons to consume more . . . and more, and more, fighting to minimize the impact.

So, if you eat "healthy whole grains" and gain "only" 10 pounds this year, that's an incredible success, since it means that you have avoided gaining the additional 31.7 pounds that could have accumulated. It might mean having to skip meals despite your cravings, or exercising longer and harder, or sticking your finger down your throat.

400 additional calories per day times 365 days per year times 300,000,000 people in the U.S. alone . . . that's a lot of dough. Is this entire scenario an accident?

Or, of course, you could avoid the entire situation and kiss wheat goodbye . . . and lose 20, 30, or 130 pounds this year.
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Comments (21) -

  • Keenan

    10/14/2011 3:56:07 AM |

    On Sept. 10 I stopped my consumption of wheat containing foods and multi-grain rice crackers. Two weeks later I began having aching elbows which have not bothered me for years. I'm a 65 yr old male, thin with a bit of a 'wheat belly'  which is shrinking but my muscle mass is also shrinking. Have you heard of anyone experiencing changes in joints after stopping wheat and grains?

  • David Klatte

    10/14/2011 10:58:16 AM |

    That math isn't right and it is pretty misleading because a person who ate 400 more calories per day would gain weight up until they reached an equilibrium. It would be better to use something like the Harris Benedict equation to get a sense of how bad that is.

    I did that for a six foot 180 pound male who is 30 years old who is lightly active. Such an individual would maintain their weight at about 2246 calories per day. If they instead consumed 2646 calories per day, you would expect their weight to top off at about 244.7 pounds after some period of time. About a 65 pound gain, so nothing to sneeze at.

  • Dr. William Davis

    10/14/2011 12:48:30 PM |

    Hi, Keenan--

    I've only seen relief from arthritis, not a triggering of arthritis. That's strange.

    Of course, we are all subject to conditions that fall outside of wheat. It will be interesting to see whether this persists.

  • Dr. William Davis

    10/14/2011 12:49:04 PM |

    Thanks, David.

    Yes, this was hardly a scientific analysis, just an argument to graphically illustrate what we are battling.

  • Philippa

    10/14/2011 12:51:54 PM |

    This would be actionable advice across the Atlantic in the UK, where the Health Minister landed himself in a controversy this week by annoucing the Brits need to cut 5 billion calories off their annual diet.
    http://www.dailymail.co.uk/health/article-2048738/Jamie-Oliver-blasts-Andrew-Lansleys-plan-tackle-obesity.html

  • Teresa

    10/14/2011 8:23:30 PM |

    I couldn't post this below about the drug companies.  

    While I agree that a person should not be made to take medications against their will, what am I to do for a patient with a blood pressure of 220/110, on several occasions?  I have had a few.  They refused meds, and also refused to make any diet or lifestyle changes that may have helped.  While I haven't discharged any patients because of this, I do make sure they know the potential consequences of severe hypertension, including death.  Or worse, complete paralysis on one side, requiring total care.  Sometimes it's a matter of lesser evils.

    More of my patients want the  pills, because they are unwilling to do anything else to help their condition, even though I encourage them, and offer referrals for further education.  I hear it's too complicated, or their insurance won't cover it and it's too expensive.  I doubt I could make a living in my community without a prescription pad.  I wish I could!  I'll keep trying.

  • Princess Dieter

    10/14/2011 9:29:06 PM |

    Just a heads up (although you may have already seen it) is that Gillian Riley, the UK expert on food addiction/breaking out of overeating, recommended WHEAT BELLY in her October newsletter. http://www.eatingless.com/archive-newsletters.html#

    I've often recommended Ms. Riley's books--EATING LESS ; BEATING OVEREATING; and WILLPOWER!--to fellow hyperconditioned overeaters.

    Not eating wheat/sugar  sure helps in the "not overeating" dept. Laughing And Gillian is on board with that.

  • Corey

    10/14/2011 9:42:55 PM |

    Love your site doctor, but this is a terribly naive and simplistic approach. Calorie numbers are irrelevant, it's the kind of calories. Yes, I understand that the 400 you mention would most likely be 400 calories of additional carbs, but calories in/calories out don't determine weight now, do they?

    Really shouldn't post anything reinforcing the outdated but still omnipresent "calorie equilibrium" theory (fairy tale is more like it) of weight gain.

    Otherwise, keep up the good work.

  • Rieland Rigg

    10/15/2011 1:30:51 AM |

    I guess that explains pretty clearly why I've been able to lose about 40 lbs so far in 9 months... Smile

  • Ted Hutchinson

    10/15/2011 9:14:49 AM |

    If you live in the Northerm hemisphere Vitamin D levels drop from September through to March unless effective strength supplementation is implemented.
    Also 65yrs old the natural production of the antinociceptive, anti-inflammatory, antibiotic, antioxidants melatonin and vitamin d will have declined (by age 75 only 25% of vit d capacity is possible if sufficient 7-dehydrocholesterol remains in skin) so everyone becomes far more sensitive to pain/inflammation (and infection).  You can replace the missing Vitamin D3, melatonin with at least 5000iu/D3/oil based gelcap and 3mg Time Release melatonin (Also pay strict attention to improving natural melatonin secretion by using Flux getting outdoors midday and total darkness while asleep. ) Search this site for good Vitamin D3 & Melatonin information.

  • Kris

    10/15/2011 12:11:25 PM |

    A few months ago I did an experiment and cut all wheat and sugar out of my diet.

    That is, if it would contain even a trace amount I would not touch it. I managed to follow this approach for two months, I didn't measure my food intake but my body fat dropped quite a lot and I could see much more muscle definition, especially in my abdominal area.

    Personally I think sugar and wheat are the two main contributors to obesity, and I think the "minimum effective dose" for optimal health would be to remove those two ingredients completely. And of course that doesn't allow any room for "cheat meals" like some people think.

  • Dr. William Davis

    10/15/2011 1:25:26 PM |

    Well said, Chris.

    I agree. In particular, I find that no wheat is far better than less wheat. I believe this is mostly due to the appetite-triggering effect of wheat gliadin.

  • Linda

    10/15/2011 1:27:22 PM |

    @Ted
    I am also living in the Northern Hemisphere [Iowa] and do not get nearly as much sunshine as I should.I tend to be a hermit and spend most of my day inside.  Also over 65. I am taking 5000 IU a day of Vit D, gelcaps.
    Without a lot of testing, is there a way to determine if I should take more and, if so, how much. My biggest concern is tightness in the hip area every morning.

  • Dr. William Davis

    10/15/2011 1:28:17 PM |

    Well, Corey, allow me to elaborate on my "terribly naive and simplistic approach."

    This is clearly not a scientific analysis, but a simple effort to illustrate what happens with simple math what could theoretically happen with an additional 400 calories per day intake but ignoring all other factors, such as proportion fat vs. carbohydrates.

    So of course this is simplistic. It just makes the point that the increased calorie consumption triggered by wheat gliadin has potentially huge effects.

  • Dr. William Davis

    10/15/2011 1:44:40 PM |

    Good to have friends in this battle, Princess!

    We are up against the incredible financial and lobbying might of vertically-integrated Agribusiness and Big Food, who have billions of dollars to allocate on lobbying, marketing, and pushing their agenda. We have social media, the internet, and our wits.

  • Dr. William Davis

    10/15/2011 1:46:00 PM |

    Hi, Dr. Teresa--

    That's all you can do: Keep on trying.

    I'm impressed that you DO try, since most of our colleagues pay no mind whatsoever to even considering genuinely effective dietary changes.

  • Dr. William Davis

    10/15/2011 2:16:54 PM |

    Hi, Philippa--

    Let's see: England, population 51 million times 400 calories per day, times 365 days per day, equals 7.446 x 10,000,000,000,000 calories, or several thousand times more than the Health Minister proposes.

    5 billion calories would be child's play.

  • Ted Hutchinson

    10/16/2011 8:41:41 AM |

    I don't think there is any way anyone can accurately predict their 25(OH)D level either from uvb exposure or daily supplement usage. It depends on individual response. The banner graph at GRASSROOTSHEALTH.ORG shows for any regular daily intake the 25(OH)D achieved varies up to 100ng/ml. Taking 5000iu daily D3 only increases your chances of staying around 50ng/ml  but you could be anywhere between 20ng/ml and 120ng/ml without testing you can't know. After you've had a few tests you get to the point where you can predict the result but it's still worth retesting annualy to make sure nothing's changed. You should be able to find a 25(OH)D test for $60.

  • Fat Guy Weight Loss

    10/16/2011 3:11:20 PM |

    I eliminated sugar and wheat from my diet just from the observation that the food did not keep me full as long compared to other foods of same number of calories.  Not only led to weight loss but also eliminated my ocassional GERD as well as frequent stomach discomfort.  Now I have even more reasons to stay off the stuff and now being 95% wheat free (indulge in ocassional small portion of dessert) I no longer crave these foods and feel great.

  • Dr. William Davis

    10/18/2011 12:52:08 AM |

    How about "Skinny Guy Weight Loss"? (I didn't feel right calling you "Fat Guy . . .")

    It's such a simple formula for returning to health. I, personally, experienced relief from the same gastrointestinal effects. With any small indulgence, I am provided a graphic reminder of how it used to be.

    Stay strong. Your body will be grateful!

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