Tag Archives: heart attack

Diabetes and Shortened Lifespan: “How Bad Is It, Doc?”

Diabetes mellitus for years has been linked with cardiovascular disease such as heart failure and coronary heart disease (blocked arteries in the heart, and the leading cause of death in the Western world).  How scared should diabetics be?

An article  in the Archives of Internal Medicine gives us one answer.

Researchers from the Netherlands and Harvard examined medical records of 5,209 people (mostly white, 64% men) enrolled in the Framingham (Massachusetts, USA) Heart Study.  This cohort has been examined every other year for more than 46 years. 

Study subjects who had diabetes at age 50 were identified; health outcomes going forward were then analyzed, with particular attention to lifespan and cardiovascular disease.  “Cardiovascular disease” in this context means coronary heart disease, stroke, congestive heart failure, intermittent claudication (leg pain during exertion caused by blocked arteries), and transient ischemic attack (stroke-like symptoms that resolve within 24 hours).

Results

Compared to those in the cohort free of diabetes, having diabetes at age 50 more than doubled the risk of developing cardiovascular disease for both women and men. 

Compared to those without diabetes, having both cardiovascular disease and diabetes approximately doubled the risk of dying, regardless of sex.

Compared to those without diabetes, women and men with diabetes at age 50 died 7 or 8 years earlier, on average.

[Specific causes of death were not reported.]

Take-Home Points

We’d likely see longer lifespans and less cardiovascular disease if we could prevent diabetes in the first place.  How do we do that?  Strategies include regular physical activity, avoidance or reversal of overweight and obesity, and low-glycemic-index diets.

The Mediterranean diet it linked to reduced heart attacks and strokes, and longer lifespan.  That’s why I’ve been working for the last year and a half to adapt it for diabetics.

ResearchBlogging.orgWe have better treatments for cardiovascular disease and diabetes and these days, so the death rates and illness numbers shouldn’t  be quite so alarming.  Up-to-date management of diabetes and cardiovascular disease will prevent some acute disease events—such as heart attacks and strokes—and prolong life.   

Steve Parker, M.D.

References: 

Franco, O., Steyerberg, E., Hu, F., Mackenbach, J., & Nusselder, W. (2007). Associations of Diabetes Mellitus With Total Life Expectancy and Life Expectancy With and Without Cardiovascular Disease Archives of Internal Medicine, 167 (11), 1145-1151 DOI: 10.1001/archinte.167.11.1145

Knowler, W.C., et al.  Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin.  New England Journal of Medicine, 346 (2002): 393-403.

Tuomilehto, J., et al.  Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance.  New England Journal of Medicine, 344 (2001): 1,343-1,350.

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Filed under coronary heart disease, Diabetes Complications, Stroke

Rosiglitazone Severely Restricted by FDA

MedPageToday reported yesterday on the U.S. Food & Drug Administration’s ruling that the diabetes drug rosiglitazone should be used in new patients only if blood sugars are not controlled with other diabetes drugs, such as pioglitazone.

It sounds as if new users and their doctors may have to jump through some paperwork hoops to get the drug, which is more reason not to prescribe it.

The problem is that scientific studies suggest that rosiglitazone increases the risk of heart attack, heart failure, and death.

Steve Parker, M.D.

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Filed under Diabetes Complications, Drugs for Diabetes

Do Calcium Supplements Cause Heart Attacks?

They might, if you’re a woman over 50 taking over 500 mg elemental calcium daily without a vitamin D supplement.

Details are at my recent Self/NutritionData Heart Health Blog post.

Steve Parker, M.D.

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Filed under coronary heart disease

Whole Grains Lower Blood Pressure: So What?

The American Journal of Clinical Nutrition earlier this month published a research report on whole grain consumption and various cardiovascular disease risk factors.  U.K. investigators compared the effects of refined grains versus whole grains in healthy middle-aged adults.  The strongest finding was that three servings a day of whole grains—wheat and oats in this instance—reduced systolic blood pressure by 5 mmHg. 

The investigators suggest this BP lowering may be responsible for the reduced risk of heart attack and stroke associated with whole grain consumption in observational studies.

Additional details are at my Self/NutritionData Heart Health Blog post of August 17, 2010.  The researchers noted a three or four percent reduction in LDL cholesterol (“bad cholesterol”) in study participants eating refined grains, yet , mysteriously, had nothing to say about that.

Steve Parker, M.D.

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Filed under Carbohydrate

Diabetes Drug Rosiglitazone About to Be Pulled Off the Market?

ResearchBlogging.orgIt’s over for rosiglitazone.

Sold in the U.S. as Avandia, rosiglitazone is a drug used to control type 2 diabetes either alone or in combination with insulin, metformin, or a sulfonylurea.  It has only one competitor in its class: pioglitazone (sold as Actos).

Both drugs in the thiazolidinedione class (aka TZDs or glitazones) increase the risk of heart failure.  Prior studies had suggested that rosiglitazone increases the risk of heart attack, heart failure, and death.  Research suggested that pioglitazone actually reduces the risk of heart attack, stroke, and death.

A study just published in the Journal of the American Medical Association directly compared clinical use of rosiglitazone and pioglitazone.  Investigators looked at Medicare data involving over 227,000 patients, average age 74, average follow-up of 105 days.

Rosiglitazone comes out the loser: users had significantly higher risk of stroke, heart failure, and death.  Risk of heart attack trended a bit higher in the rosi users but did not reach statistical significance. 

The researchers also calculated the composite risk of suffering either a heart attack, stroke, heart failure, or death:  rosiglitazone risk was about 18% higher compared to pioglitazone. 

What do these numbers mean from a practical viewpoint?  The researchers calculated a “number needed to harm.” Treat 60 patients with rosi and 60 with pio for one year; the rosi group will have one extra event—heart attack, stroke, heart failure, or death—compared with the pio users.

Why put up with that risk?  There’s no good reason.  Especially when pioglitazone is available.

Implications

If you take rosiglitazone, ask your doctor to find an alternative or switch you to pioglitazone.  Soon.

Clearly, we don’t know all of the adverse effects of many of the drugs doctors prescribe, whether for diabetes or other illnesses.  We balance the good with the bad, and that equation changes over time. 

Rosiglitazone’s manufacturer may pull the drug off the market voluntarily.  If not, the FDA will do it.  Cardiovascular disease—e.g., heart attacks, strokes, heart failure—kills 68% of diabetics.  The last thing we need is a drug that increases that risk.

Within a month, you’ll see ads on U.S. television from trial lawyers asking if you or a loved one has been hurt by rosiglitazone.  “If so, call this toll-free number now…”

Steve Parker, M.D.

Reference: Graham, D., Ouellet-Hellstrom, R., MaCurdy, T., Ali, F., Sholley, C., Worrall, C., & Kelman, J. (2010). Risk of Acute Myocardial Infarction, Stroke, Heart Failure, and Death in Elderly Medicare Patients Treated With Rosiglitazone or Pioglitazone JAMA: The Journal of the American Medical Association DOI: 10.1001/jama.2010.920

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Whole Grains Reduce Heart Attacks and Strokes

Whole grain consumption is associated with a 21% reduction in cardiovascular disease when compared to minimal whole grain intake, according to a 2008 review article in Nutrition, Metabolism, and Cardiovascular Disease.   

Coronary heart disease is the No. 1 killer in the developed world.  Stroke is No. 3.  The term “cardiovascular disease” lumps together heart attacks, strokes, high blood pressure,  and generalized atherosclerosis (hardening of the arteries). 

Investigators at Wake Forest University reviewed seven pertinent studies looking at whole grains and cardiovascular disease.  The studies looked at groups of people, determining their baseline food consumption via questionnaire, and noted disease development over time.  These are called “prospective cohort studies.” 

None of these cohorts was composed purely of diabetics.

The people eating greater amounts of whole grain (average of 2.5 servings a day) had 21% lower risk of cardiovascular disease events compared to those who ate an average of 0.2 servings a day.  Disease events included heart disease, strokes, and fatal cardiovascular disease.  The lower risk was similar in degree whether the focus was on heart disease, stroke, or cardiovascular death.

Note that refined grain consumption was not associated with cardiovascular disease events. 

Why does this matter?

The traditional Mediterranean diet is rich in whole grains, which may help explain why the diet is associated with lower rates of cardiovascular disease.  If we look simply at longevity, however, a recent study found no benefit to the cereal grain component of the Mediterranean diet.  Go figure . . . doesn’t add up. 

Readers here know that over the last four months I’ve been reviewing the nutritional science literature that supports the disease-suppression claims for consumption of fruits, vegetables, and legumes.  I’ve been disappointed.  Fruit and vegetable consumption does not lower risk of cancer overall, nor does it prevent heart disease.  I haven’t found any strong evidence that legumes prevent or treat any disease, or have an effect on longevity.  Why all the literature review?  I’ve been deciding which healthy carbohydrates diabetics and prediabetics should add back into their diets after 8–12 weeks of the Ketogenic Mediterranean Diet.

The study at hand is fairly persuasive that whole grain consumption suppresses heart attacks and strokes and cardiovascular death.  [The paleo diet advocates and anti-gluten folks must be disappointed.]  I nominate whole grains as additional healthy carbs, perhaps the healthiest.

But . . .

. . .  for diabetics, there’s a fly in the ointment: the high carbohydrate content of grains often lead to high spikes in blood sugar.  It’s a pity, since diabetics are prone to develop cardiovascular disease and whole grains could counteract that.  We need a prospective cohort study of whole grain consumption in diabetics.  It’ll be done eventually, but I’m not holding my breath.

[Update June 12, 2010: The aforementioned study has been done in white women with type 2 diabetes.  Whole grain and bran consumption do seem to protect them against overall death and cardiovascular death.  The effect is not strong.]

What’s a guy or gal to do with this information now?

Non-diabetics:  Aim to incorporate two or three servings of whole grain daily into your diet if you want to lower your risk of heart disease and stroke. 

Diabetics:  Several options come to mind:

  1. Eat whatever you want and forget about it [not recommended].
  2. Does coronary heart disease runs in your family?  If so, try to incorporate one or two servings of whole grains daily, noting and addressing effects on your blood sugar one and two hours after consumption.  Eating whole grains alone will generally spike blood sugars higher than if you eat them with fats and protein.  Review acceptable blood sugar levels here.
  3. Regardless of family history, try to eat one or two servings of whole grains a day, noting and addressing effects on your blood sugar.  Then decide if it’s worth it.  Do you have to increase your diabetic drug dosages or add a new drug?  Are you tolerating the drugs?  Can you afford them?    
  4. Assess all your risk factors for developing heart disease: smoking, sedentary lifestyle, high blood pressure, age, high LDL cholesterol, family history, etc.  If you have multiple risk factors, see Option #3.  And modify the risk factors under your control.   
  5. Get your personal physician’s advice.    

Steve Parker, M.D.

Extra Credit:  The study authors suggest a number of reasons—and cite pertinent scientific references—how whole grains might reduce heart disease:

  • improved glucose homeostasis (protection against insulin resistance, less rise in blood sugar after ingestion [compared to refined grains], improved insulin sensitivity or beta-cell function)
  • advantageous blood lipid effects (soluble fiber from whole grains [especially oats] reduces LDL cholesterol, lower amounts of the small LDL particles thought to be particularly damaging to arteries, tendency to raise HDL cholesterol and trigylcerides [seen with insulin resistance in the metabolic syndrome])
  • improved function of the endothelial cells lining the arteries (improved vascular reactivity)

Disclaimer:  All matters regarding your health require supervision by a personal physician or other appropriate health professional familiar with your current health status.  Always consult your personal physician before making any dietary or exercise changes.

Reference: Mellen, P.B, Walsh, T.F., and Herrington, D.M.  Whole grain intake and cardiovascular disease: a meta-analysisNutrition, Metabolism and Cardiovascular Disease, 18 (2008): 283-290.

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Filed under Carbohydrate, coronary heart disease, Diabetes Complications, Grains, ketogenic diet, legumes, Mediterranean Diet, Stroke

Alcohol Habit (Especially Wine) Started in Middle-Age Reduces Heart Attack and Stroke

Jesus turned water into wine at a wedding.  His mother asked him to do it.  Of all the miracles he performed and could have performed, I wonder why this is the first one recorded in the Holy Bible.

We have known for years that low or moderate alcohol consumption tends to lower the risk of cardiovascular disease such as heart attack and stroke, and prolongs life span.  Physicians have been hesitant to suggest that nondrinkers take up the habit.  We don’t want to be responsible for, or even accused of, turning someone into an alcoholic.  We don’t want to be held accountable for someone else’s drunken acts.  Every well-trained physician is quite aware of the ravages of alcohol use and abuse.  We see them up close and personal in our patients.

A scientific study published in 2008, however, lends support to a middle-aged individual’s decision to start consuming moderate amounts of alcohol on a regular basis.  It even provides a positive defense if a doctor recommends it to carefully selected patients.

This research, by the way, was supported by a grant from the National Heart, Lung, and Blood Institute, not the wine/alcohol industry.

Methodology

Researchers at the Medical University of South Carolina examined data on 15,637 participants in the Atherosclerosis Risk in Communities (ARIC) study over a 10-year period.  These men and women were 45 to 64 years old at the time of enrollment, living in four communities across the U.S.  Of the participants, 27% were black, 73% nonblack, 28% were smokers, and 80% of them had high blood pressure, high cholesterol, or diabetes.

Out of 15,637 participants at the time of enrollment, 7,359 indicated that they didn’t drink alcohol.  At baseline, these 7,359 had no cardiovascular disease except for some with high blood pressure.    Subsequent interviews with them found that six percent of the nondrinkers – 442 people – decided independently to become moderate alcohol drinkers.  Or at least they identified themselves as such.

“Moderate” intake was defined as 1-14 drinks per week for men, and 1-7 drinks a week for women.  Incidentally, 0.4% of the initial non-drinking cohort – 21 people – became self-identified heavy drinkers.

93.6% of the 7,359 non-drinkers said that they continued to be non-drinkers.  These 6,917 people are the “persistent nondrinkers.”

Type of alcohol consumed was also surveyed and broken down into 1) wine-only drinkers, or 2) mixed drinkers: beer, liquor, wine.

Researchers then monitored health outcomes for an average of 4 years, comparing the “new moderate drinkers” with the “persistent nondrinkers.”

Results

  •  Over 4 years, 6.9% of the new moderate drinkers suffered a cardiovascular event, defined as a heart attack, stroke, a coronary heart disease procedure (e.g, angioplasty), or death from cardiovascular disease.
  • Over 4 years, 10% of the persistent nondrinkers suffered a cardiovascular event.
  • The new moderate drinkers were 38% less likely than persistent nondrinkers to suffer a new cardiovascular event (P = 0.008, which is a very strong association).  The difference persisted even after adjustment for demographic and cardiovascular risk factors.
  • There was no difference in all-cause mortality (death rate) between the new moderate drinkers and the persistent nondrinkers.
  • New  drinkers had modest but statistically significant improvements in HDL and LDL cholesterol and mean blood pressure compared with persistent nondrinkers.
  • 133 new moderate drinkers consumed only wine
  • 234 new moderate drinkers consumed mixed types of alcohol
  • Wine-only drinkers were 68% less likely than nondrinkers to suffer a cardiovascular event.
  • “Consumers of moderate amounts of beer/liquor/mixed (which includes some wine) tended to also be less likely to have had a subsequent cardiovascular event than nondrinkers…but the difference was not significant.”

A Few Study Limitations

  • Four years is a relatively brief follow-up, especially for cancer outcomes.  Alcohol consumption is associated with certain types of cancer.
  • If moderate alcohol consumption indeed lowers death rates as suggested by several other studies, this study may not have lasted long enough to see it.
  • The alcohol data depended on self-reports.

Take-Home Points

The study authors cite four other studies that support a slight advantage to wine over other alcohol types.  It’s a mystery to me why they fail to stress the apparent superiority of wine in the current study.  Several other studies that found improved longevity or cardiovascular outcomes in low-to-moderate drinkers suggest that the type of alcohol does not matter.  Perhaps “the jury is still out.”  In the study at hand, however, it is clear that the reduced cardiovascular disease rate in new moderate drinkers is associated with wine.

In all fairness, other studies show no beneficial health or longevity benefit to alcohol consumption.  But at this point, the majority of published studies support a beneficial effect.

Wine is a component of the traditional healthy Mediterranean diet.  The Mediterranean diet is associated with prolonged life span and reduced cardiovascular disease.  This study strongly suggests that wine is one of the health-promoting components of the Mediterranean diet.

Starting a judicious wine habit in middle age is relatively safe for selected people and may, in fact, improve cardiovascular health, if not longevity.

Now the question is, red or white.  Or grape juice?

Steve Parker, M.D.

Reference:  King, Dana E., et al.  Adopting Moderate Alchohol Consumption in Middle Age: Subsequent Cardiovascular Events.  American Journal of Medicine, 121 (2008): 201-206.

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Filed under Alcohol, coronary heart disease, Mediterranean Diet, Stroke

Mediterranean Diet Cuts Risk of Diabetes After Heart Attack

In a blog post last year I discussed how the Mediterranean diet reduces the incidence of type 2 diabetes in healthy people.  I found another scientific journal article that examined the effect of various lifestyle factors that might influence the onset of type 2 diabetes in a different population: people who have had a recent heart attack.

Dariush Mozaffarian and colleauges studied 8291 Italians who had suffered a heart attack within the previous three months, but who did not have diabetes at the time of the heart attack.  Each study participant was followed for an average of 3.2 years to see if diabetes developed.  The researchers devised a Mediterranean diet score (range 0-15) incorporating consumption of cooked and raw vegetables, fruit, fish  and olive oil.  They also looked at consumption of butter, oils other than olive oil, cheese, wine, and coffee.  Participants’ dietary habits were assessed and scored three times over 1.5 years.  A number of other demographic, clinical, and lifestyle risk-factors were assessed.

The study did not survey other components of the Mediterranean diet, such as legumes, nuts, and grains.  This is a weakness of the study.  I suspect it relates to the fact they were using information from the GISSI-Prevenzione study, which was designed to evaluate fish oil and vitamin E in people who had had a heart attack, and researchers did not want to burden outpatient cardiology offices with full-scale questionnaires.

Over the three years of the study, 12% of participants developed new-onset diabetes, or 3.7% per year.  If not for the recent heart attack, the expected incidence rate for development of diabetes would be roughly 1.2% per year.  An even larger percentage, over 25%, of participants developed impaired fasting glucose, a kind of prediabetes that often develops into full-blown diabetes over time.

Was there anything about the people who developed diabetes that distinguished them from those who did not?  Yes – they tended to have older age, higher body mass index, high blood pressure, and they smoked.  Current smoking was associated with a 60% higher risk.  Every unit of higher body mass index, e.g, going from BMI 26 to 27, increased the risk by 9%.  High blood pressure increased the risk by 22%.

What about Mediterranean diet score?  The higher Mediterranean diet scores – score of 11-15 compared to 0-5 – were associated with 35% lower risk of diabetes.  A reduction in onset of impaired fasting glucose was similar.

The authors cite another study of 2499 patients with stable angina pectoris or remote heart attack (over 6 months perviously).  Twenty-two percent of them (one in five) developed diabetes or impaired fasting glucose over six years of follow-up, a rate of 4.1% per year.

The researchers write:

The lower risk associated with a Mediterranean-type diet suggests that diet could help reduce incidence of prediabetes and diabetes after a myodcardial infarction.  Many, though not all, trials have indicated that a Mediterranean-type diet lowers risk factors linked to insulin resistance and diabetes, including serum triglycerides, HDL cholesterol, systemic inflammation, endothelial function, and insulin sensitivity.  These physiological effects in short-term randomized trials provide biological plausibility for the inverse association between consumption of a Mediterranean-type diet and incidence of [impaired fasting glucose] and diabetes in this study.

What are the take-home points of this study for people – Italians, at least – who have had a recent heart attack?

  1. A recent heart attack is a risk factor for development of diabetes and prediabetes.
  2. The risk of developing diabetes and prediabetes may be significantly reduced by smoking cessation, prevention of weight gain, and consumption of typical Mediterranean foods.

Patients with both heart attacks and diabetes  have significantly worse outcomes  than people with only one of these conditions.  Since we can prevent many cases heart attack and diabetes through diet modification, why not?

Steve Parker, M.D.

Reference:  Mozaffarian, Dariush, et al.  Incidence of new-onset diabetes and impaired fasting glucose in patients with recent myocardial infarction and the effect of clinical and lifestyle risk factors.  Lancet, 370 (2007) 667-675.

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Filed under coronary heart disease, Mediterranean Diet