Summary of 2009 Heart Health Research
Back in January 2009, I predicted that several trends will develop over the course of the year. I'd like to review those predictions and see how they unfolded.
I said that: "We are going to hear more and more about the benefits of vitamin D when used as a "treatment." I predict that we will see formal confirmation of the effects we see everyday: dramatic increases in good HDL cholesterol, reductions in triglycerides, reductions in blood sugar, improved insulin responses, reduced inflammatory responses like c-reactive protein (a BIG effect). All these findings require formal quantification in treatment studies. When available, it will fuel the enthusiasm for purposeful replacement of vitamin D using blood levels of vitamin D for confirmation (a practice I advocate strongly)."
The argument in favor of vitamin D supplementation has indeed gotten stronger and stronger. Just in the past several months, there has been a deluge of clinical studies exploring vitamin D, the effects of deficiency in contributing to a multitude of conditions, and the effects of supplementation.
Several large studies have established, beyond any doubt, that lower vitamin D blood levels are associated with increased mortality, higher levels associated with reduced mortality. Diabetics have been shown to have lower vitamin D blood levels, with improved insulin responses with supplementation. The relationship of vitamin D deficiency and cancer, especially breast, colon, and prostate, has received further documentation.
What we still lack are treatment studies, "double-blind" studies in which participants are given vitamin D vs. placebo. Given the time and expense required for these sorts of studies, it will likely be several years before we have such experiences. In the meantime, now having corrected vitamin D deficiency in over 1000 patients, I have no doubt whatsoever that vitamin D will gain a greater and deeper foothold in Americans' health into 2010 and onwards.
Broader acceptance of low-carbohydrate diets
I said that: "While I personally advocate a wheat-free concept to my patients (not gluten-free, a different and distinct phenomenon), the related low-carb concept will gain more traction among the public and enjoy more validation in formal published clinical studies.
There is no doubt that low-carb reduces cholesterol enormously. It seems counter-intuitive, since the traditional argument is that reducing saturated fat reduces cholesterol, which it does¾modestly. But low-carb approaches, such as South Beach, Atkins', Sugar-Busters, Protein Power, and others (or my favorite: elimination of wheat, cornstarch, and sugars that I articulate in our New Track Your Plaque Diet), commonly reduce cholesterol 50, 60 mg/dl or more. What's more, many diabetics become non-diabetics, excess weight drops, blood pressure drops. The debate will eventually evolve away from low-carb versus low-fat, and instead focus on what aspects of carbohydrate-restricted diets provide superior outcomes (e.g., how much meat, should we continue to limit saturated fat, does omega-3 fatty acid content of meat make a difference, should we choose pasture- or grass-fed vs. factory-farmed livestock, etc.?)."
If the direction of online conversations about diet is any sign, I sense that low-carb diets are booming in popularity. And not because a new bestselling book came out on it, but because of the great results most people experience: weight loss, reduction in cholesterol values, reductions in triglycerides, reduction of blood sugar, reversal or improvement in diabetes and pre-diabetes. Such real-life experiences stimulate the spread of hot ideas through online discussions.
In other words, the 21st century fundamental dietary problem for Americans is consuming excessive quantities of processed carbohydrates. Research from various sources, including Dr. Eric Westman of Duke University and Dr. Jeffrey Volek of University of Connecticut, continue to build a case for carbohydrates being the culprit behind the nationwide epidemic of obesity and diabetes. They have also been at the forefront in validating low-carbohydrate diets as a means to reverse both.
In 2010, I believe that we will continue to witness better clinical validation of just what a low-carbohydrate diet means, hear more success stories of how low-carb works in our neighborhood and online, and witness more mainstream adoption of low-carb discussions on TV, magazines, and elsewhere.
Heart procedures will decline
I said that: "Over the past 10 years, heart procedures like coronary angioplasty and stent implantation have been on a boom cycle, growing 30% annually: cardiologists have made out like bandits, hospitals have expanded and put up billboards on highways to advertise bypass surgery, an entire cardiovascular industry has been created to manufacture catheters, stents, supplies, drugs, etc. 10,000 procedures are performed each and every day, 365 days a year.
That will change, thanks in part to the COURAGE trial, which showed that people with stable anginal (chest pain) symptoms fared no better with stent implantation than with medication . . .Consensus statements from the American College of Cardiology and similar organizations are putting a damper on the widespread overuse of heart procedures. 2006 and 2007 witnessed a plateau in procedure use. In 2009 I predict that, for the first time in the last 20 years, heart procedures will decline sharply. I believe that, while procedures continue to be overused and preventive efforts underused, the divide will narrow. That's a good trend."
Not only did the number of coronary bypass operations drop, they plummeted in 2009. While full numbers for 2009 are not yet available (data usually lags by one year), all indications are that the heyday of bypass surgery has come and gone. Bypass operations nationwide are likely to decline around 15% in 2009, a dramatic change for what had been the hospital industry's number one money maker and source of prestige for many years.
Part of the decline in bypass surgery is attributable to the growth in "percutaneous coronary intervention," or PCI, procedures like coronary angioplasty and stent implantation performed by cardiologists. The growth of PCI was sharply upward in the 20 years preceding 2006, only to slow since 2006. It is now flat. While precise figures for 2009 are not yet available, the quarterly sales figures for the major coronary stent manufacturers (Johnson & Johnson, Boston Scientific, Medtronic) suggest, in total, little change and perhaps a slight decline for 2009. (Medtronic is the exception, having introduced a new drug-coated stent in 2008.)
Interestingly, what I am witnessing in my city (Milwaukee, Wisconsin) suggests that declines are sharper. Many cath labs in my city are sitting idle, even laying off staff, due to the decline in procedures like PCI. Perhaps stent sales lag what I am witnessing at the street level. I predict that declines in PCI will soon be reflected in stent sales, as well as other indicators as this previous boom market becomes a declining one.
All in all, I believe my predictions for 2009 were fairly accurate. For 2010, I anticipate that all of the above trends will continue, even accelerate. What heartens me is that the above trends are all positive, signs that attentions are slowing turning towards prevention of heart disease, rather than procedural management.