15 March 2009

Making a Case for Women and Dietary Fat

I’ve been an advocate and spokesperson for the American Heart Association’s “Go Red for Women” campaign for nearly seven years now, and most recently spoke at their annual fund-raising luncheon at the Waldorf Astoria.

(Above) Dr. Nieca Goldberg, me, and Jane Chesnutt from Woman's Day Magazine

(Right) Me and Joy Behar

My overall message was that there are still troubling gender differences in the way that heart disease is researched, diagnosed, and treated; and that although more women today have a better awareness that they are candidates for heart disease and must be vigilant in recognizing the risk factors and symptoms, they are still not being taken seriously by doctors and practitioners in the same way that men are. My message was received well. I only hope it will resonate throughout the New York medical community and that fewer women will be sent home from emergency rooms like I was when I nearly died from a heart attack in 2006.

The general messaging from the AHA, however, still largely focuses on the individual.

For many reasons, I have a hard time with this, mainly because it places the sole responsibility of heart health care, and even blame, on the individual woman - a layperson. In fact, if you listen to Andie McDowell’s speech on the home page of the Go Red for Women website, you will hear her say that this campaign “helps women make smart choices,” as if to imply the reason they have heart disease and go undiagnosed is because they make foolish choices.

We rely on doctors - experts in the field - to guide us, give us medical advice, and be able to accurately diagnose and treat our diseases to their best capacity. What kind of message does it send to the public, to tell women that they cannot rely on doctors to do this, that they must do it for them? Where is the responsibility for medical professionals? And the problem is that even when patients arm themselves with information, doctors rarely take them seriously, in fact, they are usually annoyed by the “overly controlling” patient.

The other part of this campaign I have a hard time with its insistence that dietary fat and cholesterol are the major causes of heart disease.

I’ve been re-reading Gary Taubes’ Good Calories, Bad Calories, and revisiting the research-based evidence he provides to challenge the fat-cholesterol hypothesis of heart disease (which is still, by the way, nothing more than a hypothesis and has never been proven). The fact is that while high cholesterol may be associated with atherosclerosis, there is still no explanation as to why so many people have heart attacks despite having low cholesterol (including myself), and why a tremendous amount of people with high cholesterol never get heart disease.

Even though there is ample evidence (see studies below) which suggests that populations who follow a hunter/gatherer diet have longer life expectancies than those who follow a western, grain-based diet; and that high protein, yes- high fat, and low carbohydrate diets are much more effective for weight loss, reducing insulin levels, triglycerides, and raising good cholesterol; pop nutritionists and journalist are still trying to tout the low fat, high carb diet as being the healthy one, even though Americans are getting fatter on this diet every day.

Many researchers will readily admit that the evidence on the cholesterol/heart disease correlation is dubious at best. Taubes points out that one reason the medical community holds on to the cholesterol hypothesis is simply because cholesterol is measurable. Even though there are numerous other factors that are correlated with heart disease, such as diabetes, obesity, high blood pressure, and inflammation, there is no other measurable indicator that can be so easily remedied with a drug. And although statins have proven to lower cholesterol and lessen mortality in patients with heart disease, it has yet to be determined if it is statins’ cholesterol lowering properties that save lives. Statins also reduce inflammation. I am not suggesting that people with heart disease go off of their medication. I am on statins and plan on remaining on them for life. But do all people with high cholesterol (who are otherwise healthy) need to be put on statins (which have terrible side effects, by the way)? Couldn’t inflammation be controlled, let’s say, through a healthy diet? But what causes inflammation?

• Sugar
• Polyunsaturated vegetable oils like safflower, sunflower, corn, peanut and soy.
• Refined carbohydrates including flours made from wheat, corn, and soy.
• High glutinous foods like wheat, rice (even brown), and other grains.

It’s disturbing to see so many of my health conscious friends and associates follow this unsubstantiated advice that includes eating processed carbohydrates, high sugar, and soy-based vegetarian diets which have proven to raise insulin levels and cause inflammation. And people like Oprah keep wondering why they can’t take the weight off. Surely if someone like Oprah who can afford the most expensive nutrition and fitness gurus in the world can’t keep the weight off, something is wrong with the guidelines we are being told to follow.

Studies mentioned above:
A Palaeolithic diet improves glucose tolerance more than a Mediterranean-like diet in individuals with ischaemic heart disease.

Cardiovascular risk factors in a Melanesian population apparently free from stroke and ischaemic heart disease: the Kitava study.

Weight Loss with a Low-Carbohydrate, Mediterranean, or Low-Fat Diet

Dietary fats, carbohydrate, and progression of coronary atherosclerosis in postmenopausal women.

And coincidentally, my friend, Emily, just sent me this article from the Montreal Gazette:

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talesfrommidair said...

I have a great deal of difficulty with this personal responsibility thing as well--not that I don't think some responsibility rests on every one of us to take care of ourselves/loved ones. But I think there is a quick exit to blame that does no one any favors.

My Mama did do all the "wrong" things like smoke (albeit lightly for a smoker), eat "bad" food, and live without a formal, integrated exercise routine. Still, her heart condition was caused by a childhood ailment. It's inconceivable to me that, over her entire lifetime, not even one doctor had an inkling that this was in her future. They knew she had rheumatic fever. I just wonder if her life could have been saved if one of them really looked at her history.

For me, the biggest tragedy of it was that--when she got sick--my Mama blamed herself for her own condition...when she did nothing wrong. She was convinced she had brought it on herself. I cannot imagine the guilt she felt over that.

There is such a stigma that goes with heart disease. People think that, if you have it, you did something to deserve it. The truth is that *no one* deserves to go through what my Mama went through.


Laura, Enjoyer of Tea of Green said...

the fat-cholesterol hypothesis of heart disease
I've heard this from others as well, and was very surprised! From what I see on tv, magazines, and from what my soy-crazy vegetarian friends tell me, heart disease is caused by cholesterol. I use soy candles almost exclusively, but that's all I do with soy. :)

You sure take a nice picture. Will you be in the next issue of Woman's Day? I think my coworkers gets it.

Stephanie said...

Hi Alma, I'm always so saddened to hear your stories about your mother. I know it was a tremendous loss for you and that she (and you) suffered a great deal.

You are right, unless you have been told that you have some sort of genetic disposition, there can be a lot of guilt and self-blame attached to having heart disease. Even though we may think we're doing everything right or at least living our lives just like everyone else, once we get a diagnosis like that, we can't help thinking of what we may have done wrong.

I think we live in a culture that is very hard on the individual. I suppose that may be one of the downsides of living in a country that promotes free enterprise. The real confusion, however, lies with deciphering which behaviors are healthy and which are not.

For the longest time, smoking was considered acceptable, albeit dangerous for some (yet continuously debated). And what is "bad" food? And is exercise really the key to good health? I think the answers to these questions are constantly revisited and we rely on "experts" to tell us the answers, no matter how much they change their tune from year to year.

I guess there are never any guarantees so one should never feel responsible or guilty for the randomness of disease. We just do the best we can with the information that is available to us.

Mark said...

One might counter that you're being too critical of a campaign that is designed for the individual layperson within the larger context of a suite of campaigns also directed toward medical professionals and policymakers. If it were true.

As you pointed out during our conversation last night, the AHA does fund research and actually has good data for medical professionals and informed laypersons, but it's hard to access, and doesn't appear to be a part of the main "face" of the AHA message. It would be interesting to know whether or not the AHA has a presence during medical training (CME) seminars.

Stephanie said...

Hi Laura,

Well, I had a 99% blockage in my artery and had the cholesterol levels of an athlete. The whole idea that cholesterol in itself clogs your arteries like bad plumbing is a myth, and most doctors know this. It's just an easier way of describing the process. In reality, atherosclerosis happens when small LDL particles crack off the artery wall and build up. There are many doctors who feel that it is sugar and carbohydrates, especially processed snack foods, that causes this launching of particles.

If anecdotal evidence means anything to you, I can tell you that after my first heart attack, I was put on a completely fat free diet, one that was recommended by Dr. Dean Ornish and Dr. Mehmet Oz (Oprah's doctor). I was forbidden from eating meat, dairy, all oils, avocados, fish, EVERYTHING. I was pretty religious. I lived on veggies, beans, rice and other whole grains, and soy, and wheat gluten, and all fat free meat substitutes. Four years later, I had the big one - the 99% blockage that almost killed me.

I think those fat free diets are a lot of bull. Our bodies aren't made to ingest so many carbs and so many foods that have been processed down to remove what comes natural to them - fat.

Alas, I think my Woman's Day centerfold days are over. I can only be a victim/spokesmodel for so long. :)

Stephanie said...

Mark, the AHA sponsors numerous scientific conferences and symposiums every year. They must be of good quality, although who knows who attends them.

The point is that doctors can choose to continue their education and read medical journals in their entirety if they want. But many don't. That is when a national campaign comes in and alerts the public with some very specific messaging. That messaging should target all of the people who are responsible for individual and public health. I think a more collective initiative, would be much more effective, don't you?

Mark said...

I do, with the understanding that specific portions of the message will be tailored to specific audiences.

Regarding the AHA and its interaction with the professional medical community, I was thinking less of AHA sponsored events than AHA involvement as instructors in events sponsored by medical educators; there's a big difference. If the AHA can position itself within non-AHA-sponsored medical training to captive audiences (general talks at medical education conventions as opposed to elective, "break-out" sessions), that would be great.

I'm enjoying the good information you're putting out there about appropriate use of healthy fats. As usual, your comments are as worthy as your posts.

Anti said...

Doctors get their core knowledge from medical school and the "on-the-job" training they got during internship and residency.

By the time they reach the point where they actually set up practice, they have been totally indoctrinated by what the established standards of practice have been for nearly a generation.

If they choose a specialty (such as cardiac medicine), they will certainly get advanced training in that specialty, but it's still based on established standards of practice - which changes very slowly.

And even if a cardiologist is especially up-to-date, she is probably in a very specialized area of the field or doing research in some university. So the woman who could benefit from this specialized knowledge isn't likely to have any contact with this specialist unless they develop a heart problem that needs very specialized attention... and could actually access this person.

Your General Practitioner isn't going to have this specialized knowledge, nor does she have any incentive to acquire it.

It comes back, then to the individual - the one who has the strongest incentive of all.

We are blessed at having the ability to access information almost instantaneously via the Internet, and there are hundreds of good books available for a pittance compared to the cost of spending even one day in the hospital.

So, take advantage of it - or not... it's your choice.

Stephanie said...

Anti, I understand that most doctors are deeply immersed in their core medical training, and I also know that much of these curricula, especially when it comes to gender, are outdated.

I became a patient advocate because I knew that it would take some speaking out to stir up public awareness on the whole women and heart disease issue, and I also wanted to encourage people to educate themselves about their health (hence, this blog). You are right. It is essential and it is available.

However, that still doesn't excuse one of the biggest advocacy organization's failure to address this issue in a way that doesn't blame the patient and make them solely responsible. My cardiologist, Nieca Goldberg, published a book called, Women are Not Small Men, a sort of patient-friendly handbook on how heart disease presents itself differently in women than in men. A message as simple as that not only alerts women to the dangers of heart disease, but alerts doctors and the general public as well.

To continue to promote the message, "Women, take charge of your health!" is fine and good, provided that doctors are going to listen and take them seriously, and once in their care, are going to provide equitable treatment. Last year it was reported that even after a positive diagnosis of myocardial infarction, more men received life-saving procedures than women, and more men were referred to cardiac rehab than women. I realize that these are structural ills that may take generations to change, but at whose expense? and who is responsible for this change? Isn't it an advocacy organization's job to speak FOR the patients they are purporting to serve?

Flying Mermaid said...

I'm so used to doctors not doing their jobs, and never knowing my body as well as I do, that I EXPECT to do all the work, but it does suck, doesn't it? Especially for those less medically-minded and unfamiliar with their bodies. I'd LOVE to have a doctor I trust and respect, but the truth is, I haven't had one at all now for more years than I can remember. My pediatrician?

About 30 years ago I gave up red meat, dairy, eggs, sugar, fried foods, and refined carbs, which enabled me to eat all day long without gaining a pound. And since I love ALL food, and have much better luck at restricting WHAT I eat, than how MUCH, this worked for me.

But without changing my diet, I gained a third of my body weight practically overnight when peri-menopause hit. I'd always felt Americans eat too much protein, and though I'd been eating fish and poultry all along, it was by no means at every meal, and maybe not even every day.

My excess nature caused soy to lower my thyroid, so that was out.

My father and his father before him both dropped dead of heart attacks when quite young -- before cholesterol testing. My cholesterol was high by the time I tested it in my late 30's, I had a certain amount of blockage, and went on statins.

When I gained all that weight at peri-menopause, I read a menopause diet book which said that your pancreas processes food differently after menses, and the diet the book recommended was much more like a diabetic diet -- smaller meals more often, never carbs without protein, etc.

I began following that, then wound up giving up all carbs but fruit and red wine, at which point all the excess weight fell off me, quickly.

Then I discovered I had (have?) some glucose intolerance, and consequently gave up fruit. So these last couple of years I've been pretty well fucked, in terms of getting full -- because I have a tremendous appetite! I was so used to cramming down fruit after each meal, and I'd probably be fine, if I had the slightest sense of moderation, but I don't.

I started chomping on cinnamon sticks after meals, which I thought was brilliant, as they're good for balancing both glucose and cholesterol levels, and made me feel dessertish, replaced the fruit well.

But my necessary EXCESS of cinnamon sticks made my teeth black and messed up my stomach, so I had to quit. I took up nuts after meals, instead, after having avoided them for years, because of the fat content. Worked like a charm, until the arginine gave me severe herpes and I had to quit nuts.

That brings me to the present. I ran out of statins, doctors, and scrpits almost 2 years ago, and suddenly, out of desperation these last few weeks, I have been eating lamb, eggs, and tons of cheese, just can't seem to stop!

After 30 years my body is just saying STOP! (Or is that START?) The amounts I've been eating of these things -- especially cheese -- is downright disgusting, but I'm so tired of all the health theories changing every minute! One minute it's COCONUT OIL IS THE DEVIL! The next it's COCONUT OIL IS THE BEST THING SINCE BREAST MILK!

I just can't take any more!

As a consequence, I seem to have turned my excess on your comment box -- sorry!

Thanks for the blog, and that article, too. I am beginning to suspect this lamb, at least, is good for me, though I don't go for the billions of years theory, of humans eating meat. Doesn't seem all that relevant, since folks didn't live long enough for heart disease in those days, anyway.....

Stephanie said...

From what I have learned, FM, Paleolithic (hunter/gatherer) people’s life expectancy was short mainly because of warfare, the burden’s of a nomadic life, and climate – not because of meat consumption. They were also taller, had larger brains, and larger pelvises than neolithic people who began grain consumption. Modern agriculture and grain farming brought with it a host of diseases, nutritional deficiencies, and shorter people.

In modern day hunter-gatherer populations today, people live longer than those on a western diet. The fact is that people who adopt the western diet of sugar and processed carbs begin to exhibit signs of chronic diseases (obesity, high blood pressure, high cholesterol levels).

It was the discovery of antibiotics in the 1920s that increased life expectancy by 10-20 years, not vegetarian low-fat diets. Our life expectancy had been back on the decline since 2000.

It sounds like you know exactly what your body wants. Lamb, eggs, cheese… those are all REAL foods. It’s not like your pigging out on potato ships and twinkies. Your diet sounds pretty healthy to me.

My grandparents lived well into their 90s, so as a rule of thumb, I like to ask myself, “What would Grandma eat?” Being from France, they ate a typical European diet of meat, fish, vegetables in season, salads, cheese, a bit of fruit, and coffee every morning. My grandparents also swore by cod liver oil and they took it religiously every day. They were disease free.

Flying Mermaid said...

I'm not at all suggesting that their diets had anything to do with their dying young, merely that they didn't live long enough -- for the reasons you mentioned -- to KNOW how their organs may have fared. I'd think that for 40 to be old, ANY diet would work.

Also, I don't see how this got narrowed down to diet choices being either meat-eating or bullshit junk food eating?

You say my diet sounds healthy -- and I'm sure it is, having not even touched on many other things that make it so -- but I'd always had a weight problem until I cut out red meat and diary, though I wasn't much of a junk food eater and always ate a lot of fruit and vegetables. And post-menopause, with the same healthy diet, I had a weight problem again, until cutting out all carbs, including fruit and whole grains.

But I know all bodies are different, and I'm an extreme case. Both being reasons I prefer to listen to my own intuition than any doctor.

Stephanie said...

It sounds like your intuition is very good when it comes to food and your body.

Even though we share a certain amount of skepticism when it comes to doctors, I would still encourage you to get everything checked out at some point if you were once diagnosed with atherosclerosis. Did you have an angiogram?

Stay well, FM!

Steve said...

Hi Stephanie.

I feel your ire. Yes, it seems there is a deluge of information linking the occurrence of heart disease to poor lifestyle choices--as if anyone who has it must be an overweight, lazy, chain-smoking slob who doesn't have to will or ability to free themselves from a toxic lifestyle. You're right. This is bullshit. I would be angry too.

I can only speak from experience, and from what I've been told for almost my entire life:

1) that heart disease is way high up on the list of most common causes of death--right up there with cancer and car accidents (for some demographics at least).
2) that although, like many illnesses, some people are born with it or have a predisposition, it is mainly a disease attached to a certain lifestyle-like smoking, poor diet, lack of exercise.
3) that, like smoking, it is also way up high on the list of the most preventable causes of death, which again would tie it into a lifestyle or choice.

Thanks for helping me see through these statistics and stereotypes.

Stephanie said...

Thanks Steve,

When I read your bullet points, I realize there certainly is a lot of gray area out there. We all know there isn't any magic formula to good health and longevity, but I think the average person is well aware of certain lifestyle choices that can minimize the chance of chronic disease.

But when you start seeing such large disparities in who is getting sick and who is dying more frequently from these chronic diseases (i.e. poor people, Latin Americans, African Americans, and women) you have to start asking yourself if there is something more structural going on. Even the genetic thing starts to sound like the responsibility is constantly being shifted from structural and environmental possibilities to someone's inferior gene pool.

But meanwhile (no offense AHA friends), the AHA is endorsing the very products - like hydrogenated margarines and sugary breakfast cereals - that are contributing to the "bad behaviors" they are telling us to stop.

In my idealistic mind, I would like to see a more comprehensive approach to reducing chronic disease, something that goes beyond research for new drugs, and campaigns that tell people how to live.

Reducing poverty and equality in health care would be a tremendous start.

Henrike said...

This just tapped into something as I have been up against doctors recently who do just that: seek blame in the patient. And with every argument you have, using facts, to make them realise their conclusions are based on thin air they start to just view you as some annoying patient without wanting to face the truth that it is not merely a matter of someone taking good care of their health. You are an excellent advocate for patients and I agree with all you said here! I wish more people who take the time and take a serious look at all this! Thank you!

Stephanie said...

Hi Henrike,

I'm sorry you're experiencing that. There are probably a myriad of ways that doctor/patient relationships could be improved upon. For one, if a doctor doesn't listen to you or take you seriously during your first consultation, it is probably a good idea to shop around a bit and find one who does. It's also important as patients, that we communicate our needs as clearly as possible. If you are in an emergency situation, it always helps to have someone with you that can advocate for you.

There ARE really good doctors out there who should be able to listen well, treat our ailments as best to their ability, and to give us good lifestyle recommendations without making us feel bad. It's just unfortunate that patients these days have to shop around and come armed with information. Not everyone has that luxury.

Henrike said...

Yes, that’s what I should have done in December already! Yet here I was questioning myself instead of my doctor. Good news, thanks to my friends support I eventually did step off and indeed went “shopping”, I am in a lucky position with the health system here that offers me free choice so I searched and researched and settled of a clinic that is been viewed as the best in Holland … even though it takes me quite a travel to get there. After only the first meeting I was shocked to see how many tests they have planned but relieved as I now do feel like I am in good hands and my condition and all the stuff that does not add up in my case and cannot be explained but that has been ignored by the old doctor is taken serious. I did a lot more research on various issues by now so know much better what to ask for and look out for. I felt like suddenly I was studying medicine and it is annoying as no one who struggles with health should have to spend the remaining little energy on that but should be able to trust a doctor wherever they go to. After almost 5 months I am in for more lung tests but now they also are checking out my heart and test on auto immune diseases. :o It would not surprise me to hear that the 3 months on 6 different antibiotics that I was brushed off with by my old doctor and that I reacted very bad too have caused additional damage to my system too but the thing is if that is the case I cannot even sue the old doctor but have to del with the consequences of their carelessness.

Ah sorry for venting, didn't mean to write a whole story … you can feel the whole topic just makes me angry – not just for me but indeed for everyone out there who has to go through a similar ordeal and is up against superficial attitudes and ignorance of those who should know better and have the insight that there usually is more involved than merely a person’s life style. And if they cannot use that then it is because you are too tall or too small or whatever else. :(

Stephanie said...

It sounds like you're in good hands now. I hope you're feeling well.

Methuselah - Pay Now Live Later said...

Stephanie - have you seen Fat Head? I watched it for the first time this week and whilst I don't agree with everything he says, it seems like the best shot we have at explaining to the mainstream that fat is not the bad guy here. I reviewed the film here if you are interested - and there are a few resources there too.

Stephanie said...

Methuselah - I have not yet seen "Fat Head" but I did, in fact, read your review and subsequently put it on my netflix queue. I look forward to seeing it.

I also directed my boyfriend, Mark (the other author of this blog), to your fitness page. I think he will get a lot out of it. Thanks!