Category Archives: Heart Disease

Chinese Spring Festival Eve: As Unhealthy As Thanksgiving?

Next week’s Spring Festival will already be my sixth here in Beijing, and Spring Festival Eve is always one of the highlights of my year. My wife and I spend a wonderful evening with our Chinese in-laws, and all two dozen of us will gorge for hours on endless rounds of dumplings and snacks, drink all types of alcohol and juices, and happily shout at the TV screen as another awful performer lip syncs yet another tacky ballad.  Just before midnight we will all rush to the rooftop and spend the next hour in awe at the lightshow and sound spectacular coming from every corner of Beijing. It’s difficult to describe to people back in the US just how impressive Spring Festival is. It’s like a combination of American Thanksgiving, Christmas and the Fourth of July — only much, much more intense, and lingering for a couple weeks, fading away with one last blast on Lantern Festival.

Chinese New Year Spring FestivalOne of the major connections, unfortunately, between Chinese Spring Festival and the American holidays is the habit of ending these festive days slightly heavier and more unhealthy than when we started. So let’s continue another annual tradition: news media filled with warnings by nerdy doctors like myself lecturing their readers to not have any holiday fun. So I now shall try the difficult task of balancing health advice while not ruining your party. I could just say “everything in moderation!” and send you on your way to the supermarket, but I would like to make a couple points first. So please bear with me, and I’ll reward you with a cookie at the end. Or maybe just a sticker.

I think it’s important to step back a bit and make sure everyone realizes that the main killers and causes of disability across both China and the USA are cardiovascular disease, especially heart attacks and strokes. And for many reasons, the situation in China is more serious, according to the World Bank’s fascinating report from 2011 regarding the global burden of disease in China. They report that the average Chinese person can expect to live only 66 “healthy years” (years free from disease and disability), which is ten years less than in some leading G-20 countries. Strokes, in particular, have “the largest health and well-being impact on an individual.

I find these statistics alarming, but in my talks with my Chinese patients, most have no idea about this data. Nor do they know about the report’s other warnings that Chinese eat an astonishingly dangerous amount of salt every day, more than 12 grams on average, which is more than twice the recommended maximum amount. The World Bank calls excess salt, “by far, the most prevalent modifiable risk factor for non-communicable disease in China.” Too much salt is one of the major causes of high blood pressure and strokes, and lowering salt intake across China would probably be one of the quickest and most cost effective measures that public health groups could tackle. Most of this salt comes from processed foods such as instant noodles as well as the incredible variety of sauces in China.

How does all this tie in to Spring Festival Eve?  The great majority of us survive the holiday fun just fine, but what I mostly worry about are the well documented spikes in heart attacks and strokes after classically large meals such as American Thanksgiving and Chinese Spring Festival Eve. Emergency room doctors in both countries report spikes in patients during these holidays, for a multitude of illnesses mostly traced back to indulgence with food and drink. Many of these high salt foods are eaten in abundance during the Spring Festival revelries. A large dose of salt can easily raise your blood pressure and lead to strokes and heart attacks in those of us at most risk for heart disease. Also, this salt infusion makes all of us retain water, which inevitably leads a few people into congestive heart failure, heart attacks and strokes.

One of the great tragedies of these holiday parties is that all of us are trying to relax and have a great time with our families and loved ones, and the last thing we want to do is to ruin the party. Therefore, some people may actually be having a heart attack during the meal, and they will ignore the pain so as not to upset the others, trying to wait until after the party is over to get some help. Another group will feel the chest pain but mistake it for a stomach problem such as indigestion or heartburn, and they will show up the next day in the doctor’s office or the emergency room with “really bad heartburn” which actually is a half-day old heart attack.

So if you have to absorb just one party-pooping take-home message from me today, it’s this: if you feel pressure or pain around your left chest during the party, especially if this pain radiates into your jaw or left arm, please do not ignore it until the next day. I’m deadly serious: if you truly are having a heart attack, then you need to be having emergency treament at your local hospital within 90 minutes to three hours, otherwise your survival rate starts to drop dramatically. Time is crucial with heart attacks, and your heart’s muscles are being starved of oxygen and need treatment ASAP, otherwise the muscle tissue may die forever — and so may you. Trust me, your relatives would much rather have you ruin the party and stay alive than be the life of the party now but dead tomorrow.

OK, everyone, go have fun! Here, have some more Coke with your third plate of dumplings. Don’t worry, these ones are vegetarian.

Perhaps I should have stopped earlier when I told everyone the horrible cliche, “everything in moderation”, because that actually is the obvious answer to avoiding this above dilemma. Hopefully the people cooking the holiday foods can try to use healthier oils and lower salt sauces, especially soy sauce, which is probably the easiest to find. And maybe the host can put out their smallest kitchenware, since it’s been proven many times that people eat less and feel more full when they use smaller plates, bowls and cups.

Otherwise, the rest is up to each of us and our self control when faced with bounty. I’d like to add some tips from my family medicine colleage Dr Liang Lijun (梁立筠), who also has a masters degree in nutrition and public health:

On the day of a big evening gathering, wake up at a reasonable time, eat a satisfying breakfast, and exercise so that you are not so hungry by dinner time. If you really want to be health-conscious, survey the table, choose a colorful palette of foods to eat, and try to eat the healthier foods first. This way you leave less room for oily, rich foods that are sure to tip the bathroom scale. Also, be wary of drinks, which can contain a lot of hidden calories. Try to make sure you prepare some tea (flower tea is best) to drink, or choose wine over cocktails and beer. And, perhaps most importantly, eat slowly, pause often to enjoy the conversations flowing around you, and do your best to remove yourself from the table when you’re full.

I will be the first to admit that I’m terrible at self control, and it takes me weeks to work off the excess holiday weight — an increasingly losing battle. And if I added up my total calories from my usual Thanksgiving meal, I’d probably have a heart attack just from the sticker shock. But I hope some of these recommendations can help some of you to take action, ensuring that you continue to enjoy Spring Festival with your loved ones for many more years.

Red Meat: Not So Good For Your Heart. Here's More Proof

Red meat cow cardiac disease

A couple years ago I wrote a post discussing data showing how some red meats are bad for your heart; now a major new study again confirms this concept. This huge study from the Harvard School of Public Health analyzed data from 2 studies which followed 120,000 people over 20 years. They found that the more red meat people ate (especially processed meats) the more people died from heart disease. Here’s a nice summary from the very cool Meatless Mondays website:

…They discovered just one 3-ounce serving of red meat daily (about the size of a deck of playing cards) was associated with a 13% greater chance of dying over the course of the study. What’s more, participants who consumed daily servings of processed meats like hot dogs and bacon were at 20% higher risk of mortality. As the amount of meat consumed increased, so did the risk of death.

Conversely, replacing beef and pork with a serving of nuts, legumes, whole grains or low-fat dairy seemed to improve longevity. Nut consumption was linked to a 19% lower risk of dying during the study, whole grains with a 14% reduction, and beans and dairy with a 10% decrease in mortality.

“Any red meat you eat contributes to the risk,” An Pan, a postdoctoral fellow and lead author of the study told the LA Times, “If you want to eat red meat, eat the unprocessed products, and reduce it to two or three servings a week,” he said. “That would have a huge impact on public health.”

Dr. Dean Ornish, a UC San Francisco researcher and author of an editorial that accompanied the study in the Archives of Internal Medicine, agrees, suggesting that red meat lovers can reduce their risk by cutting meat one day a week. “Something as simple as a Meatless Monday can help,” he said. “Even small changes can make a difference”

I discuss this article on my March 14th weekly radio interview on EZFM’s Beijing Hour. Paul and I also discuss a Xinhua news report discussing the lastest campaign to decrease the massive overuse of antibiotics in Chinese hospitals.

Click on the arrow below to listen to this podcast, or click here.
[podcast]http://66.147.244.109/~myfamio6/myhealthbeijing/wp-content/uploads/2012/03/031407_CUT.mp3[/podcast]

More Podcast Information

You can listen to all my previous podcasts at my podcast archive. You can always listen live to my radio interview each Wednesday around 7:35am Beijing time, on the Beijing Hour program on EZFM 91.5, which is broadcast from 7-8am every weekday by host Paul James. EZFM is the popular bilingual radio station on the China Radio International network, broadcasting here in Beijing and on multiple stations all over the world, as well as live online.

High Cholesterol Hits Home…

 

st-cyr-children

I’m in America right now, visiting my family for the first time in over a year. I’ve been having a wonderful time with them – right up until my older brother casually told me how, a year ago, his cholesterol was checked for the first time and “something was high, like I think my triglycerides were over 800, and my good cholesterol was low, and my total was over 300. Something like that…”

Well, that certainly perked up my ears. My oldest brother had cholesterol problems at such dangerously high levels (normal TG is under 150) that he was a “walking heart attack risk” before the age of 50. Needless to say, I picked up my jaw off the floor and had a long brother/doctor heart-to-heart discussion with him about how serious this was. I even showed him his cardiovascular risk score (from myhealthcheckup.com) and showed him how he has a 12% risk of having a heart attack or a stroke in the next 10 years (normal risk is ~5%; mine is 1.5%; anything over 10% worries us docs). I’m not exactly sure how that doctor last year let him get out of his office without medicines or strong warnings, but it doesn’t really matter now; I have no intention of letting my only older brother depart from this world prematurely.

One important point for my readers is that for many of you, as well as for my brother, lifestyle changes only take you so far. Honestly, even if my brother spent 3-6 months losing 10 kilograms and having a hardcore low-fat diet, his levels still would be higher than normal, certainly still high enough to be laying down that artery-clogging cholesterol plaque in his heart and brain. Many people cling to this noble idea that lifestyle changes will help a lot, and they absolutely do and should be a part of anyone’s treatment, including when on prescription meds. But for a great many of us, medicines are inevitable. That’s not a bad thing at all! It’s just the hard draw of our genetic makeup. This idea is called epigenetics, a very trendy and exciting research term: our genetic makeup determines a lot about which diseases we get, but our environment can dramatically effect how severe, or how quickly, we develop those pre-programmed diseases. In my brother’s case, he likely has a genetic weakness for cholesterol, especially triglycerides, but his decades of a typical American diet clearly makes his condition worse than it could be.

That’s why cholesterol-lowering medicines for many of us are not only inevitable but essential. The prescription statins such as Lipitor have been remarkably effective for tens of millions of people, and they literally can cut your risk of heart attacks and strokes more than 50%. But another take-home message is that a few natural medicines can also really help many of us. The best evidence is for omega-3 fatty acids as well as niacin, but fiber and other natural products also help a bit.

St-Cyr-Kids

I’ve written a lot about omega-3, a natural fatty acid which is found in all the fatty fish, especially salmon, mackerel and sardines. The healthiest way to get this is to eat those fish as often as possible, at least twice a week. If that’s not too practical, all pharmacies carry fish oil supplements.
If you do decide to take it, and if you can tolerate the fishy aftertaste, there are some key facts:

  • LOOK CLOSELY AT THE FINE PRINT. Sure, it may say “1000mg fish oil”, but we’re not interested in that. We want to know the TOTAL AMOUNT OF OMEGA 3 (DHA and EPA) – which is usually only a third of the total oil amount! So the key is to look at the nutrition label to see how much TOTAL omega 3 it has — again a combination of DHA and EPA. Usually, your 1,000mg of fish oil only has about 360mg of omega-3. That means, if you need to take 1 gram a day of omega 3, you need to take 3 capsules. (Shoppers tip: in the US, the megastores Costco and Sam’s Club have big bottles of higher-strength, and enteric-coated, softgel capsules. I always stock up at Costco when I go home).
  • For general low cholesterol issues, people should usually take 1 gram a day of the omega 3.
  • For more severe cholesterol problems (such as my brother), usually 2-3 grams a day of omega 3 is recommended. That means some of you may need to take ~8 pills a day, if you can tolerate them.
  • Don’t forget that omega-3 is mostly beneficial for triglycerides; it can lower TGs by 23-45%. It is NOT very effective for lowering total cholesterol, and it actually raises LDL a bit, which may surprise many of you. But it also raises HDL, the “good cholesterol”, by a similar amount – thus canceling out the bad effect on LDL (we think). To be most effective in my brother’s case, he would need to take a lot, at least 2 grams – but 4 grams is even better, if he can tolerate it.

Another natural treatment for cholesterol, niacin, is actually a simple over-the-counter mineral which is quite cheap. Niacin is quite effective for some types of high cholesterol but isn’t commonly used – mostly due to the side effects and liver problems. Here are some important points:

  • Niacin is great for lowering triglycerides, at high doses >1,500mg daily. It lowers triglycerides by 20% to 50%.
  • Niacin decreases LDL-C by about 5% to 25%.
  • It’s excellent for increasing HDL-C. It increases HDL-C by up to 35%.

But side effects of niacin are very common, and many people cannot tolerate this for too long. The most common problem is headaches and a flushing reaction people get after taking their medicines, almost like a hot flash. This can range from barely noticeable to intolerable. Some tricks to avoid the side effects are to take a baby aspirin 1/2 hour before your niacin, and also to buy the extended-release and not the immediate-release niacin. The most concerning — but rarer — side effect is liver toxicity; you should not start niacin by yourself without first getting your liver function tested by your doctor. And your doctor can help you choose which niacin is best. The extended-release pills have less flushing and headache effects but they also increase the risk of liver toxicity.
Niacin can also increase glucose levels, so diabetic or pre-diabetic persons should discuss this issue with their doctor before starting niacin.
One great thing about niacin is price – the OTC versions can be as cheap at $10 a month. But then you also cannot guarantee that the doses are totally accurate; in some cases, it’s still better to get the prescription versions. If you have insurance, it’s probably best to get it from your doctor, or at least get their recommendation as to which, if any niacin, you should take.

As for prescription medicine, my brother’s triglycerides are best treated with prescription fenofibrate, usually called Tricor in most countries. This medicine has a long track record and is, by far, the top choice that doctors would use in this case – much more than niacin, for example. Fenofibrate lowers TGs over 50%, and it also lowers LDL and raises HDL. Thus, it’s a potent triple-benefit for people with seriously high triglycerides. But since he’s currently waiting for his health insurance to kick in (welcome to America!), there’s nothing at all wrong with now starting omega-3 supplements right now, and perhaps niacin if he gets his liver tests first. There’s also a bunch of fiber supplements and others that work a bit: here’s a nice graph from the Natural Medicines Database article on natural ways to lower cholesterol:

natural medicines to lower cholesterol
natural medicines to lower cholesterol

So I’m now heading back to China, at least feeling a bit better that I could help my brother out. The hardest part – lifestyle changes and weight loss – will be up to him.

Taking Chantix to Stop Smoking: Do The Benefits Still Outweigh The Risks?

A few weeks ago I wrote a piece discussing options for smoking cessation, and I specifically plugged varenicline, known as Chantix in most countries (“Champix” here in China), as being perhaps the most effective tool we doctors can now offer. Since my posting, a few drug warnings have come out, and it begs the question: do the benefits still outweigh the risks? I say yes — I would still recommend for most people, but first let’s look into the new data.

The FDA recently added a box warning on the packaging, discussing varenicline’s increased risk of serious psychiatric symptoms. This June, there were some new warnings from the US FDA that taking Chantix slightly increases risks for heart attacks. And just last week comes a larger study which confirms this risk. More specifically (from the NY Times article):

The new study, known as a meta-analysis, compiled data from 14 random, blinded, placebo-controlled clinical trials that tracked cardiovascular outcomes. It found 52 out of 4,908 people taking Chantix had serious cardiovascular events, a rate of 1.06 percent, compared with 27 out of 3,308 people taking a placebo, a rate of 0.82 percent. While the absolute difference is only 0.24 percent, the weighted, relative difference is 72 percent.

Here’s another way to look at it: “doctors could expect to get one extra cardiac event associated with Chantix for every 28 smokers they treated with the drug. The researchers also estimated one additional person would quit for every 10 treated with Chantix.”

What About The Side Effects of Not Stopping Smoking?

So there’s the hard data: 0.82% of the placebo group had an event, and 1.06% of the Chantix users had an event. This is the data we docs need to be telling patients. Honestly, I find the absolute difference of an increased 0.24% to be very small, and if I were a smoker I would take the chance. After all, what about the “side effects” of not stopping smoking? Smoking itself is one of the major causes of heart disease! Not to mention all the deaths from lung cancers, chronic emphysema and other cancers. Let’s compare that absolute risk of 0.24% versus the facts of smoking:

  • A smoker’s cumulative risk of dying from lung cancer before age 85 years was 22.1% for a male smoker and 11.9% for a female current smoker, in the absence of competing causes of death. For nonsmokers: a 1.1% probability (men) of European descent, and 0.8% in women. (source)
  • Smokers under 40 are five times more likely to have a heart attack. (source)
  • Male and female smokers lose an average of 13.4 to 14.3 years of life, respectively (source)

Let’s repeat that, in a way I would say to my mostly male smokers:

“You have a 0.24% absolute risk of a cardiovascular event on this medicine. You have a 22% risk of dying from lung cancer from continuing smoking. You decide.”

Even the FDA tries to keep the risks in perspective:

Smoking is an independent and major risk factor for cardiovascular disease, and smoking cessation is of particular importance in this patient population. The known benefits of Chantix should be weighed against its potential risks when deciding to use the drug in smokers with cardiovascular disease.

If my patient were a pack-a-day smoker for 30 years and wanted to quit, I still would recommend Chantix to them if they had no major psychiatric history. But this issue is now hotly debated among doctors, many of whom indeed want this drug pulled off the market. The excellent cardiovascular blog theheart.org has a nice review of this week’s controversy, including some of these highlights:

…In an accompanying editorial, Dr Taylor Hays (Mayo Clinic, Rochester, MN), who has been involved in clinical trials of varenicline, writes: “Although these results suggest a measure of caution should be taken in prescribing varenicline for tobacco dependence treatment, the small absolute risk of cardiovascular events associated with varenicline treatment is outweighed by the enormous benefit for reducing cardiovascular morbidity and mortality that can be achieved with successful smoking abstinence.”

Independent observer Dr Robert Bonow (Northwestern University, Chicago, IL) tended to side with Hays. He commented to heartwire: “The effects of smoking are so horrific that the benefits of stopping outweigh the risks of this drug in my view.”…

…Singh notes that while 1 in 10 people on Chantix quit smoking, the number needed to harm is 28. “There is not a great difference there.” He added: “We don’t know if the cardiovascular risk with Chantix stops after the drug has been discontinued. We have only looked at one-year’s data—when the patients were actually taking the drug. And we showed a 72% increased risk of cardiovascular events. We don’t know what happens later on.” He also noted that the actual cardiovascular risk with Chantix may be even greater as more people in the Chantix arm stopped smoking and so should have had an immediate reduction in risk.

“We all know the harms of smoking, and I am not disputing the need to quit. But I would advocate using a different method to help you quit. There are lots of other aids out there that work without increasing cardiovascular risk.”

Furberg reinforces this view. He commented to heartwire: “Quitting smoking is exceedingly important. If Chantix was very effective at getting people to quit smoking, you might argue in favor of its continued use, but it is only modestly effective. With Chantix, for every 10 people who take it, 9 have relapsed after a year. And we don’t know what happens to the 10th person after a year. So the efficacy is weak. And the adverse events are piling up.”…

My bottom line: smoking is a terrible disease and worldwide killer, and I still think varenicline is a very useful tool to get people to quit — although the side effects are more serious than we previously thought, and each patient needs to make their own decision.

One Serving of Veggies: Does Anyone Know How Much That Really Is?

Everyone always hears that you need multiple servings of fruits and vegetables for a healthy diet. I remember the older food pyramid in the U.S. recommending 5 servings a day; a couple years ago that increased to 8-9 servings per day. The idea of 8-9 servings a day of anything is discouraging enough to make me want to hide in the corner with a box of Twinkies. But who even understands what exactly is “one serving”? As usual, the U.S. CDC can help us out.

There’s a great website from the US CDC called “Fruits and Veggies Matter“. The website has a lot of resources for consumers as well as health professionals, including a really fun and useful “Analyze My Plate” interactive menu where you can drag-and-drop foods. And the best news is they’ve made it easier to understand “servings” as a more user-friendly “cup” portion. The front page has a nice calculator to determine how many cups a day you need. For example, I did the calculator and got instant recommendations that I need 2 cups of fruit and 3 cups of vegetables every day. I find that a lot more approachable than the generic “8-9 total servings a day”. Also, they have a nice group of photos that show exactly how much each portion counts as a cup. It’s great and very readable information that you can easily show children as well. For example, 1 small banana in cereal = 1/2 cup.

Fruits & Veggies Can Lower Blood Pressure

Now is as good a time as any to replay my slideshow on high blood pressure, the world’s #1 killer. People may not realize that diet alone can lower blood pressure! This slideshow below discusses all the healthy, non-prescription ways to lower your risk for blood pressure. I strongly recommend you watch it full-screen; just click on the “full” icon below the slide.

(Most of this article was originally printed in an earlier MyHealth Beijing article; I am reposting some archives as I am on vacation now. I return to work on May 2nd at my new position at Beijing United Family Hospital, where I continue my family medicine practice but also am their new Group Director of Clinical Marketing and Communications for their national chain of hospitals.)