The Arrow #191

Hello everyone.

Greetings from Dallas, where it is hot and humid. Brutally so, especially to us after spending most of the summer in Montecito where the weather was glorious. I’m re-learning just how awful it can be in the South in the summer. My video of the week this will provide an example. From Little Rock, Arkansas, no less.

Well, once again, I was surprised at the feedback from last week’s Arrow. It never ceases to amaze me how wrong I can be about what might strike the fancy of readers of this newsletter. A while back, I posted an excerpt from the book Oliver Wiswell, a novel about the Revolutionary War told from the perspective of a British Loyalist. I put in the excerpt, then I took it out, thinking no one would want to read this. Then, at the last minute, I stuck it back in again.

I ended up getting a ton of emails and poll responses from people telling me how much they liked it.

Same thing happened last week. I agonized over whether to include the excerpt from Ben Franklin’s autobiography about how he had been chastised for being so prideful. But, because I was annoyed by so many people telling me I was dead wrong about this or that without tempering their statements, I finally decided to include the excerpt about how ol’ Ben, himself, learned a bit about humility.

Same thing. A bunch of people wrote through various channels about how it reminded them (as it did me) to be a little more temperate in their own speech during arguments over volatile issues.

One final point. I got a few responses about the ad in last week’s Arrow. The platform finds these advertisers from me. I just run the ads. It doesn’t mean I endorse the products advertised. I turn down most of them, in fact, because they have nothing to do with what I write about. I thought long and hard about last week’s ad for Gundry, but I figured it was a nutritional deal, and readers here are nutritionally sophisticated enough to choose for themselves.

The NY Times and the Wall Street Journal as well as numerous other publications all accept ad placements for products and books they don’t particularly support.

I’ve finally been approached by a company whose products I do use and endorse. They are my advertiser today. More about which later.

Okay, let’s look at some feedback.

Poll Responses, Comments, & Emails

Still Uncertain About Statins and Heart Disease

I wrote a long reply last week to a comment from a man wanting to know how he should decide to deal with his lipid situation. He reads my thoughts on the matter and Peter Attia’s, which are pretty much polar opposites on this subject.

He comes back this week with the following comment:

I appreciate that you responded to my question about statins, but you didn't really answer the question about opposite views from two trusted medical sources. People can have different opinions on which diet results in the most sustained weight loss. Some things are a matter of opinion. There are diets that work better for some people or are easier to stick to, so having different ways to attain the same end is probably useful. Penn Jillette lost 100 pounds just eating potatoes. You say doctors disagree all the time, which is understandable with clinicians who develop their judgement from their experiences with patients, but references to scientific trials is theoretically supposed to move these questions from the realm of opinion to something replicable and objective. I appreciate that you have again told us why you think how you do. I find it persuasive. But I am uneasy with the fact that Attia doesn't. I am interested in your view of Coronary Calcification Screening results. [My bold]

This is why everyone recommends people get a second opinion before committing to any specific treatment regimen. In many cases, both the first and second opinions offered depend upon the speciality of the doc doing the opining. Many disorders can be treated equally well by surgery or other medical therapies, so your recommendation is going to depend upon whether you go to a surgeon or an internist. And probably in the end come down to which doc you like the most. That usually plays a huge role in the decision.

There is an old saying about successful doctors. “Three things determine success in a medical practice: Affability, Accessibility, and Ability. And the least of these is Ability.”

In this case, all I can do is give my opinion based on the medical literature and my own experience as a physician. Peter Attia is doing the same.

But there is a bit of a difference.

As the commenter above wrote, which I bolded:

You say doctors disagree all the time, which is understandable with clinicians who develop their judgement from their experiences with patients, but references to scientific trials is theoretically supposed to move these questions from the realm of opinion to something replicable and objective.

That’s what I thought I did. The scientific trials showed statins to have no benefit in terms of a reduction in all-cause mortality, which is what you want to evaluate to adopt a particular therapy. In the case of statins, those who took them had fewer heart attacks, both fatal and non-fatal, but as a group they didn’t end up living any longer. Which means the therapy fixed one thing, but broke another. There was no net gain in terms of longevity, other than in the one small group I mentioned (men under 65 who have had a heart attack), and even it that group the decrease in all-cause mortality was minimal).

So, how come Peter Attia believes lowering lipids will help him live longer?

As I learned from reading his book (because I had the same question) and another reader reminded me in one of the responses, Peter saw a study using Mendelian randomization that showed elevated lipid levels to be a risk factor for heart disease.

A year or so ago, I did a deep dive on Mendelian randomization, and it is pretty thin gruel. It’s basically a smart sounding way to do an epidemiological study, but in the end, it’s still epidemiology, which doesn’t prove causation.

But if your mind is made up that condition A causes B, then even an epidemiological study will serve to confirm your bias. It shouldn’t, but it does.

I mean if you have some weird behavior you like to indulge in, and everyone tells you it’s dangerous, all you have to do is go to Google. Search whatever it is, and you’ll find that it is not only not dangerous, but actually makes you live longer. You may have to scroll through the first 35 pages to get to it, but I can just about guarantee it will be there if you search long enough. When you get to it, you can say: See, I was right.

In the case of statins, the great mass of RCT medical literature shows no benefits for all-cause mortality. To me, that should answer the question.

In his book Good Calories, Bad Calories, Gary Taubes wrote about a physicist named Pief Panofsky, who was the founder of the Stanford Linear Accelerator Center and former presidential scientific advisor to the Manhattan Project. He posited something that became known as Panofsky’s law. He said, “If you throw money at an effect, and it doesn’t get bigger, that means it’s not really there.”

God only knows how much money has been thrown at trying to prove statins decrease all-cause mortality, and the effect shown—no change—hasn’t gotten any bigger. Mendelian randomization shows that a lot more money has been thrown at the hypothesis, but it hasn’t really shown the effect to get bigger.

I happened to be looking for something else a few days ago and came upon an old video I made years ago about this very subject. At that time, a study had just come out showing that subjects on statins developed type 2 diabetes at significant rates. Since type 2 diabetes is a major risk factor for heart disease, it kind of threw a wrench in the works of the entire statin industry. Big Pharma had gotten one of its pet Harvard Professors to calm other doctors, so, one assumes, they would continue writing statin scripts by the boatload.

I kind of like this format. I wish I could figure out how I did this 12 years ago.

I looked up the old post in which I placed this video. It contains some other valuable info on the statin situation, but I haven’t had the time to update it since moving to a new theme. All the paragraphs are jumbled together and the video does’t play in the post, because the coding is now different. I’ll have to sort it when I have the time.

It also links to another post, which is also not updated. Some of its links don’t work, but I did find another video I had forgotten about. It’s Dr. Kendrick discussing a cholesterol vs heart disease study that had just come out.

Finally, Nick Norwitz just came out with a new video about a recent study he was involved in looking at plaque progression as shown by coronary calcium scanning in lean mass hyper-responders vs another group with vastly lower LDL levels. As it turned out, there was no correlation between LDL levels and the degree of plaque. And there was no real plaque progression in those with hugely elevated LDL levels. If LDL were truly a driving force behind the development of coronary artery disease, those harboring vastly elevated LDL levels should have shown increases in plaque over several years. But they didn’t.

At the meeting in San Diego where I spoke a couple of weeks ago, Dave Feldman gave a talk in which he provided data from a longer follow-up of this same study. The results have not been published yet as the paper hasn’t gone through the peer review process. But, according to Dave, the raw data show no correlation between LDL levels and the progression of plaque.

As soon as the video of his talk is available, I’ll post it in The Arrow.

The disgusting thing about the entire lipid hypothesis is that decades ago, long before anyone was associating any risk factors with heart disease, evidence was emerging that sugar might well be a driving force behind the disease. Big Sugar then stepped in and mounted a campaign to divert the possible causality from sugar to fat. And the lipid hypothesis took off and has been the primary hypothesis since. I’ll write about all this in a future Arrow.

I’ll address this commenter’s request to elaborate on calcium scoring later in today’s Arrow.

Whey Protein Concentrate

I got a handful of questions about whey protein concentrate. I should have been clearer last week when I wrote about Simplesse, the ubiquitous product in many ultra-processed foods.

I was shocked to learn that Simplesse is labeled as whey protein concentrate. I am in the business, and I did not know this. The most nefarious thing is, however, that there is actual good whey protein concentrate, and you can’t know the difference unless you call the company. I tried to get information on Simplesse, and it is almost impossible. I have no idea what’s in the other 47% of it. Also, I did some research of my own, and I am wary that turning whey into nano particles will end up causing some inflammation and/or possible destruction of the tight junctions in the gut. There is evidence of this with nano particles of titanium dioxide. I am including a link to an excellent article on nanoparticles. Thank you for bringing this to my attention! https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8952728/

 

The article linked is excellent. I had not seen it, so I was happy to get it. The authors spell out the issue caused by nano particles.

Here’s another that came via email:

In Issue #190 of The Arrow, you wrote about how whey protein concentrates are not great. You wrote, “So even though it is only about half protein (and God only knows what makes up the other half), it “supports a whey protein label claim.”

Now you know why you see Whey protein concentrate on a ton of ultra-processed foods. You, like me, probably thought that was a good thing.”

I was curious about this, and looked at various whey protein shake mixes I’ve used in the past. I also posted a question on the difference between the concentrates and the isolates in The Arrow.

Then I happened to click on the link to the HLTH Code protein powder mixes, one of your sponsors. The ingredients list begins with “Protein Blend (whey protein concentrate …)”

[She then attached a copy of the HLTH Code label showing whey protein concentrate as part of the protein source for the meal replacement]

Just a heads up. Do you still recommend the product? Maybe there’s a caveat?

Okay, here is the deal with whey protein concentrate. Real whey protein concentrate and whey protein isolate are good products used in many different nutritional supplements and protein powders.

Whey is the protein-rich part of milk that is left when the fat is removed to make butter or cheese. The whey, which is a kind of whitish looking liquid resembling watery milk (sort of what it is), is basically filtered to remove the rest of the fat and other particles that might be there. Then what is left is dried, so the fluid part evaporates leaving the residual whey protein. (It’s a bit more complex that this, but my description is generally what happens.) The whey protein concentrate is then used to make up the bulk of many protein powders and other protein-containing products. It is a terrific blend of amino acids with a lot of leucine, the specific amino acid that signals mTOR to active the muscle synthesis process.

Whey protein isolate is simply whey protein concentrate filtered a little more so the concentration of the protein is higher. Both have some residual fat and other substances in them, with whey protein concentrate having more protein than whey protein isolate. Both are excellent sources of protein, but whey protein isolate is more expensive is because it takes more time and effort to filter and deal with.

Simplesse, the product I described last week, is made from whey protein, but the protein is micro-particulated and turned into a substance that has the mouth feel of fat. It is used to thicken some drinks and make them seem more substantial. The company has basically converted whey protein into a low-calorie ‘fat’ in terms of how it tastes and feels. The issue with it is that since it is made from whey protein concentrate, the company can list it on the label is whey protein concentrate.

As the company says in its brochure, Simplesse “can be used to support a whey protein label claim.” As I wrote last week, there is communication between the gut and the brain. If you eat actual fat, both the brain and the gut know, and you get the satiation signal and quit eating. If you are fed what is basically a low-cal fat substitute (protein has 4 kcal/g—fat contains 9 kcal/g), you’ll feel like you’re eating rich, tasty fat, but your brain and gut won’t be fooled, so you’ll continue to eat beyond what you would have had it been actual fat. Since Simplesse and others of its ilk are typically used in snack foods, when you eat more, you end up with a lot more carbs as well. And more carbs means more insulin, and more insulin… You know the drill.

The HLTH Code products, which I do endorse and use myself, don’t need to add Simplesse or micro-particulated whey to provide mouth feel because the meal replacements include actual fat, including saturated fat. Which is why I use them.

The way you can tell from reading a label whether or not the whey protein concentrate is actual whey protein concentrate used for it’s amino acid content or whether it is Simplesse processed whey protein concentrate is by where it’s located on the label. If whey protein concentrate is at the front of the label, as it is with the HLTH Code meal replacements and other high-protein products, you can pretty much be sure it’s actual whey protein. If it’s near the end of the list of ingredients in snack products not known to be high in protein, then you can figure it’s a Simplesse-type product.

Try Harlo’s New 3-in-1 Drink Mix!

Harlo combines collagen, creatine, and electrolytes in one powerful mix for enhanced energy, health, and hydration.

The ad above is for a product I actually use and like. It’s a electrolyte supplement with some creatine in it. I use it for hydration and electrolyte replacement when I’m playing golf. Especially in Texas. Give it a look.

Speaking of Ultra-Processed Foods…

The times they are a changing.

All the many articles published by the mainstream media bashing ultra-processed foods are having an effect. Big Food is listening and changing. Which is all for the good, at least in my opinion.

I was in the grocery store a few days ago and took a look at the ice cream freezer. I wanted to see what the UPF situation was with plain old vanilla ice cream.

The first one I looked at was Häagen-Dazs, which despite it’s European-sounding name is a product of Big Food. It’s been owned by Pillsbury, General Foods, Nestle, and has now been sold to Froneri. Here is the ingredients label.

As you can see, there is nothing in this product that wouldn’t be found in a home kitchen, except maybe the ground vanilla beans. But even they are a natural product.

Compare this with a vanilla ice cream I found right next to it made by Tillamook, which is a farmer owned dairy cooperative in Oregon.

The Tillamook brand is loaded with all kinds of gums, natural flavors, and coloring. Why do you need coloring in vanilla ice cream? It’s supposed to be white. All the gums are emulsifiers that make the product smoother, more creamy, and have better mouth feel. But they also have been known to cause GI problems, and, in the case of xanthan gum, to be toxic to infants.

If you’re using real cream, milk, and egg yolks in your product, why do you need extra emulsifiers and thickeners?

Other ice creams I looked at had even longer lists of added ingredients than Tillamook.

As noted, the Big Food produced Häagen-Dazs has no added ingredients. Big Food has seen the writing on the wall and is trying to stay ahead of the curve on the UPF front. Which I believe is a good thing overall. Not that I’m a promoter of ice cream, but plenty of people eat it. And most probably never look at a label, but they’ll be better off in the long run if Big Food cuts all the UPF ingredients.

In my romp through the internet (it was actually MD’s romp—she found these and sent them my way), I came across a couple of interesting products.

As we all know, the carb-fat combo is hard to resist. But strangely, it really isn’t found anywhere in nature, except for mother’s milk. Which, of course, is designed by nature to stimulate growth, a process we’re not really interested in after we’ve gone through our growth phase.

In the good old days, back before we all became obese, the carb-fat combo was usually made of carbs and saturated fat, usually beef tallow. McDonald’s French fries used to be fried in beef tallow. Once the nutritional guidelines came out in the early 1980s, and all the do-gooder organizations such as the CSPI started militating to remove animal products from food, because, gasp, they caused heart disease, Big Food moved away from saturated fat toward seed oils. So healthful…from plants and all.

In the early 1990s, even McDonald’s switched to seed oils for their fries. They didn’t taste the same, but with the magical touch from food technologists, who can make food taste like whatever they want it to taste like, the seed-oil saturated fries tasted pretty much the same.

Now virtually every tortilla chip and potato chip is made with corn or potatoes and seed oils. Every one. I’ve looked at every bag at Whole Foods, and I defy you to find one without seed oils as an ingredient. They go to great lengths to make the seed oils look healthful, as in expeller-expressed sesame seed oil and crap like that. Doesn’t matter; they’re all seed oils.

So, imagine my surprise when MD sent me the following two products.

The first was Masa Chips. These are made with only three ingredients: corn, beef tallow, and sea salt. Here is the nutritional ingredients label.

I especially love the tagline: “Not suitable for vegetarians.”

I have never tried these, so I have no idea how they taste. I suspect they taste pretty good, but they do contain a bunch of carb. However, if you are going to occasionally consume the carbs, better to have them with beef tallow than seed oils.

The problem I see with this product is its cost. To get 8 bags of them, you have to fork over $104, which puts them at $13 per 5 ounce bag, which is half the size of the typical bag of tortilla chips.

Corn is dirt cheap, beef tallow is really dirt cheap, and sea salt isn’t expensive. So why the high price?

The next product is a potato chip. Like the above product, Vandy Classic Potato Chips are made with only three ingredients: potatoes, beef tallow, and sea salt.

Hmmm. In reading their label, I noticed the same tagline as the Masa Chips. Plus the pricing is the same outrageous $104 for an 8-pack of 5 ounce bags. As it turns out, these are made by the same company that makes the previous product.

The point is, other products made without all the UPF crap are entering the market. That combined with the fact that Big Food is taking notice and cleaning up their labels gives me hope that before long most processed foods won’t contain all the additives they have in the past. It will be interesting to see if it makes a difference in the obesity epidemic. I would bet it will make a difference in overall health over time. At least I hope so.

In case you’re wondering, I have no affiliation with the above company or its products in any way. I just find it fascinating to see the movement away from UPF.

Before I leave this subject, I’ve got to tell you about one other product I have consumed that upon reading the label I discovered was awful.

I don’t know how many of you know what Buc-ee’s is, but it is an iconic roadside gas station/food/merchandise combo that is famous throughout Texas. These stores are humongous—about 2/3 to almost the same size as a Costco. They are scattered across rural areas of Texas off the main freeways. If you travel out of any major cities in Texas, you’ll find a Buc-ee’s within the first 50 miles or so out of town.

The stores have hundreds of different food items, most made in house or at Buc-ee’s central, wherever that is. When MD and I travel anywhere by car from Dallas, we run into a Buc-ee’s an hour or so out of town. We always stop to get gas, which is cheap, and use the restrooms, which are huge, clean, and never closed. And we typically grab a bite to eat.

I usually get a Texas cheesesteak burrito, which, like Texas and Buc-ee’s, is huge. And since it comes in a tortilla wrap, I can eat it while driving. The tortilla wrap gives me a few carbs, but since I eat very few carbs overall, I can still stay within my daily limit. The last time we stopped at a Buc-ee’s was several months ago while we were on our way to Little Rock for our grandson’s graduation. As per usual, I got the Buc-ee’s Texas cheesesteak burrito and ate it while driving.

It occurred to me that I hadn’t really looked at the label. Since I’ve become interested in UPF, I’ve started examining labels much more carefully. Before, all I would look at was the part showing the carbs, proteins, and fat, mainly to watch the carb content. Sad to say, I pretty much ignored the part below describing all the ingredients.

When we stopped, I grabbed the label out of the bag of trash MD had assembled to be thrown away. Unfortunately, the name of the product was separated from the label, but I was stunned to see all the crap this food contained. It was a Frankenfood created by food technologists to taste great, which it certainly did. The label tells the tale. I brought this up in my talk in San Diego. Here is the slide I made showcasing the label.

On the right, I listed all the actual real ingredients it takes to make a Texas Cheesesteak Burrito. You can see all the stuff included in the Buc-ee’s version.

Jesus wept.

Variable Resistance

I continue to get many questions about variable resistance and the use of the X3 Band System, which I use to build and maintain my muscle mass, such as it is. I’ll run through a bunch of them, then provide my thoughts.

You are definitely right about slow motion exercise. It's especially important as we get older because It's safer. You're much less likely to hurt yourself and recovering from injury when you're older takes much longer. I'd argue that avoiding injury is the most important goal when exercising after her age 50.

Merci for your insights on the X-3 program....and what a game changer is has been for us 70 year olds. Just wish I could figure how to deal with the next day stiffness in trying to build that promised lean musculature! Are we causing a problem sipping alcohol too?

Regarding the X3 - if you’d joined the Facebook groups about it in the beginning (after watching all John Jaquish’s videos on the website) then you’d have saved yourself a few wasted weeks! They’re always posting ‘form’ videos that others happily critique and the big muscle guys are always posting videos of themselves in action. There’s even a prolific lady on the Ladies of X3 who posts regular videos of her form ( recently whilst wearing an evening gown as she was just about to go out!) and she is being coached by one of the muscle guys via zoom. My children ( aged 19-22) laugh at me with my X3 and tell me I’ve been conned and that their way of building muscle in the gym is ‘way better’. I showed them pictures of John on the enclosed laminated exercise sheet, and they both laughed and said ‘he’s on steroids’. Is he? I don’t follow the men’s groups where they discuss such things. Anyway, I’m choosing to believe you and find the X3 to be the only kind of resistance training that I’ll actually consider doing!

Dr. J would have fifty fits if he saw you standing on the bands, if his scoldings on Facebook are anything to go by.

I found the most difficult part of X3 use was that keeping the muscle group under stress at all times, which took many days of exercise to get right.

About the bands, how soon after a workout are you able to do most normal things? Would you workout on a golfing day?

One of my readers answered the above question with her own experience:

In my experience, recovery takes only a few minutes. If you use good form, you won’t have aching muscles afterwards - that’s one of the features of the X3 Bar. I don’t play golf, but I would certainly go for a walk, or a swim, or heft things about on my allotment after a workout.

The first commenter is absolutely correct about preventing injuries. If you do the various exercises or movements with good form and slowly, you will minimize any chance of injury. You will reach failure at a lower number of reps if you do it slowly. Trying to increase resistance too fast leads to poor form, which increases the chance of injury. The objective is to do the exercises slowly with perfect form until failure, not to see how quickly you can increase the number of reps or the band size. That was my problem. I let my ego get in the way. I wanted to get to what I called the Big Boy Band as quickly as I could. Don’t be like Mike. Do it slowly with perfect form. It will seem easy at first, but all too soon it won’t be easy. Just keep going slowly until you can’t without losing form. Best way ever to build muscle. All you’re doing with the bands is setting the muscle-building process in motion. The real work is done during the night and your rest day.

Alcohol has its upside and its downside. I drink a bit, but not too much. I don’t know if has a major effect on muscle building. I’m kind of afraid to look.:)

I don’t know if Dr. Jaquish is on steroids. And I don’t care if he would get pissed because I stood on the bands. It worked for me during travel.

It does take a bit of time to get the hang of always keeping the muscles under stress. Most people who have lifted weights tend to use momentum to get them going, then brace them for a few seconds of rest during full extension. Always keeping the muscles under stress takes you to failure more rapidly, which is the goal. Not increasing the number of reps or the band size.

When you first start doing the workouts, you can get pretty out of breath when you finally get to failure. I do my workouts in the bedroom, and when I’ve gone as far as I can go, I quit and fall onto the bed, where I gasp like a netted carp for a few minutes. When I first started, the gasping lasted a lot longer than it does now. Which means my recovery time has improved significantly.

I can do and have done workouts on days before I played golf, but usually do them after if golf falls on a workout day. Which reminds me, if you keep track of your reps, which you should do, it’s not a black mark against you if on one day you can’t do as many reps as you could the previous session. Just keep going till you can’t do any more irrespective of how many you did the time before. When I work out after walking 18 holes, I generally can’t get in the same number of reps that I did the time before when I came to it fresh. My muscles were already a bit fatigued from the round of golf, so taking them to failure didn’t take as many reps. But I still get the same growth stimulus as long as I go to failure.

A Spoonful of Sugar

A reader wrote asking about a quantification of glucose levels mentioned in one of Dr. Chaffee’s videos.

I went to YouTube and listened to “Why Cutting Down on Carbs is Essential for Your Health”, Anthony Chaffee MD. https://www.youtube.com/watch?v=wKR0Az4-SNM ;

I thought the 4 g of glucose in the blood was not really well explained. It almost seemed that it was a static amount that did not need replacing but of course gets used and does need topping up, which he knows. [My bold]

I calculated the amount of glucose in the blood of someone with a normal reading years and years ago. I used it in all my talks, because everyone was stunned to learn that there was less than a teaspoon of sugar dissolved in the blood of someone with normal blood sugar levels.

When I started blogging 20 years ago or so, I wrote a blog post about it so that I could provide a link to those who wondered how I came up with that figure.

Here is the link. Shows how I did the calculation and how to calculate the amount of sugar in the blood for any blood glucose reading.

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Coronary Calcium Scoring

Several years ago a paper appeared in the Journal of the American Medical Association (JAMA) describing a better way to append risk to a coronary artery calcium (CAC) score. One of the authors of the paper is Matt Budhoff, who has probably published more papers on CAC scoring than anyone. He is also the lead author on all the Dave Feldman, Nick Norwitz studies such as the one I wrote about above and the new one going through peer review.

There are two types of plaque in coronary arteries: stable plaque and unstable plaque. Stable plaque is basically what it’s name implies. It is stable and not prone to rupture and release a clot that could cause a heart attack. Unstable plaque, on the other hand, is a more volatile, dangerous situation. Unstable, soft, plaque can easily throw off a thrombus creating a real problem.

Years ago a researcher named George Mann did a lot of work with the Masai in Africa. He was one of the people involved early on in the famous Framingham study, so he was well aware of the lipid hypothesis. He knew that the Masai, who were herders, consumed a diet of primarily meat, milk, and blood. He also knew that everyone thought dietary saturated fat, of which the Masai ate plenty, was a risk factor for coronary artery disease. He was also aware that the Masai rarely experienced the endpoint of heart disease—ie angina and heart attack.

In his first study, he did electrocardiograms on a large number of subjects and found few indications of heart disease. Several years later, he collected the hearts and aortas from autopsies of 50 Masai who had died from accidents. Surprisingly, he found extensive atherosclerosis in these subjects, yet they had no signs of cardiac damage. Despite the large amount of plaque, the arteries were wide open. Mann concluded that the active lifestyle of the Masai protected them against the effects of their extensive plaque.

I’m sure if those Masai were put through a CAC scan, they would have been found to have extraordinarily high scores. Yet they didn’t have what we could call “heart disease”.

They didn’t have heart disease because their plaque was stable.

Many, many people today have high CAC scores, but are not at risk of dying of a heart attack for the same reason. Although they have a lot of plaque, the plaque they have is stable.

But how to tell?

That’s what the JAMA paper mentioned above is all about.

The authors developed a scoring system that identifies stable plaque. They then looked at a large number of people who had undergone CAC scans years before and found out who had had heart attacks and who hadn’t. When they compared the scores determined by their new method of calculation, they found that the number of heart attacks fit nicely on their curve. Those in the 4th quartile, who were those with the most stable plaque, had very few heart attacks, while those in the 1st quartile, the least stable plaque, had the most.

When I was a partner in a scanning center (which I wish I still had), the software provided our patients with the regular score, which is called the Agatston score. I would then run calculations based on the JAMA paper methods, and the vast majority ended up in the 4th quartile, which was the one with the least risk.

In order to calculate what I call your true risk, you’ll need your Agatston score, which is the score you’ll be given with your test. You’ll need the plaque volume, which is usually included in the printout you get. You’ll need the thickness of the CT slice they took of your heart. This is included in about a third to a half of the reports I’ve seen from various centers. It will be either 3mm or 2.5mm.

You can tell which it is by the time it took you to get the CAC scan. If it took ~ 45 seconds to one minute, then you were scanned by an EBT machine and your slice thickness is 3mm. If your scan took 35 minutes to an hour, then you had a helical scanner and your slice thickness is 2.5mm.

Once you have that in hand along with your scan, you're ready to roll. Here are the steps.

  1. divide the volume score by the slice thickness

  2. take that number and divide it into the total calcium score

  3. look up that number on the chart below (Table 2 in the JAMA paper).

Let’s take a look at a scan that a friend of mine sent me.

I happen to know this scan was done on an EBT scan, so the slice thickness is 3mm.

The total calcium score (the Agatston score) is 476.65. We can see that the volume score in the middle column above 401.73.

Dividing the volume score by the slice thickness (401.73/3) gives us 133.91.

Dividing that number into the calcium score of 476.65 (476.65/133.91) gives us 3.56.

When we look up 3.56 on the table below, we find this person to be in the 4th quartile (he/she falls into the 3.19-4.0 range), which means he/she has low risk, despite his/her high Agatston score.

I just had a friend come to me panicked about a calcium score he had received of 3,000, which is the highest I’ve ever seen. When I ran his calculations for him, I feared the worst, but he came in at 3.30, which puts him in the 4th quartile.

Before he came to me, he had already undergone a thorough workup by his cardiologist, which included a stress echo. Which is the first thing that needs to be done in the face of a huge calcium score. His was perfect.

His cardiologists wanted to pull out all the plugs, and give him every cholesterol-lowering agent known to man, despite his having a low LDL to start with. All of which he opted to forego. He is in otherwise perfect health and choses not to chase a lab value.

I hope this helps in your understanding of what I feel is a better way to evaluate calcium scans. If it seems confusing, let me know, and I’ll try to explain it better next week.

Odds and Ends

Newsletter Recommendations

As per usual, I commend the pen (well, keyboard) of my Bride and her OutlanderMD Substack. This week, she tackles the grim specter of smallpox in the 18th Century as Claire encountered it in the harbor at Le Havre, France in Ep201. What did she see? Was she right? Did the show get it medically correct? Tune in and find out outlandermd.substack.com

You can also take a look at Books & Biceps, which is a newsletter for people who like to both do strength training and read. An interesting Venn diagram, that’s for sure, but one I happen to fit into.

If you like Dad jokes, you can give The Town Crier a try. It’s free and funny. Sometimes.

Video of the Week

The VOTW this week is definitely not safe for work (NSFW). If you are offended by the F-word, do not watch. There is a bleeped out version of this short video in the video that follows, so you can see it there without all the bad words. You’ve been warned.

I first saw this video years ago and have watched it probably more times than any other video I’ve ever watched. Our whole family loves it despite the salty language. It perfectly describes summer in the South. And it was filmed in a small town outside Little Rock while we lived there. But, as I discovered, it didn’t see the light of day until years later.

The ‘star’ of the show is a reporter doing an on-the-scene report when a large bug flies into his mouth. I’m sure he’s already hot and sweaty, but this puts him over the edge. He goes on this magnificent rant while he is hopping (literally) mad about being there.

When the video was first uploaded to YouTube, it instantly went viral. But it was ten years after the fact. At the time, the guy was working at a station somewhere else and had no idea what was about to happen to him. I found a video of him on a talk show telling the story. It is preceded by a bleeped out version of the viral video.

Here is the real one.

The video below is an interview with the guy above. His life pretty much changed after this video came out, which it did ten years after he was filmed. He didn’t even know it existed, then, all of a sudden, it went viral. He explains the situation to the host, who shows the video with all the naughty words bleeped out. I’ve cued the video to the point in the longer conversation when the above is discussed. I haven’t had a lot of success cueing these videos of late, so if my efforts are futile and your version starts at the beginning, scroll forward to 3:47.

Time for the poll, so you can grade my performance this week.

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That’s about it for this week. Keep in good cheer, and I’ll be back next Thursday.

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This newsletter is for informational and educational purposes only. It is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice.

Thanks for reading all the way to the end. Really, thanks. If you got something out of it, please consider becoming a paid subscriber if you aren’t yet. I would really appreciate it.

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