Working in the field of Endocrinology, I’m bombarded by patients quoting at me what they’ve read from the latest diet books. Whatever the program du jour, it’s guaranteed to stoke your metabolism, increase your energy, and result in more intense orgasms…got your attention there, didn’t I? Sensationalistic claims sell books, sure. But sadly, most of the books in this genre will either: (a) not help you at all, or (b) give you a temporary placebo effect, just from being more focused on your health, but then you’ll eventually regress to your baseline because the program isn’t sensible or sustainable.
Today, I’m pleased to write a review of a trend-bucking new book called Your Best Health Ever! The Cardiologist’s Surprisingly Simple Guide to What Really Works. It’s written by Dr. Bret Scher, who practices in San Diego. Disclosure: although I have no direct financial relationship with Dr. Scher, I will be paid an infinitesimally small amount of money if you purchase his book using the Amazon affiliate link below. Additional disclosure: I know Bret personally, and I can tell you he’s an excellent doctor and an all-around great guy. I promise you, if he was a quack with a lousy book, I wouldn’t lie to you, my reader (or readers, if I really want to be optimistic about the reach of this blog). Being a coward, though, because Bret’s my friend, I probably would have lied to him and said his book was “good” and left it at that.
To get a sense of what this book is, what isn’t this book?
This book is not a weight loss book or a diet book. It is not a sensationalist book built around extreme ideas or extreme programs. If you follow the tenets in this book, you will become healthier. You will reduce your risk of chronic diseases. Period.
So unsexy, right? I love the fact that Dr. Scher takes the honest, straightforward approach, as opposed to making outlandish claims he’ll never be able to support. You can tell he didn’t have a book agent advising him, though, because this brand of bland honesty is unlikely to sell as many copies.
Become healthier? Reduce my risk of chronic diseases? What about the six-pack this program’s going to give me? And the orgasms? I want my orgasms.
Listen, I’m going to editorialize for a moment here. One of the major reasons why people fail to get and maintain health is because they’re looking for two things that do not exist: a smoking gun and a magic bullet. For the sake of illustrating my argument, let’s focus just on weight management. There are so many things that factor into weight gain and inability to lose weight – resting metabolic rate; caloric intake; macronutrient composition of your diet; exercise type, frequency, duration, and intensity; sleep duration and quality; stress; mood; cravings; social circumstances; work circumstances; hormonal issues; sleep apnea; medications…the list goes on and on and on. With the myriad things that tend to affect weight, it is my clinical experience that there is almost never one smoking gun which, if discovered, will lead to a magical melting off of excess poundage. Nonetheless, my patients appear to be on a lifelong Quixotic quest for this mythical smoking gun. Why?
It would be easy – but intellectually lazy – to simply chalk this up to stereotypical American laziness (if I have any readers outside of the U.S., I’d love to hear from you in the Comments below, as to whether your countrymen and women also have the laziness gene). Anyway, I think it’s more complicated than just being lazy. I’ve seen how much time, energy, money, and emotional capital my patients spend searching for the smoking gun. That’s not laziness. In part, I think it’s about hope – hope that there’s an answer. We like answers, probably because we are rational beings. If there is a problem, there should be an identifiable cause of said problem, right? The idea that there is an answer out there that simply needs to be discovered gives us hope, and hope enables us to avoid confronting some hard realities. Confronting hard realities – like the fact that there is no smoking gun – is depressing. And people don’t want to be depressed (duh).
The second thing that doesn’t exist is the magic bullet. People who have been fruitlessly searching for the smoking gun still seem to hold out hope that there is a magic bullet – one that will help them lose weight regardless of the fact that none of their doctors has ever been able to identify a smoking gun. Do you see how desperately people hold on to hope, even when it makes no rational sense? If there was truly a magic bullet that could be purchased at GNC or Super Supplements (like Dr. Oz would have you believe), does it make sense that more than 1/3 of adults in the U.S. are obese? Of course not. But people want to believe, even though that isn’t rational.
When we stop being rational, our emotional nature takes over. And when it comes to losing weight and getting healthy, emotion is no good. Emotion leads us to make poor choices that give the brain’s pleasure center a quick hit, and emotion leads us to look for easy solutions. Easy solutions make us feel better faster, and that’s what we want. We are overweight now, and we want to lose the weight yesterday. When there’s a book that comes along and claims that if we just eat this and don’t eat that, everything will be fine, we want to give ourselves over to it and let the change cascade over our bodies like warm water in the shower…wake up, people! That ain’t going to happen. This type of change takes a lot of hard work. Not only that, but the work doesn’t stop once you’ve lost the weight. Now you have to maintain your new, healthier lifestyle, or you will regress to right back where you started – maybe worse. There is no finish line when it comes to health.
Depressing, right? Now you’re starting to get a sense of why people are resistant to substantive change. I know there’s some laziness there, given all this talk about hard work. But it’s also about letting go of totally irrational hope and embracing a rational course of lifestyle change, which could fail! The magic bullet never fails, because it’s magic. But once you take ownership of your life and implement change, you might fail, and that’s scary, because that’s all on you.
Back to the Book
All of my mumbo jumbo is meant to provide some context for the structure of Dr. Scher’s book, which is intended to help you achieve and maintain health. According to him, health is not merely the absence of disease. It’s about integrating the mind and body in a way that promotes happiness, energy, sleep, ease of movement, and the absence of chronic disease. If one of your goals is to lose weight, that will probably happen if you follow this program, but he actually encourages you to put away the scale, at least initially:
Health is about much more than weight. When we can transform our lives and prioritize our health, appropriate weight loss will follow.
That’s why I don’t recommend using a scale as your guide to your success. Many of my clients are uncomfortable when I tell them to put their scale away for the next four weeks. They ask: “How will I know if the program is working? How will I know how I’m doing?”
You’ll feel better, have more energy, and see the world in a brighter light.
Your pants will be a little looser.
You’ll notice your exercise routine is getting easier and more comfortable.
You’ll enjoy your meals, and you’ll enjoy being mindful and being present.
And after four weeks, you’ll also notice a positive impact on your blood work, your blood pressure, and other health markers.
Dr. Scher provides a “four-week plan,” but it’s not in the same league (or even the same universe) as the hcg-diet your chiropractor put you on last year. Like the good doctor says, this isn’t a “diet.” This is a way to approach your life and help you make lasting, sensible, sustainable change. Each week, you’ll be focusing on just a few tasks from each of the following main categories: Modify Your Mindset, Nourish Your Body, Move With Purpose, Manage Your Stress and Sleep, Build Your Support Community, and Re-examine Your Healthcare. Honestly, there weren’t too many surprises in this book, at least for me. You, also, may know a lot of what is in this book. But what you know is worthless until you put it into action, and that’s where this book excels. Dr. Scher gives you discrete chunks of eminently doable tasks each week, which should prevent you from becoming overwhelmed and giving up. Importantly, he also stresses that you must give yourself permission to fail:
Be Your Own Caddie
Don’t worry, this isn’t about golf. This is about being kind to yourself, encouraging yourself, and supporting yourself.
I’m not a very good golfer. Sometimes I’m downright awful, and I can get very frustrated. It’s all too easy to say to myself, “How could you do that!” “That was so stupid!” “Are you kidding me with that shot? What’s the matter with you?”
I’m not proud of that. No surprise, my next shot often just gets worse. How could I expect anything else with such a negative mindset?
Would a golfer’s caddie ever say “You are an idiot! You are a terrible golfer! How could you hit such an awful shot?”
Of course not! But that doesn’t stop us from saying that to ourselves.
The same is true when it comes to a healthy lifestyle. It’s all too easy to get down on ourselves. “How could I be such an idiot for eating that ice cream. I have no willpower, I’m too weak to resist!” “I’m such a lazy slug. I can’t even get 8,000 steps in a day. What in the world is wrong with me?”
Be Your Own Health Caddie
When these thoughts creep in, ask yourself if your caddie would say those things to you. If not, reframe your thoughts the way your health caddie would say them:
“Sure, you shouldn’t have had the whole carton of ice cream. What a great learning experience. Take note of how you feel at this moment and remember that next time you start to dig into the ice cream.” “You got 6,000 steps today. That’s certainly better than none. Let’s find ways to get you to 8,000 tomorrow.”
Doesn’t that sound better?
So what does the program actually look like? As a teaser, I’ve cut and pasted Week 1 from each of the main categories on which you’ll be focusing. Obviously, these bulleted points are fleshed out more comprehensively in the body of the book, but notice the simplicity of each task. Now, I’m concerned that people who read the book will be tempted to skip steps that seem overly simple, obvious, or new-agey – don’t skip steps! Don’t roll your eyes and discount the message when the doc uses words like “mindfulness.” Just recognize that he’s from southern California, and sometimes Californians say some stuff that sounds a little “hippy dippy” to the rest of us normal people. In order to succeed, you should buy in to the whole enchilada, so I’d urge you to read and do it all. Most of the steps in the program are simple because getting healthy is simple.
THE PLAN: MODIFY YOUR MINDSET
- Define your goals, write them down and sign the paper. Take time to visualize what it looks like to accomplish those goals. Remember to visualize the habits that coincide with achieving those goals, too. Start asking your positively framed “What if” questions.
THE PLAN: NOURISH YOUR BODY
- Become more mindful with everything you eat. Ask yourself, what nutrition does it provide? Does it help you feel full and feel energized? Do you enjoy it? Does it help you or hurt you?
- Practice mindful techniques when you eat. Start each meal with three mindful breaths, and focus on your food as you eat. Use this to help you assess your fullness, so you stop eating when you’re no longer hungry.
THE PLAN: MOVE WITH PURPOSE
Here’s the core principle behind this plan: when you exercise with purpose and intensity three days each week, and use your activity tracker to make sure you’re moving more the rest of the week, you don’t need formal exercise every single day to achieve better health and lower your risk of chronic diseases.
- Increase your daily activity: park farther away, take the stairs, walk every 30 minutes at work, start a gardening project, etc.
- Get an activity tracker and determine your baseline activity level.
THE PLAN: BUILD YOUR SUPPORT COMMUNITY
- Talk about your goals with your friends and loved ones.
- Gauge their responses. Are they supportive, or dubious? Constructive, or critical?
- Use this feedback to help you decide who to include in your community, and enroll at least two people the first week.
THE PLAN: RE-EXAMINE YOUR HEALTHCARE
- Know your baseline blood tests. At a minimum, get a standard lipid panel, hs-CRP test, fasting glucose and insulin levels, and Vitamin D level.
- Even better, discuss with your doctor the option of getting advanced lipid testing.
- Measure your baseline weight, BMI, waist circumference, and body fat percentage.
- Carefully review your medications with your physician. Inform him or her that you intend to implement purposeful lifestyle changes to safely decrease your dependence on them.
So that’s Week 1. Easy, right? The subsequent 3 weeks then build on Week 1 with more specific tasks and goals. Dr. Scher acknowledges that it may take 8-12 weeks or longer to complete all the objectives, which is fine. The point is to incorporate all of this into your daily life so it transforms from a “program” into just “life.”
My Personal Takeaways from the Book
I’m fit and healthy. But like almost everyone, I could do better. I did find a few things in this book that caused me to reevaluate my own food choices, reconsider my medical practice, and revisit some controversies in the realm of nutrition that I hadn’t thought about for quite awhile. In no particular order:
Dr. Scher makes a good case for looking at the ratio of “anti-inflammatory” omega-3 fatty acids to “pro-inflammatory” omega-6’s in your diet. If you’re like me and you buy the cheap stuff when it comes to meat, fish, poultry, and eggs, you’re probably buying animal products that are higher in omega-6’s and lower in omega-3’s. If you convert to grass-fed beef, wild fish, and pasture-raised chickens, the feed for these animals is different, and may result in a more optimal intake of omega-3’s. I’m a bit torn here, because the theory makes intuitive sense, but there isn’t sufficient hard end-point data (like prospective studies showing reduction of heart attacks, strokes, diabetes, and cancer) to make the extra cost a no-brainer. Plus, there isn’t anything close to universal agreement that omega-6’s are pro-inflammatory.
Additionally, I don’t think we can say that wild, grass-fed, and free-range are always better. For example, farmed (Atlantic) salmon has a very high fat content, resulting in the total amount of omega-3 fatty acids in a serving being equal to or even greater than a similar serving of wild salmon. Incidentally, this probably explains why the only type of wild salmon I enjoy is king (ka-ching!), which has a higher fat content than other wild salmon.
As for grass-fed beef, did that beautiful slab of steak on your plate come from a cow that was slaughtered at the end of summer, after months of eating omega-3-rich grass? Or was it slaughtered in winter, after months of eating hay (technically still grass-fed, just drier), which is much lower in omega-3’s? Not only that, but was your meat cooked at a gentle temperature, thereby preserving much of the heat-sensitive omega-3’s, or was it thrown on a grill with the gas cranked up to 11, Spinal Tap-style, which could result in significant degradation of the healthy omega-3’s?
And eggs…don’t get me started on eggs. Although there’s no question that chickens permitted to forage naturally on grass and insects will lay eggs higher in omega-3’s, finding those eggs at your local grocery could be a thrash. Organic? Means nothing when it comes to omega-3 content. Cage-free? Just means your chicken was wandering around an overcrowded, poop-filled barn, instead of an overcrowded, poop-filled, tiny hen house. Free-range? Technically, your chicken could be mostly cooped up in a hen house with a small door to access the outdoors, presuming your chicken could fight through all the other chicken bodies to actually get outside. If you have the time, access, and cash, and you want to boost your omega-3 intake, buy your eggs locally from a farmer with pasture-raised chickens.
Shifting gears, Dr. Scher recommends that everyone take a vitamin K2 supplement to promote bone and (possibly) cardiovascular health. This one is interesting, as I recently saw a patient I treat for osteoporosis come in with a K2 supplement, claiming that it acts like a drug to reduce fracture risk (her claim based on her own “research”). I didn’t know much about K2 at the time but had intended to look into it. I promptly forgot about it until Dr. Scher’s book brought it to my attention again. After doing some digging, I would agree with Dr. Scher that this vitamin has some potential clinical applications. However, the research has not shown significant increases in bone mineral density with K2 supplementation, nor have any well-designed clinical trials shown significant fracture risk reduction.
There is some data out there suggesting benefit, but I don’t think it’s conclusive enough to recommend that everyone go out and buy vitamin K2. As more data emerges, I may change my tune. One last thought on this topic: I think Dr. Scher’s argument would have been more powerful if he cited studies from peer-reviewed journals, instead of citing talks given by his friend, Dr. John Neustadt, a naturopath who apparently has expertise in the arena of K2. I don’t know Dr. Neustadt and don’t mean to paint him with the same brush I often use for naturopaths around here, but my negative impression of his field colors my outlook on the recommendation in favor of supplementation. Consider that my disclosure of bias.
The final nugget I wanted to mention is Dr. Scher’s take on statin therapy. This section of his book forced me to look at the issue of when to start a statin from a different angle than my usual one. Because my typical patient population consists of many type 2 diabetics, the choice regarding statin therapy usually isn’t whether to do it or not, but whether the patient gets a moderate dose or a high dose, per American Heart Association guidelines.
Because Dr. Scher is a preventive cardiologist, he gets to see many people before they actually have a high-risk chronic disease like diabetes, so there is more nuance to the decision of whether the patient in front of him will benefit from a statin or not, with respect to reduction in the risk of heart attack and stroke:
The guidelines mention that in addition to the calculated risk, physicians may want to consider:
- the person’s family history of premature heart disease
- the high-sensitivity CRP (hs-CRP) inflammation blood test
- the ankle-brachial (ABI) test for peripheral vascular disease
- an elevated coronary calcium score that is above 300 or above the 75th percentile for age
Amazingly, the recommendation is to use these tests only for deciding in favor of statins. The guidelines don’t mention, for example, using a calcium score of zero to eliminate the need for statin therapy. They don’t mention using a normal ABI and a normal hs-CRP as evidence that your risk is lower, and you therefore don’t need statins.
Why not? Likely because the guideline authors have a bias towards initiating statin therapy—the “more is better” approach. Believing that more medicine is always better is a very common bias in medicine that comes from the desire to help.
Unfortunately, it’s not always best for your health.
I take the opposite approach. What if our bias is against starting a statin?
A trial published in the Journal of the American College of Cardiology looked at that exact question. They found that about 50% of the people aged 45-75 who met other criteria for starting a statin also had a calcium score of 0.
Factoring this calcium score into their risk analysis reclassifies them into a lower-risk category that no longer meets the threshold for statin therapy. That’s a lot of statin prescriptions that could be avoided, thus reducing the cost and risk to the patient.
I think Dr. Scher is right that, as a profession, doctors are often too quick to pull the trigger on a prescription. Elsewhere in the book, he talks about the concept of reduction of relative risk versus reduction of absolute risk, which is an important concept to grasp, especially when we’re talking about how much you will really benefit from taking a statin for the next 30-60 years! If your absolute risk reduction is very low because of great health and ideal biomarkers in the rest of your testing, maybe that 20-30% relative risk reduction should not be the driving force to add yet another pill to your daily routine. I will reiterate that my patient population is going to get the statin anyway because they are high-risk, but I do occasionally see lower-risk patients, so Dr. Scher’s framework provides a sensible approach.
OK, let’s wrap it up. Who is going to benefit from Your Best Health Ever!? Highly motivated people who approach their health with the mindset of taking personal responsibility and embracing hard work will get a lot out of this book. The book provides a comprehensive framework for approaching health and, as such, can be used as a reference to sustain the changes made during the program.
Who will not benefit from the book? Those who are still searching for smoking guns and magic bullets. Those who deposit themselves in their doctor’s office and demand to be fixed. Those who do not have the self-awareness to realize that their current choices are poor. So, pretty much 95-98% of the people I see in my office. And with that, you now understand the unfortunate title of this book review.
Want to prove me wrong? Take control of your health and buy the book!
What do you think? Are you a health care provider who counsels patients about lifestyle modifications? What have you found successful? Unsuccessful? Do you walk the walk, or just talk the talk? Are you a patient who has struggled with your health? What has worked best for you in the past? Comment below!
By interacting with me in the Comments, you agree that you have read and will abide by my Disclaimer.
56 Replies to “The Best Weight Loss Book You’ll Never Read”
I am not as enthusiastic as you about this book, perhaps because I don’t know Dr Scher and therefore have no skin in the game. While mild by comparison, there is more than a hint of woo from what you’ve quoted. I have a family history of early onset heart disease that has been very well-managed since stent implant in 2000, including lifestyle management resulting in significant AND MAINTAINED weight loss, which is now in its tenth year. None of my success involved any type of “mindfulness”, although I do advocate for sitting at the table with a nice setting and appreciating my small portions. I rarely eat away from home–this is huge in the current obesogenic food environment. I see a Registered Dietician regularly for support and strategy discussion. No supplements, no woo, including dubious “mind-body” philosophy, and no paling around with Naturopaths with any of my providers.
I also think the discussion of statins leans too far into the “pills are evil” territory and the misbegotten idea that lifestyle will always outright cure whatever ails you. While my meds were reduced with weight loss and diabetes disappeared entirely, I still have high BP, and I still need a statin. Genes don’t have to be destiny, but they are likely to hold sway in the end. I am now Medicare age+, and have outlived most relatives, and so far have avoided what killed or struck them, something I attribute to a balance of good medicine and sensible lifestyle management.
The only reason I offer my personal anecdote is that I think it’s illustrative of what can be done and how effective it can be, but the fact remains that, as you see in your practice, most people continue with the smoking gun, silver bullet approach. Perhaps Dr Scher can inspire them, but I wouldn’t hold my breath. It’s a huge cultural problem. Managing my weight has socially isolated me–and I’m not exaggerating People will not accept that they have to eat less consistently–MUCH less, sometimes. They associate every social interaction with food and start to treat you rather suspiciously when you consistently pass on their offers, or only eat a small portion of your food at a restaurant. They accuse you of various “problems”, including anorexia. All the mindfullness in the world isn’t going to address the excruciating over-abundance of food in our environment.
Thanks for sharing that, kissmetoad. If you decide to read the book, I think you’ll find that there isn’t an off-putting amount of “woo-woo” stuff in there. But, as any lifestyle coach or doctor will tell you, and as you have found on your own, there is no one, best way to get healthy. In fact, if most people would just try to make one better decision per day, they would incrementally improve their health dramatically over the long run. It doesn’t really matter what that decision is – eat half a bowl of ice cream instead of the full thing, walk up the stairs instead of taking the elevator, etc. One better decision per day could have a dramatic impact long-term. We don’t really need to tell people to eat this and not eat that, as most of them already know it – they just don’t do it. There’s a quote I love from Derek Sivers, “If [more] information was the answer, we’d all be billionaires with perfect abs.”
Dr. Scher probably can’t inspire the people who are convinced there is a smoking gun or a magic bullet, but his book would provide a reasonable template for an open-minded person trying to get healthy, through incremental better decisions.
I had written a long screed on how I accomplished my goals without any outside assistance, but then decided it doesn’t really matter. I am probably an anomaly. I am naturally curious, read a lot, am well-trained in logic and basic science, and don’t suffer fools. If anyone is helped by this book, well, fine by me. It certainly beats Dr. Oz, et al. I would prefer, however, that people put their efforts into political change that would lead to greater regulation of advertising, labeling, and education of the hands-on type.
Oh, and please, call me toad. : )
I’ve never called anyone “toad” with anything less than insulting intentions. This is a first for me.
I take your point, but it seems better than kissme! Anyway, no offense will be taken and I rather like it as I age into my curmedgeon stage of life.
Thanks for your comment “Toad.” I appreciate your insight that you are curious, you read a lot, and most importantly, you prioritize your health. That is a very important step that many people never take. The information and knowledge mean little if we cannot prioritize and care about our health. I congratulate you on that.
It is important to note that everyone is different, and numbers don’t always tell the whole story. For instance, I use statins frequently in my practice in people who have had stents, bypass, or are at very high risk for heart disease. One of the main points I hope to make is that the use of statins has been extended to those at lower risk, and that extension has been based on very suspect evidence. Again, it does not mean they are useless. It means we need a much more detailed conversation about their true risks and benefits than most people get from their doctor.
And I don’t want you to underestimate the importance of lifestyle modification for the average person, and what an important tool mindfulness can be for achieving those modifications. For those who have difficulty adhering to meaningful lifestyle changes, focusing on your mindset and incorporating mindfulness can be the most important intervention we can make.
I congratulate you on your health improvements, and am encouraged that there can be more people like you improving their health and improving their lives every day.
It is kind of you to read and respond to my comment Dr Scher, but I’m afraid I will need citations for your views on statins as you imply things that you don’t substantiate with numbers and evidence. Who are these doctors who are “extend[ing] [statins] to those at lower risk”? (why are they doing so and at what cutoff point?), and please cite the “very suspect” evidence to which you refer. I cannot respond adequately without specifics. I CAN say that I wonder if you read my remarks carefully, as you make several comments that seem to say that I have not considered any number of things that I clearly stated. I know that people are “different”, but medically, probably not so much as they think–as HD writes in this very post. I don’t see how you could think I am underestimating the importance of lifestyle modification when I stated clearly, “ something I attribute to a balance of good medicine and sensible lifestyle management”. I am the one who reversed diabetes and brought my numbers to normal ranges with significant weight loss–I already had a good diet and exercise lifestyle. I clearly didn’t use any overt mindfulness (whatever that actually is), which clearly indicates that simply following through with a competent Registered Dietician and being motivated can be enough. I try to make clear whenever I cite my own example, that I am aware that I am in a rather exclusive minority with my accomplishments. I have also tried to be clear that I lay the blame on our obesogenic environment and not so much on the resulting obese people. In this environment, most people’s best efforts to EAT LESS (sometimes much less) will be doomed in the long run.
I have conceded that some may find your approach helpful, but I ask only to see the evidence–that “mindfulness” has any significant effect on weight loss, and more importantly, the long-term maintanence of that weight loss.
You should be aware that people who read blogs about real medicine have high standards for evidence and very sensitive skeptic antennae. We tend to be highly suspect of anything “integrative” because as we like to quote from one of our favorite skeptical doctors:
Mixing cow pie with apple pie does not make the apple pie better, in fact, it makes it worse.
–Mark Crislip, MD
I appreciate your desire for evidence based recommendations. I whole heartedly agree that our decisions need to be made with good research as the guide. I apologize that I did not supply specific studies to back my claims in my prior post. Allow me to clarify.
When I said “suspect data,” most of that centers around the Cholesterol Treatment Trialists (CTT). They summarized years worth of data and published their conclusions about statin efficacy in primary prevention. That was the main evidence used in the more aggressive 2013 ACC?AHA cholesterol treatment guidelines. It is common in research communities that you provide all your data so that it can be confirmed by independent analysis to ensure it’s accuracy. Unfortunately, the CTT actors have refused to release their data, citing NDAs they signed with the pharmaceutical companies. To me, that is very suspect data and not good science and leaves me wanting more evidence.
CTT aside, there are plenty of studies showing the efficacy of statins in primary prevention. The Jupiter trial showed that treating 500 people for 1 year prevented 1 heart attack. The HOPE-3 trial showed treating 250 people for 3 years prevented 1 heart attack. The WOSCOPS trial showed treating 42 people for 5 years prevented 1 heart attack. A decent summary at nnt.com tried to integrate all the available evidence and came up with an average of treating 60 people for 5 years to prevent 1 heart attack. Said another way, 59 people taking the drug for 5 years will not see a benefit.
So again, that does not mean they are useless and should be thrown out. It means for some they may be beneficial. I question the shotgun approach of applying their use to millions of individuals without heart disease and not at high risk for heart disease. With a more detailed screening process and risk assessment (advanced lipid testing, coronary calcium scores and now genetic tests) we can better identify those who may benefit and this who likely will not. That saves millions the cost and potential side effects of the drugs.
I hope that clarifies my position on statins and shows you the evidence behind my position.
Thank you for asking the hard questions and keeping us all honest and on our toes!
Bret Scher MD FACC
Please cite some evidence of all this willy-nilly subscribing of statins to healthy people!
Toad, I’m not sure what you think mindfulness is, but it’s really not a specific practice or method. Making an effort to eat sitting down, at a nice table, definitely falls under the heading of “mindful eating.” Leaving aside its sort of Buddhism-inflected name, it’s just deliberately calming oneself and paying attention to what you’re doing. In the context of eating, it’s an alternative to frantically stuffing yourself while standing at the kitchen sink while fretting about work, bills, relationships, etc. It’s as if you’re saying, “Prove to me with numbers that calming down will help people make better eating decisions.” I mean, of course it does. There’s no three-step mindfulness technique to evaluate. It’s literally just saying, “Take a minute to calm down. Have a few deep breaths. Step away from your phone. Pay attention to your food and whether or not you are full.”
By your definition, I absolutely concede, but to my mind, more is implied. I wasn’t only referring to the “mindfulness” at any rate. I am not here to attack the book, only to come down on the side of rational thinking and science-based medicine. The mindfulness issue was only one of a few red flags, though I can see that the book is miles ahead of the usual quackery that is “diet” books.
I too have a need to lose the pounds. My Dr. says so and the early results have shown to lower my blood pressure and reduce my grocery cost. Other benefits may come. My mother died of Arteriosclerosis (so said the coronor’s report) at the less than ripe-old-age of 42. I had my heart attack at 53, a dye test showed a peculiar “knot” (Dr. talk) in my Left Ventricle Artery, an oops of birth I imagine at the root cause and “not easily stented”, he offered drugs. The drug option(s) taken and now find myself providing shelf space for 9 drugs and 2 supplements (Vitamin D and A baby asprin) that I take in varying amounts daily. I am now 73, it’s been a 20 year love affair with the medical world and my pills. I want to weigh 180 lbs but my body said “huh” as I started on my trek at 225 (my lifetime high) 3 months later I’m at 215 and hoping for 180 some day. Your review was helpful and gave me a bit of hope I was losing as I want the weight gone and work against that laziness and drug actions and interactions that prevent or lessen the effort substantially. I’ll keep you posted.
I’m pleased to hear this post inspired you, Howard. Keep me posted, and give the whole book a read if you haven’t already. It’s a quick read and you may find a few gems in there.
i suggest you review this post by michael eades
in particular the section on grass-fed vs grain-fed beef. although the ratios look significantly different, it turns out the absolute quantities are minuscule in comparison with, e.g., a handful of nuts.
so paying an extra $15/lb [e.g.] for a grass fed steak is not a great investment in health.
i agree omega-3’s vs omega-6’s are something to pay attention to. i just don’t think grass-fed is the way to do it. eat some fish.
Wow, that link was very enlightening. Thanks for sharing.
I don’t take advice, nutritional or otherwise, from anyone (including MD’s) who sell untested and unproven supplements from their sites. Some of the content in that post is valid and some is not. He doesn’t document it, but I will forward it to someone at ScienceBasedMedicine.org and see if one of them will take it on point by point.
I read through the comments on Eames’ blog and it’s typical of exactly what HD and others are trying to combat. Lots of “it makes sense”, and anecdotes of all sorts. It is scientifically pathetic. This kind of quackery is all dressed up in science-y verbiage, but it quacks all the same.
why not let the data speak for itself?
Because data can be cherry-picked, and otherwise manipulated.
i see, so we can’t trust ourselves to survey an area and discern whether data is “cherry-picked.” since no data is trustworthy, i guess we just have to rely on faith-based “science.”
Science has no faith element. It is a method of investigating the natural world that is self-correcting. It relies on evidence and replication, not faith. You can’t tell if data has been cherry-picked unless you have expertise in the relative areas of science. That is why you should pick your sources carefully and always be a skeptic–especially when something sounds too good to be true.
thanks for clearing that up.
since you say ” Some of the content in that [eades] post is valid and some is not,” why don’t you help us all by specifying at least some of the statements in which the eades post is off base? [and provide references]
I will have a go at it, but as I said, I would rather have people with the relative expertise go over it and dissect it, to which end I have forwarded it to a couple of people from the excellent sciencebasedmedicine.org
My analysis would be as a skeptic and the first red flag for me is that he SELLS products. The second is that he makes sweeping statements with no evidence offered. When I say that some of it is valid, I mean generally that it’s not as openly quaky as something like Natural News or homeopathy.
I have a busy day ahead, but will try to reread and offer something more thorough tomorrow.
your first red flag has nothing to do with the content of the post. i’ve read some of eades’ stuff and on the whole i think he’s a straight shooter. either way, your “red flag” is a species of guilt by association.
your second criticism is more to the point, but otoh eades’ piece is just a blog post, not an academic paper.
Remember that this guy is selling products and making health claims. His blog needs to cite academic papers when making claims. If you don’t want to read critically, I can’t help you, If you don’t see blog posts as marketing for products sold at the same blog site, I can’t help you.
You want to believe all this. You are not being logical or applying any critical thinking. Why do you think he is a “straight shooter”? Experts widely agree that supplements are mostly unnecessary. They are also mostly unregulated and tend to make claims that are unsupported by any accepted science. So, when someone writes blogs and sells supplements, that’s a red flag to a person trained in critical thinking and the scientific method.
iirc his books cite literature, but not his blog posts. he was an early exponent of low-carb diets, albeit post-atkins.
the only ad i see at the link i provided is for the book he wrote 20 years ago, when as a pcp he finally gave up on the orthodoxy of eat less/move more and started to teach his patients about going low carb. maybe my ad blocker is screening out other things, i don’t know, nor much care frankly. but i’m curious- are there really supplement ads on the site?
as for whether someone is a straight shooter, my assessment rests on whether their writing is full of excited hype and big promises as opposed to being reality based. i also assess whether the content is consistent with the many other sources i’ve read. if it is in disagreement with the rest of my knowledge base, i am open to being convinced but then i want a want a lot of well documented proof.
i tend to steer my patients away from supplements precisely because of the lack of regulation. consumer reports, consumerlab.com and the ny times have all done write ups on supplement contents being inconsistent with the labelling and/or having heavy metal contamination.
the desire for something “natural” is truly misguided. i usually respond by first asking whether the questioner has eaten any [natural] toadstools recently – they’re completely natural. [nothing personal, kissmetoad.] otoh, natural products may have powerful medical effects. the foxglove plant was the original source of digitalis and its derivatives used in cardiac care. the ancient greeks used willow bark for pain, not knowing it contained salicylates. i will tell patients that, and also tell them i subscribe to consumerlab.com and the natural medicines database for precisely those reasons. i hope that acknowledging the potential potency of “natural” products will give me more credibility when i nevertheless discourage their use.
The above link is from the site. There are tabs at the very top. The blog is there to lead you to the “shop” tab.
In what capacity to you see “patients”?
There is no magic in low carb diets. If they reduce calories (as they often do) they will lead to weight loss. The trick, of course, is sticking with it in the long term. As someone who has lost 1/4 my body weight and kept it off for ten years, I do have some insight to this. I had Type II diabetes at the time–now I have normal blood sugar. I reduced carbs (and calories) in an overall healthful diet recommended by a Registered Dietician. If everyone ate like a diabetic, there would be fewer diabetics. I still eat carbs, mostly in the form of whole grains. I just eat them in small portions, like the rest of my food.
Your criteria for evaluating content is far looser than mine.
never noticed the “shop” tab. i have eades on a feedly alert- he posts quite rarely.
i see “patients” in my capacity as a “board certified psychiatrist.” i’m also on the “clinical faculty” of the local “medical school,” for which i tutor medical students. i have many years of “clinical experience.” early in my career i did “psychotherapy” for families, couples and individuals, along with doing “pharmacological treatment.” in the mid and later parts of my career i have just practiced “psychopharmacology”, with a special interest in “bipolar disorder.” i am the coauthor of several papers, a few about family systems therapy and several case series of novel agents for refractory bipolar disorder.
my criteria for evaluating content may be looser than yours because i am very critical of what passes for high level evidence in the field i know best. thus i consider the highest quality evidence as provisional at best. this means the gap between so called level a evidence and lower quality information is not as great as one would hope.
My apologies for all the scare quotes. I was thinking you might be a naturopath or some such! I have every respect for your specialty as the mother of a bi-polar son. I understand what you say about evidence in the context of psychiatry (and had I known this I may have taken a different approach), but outside of psychiatry, no such lenience is granted in my view.
Diet is an especially grievous area of abuse and always sparks my skeptical antennae. Psychiatry never helped my son very much, but it wasn’t for lack of trying. Actually, it was my in part my experiences on the fringes of alt med that eventually led me to a higher level of skepticism. It was the psychiatrists who gently and respectfully, helped me down that path. I would refer you to Stephen Barrett, MD (psychiatrist) of Quackwatch fame, who helped me enormously.
quackwatch.com (it might be .org)
no harm, no foul, kissmetoad. there’s a saying that economics exists to make astrology look like science, and i’d say nutritional studies exist to make psychiatric practice look like science. part of the problem with both nutrition and psychiatry is the vast range of individual variation. i suppose this is true in every medical practice. but its effect is greatest in those areas in which we have the least understanding of the underlying physiology.
Please, call me “toad”!
ps re low carb. i don’t think it is a universal solution but i think it is helpful for a great many people. one of my patients lost 140lbs in 15 mos on a ketogenic diet i suggested to him. i have an interest in metabolism and obesity both for my own benefit and for that of my patients– so many of meds i prescribe cause weight gain! whether or how much one must restrict carbs depends on both the mechanism underlying the weight gain [e.g. if it’s high cortisol then low carb will be less useful] and how badly “broken” one’s metabolism is. some people can tolerate a higher carb intake and not gain weight. in general, with weight loss [as with all medical treatment as well] compliance is a huge issue. for most people merely restricting calories and being hungry much of the time will not be sustainable.
I’m going to jump in here for a second to clarify something about cortisol and weight gain. The vast majority of weight gain will not be due to a pathologic overproduction of cortisol. To the best of my knowledge, there is no advantage to attempting to tailor a diet to someone’s “cortisol status,” as there really isn’t any such thing as cortisol status for the non-Cushing’s, non-Addison’s, normal person. Perhaps I misinterpreted your point, though?
The ketogenic diet may be a powerful tool for all kinds of things (medication-refractory seizures, preventing chemotherapy side effects, weight loss, etc), but it is so extreme that I think 99+% of the people who try it will fail. There will be the occasional success story like your patient, which is awesome, but I don’t think most people can hack it.
But, I’m really pleased to hear that you make suggestions to your patients for mitigating the weight-gain side effects of the meds you prescribe. I’ve seen a fair amount of diabetes from weight gain related to antipsychotics, over the years.
i mentioned cortisol to say that i know not every weight problem can be addressed by diet.
in general i suggest reducing carbs as the simplest, most straightforward, and most sustainable intervention to promote weight loss, or at least limit weight gain. it’s easy for people to understand and doesn’t require any counting, tracking or other extra procedures.
and if someone makes a “special exception” to enjoy a pizza one day, they can still go back to restricting carbs the next day and that will be beneficial. again, it’s an easy but effective thing to focus on.
some patients just dismiss the idea out of hand [i can’t count how many times i’ve heard: “but i’m italian!”]. i agree most people will not take their carbs so low as to go into nutritional ketosis, but limiting bread, pasta, cereal, potatoes, etc will tend to lower their calories [both protein and fats are more satiating] and hopefully lower their insulin levels as well.
I also suggest people restrict their intake of the white, starchy carbs, as that seems to be what many people overeat the most (besides the obvious when they have a major sweet tooth). While any calorie-restricted eating strategy will work, it obviously has to be something that resonates with the person in order to be sustainable. Tim Ferriss’ slow-carb diet is another sensible take on the low-carb approach, but anything in that genre is likely to work if someone can stick with it.
i don’t do it myself, but i have patients for whom some other doctor has prescribed metformin, [the patient says] for weight loss. comments?
This probably deserves a post, but I’ll take a stab at being brief. The theory behind using metformin for weight loss in insulin-resistant patients makes sense. Insulin resistance results in the pancreas making more insulin to overcome the resistance. These high levels of insulin will flood cellular insulin receptors, so you’ll get enough activation of these receptors to allow glucose into the cells, where it belongs (instead of having glucose in the bloodstream, where in high levels, it is toxic to the insides of blood vessels). Glucose levels in the blood may be normal early on in this process, because the pancreas is working overtime, cranking out tons of insulin to overcome the resistance.
Because high insulin levels promote the storage of fat, it is hard to lose weight with tons of circulating insulin. That’s where metformin comes in. Metformin enhances insulin sensitivity, which means the pancreas doesn’t need to work as hard, which means that insulin levels can fall to more normal levels. It just doesn’t take as much insulin to keep the blood sugar normal when the cells are more sensitive to the effects of insulin.
So, if high insulin levels are responsible for more fat storage, and metformin can lower insulin levels, then it stands to reason that metformin will make it easier to lose weight.
That’s the theory. In practice and in clinical trials, the results have been disappointing. Trial data is mostly negative with respect to metformin being a weight-negative medication in this circumstance.
However, many of us, myself included, still use it in insulin-resistant patients. Why? Well, there is data proving that early use of metformin can delay/prevent the onset of type 2 diabetes. So even if I can’t help my patient with PCOS (another condition that often goes hand-in-hand with insulin resistance) lose weight directly with metformin, I can still help delay the onset of diabetes, a worthy endeavor.
Another reason for using it: I have so few useful tools in my arsenal to help people lose weight, and there is often a desire on my part and the patient’s part for me to “do something.” Metformin is one of the most benign medications out there, with some potential upside (delay onset of diabetes, may reduce risk of certain chronic diseases/cancers) and little downside. Psychologically, when someone finds out they have insulin resistance and that makes it hard to lose weight, I think my being able to offer something that addresses the underlying issue may help give the patient hope and motivate her to work hard to lose the weight.
So, if one wants to be strictly evidence-based, I’d say no to metformin for just weight loss. But, when taking the whole clinical picture of insulin resistance and motivation into account, maybe it’s worth a try.
And there you have the crux of it! Somehow, one must eat less–no way around it. I’ll never understand why simply tracking calories is seen as such a dreaded strategy. It can open your eyes in a way that preaching never can. Every “diet” book I’ve ever read or read about, tries to pretend that there is some magical way of sorting out food groups that results in even more magical weight loss. The easiest thing I ever did (on the advice of an RD) was to reverse the plate ratio; that is, mostly veggies on the plate and a bit of protein and a bit of carb, preferable whole grain. Even so, those need to be measured so as not to overdo, especially the grains. Half a cup ain’t much, but as the pounds come off, it gets easier. Something that annoys me no end is the lack of whole grains in restaurants–and what is presented as “whole grain” often is NOT. It may have whole grain, but the first ingredient is often WHITE flour, in bread, for example.
the problem with reducing calories is hunger. the debate about various dietary approaches comes down to finding out how to minimize hunger while still restricting calories. those who struggle with their weight do not have your self-control, kissmetoad. otoh, this may be a function of higher levels of ghrelin, lower levels of leptin, or perhaps differences in their receptor populations for those signalling hormones. again, it is important to make room for individual variation. you are lucky that your physiology allowed you to take the path you’ve taken. for others, that particular path might be impossible.
I agree, to a point. It was, and is, not easy for me to maintain my weight loss. I still see the RD every now and then for support. I have to recalibrate frequently when I start to gain weight. It is never just a matter of reaching stasis. If I have anything that others don’t, it is blind stubbornness. Also, perhaps a bit of vanity–I really hated being fat and being thinner has boosted my self image like no amount of therapy ever could.
It’s not so much self-control as just working at it every day and admitting that I will always have to measure my food. As to the “always being hungry” issue…again, I don’t see myself as super-human about this, just practical. You have to choose wisely when hunger nags. Firstly, over time, you can learn to ignore it for longer than you might think at first. Setting eating times can help. Delveloping a mindset of “snacking” as a marketing ploy to underminde you can help. Also, admit that there will be lapses. Try to compensate the next day.
It’s the combination of a lot of little strategies that help over time. Frequent weighing, small plates and utensils (don’t laugh), setting the table, avoid restaurants (lots of sub-strategies here), truly define “special occasion” and then savor every minute of it.
I’m not so much different as truly well-informed. I am naturally curious and read a lot, mostly non-fiction. I have a degree in anthropology, so have a good understanding of human evolution and know how silly “paleo” eating is. I know that the biggest obstacle is getting people to do the most basic thing toward weight loss, which is to keep an honest food journal to determine the current calorie level, which you need to know so that you can figure out the reduction needed to start weight loss. People steadfastly refuse to do this, just as they reject calorie counting as some onerous task. They won’t listen that 1 lb a week is the best strategy for long term success. They laugh at my saucer and child fork, my measuring cups and scale. They roll their eyes when I bring my own food to a party or pass on desserts. They call me “scrawny”–I am NOT. I have settled for a weight that is about six lbs more than I would like as I have found it reasonable to maintain and I see people every day who are quite naturally thinner than I. It bothers me no end that they can eat things I cannot and sometimes it make me go right out and get a bag of Cheetos, BUT I will drive the extra two miles to the store that has the tiny (one serving) bag, not the usual “small” bag that is actually three servings. I do this because I KNOW that I will eat the whole bag, because I am not a tower of willpower, just smart enough to know I have to limit exposure and make the best choices I can. I think my biggest strength is that I’m very rational. I’m an atheist, so I don’t expect gods or prayers or diet gurus to help me. I have to help myself. I do come close to worshipping my Registered Dietician, however. : )
you are really working at it, toad, and it’s working! that’s great, and it is clear you are maintaining your weight via constant vigilance. just remember, though, that just as you may envy those who appear to get away with eating things you cannot eat, there may be people who envy you your abilities and metabolism.
I have never tried to “shame” anyone about weight. I have a morbidly obese daughter who is going to have gastric bypass. She claims to eat normally. Some people won’t lose weight until they cut to 800 calories/day I think, so I totally understand how hard it can be. I aim for 1000 calories/day, but often go to 1200 (which is what the RD wants). It’s extrememly difficult to find that “sweet spot” where you don’t gain or lose.
I am not special. I just understand the problem, face it, and work at it. I do NOT have natural appetite control as do some who have been at the same weight most of their lives and seem to not care much for sweets or beer! This is why I am so big on calorie counting. It is the only way to keep track. The other thing that I am dedicated about (and many have no clue) is label reading! People are often amazed when I point out something on a label. Good grief–it’s right there for everyone who will bother. I admit that I don’t suffer fools, not gladly anyway, but I am willing to share what I know; I just find that most tune out and move on to the next “magic diet” book and then get depressed all over again when it doesn’t work. It’s the intellectual laziness that bothers me, not the fat itself.
I should also say that I was fat for 20 years before I got the message. Because I ate healthy (Mediterranean type diet), I thought it was my “metabolism” or some other mysterious thing keeping me overweight. It wasn’t until I came down with Type II diabetes, that the shoe dropped. I immediately cut my calories in half (a bit extreme, and I played with that later) and had no problem with that. I am on my tenth year and I have to repeat that there’s nothing superhuman or special about it. I just get up every day and write down what I eat in one column with the calories in another column. Seeing it on paper is such a good way to set off alarms about just how calorie rich common foods that are taken for granted can be. But I find that people just won’t do this.
I have every sympathy for anyone who faces our over abundant food culture, but help is there in the form of real science, laws of physics information. Calories count, no matter how many books are written that try to weasel out of that. Eat what you like (within reason) and get a grip on the portions. Drink only water and the occasional beer if you like it. Occasional can be difficult to define and it will vary depending on your total caloric allowance. I get one beer/week and a martini and something decadently chocolate on my birthday. I find that making these things truly special makes them even more enjoyable.
Finally, let me be very clear that I screw up sometimes. I have a self-imposed pennance for this. I make it up in the next two or three days depending on the magnitude of the “sin”.
I know I said “finally”, but I would also put in a word for Weight Watchers. I don’t use it, but I think it’s a great group that operates on sound principles and offers support for those who find temptation too much to cope with.
How long has your patient maintained his/her weight loss? That is really the question.
he started losing weight in sept ’15 and hit his goal in nov ’16. he has been stable since, he says without any particular effort.
Get back to me in ten years on that.
you are right to be skeptical, based on population-based information. i’m more optimistic for this particular individual, however, because of the apparent ease with which he did what he did. there was no sense of struggle, whatsoever. some people have it easier than others.
I think it’s well known that men lose weight easier than women. Not sure about maintenance. Best of luck to this fellow, but I will remain skeptical at least until the five year threshhold. The diet (kept) is extreme, but perhaps he responds to that challenge.
I think you are a very compassionate doctor and it’s great that you spend time searching for options for your patients. I would only caution you to be very skeptical of anything that sounds too easy, or is accompanied by a “shopping” page at its website. Better to work on support and encouragement. That is what I get from the RD these days. She praises me for being so well-informed, and that inspires me to keep going.
that’s the same argument as for low carb being the first approach to weight loss. low carb => lowered insulin levels.
slow carb and low glycemic index [whole grains] might be useful for someone who is not already obese and who has a healthy metabolism. but i’m skeptical [but not knowledgeable] that such halfway measures would work with someone who is already developing some insulin resistance [say someone with a mildly elevated HbA1C].
I think the low-carb approach is valid for any patient who wants to lose weight, though I suppose the magnitude of the effect of lowering insulin levels may be different depending on how far along the spectrum of insulin resistance they are.
Since the weight loss probably comes more from calorie restriction than the relative paucity of starch itself in the diet, I don’t think it matters whether we’re talking about someone with normal glucose tolerance or someone with insulin resistance/prediabetes.
i would think than in any case it would be beneficial to minimize insulin levels. or do you think there are obese people for whom that wouldn’t matter much? or matter enough?
I think that, while it’s interesting to think about weight loss in terms of minimizing insulin levels, we’re spinning our wheels if we focus on that too much. While low-carb is a reasonable way to lose weight and probably minimizes insulin levels, a relatively higher carb vegan eating strategy that is calorie-restricted is also a great way to lose weight. This even applies to an insulin-resistant, obese person. Point-being, I don’t really care that much about minimizing insulin levels as long as we are calorie-restricting, eating high-quality macronutrients (e.g. complex carbs as opposed to simple starch) and the person is losing weight. Admittedly, though, lots of these eating strategies will be associated with lower insulin levels. I’m just not sure that is the really important part on which to focus.
I suppose that while insulin reduction was the theory behind metformin use for weight loss, you weren’t that convinced about metformin in the first place.
Just a quick comment to thanks you all for the comments posted in this thread / post. You instilled some good sense for me to hit up the website of one of the universities here (there are 4 with 2 extremely well known) and register for an appointment to the nutrition clinic which will be reopening in August. Some years ago, I have been diagnosed with chronic pancreatitis and traces of fat on the liver.