Shorts

briefed by Jule Klotter

Evaluation of ACC/AHA Clinical Practice Guidelines

Many interventions and therapies recommended in American College of Cardiology/American Heart Association clinical practice guidelines lack solid evidence for their use, according to a 2009 analysis led by Pierluigi Tricoci, MD, MSH, PhD of the Duke Clinical Research Institute. In examining the “evolution” of ACC/AHA cardiovascular guidelines from 1984 to September 2008, Tricoci and colleagues note that the number of recommendations has increased while the level and class of evidence has decreased: “Recommendations issued in current ACC/AHA clinical practice guidelines are largely developed from lower levels of evidence or expert opinion. The proportion of recommendations for which there is no conclusive evidence is also growing.”

When developing cardiovascular practice guidelines, panels usually include a level of evidence and a class of recommendation for each recommendation. The level of evidence refers to the types of studies supporting the recommendation. Level A evidence consists of more than one randomized clinical study or meta-analyses. Level B evidence consists of a single randomized trial or multiple nonrandomized studies. Expert opinion, case studies, and standards of care fall into Level C and are considered the least conclusive. “Considering the 16 current guidelines reporting levels of evidence [not all do], only 314 recommendations of 2711 total are classified as level of evidence A (median, 11%), whereas 1246 (median, 48%) are level of evidence C,” according to Tricoci et al.

Unlike the objective level of evidence rating, the class of recommendation represents guideline writers’ judgments about the strengths/weaknesses of study data and their perception about the importance of identified risks and benefits. A Class I recommendation means guideline writers agree that a procedure or treatment is both useful and effective – even though solid evidence may be lacking. Of the 1305 ACC recommendations with a Class I rating, only 245 (median, 19%) are supported by multiple randomized trials or meta-analyses. A Class II recommendation reflects divided opinion among the guidelines’ panel. Forty-one percent of the recommendations in the current ACC/AHA guidelines are Class II. In charting the changes in recommendations over the years, Tricoci et al report, “Overall, the guidelines shifted to more class II recommendations and fewer class III recommendations, while the use of class I recommendations remained fairly constant over time.” Class III refers to recommendations “for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful.” That any recommendations in clinical practice guidelines would fall into Class III is puzzling. Yet, 20.6% of current interventional guidelines (concerning percutaneous coronary intervention, bypass graft, and pacemakers) are class III; and 18.0% of current diagnostic guidelines (concerning exercise testing, echocardiography, and radionuclide imaging) are class III.

Tricoci and colleagues urge practitioners and policy makers to recognize the limitations of ACC/AHA guidelines. The evidence behind most of the recommendations is by no means conclusive. More solid research, particularly studies that “address questions of comparative effectiveness or routine clinical practice,” is needed to improve evidence levels, say Tricoci and colleagues. Unfortunately, research funding on topics that won’t produce a marketable product is scarce. Guidelines help time-pressed practitioners make decisions about patient care. Dangers to patients and to non-conforming practitioners arise when poorly-supported guidelines become the main arbiter of what constitutes good care. Such medical legalism ignores a physician’s skill, experience, and knowledge of their patient.

Ghali JK, Massie BM, Mann DL, Rich MW. Heart failure guidelines, performance measures, and the practice of medicine [abstract]. J Am Coll Cardiol. 2010;56:2077–2080. Available at: www.content.onlinejacc.org/cgi/content/abstract/56/25/2077. Accessed February 22, 2011.

Joelving F. Medical ‘best practice’ often no more than opinion [online article]. Reuters. January 10, 2011. www.reuters.com/article/2011/01/11/us-medical-best-practice-idUSTRE70A06J20110111. Accessed March 4, 2011.

Tricoci P, Allen JM, Kramer JM, Califf RM, Smith, SC. Scientific evidence underlying the ACC/AHA clinical practice guidelines. JAMA. February 25, 2009;301(8):831–841. Available at: www.jama.ama-assn.org/content/301/8/831.full.pdf+html. Accessed March 3, 2011.

Improving Health Care While Reducing Costs

Surgeon Atul Gawande gives a fascinating and inspiring look at what some doctors and hospitals are doing to lower costs while improving care in his article “The Hot Spotters.” Jeffrey Brenner, a family physician, is the driving force behind the nonprofit Camden Coalition of Healthcare Providers (CCHP) that seeks to improve healthcare quality and accessibility in Camden, New Jersey. Brenner began by tracking emergency room visits for 2002 to 2007 in this low-income city. He learned that a small group of patients accounted for most of the health costs: “ … 13% of the patients accounted for 80% of the costs (mostly to Medicaid and Medicare) and 20% of the patients generated 90% of the costs. … The top 1% of patients (1035) visited the ER and hospital between 24 and 324 times.” People who make repeated trips to the emergency room often have more than one chronic condition such as uncontrolled asthma, uncontrolled diabetes, severe migraines, congestive heart failure, and addictions. In Brenner’s view, the high costs reflect bad care. “‘Emergency-room visits and hospital admissions should be considered failures of the health-care system until proven otherwise,’ [he told Gawande] – failures of prevention and of timely, effective care.” He wanted to help these patients.

In spring 2007, Brenner asked some emergency-room doctors and social workers to introduce him to their most difficult-to-help patients, patients without a family physician to kept track of all the diverse medical plans and prescription doled out by specialists. Patients on Medicaid and Medicare with little income. People without hope of ever seeing their situations improve. With the help of a nurse practitioner willing to make home visits and a social worker willing to help find ways to improve living situations, Brenner began. “‘My philosophy about primary care is that the only person who has changed anyone’s life is their mother,’” Brenner told Gawande. “‘The reason is that she cares about them, and she says the same simple thing over and over and over.’ So he tries to care, and to say a few simple things over and over and over.” Since our present medical system pays for each test and visit, not for the kind of integrated services these people needed, Brenner obtained grants to pay his small staff.

Data from the first 36 Camden Coalition patients shows a marked reduction in health care costs. Before joining Brenner’s program, these patients averaged 62 hospital and emergency-room visits per month, costing a monthly average of $1.2 million. After joining the program, the hospital visits dropped 40% to an average of 37 visits per month, costing about a half million.

What about situations in which the patients have private insurance? In 2007, the health-benefit programs of the casino workers’ union in Atlantic City, New Jersey, and the AtlantiCare Medical Center began an experiment. The union and the medical center both pay for their workers’ health care directly. Both employers have been struggling with rising health-care costs. Like Brenner, they decided to focus on workers with the highest medical costs and hired internist Rushika Fernandopulle to set up a clinic just for them. As in Camden, these high-cost patients have chronic health problems.

Instead of paying for every individual office visit, the union and hospital pay a flat monthly fee for each patient enrolled at the Special Care Center. As a result, staff focuses on good care and service to retain patients (and income) instead of trying to see as many patients as possible. Flat fees also relieve the high costs of billing and paperwork. Clinic patients have unlimited access to clinic services at no charge. The clinic uses exceptional customer service and electronic information systems to help patients improve their health. Sick patients get same-day appointments and a follow-up call within 24 hours. Every morning the entire staff – two physicians, two nurse practitioners, a social workers, front-desk receptionist, and eight “health coaches” – meet to discuss patients and review test results. Although few have a clinical background, the health coaches maintain communication with their patients and provide ongoing support and guidance. Most health coaches come from the patient’s community and speak the same language. These health coaches make all the difference. As one patient told Gawande, she listened to her coach when she listened to no one else because “she talks like my mother.” Like Brenner, Fernandopulle knows that people, not technology, make the difference in health care.

During the center’s first year, its 1200 clients made 40% fewer trips to the hospital with 25% fewer surgeries. Patients were also healthier: “Among five hundred and three patients with high blood pressure, only two were in poor control. Patients with high cholesterol had, on average, a fifty-point drop in their levels. A stunning sixty-three per cent of smokers with heart and lung disease quit smoking. In surveys, service and quality ratings were high.” In a preliminary study, the Atlantic City casino union health care costs for one year had dropped 25% in comparison to a similar group in Las Vegas.

Not everyone is happy with this cost-savings, however. Some doctors who derive income from insured patients’ visits have refused to cooperate with the Special Care Center. For example, Special Care staff told one patient that she didn’t need to continue seeing a cardiologist for an exam and electrocardiogram three times a year and a cardiac ultrasound every year. She had been seeing the cardiologist regularly without showing any abnormal results after experiencing a temporary condition two decades before. The cardiologist told her that if she quit seeing him, her health was at risk. She went back to her quarterly visits. Research shows that patients with hospital doctors who get paid by the visit rather than by salary have longer hospital stays.

Hospitals also get less income from these kinds of integrated systems. Gawande asked the CEO of the AtlantiCare hospital system why the hospital was investing in the Special Care Center when it would cut the hospital’s income. He replied that the local economy simply “could not sustain his health system’s perpetually rising costs. His hospital either fought the pressure to control costs and went down with the local economy or learned how to benefit from cost control.” When quality and availability of outpatient primary care improves, the need for hospital care declines. Hospitals that have relied on fees for a surfeit of tests and on chronically ill, repeat patients will have a difficult time staying open as health-care dollars are spent more carefully.

Consumers need to understand that having fewer hospitals does not mean less access to necessary care. The Dartmouth Atlas shows that areas with the highest health-care costs have more specialists and hospitals than the population needs. These high-cost areas also have too few primary care practitioners. Without a central physician or clinic to oversee all aspects of a patient’s care, service lack coordination, resulting in additional, unnecessary tests and conflicting treatments. As the Camden and the Atlantic City programs show, primary care is the vanguard of health-care improvement.

“‘In the next few years, we’re going to have absolutely irrefutable evidence that there are ways to reduce health-care costs, and they are ‘high touch’ and they are at the level of care,’” says Brenner. “‘We are going to know that, hands down, this is possible.’”

Brenner J. Building an accountable care organization in Camden, NJ. Rx Excell Health Care. Summer 2010;9:6–8. Available at: www.jefferson.edu/population_health/documents/RxforExSummer2010Issue9FINAL.pdf. Accessed February 14, 2011.

Gawande A. The hot spotters. New Yorker. January 24, 2011. Available at: www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande?currentPages=all. Accessed February 12, 2011.

Broken Heart Syndrome

Chest pain, shortness of breath, an irregular heartbeat, and generalized weakness are common symptoms of a heart attack. These symptoms also characterize “broken heart syndrome,” a temporary heart condition usually induced by sudden emotional or physical stress. Broken heart syndrome is also known as takotsubo cardiomyopathy, stress cardiomyopathy, left ventricular apical ballooning syndrome, or ampulla-shaped cardiomyopathy. A loved one’s unexpected death, a frightening medical diagnosis, domestic abuse, earthquakes, stage fright, a surprise party, accidents, even asthma attacks have caused the heart’s left ventricle to dysfunction temporarily. If examined with cardiac MRI, the ventricle’s shape “resembles a flask with a short, narrow neck and wide, rounded body” much like a Japanese fisherman’s octopus pot (the tako-tsubo).” In addition to changes in the heart’s shape, patients with broken heart syndrome may also have a rise in cardiac enzyme levels, typical of myocardial injury, and reduced arterial blood flow even though the coronary arteries show no blockages. Broken heart syndrome is most common in women over 50 years. Although in rare cases people can die from broken heart syndrome, the heart usually returns to normal within a week.

Until the diagnosis is clear, patients are treated as if they are having a heart attack. Uncertainty about the physiological cause of broken heart syndrome has prevented a standard treatment. In 2008, a British research team, led by Alexander R. Lyon, hypothesized: “Stress cardiomyopathy is the result of the direct [biochemical] effects of high levels of epinephrine on the ventricular myocardium.” If their hypothesis is true, giving therapeutic epinephrine or other medications that have a similar effect on heart contractions may be counterproductive.

Lyon AR, Rees, PSC, Prasad S, Poole-Wilson PA, Harding SE. Stress (Takotsubo) cardiomyopathy – a novel pathophysiological hypothesis to explain catecholamine-induced acute myocardial stunning. Nat Clin Pract Cardiovasc Med. January 2008;5(1);22–29. Available at: www.nature.com/nrcardio/journal/v5/n1/full/ncpcardio1066.html.

Mayo Clinic. Broken heart syndrome [online article]. February 10, 2011. Available at: www.MayoClinic.com. Accessed February 14, 2011.

Health at Every Size

“While it is well established that obesity is associated with increased risk for many diseases,” Linda Bacon and Lucy Aphramor write in their literature review for Nutrition Journal, “causation is less well-established.” When epidemiological studies control for factors such as fitness, activity, nutrient intake, socioeconomic status, and weight cycling (repeated dieting and weight gain), the link between weight and disease often disappears or significantly declines. In addition, most epidemiological studies find that people who are overweight or moderately obese live as long – if not longer – than people of “normal” weight. (“Normal” differs according to culture and body type. I don’t know how the US determined a one-size-fits-all “normal” weight.) Only at statistical body-mass-index (BMI) extremes do weight and shorter lifespan remain consistently, albeit weakly, linked. Otherwise, weight does not directly correspond to health. “Among US adults, there is a high prevalence of clustering of cardiometabolic abnormalities among normal-weight individuals and a high prevalence of overweight and obese individuals who are metabolically health,” according to a 2008 Archives of Internal Medicine study. (The researchers define normal weight as <25.0 BMI; overweight 25.0–29.9 BMI; and obese, ≥30.0 BMI.) Nonetheless, the BMI has become holy writ, and losing weight has become a cultural obsession.

Focusing on weight keeps people from focusing on their health as a whole. If the goal is to improve health, then focus on health. Do not gauge success by pounds, but by changes in blood pressure, insulin sensitivity and blood lipids, say Bacon and Aphramor, both of whom are Health at Every Size (HAES) practitioners. By focusing on weight, practitioners unwitting contribute to weight cycling. Even when people maintain good diet and exercise habits, they often regain weight, according to long-term follow-up studies. As weight yo-yos, inflammation, which is associated with obesity-related diseases, increases. Hypertension, insulin resistance, and dyslipidemia also result from weight cycling. In addition, dieting produces psychological stress and increases cortisol production. Stress itself can affect metabolism. “Weight cycling can account for all of the excess mortality associated with obesity in both the Framingham Heart Study and the National Health and Nutrition Examination Survey (NHANES),” the authors state. “It may be, therefore, that the association between weight and health risk can be better attributed to weight cycling than adiposity itself.”

HAES encourages people to focus on health first: “The primary intent of HAES is to support improved health behaviors for people of all sizes without using weight as a mediator; weight loss may or may not be a side effect.” HAES is based upon compassion-focused behavior change theory that encourages self-acceptance. Research on HAES and eating disorders shows that self-acceptance and self-esteem encourage self-care. Shame and stigmatization do not. In place of calorie counting, HAES encourages people to pay attention to their bodies’ internal regulators such as hunger and satiety. The program teaches people to connect food choices to their mood, energy levels, ability to concentrate, and ease of bowel movements. Instead of having a structured exercise routine, HAES urges people to incorporate enjoyable physical activity into daily life. For more information about Health at Every Size, see www.haescommunity.org.

Bacon L, Aphramor L. Weight science: evaluating the evidence for a paradigm shift. Nutr J . 2011:10(9). Available at: www.nutritionj.com/content/10/1/9. Accessed January 25, 2011.

Wildman RP, Muntner P, Reynolds K, McGinn AP, et al. The obese without cardiometabolic risk factor clustering and the normal weight with cardiometabolic risk factor clustering [abstract]. Arch Intern Med. August 11/25, 2008;168(15):1617–1624. Available at: www.archinte.ama-assn.org/cgi/content/full/168/15/1617. Accessed March 7, 2011.

Controlling the Uncontrolled with Stories

A 2011 study conducted by Thomas K. Houston, MD, MPH, and colleagues tested patient narratives/storytelling as an intervention in a randomized, controlled trial at an inner-city safety-net clinic with a large number of African-American patients in Birmingham, Alabama. When we hear personal narratives from others and can identify with the storytellers and their narratives, we become engaged on a holistic level that dry instructions fail to achieve. Houston and colleagues hoped that stories told by community members with hypertension would encourage behavior changes in clinic patients.

Hypertension is difficult to control because it requires a long-term, multidimensional approach consisting of diet, exercise, medication, stress-reduction, and medical follow-up. For poor African-Americans living in an inner city, controlling hypertension is complicated by poor access to markets with nutritious food, lack of exercise, and stress due to living in an unsafe environment, limited access to medical care and medications, and distrust of the medical system. (Given the Tuskegee syphilis experiments, that mistrust is not unfounded.) Only 16.1% of the 230 African-Americans (mostly women) with hypertension involved in this study reported a household income of $16,000 or more. About 60% had a household income of less than $12,000 even though more than half of the participants at baseline had had some college education.

Half of the study’s participants watched 3 DVDs that consisted of actual patients from their local community telling personal stories about dealing with hypertension. These intervention DVDs also had “Learn More” sections that gave information about blood pressure, exercise, improving communication with their doctors, how to avoid sodium in foods, and other topics useful for controlling hypertension. The rest of the study participants were given DVDs without personal narratives that discussed health topics unrelated to hypertension. (The benefits of patient narratives might have been clearer if the control DVD had focused on the same hypertension information covered in the intervention DVDs.) All participants watched their first DVD at the clinic, but the remaining DVDs were mailed to participants’ home at three months and six months after the study began. Researchers relied on participants to report which segments of the DVDs they watched.

Patients in the intervention group whose hypertension was under control at baseline did not show any significant difference in blood pressure (although it did improve somewhat) compared with those with controlled hypertension in the control group. However, intervention patients with uncontrolled hypertension exhibited a marked improvement in comparison with their counterparts in the control group. Mean systolic pressure decreased from 152.35 at baseline to 135.24 at three months in the intervention group compared to a mean of 153.06 mm Hg (baseline) to 147.16 mm Hg (three months) in the control group. Mean diastolic pressure also showed a greater improvement in the intervention group (−7.39 mm Hg) compared to control (−0.96 mm Hg). All mean readings for both groups increased between 2 and 4 mm Hg at the six- to nine-month checkup.

The authors state: “Additional studies are needed to clarify the mechanisms through which storytelling works, address more long-term follow-up, and test similar interventions for different populations and conditions.” Narratives from peers may prove to be as convincing to patients as research-based information – maybe more so.

Houston TK, Allison JJ, Sussman M, et al. Culturally Appropriate storytelling to improve blood pressure. Ann Intern Med. 2011:154:77–84. Available at: www.annals.org/content/154/2/77.full.pdf+html. Accessed February 12, 2011.

Nickel Nanoparticles

and Atherosclerosis

A September 2010 mouse study, led by Gi Soo Kang, found that inhalation of nickel hydroxide nanoparticles produces oxidative stress and inflammation in lung tissue and, during long-term exposure, atherosclerosis. “So what?” you say. Nanotechnology is quietly infiltrating the marketplace; and, like wireless technology and GM crops, it may have unforeseen health and environmental health effects. Nanotechnology makes use of microscopic particles with a large surface area and high reactivity. Nickel nanoparticles, in particular, have the potential of revolutionizing mechanics. These particles are used to create tiny microelectromechanical systems (MEMs), some the size of a grain of sand, that will find their way into new energy and medical technologies.

This animal study is, reportedly, the first to show cardiovascular toxicity caused by inhaled nanomaterial. The New York researchers exposed mice genetically susceptible to atherosclerosis to nano-nickel hydroxide at either 0 or 79 µg Ni/m³, using a whole-body inhalation system. Instead of exposing the mice to nanoparticles 24 hours a day, the researchers mimicked a part-time human work week. Mice inhaled the nano-nickel hydroxide for five hours per day, five days per week for either one week or five months. Five months is a long time for a mouse that typically lives about three years. The researchers measured nickel content in the lung, liver, heart, spleen, and whole blood; determined presence of inflammation and oxidative damage using serum analyses, bronchoalveolar lavage fluid analyses, and assessment of mitochondrial DNA damage; and examined the ascending aorta for plaque formation and the lungs for tissue changes. In comparing the exposed mice to the controls, the researchers determined that inhaled nano-nickel hydroxide “induced significant oxidative stress and inflammation in the pulmonary and extrapulmonary organs.” While aortas in mice exposed for just one week appeared unaffected compared to controls, those exposed for five months showed “progression of atherosclerosis.” Also, inhaled nanoparticles accumulate in the lungs in a dose-dependent manner: “The average amounts of Ni found in the whole lung were 46.9 ng for the [one week] group and 306.7 ng for the [five month] group.” The researchers did not perform this study purely for academic interest. Their study should be viewed as a preventive measure: “We believe that these findings will contribute to the further understanding of potential risks and mechanisms of NP-induced toxicity and to establishing a database for NP-specific regulations in occupational settings.”

Researchers at Idaho National Laboratory have produced an inexpensive nickel-chromium alloy that converts infrared waves into electrical energy, according to a presentation at the International Nickel Study Group (April 28, 2010, Lisbon, Portugal). The material is a flexible sheet covered with thousands of microscopically small antennae able to convert infrared waves into electrical energy with 80% efficiency. Conventional solar panels convert about 20% of the sun’s energy into electricity. Such technology is revolutionary and has the possibility of untold benefits. Wouldn’t it be wonderful if the nanotech industry made an attempt to avoid known health risks from the beginning?

Heffernan V. Nickel in nanotechnology. Nickel Magazine. June 2000. Available at: www.nickelmagazine.org. Accessed February 22, 2011.

International Nickel Study Group. Presentation at 28 April 2010. Available at: www.insg.org/presents/Mr_Stewart_Apr10.pdf. Accessed February 22, 2011.

Kang GS, Gillespie PA, Gunnison A, Moreira AL, Tchou-Wong K-M, Chen L-C. Long-term inhalation exposure to nickel nanoparticles exacerbated atherosclerosis in a susceptible mouse model. Environ Health Perspect. 2011:119(2): doi:10.1289/ehp.1002508. Available at: http://ehp03.niehs.nih.gov/article/fetchArticle.action?articleURI=info%3Adoi%2F10.1289%2Fehp.1002508. Accessed February 12, 2011.

LDL Cholesterol

In 1977, the US Congress adopted the saturated fat-heart disease hypothesis as truth when it recommended a low-fat diet. Government health agencies have been blaming dietary saturated fat for the rise in LDL (“bad”) cholesterol and heart disease ever since. Unfortunately, the saturated fat hypothesis was primarily based on epidemiological evidence compiled (somewhat selectively, critics say) by physiologist Ancel Keys, PhD. When lipid scientist Ronald Krauss, MD, began taking a closer look at LDL cholesterol in the 1970s, he gained information that strongly challenges the assumptions in Keys’s saturated fat hypothesis.

All LDL particles contain a molecule of apolipoprotein B. Larger, “fluffy” LDL particles contain more cholesterol and triglycerides than small, dense LDL particles and apo B particles. Contrary to expectation, people with heart disease have a higher level of the smaller, dense particles. Overconsumption of carbohydrates increases the number of apo B particles and small, dense LDL. When people decrease the fat levels in their diet, they usually increase carbohydrates. As carbohydrate consumption increases, HDL (“good”) cholesterol levels decrease and dense LDL levels increase. Scientists know that eating carbohydrates, particularly starches and sugar, increases blood sugar levels, which causes the body to release insulin. In addition to transporting sugar into cells, insulin tells the liver to turn excess sugar into fat, specifically triglycerides, for storage. Triglycerides have become a significant marker of heart disease risk over the past decades. Even though physiological research has found no indication that saturated fat increases dense LDL cholesterol or triglycerides, policy makers and many scientists tend to ignore this information, as Nina Teicholz explains in an article for Men’s Health.

What about the epidemiological evidence that “proves” saturated fat increases heart disease risk? In 2000, published data from a Cochrane Collaboration meta-analysis of 27 studies on cholesterol-lowering diets “shows that diets low in saturated fats have no significant effect on mortality or even on deaths due to heart attacks,” says Teicholz. Recent studies that compare people on a higher-carb-low-fat diet to those on a higher-fat-low-carbohydrate diet show that “the [higher-fat-]low-carb dieters typically scored significantly better on markers of heart disease, including small, dense LDL cholesterol, HDL/LDL ratio, and triglycerides. …” (I don’t know if this will translate to greater longevity/fewer deaths for the high-fat diet. Studies that measure markers are not as useful for showing real benefits as studies that look at longevity and deaths.) In January 2010, Ronald Krauss published a meta-analysis of 21 epidemiological studies, involving 347,000 participants, that looked at the effects of dietary saturated fat. It found “no significant evidence for concluding that dietary saturated fat is associated with an increased risk of coronary heart disease or cardiovascular disease.” He told Teicholz that studies that show cardiovascular benefits from replacing saturated fat with unsaturated fats do not prove that saturated fat causes cardiovascular disease: “‘It may simply suggest that unsaturated fats are an even healthier option. …’”

Despite all the evidence that excessive carbohydrates in the diet, not saturated fat, is the real smoking gun for heart disease, the 2010 Dietary Guidelines put forth by the US Department of Agriculture and the US Department of Health and Human Services continue to urge people to “consume less than 10 percent of calories from saturated fatty acids. … increase intake of fat-free or low-fat milk and milk products … .and use oils to replace solid fats where possible.” The guidelines summary does not distinguish between types of oils, lumping olive oil (high in more beneficial monounsaturated fats) in the same category as corn oil (high in inflammation-producing omega-6 polyunsaturated fats). The US government agencies may be slow to rock the saturated-fat boat. Nonetheless, the “misguided war on fat” is making its way into popular publications like Men’s Health. Eventually, guidelines may actually concur with the evidence.

USDA. Dietary Guidelines for Americans, 2010 – executive summary [Web document]. http://www.cnpp.usda.gov/publications/dietaryguidelines/2010/policydoc/execsumm.pdf. Accessed February 12, 2011.

Ronald Krauss, Part 2 [blog entry]. Keith Connects the Dots.com. January 31, 2009. http://keithconnectsthedots.com/2009/01/31/ronald-krauss-part-2.aspx. Accessed February 12, 2011.

Moyer MW. End the war on fat [online article]. Slate.com. March 26, 2010. www.slate.com/id/2248754. Accessed February 12, 2011.

Scott P. On saturated fat and LDL cholesterol, messages may well be counterproductive [online article]. MinnPost.com. February 24, 2010. www.minnpost.com/healthblog/2010/02/24/16191. Accessed February 12, 2011.

Teicholz N. What if bad fat is actually good for you? Men’s Health. October 10, 2007. Available at: www.menshealth.com/health/saturated-fat. Accessed February 12, 2011.

Vitamin D and Calcium for Eye Problems

When ophthalmologist Arthur Alexander Knapp, MD, performed animal experiments investigating the effects of vitamin deficiencies during the 1930s, he discovered the importance of vitamin D and calcium to eye health. “While all of the experimental animals revealed retinal vascular disease,” he wrote in “Blindness: Forty Years of Original Research,” “it was only the D deficient low-calcium ones that consistently developed several … eye diseases similar to humans. And all of their pathology grew progressively worse as the nutritional deficiency worsened.” As a result of these studies, Knapp began using high intermittent doses of vitamin D (50,000 IU) and calcium (1 gram) to treat several eye problems including myopia (nearsightedness), keratoconus (myopia with corneal protrusion), retinitis pigmentosa (retinal degeneration), and allergic conjunctivitis. (Knapp does not specify what he means by “intermittent” in this article. Laypersons should not attempt taking such high doses of vitamin D without consulting a practitioner.)

According to Knapp, myopia, keratoconus, allergic conjunctivitis, and retinitis pigmentosa all stem from vitamin D-calcium deficiency. In his research with patients, Knapp found that D-calcium supplementation stabilized vision in many patients with these conditions. If the condition was recent and irreversible pathological changes had not occurred, vision often returned to 20/20. In patients with keratoconus, eyesight improved and the corneal flattened to a more normal shape after six weeks of supplementation. According to Warren M. Levin, MD, Knapp had a special permit from the FDA to use his treatment on high myopic children.

In addition to supplements, Knapp employed sphenopalatine blocks, using topical anesthesia, to improve all types of chorioretinitis, including macular degeneration. Blocking the sphenopalatine ganglia (accessed through the nose) with anesthesia is presently used to treat facial, sinus, and migraine pain. Knapp discovered that sphenopalatine blocks shrink the nasal mucosa and increase the blood supply to the fundus oculi (back of the eye). “This healing power reduces the inflammation of the retina,” he explains, “and is sufficient to give rise to regeneration of the damaged retina with consequent increased vision. In early inflammations it is possible to obtain complete retinal regeneration without scarring or any evidence of previous disease.”

Knapp AA. Blindness: forty years of original research. Journal of IAPM. 1977; 50–72.

Levine WM. Letter to Jonathan Collin, MD. November 30, 2008.

Spilner M. Vitamin D deficiency linked to eye problems. July 16, 2009. Available at www.stopagingnow.com. Accessed February 22, 2011.

Windsor RE, Jahnke S. Sphenopalatine ganglion blockade: a review and proposed modification of the transnasal technique. Pain Physician. 2004;7:283–286. Available at: www.painphysicianjournal.com/2004/april/2004/;7;283-286.pdf. Accessed February 22, 2011.