Does Every Diabetic Really Need A Cholesterol PIll?

In 2009, HMSA (Hawaii's largest health insurance company) will start fining doctors who don't put every last one of their diabetics over the age of 40 on a cholesterol lowering pill. No matter what your cholesterol, if you are a diabetic, your doctor will probably write you a prescription. Even if you don't have heart disease. How can they justify this?

I asked HMSA's medical director. He says the practice is well supported by extensive research. But when I look at the articles cite by the company HMSA hired to outsource this decisionmaking process, I see some very fishy writing.

Two of the articles are based on the opinions of nine doctors, eight of whom are paid drug company consultants.

One citation is a CDC web site that has disappeared.

The only article of any merit is about a study done on about 2,000 people with diabetes, half of whom took a sugar pill and half of whom took a cholesterol pill. Almost two hundred people had to stop the cholesterol pill due to side effects. This effectively weeds out the more sickly people and so, it is not surprising that in the group taking the pill there were fewer heart attacks - at least to start with. The study was stopped early, for reasons they don't explain. What has me worried is that, when I look at the graph comparing death rates in the two groups, the first few years look pretty good for the group on the drug. But by the end of year three, people start dropping dead fast - so fast the line looks like its starting to go straight up. What is the real reason they stopped the study prematurely? Could it be that they saw where the line was heading, and decided to quit while they were ahead?

Remember, this line is the group of healthier people (b/c they could handle the side effects of the drug) and even they started to die after taking it for almost four years. HMSA wants diabetics to stay on it for life.

The research does show that people who have had heart attacks do benefit from statins. But the research does not support what HMSA plans to pay your doctor to do now. If I don't go along with this, I will loose money. This is not fair to me as a conscientious physician, and its not fair to HMSA's customers who may pay a price with their lives in four years time.



Safe For Four Years? In this highly selected group of people, problems seem to increase just before the study was ended prematurely by the organizers.

Nutraceuticals

Goji berries....Antioxidants....Omega-3...Oh, my!!

You could spend all day reading up on supplements and only scratch the surface. You could also spend a lot of money - and many of my patients do - upwards of a thousand dollars every few months. But what are you really buying? Is it hype? Or is it real?

The answer: a bit of both.

Nutraceuticals from powders to pills to gels and creams are certainly a heterogeneous group of consumer products and it's hard to lump them all into one post in any kind of logical way. But that's what I'm going to try to do.

I call the nutraceutical business the modern snake oil business. Snake oil salesmen actually sold snake oil, at one time. And snake oil, as some of you may know, is full of omega-3 fatty acids which are anti-inflammatory. Omega-3 fatty acids should be part of everyone's diet. But back in the days of the oil salesmen, people were buying snake oil for everything under the sun. And not only that, they were told that nothing else could help them.

Sound familiar?

Today's savvy consumer knows that omega-3 comes from a variety of sources. It comes from fish, flax, and more. One of the most abundant sources of omega-3 that you won't see advertised on the flax or fish oil web sites is super cheap: organ meat. (Yucky? Only if you never learned to cook it!) Another source is egg yolks from chicken free to eat their normal diet which includes omega-3 rich plants and insects.

In the same way that snake oil salesmen wanted people to think their only hope was a bottle of their patented snake oil blend, nutraceutical companies want you to think the antioxidants, flavinoids, and other compounds they list as selling points, only come from their patented blends. Nonsense. All plants contain antioxidants, bioflavinoids and so on. So the more vegetables and herbs and so on you eat, the more of these goodies you get. And what's more, there are far more active antioxidants and healthy bioflavinoids when plants are fresh than when they are dehydrated and encapsulated or otherwise formulated to sit on a shelf unrefrigerated.

I tell my patients that the "average" nutraceutical for sale is probably no more or no less dangerous than the "average" prescription medication. The FDA does not regulate the industry at all, not that they've done such a good job with pharmaceuticals but at least they contain what they claim to contain. The neutraceutical industry, however, is completely on the honor system. And when people get hurt and killed, there's no system in place for notifying people selling tainted or just outright deadly cases to be notified. At least with pharmaceuticals pharmacists and doctors must be notified by law.

One of the more notorious cases was Kava Kava, which was banned from Germany after several people died from taking it. Kava Kava is a polynesian herb used as part of religious ceremonies and also for relaxation, a bit like the Irish use Guiness. The polynesians who use Kava Kava know that it can cause skin rashes, violent stomach upset, and other gastric problems. Clearly, just because something has been used "traditionally" and comes from a plant growing in the dirt as opposed to a plant off the Turnpike in New Jersey, doesn't mean it's free of painful and potentially harmful side effects.

But Kava Kava has more to teach us about all Nutraceuticals, not just the mind-altering ones.

Like all plants, Kava contains dozens of chemical families and perhaps thousands of individual chemicals. At the time people took their deadly capsules of Kava Kava, little was known about it. And few suspected there might be something about the way the Polynesians prepared the drink that might prevent them from dying. So when the factory made it's Kava nutraceutical product, they followed a totally different protocol their product was a dry powder rather than a drink). It turns out, that little detail made the difference between life and death for some people.

Traditional preparation is done using what chemists call an aqueous extract, meaning water is used to remove the active ingredient from the source. This was traditionally done by soaking crushed Kava leaves in either water or coconut oil. In the factory, however, the chemists figured that they'd use a different kind of material to extract more of the active ingredient. It worked, and customers who took their product got plenty relaxed. But some, perhaps those with poor liver capacity, ended up permanently relaxed. Why?

The mind-altering Kava alkaloids are potentially toxic to the liver. Fortunately, aqueous extraction also removed compounds which helped reduce the toxicity, specifically one compound called glutathione. Glutathione is water soluble. And the factory, wanting to improve the efficiency of the extraction process, used an alcohol based solvent instead, leaving the glutatione behind. The result was deadly. Now, Kava manufacturers make sure the glutathione gets into the capsules. This was only one lesson learned, and some paid with their lives. How many other similar mistakes will be made?

The Solution Is Dilution

This was one of my toxicology professor's favorite sayings. And it's been taken to heart by the Nutraceutical companies who now put a tiny bit of numerous plants into their products. This safety measure reduces the chances that any one toxin can be present in large concentration. A good idea.

But is buying pills and powders really the only way to get all those antioxidants and other good things? Isn't there a safer, tastier, more natural way?

There certainly is. And the answer may inspire you to check out a few of my salad dressing recipes.

Vegetable Oil Is Everywhere

Most of us eat a lot of vegetable oil. Is it really good for us?

Cooking Meat - Timing Is Everything

How you cook your steak makes the difference between having a healthy meal and you-may-as-well-be-eating-mystery-meat.

Overcooking burns nutrients, and so the proteins, essential fatty acids, and vitamins that your body needs get destroyed. In their place, new chemicals that weren't in there before get formed, compounds like cyclic amines, lipid hydroxides, and glycated proteins. Some of these byproducts of overcooking are carcinogens, and others damage your blood vessels, especially the blood vessels in your kidneys.

So how do you cook meat right?

To guarantee that fish, chicken, steaks, oysters and all your other favorites retain their nutrients, you have to cook everything gently. The best way to prevent overcooking is to ensure that the meats stay moist. One of the biggest mistakes people make when cooking red meat especially is to try to "cook the fat out." The liquid that oozes or steams out of a roast, a steak, or a hamburger does contain a little fat, but mostly it's water and water-soluble nutrients including protein and minerals. By the way, those nutrients have flavor, so keeping them around ensures a more complex, intensely flavored meal. Here's what I recommend:

• Cook steaks and fish rare
• Leave the skin on chicken. Skin keep the moisture from escaping, prevents overdrying and it tastes great!
• Leave the yolks in your eggs just a little bit runny
• When baking, baste often
  
• Stewing and braising are healthier options than frying

So if you want to be healthy, you don't need to cut meat out of your diet. You only need to cook it right!

Bon Appetite

Meat: Is it really bad for your health?

It Alll Depends On How You Cook It

When it comes to steak, like all foods, you must cook it gently to protect the nutrients. You know that soggy overcooked broccoli is not going to be as good for you as a perfectly steamed bright green sprig. When you think about it that way, it becomes clear how you should cook your meat, doesn't it? Rare. Except hamburger, because bacteria are everywhere not just on the outside. Bottom line: Don't overcook your meat, fish, eggs, or anything else, you are killing the nutrients and that's how you create carcinogens and bad fats. Here's my advice on cooking meat.

Which is better for you, beef or chicken?

The answer?

It depends on what the animals eat and how healthy they are. If you can get your hands on pasture raised beef, it's extremely healthy and far better for you than confinement-raised poultry. On the other hand, if you can find free range chicken (hmmm, how about that one in your yard at 3 am?) it's going to be much healthier for you than burgers made from grain fed, unhappy industrially-raised cows. The same goes for fish, which is why wild caught is healthier than farm raised.

More About Cholesterol Pills

The Nitty Gritty

For those of you who want to know more than I posted here this is a slightly more techincal section.

The image on the top right is a view of the skeleton of your cells. The whispy yellow and blue-grey fibers are called the cell's cytoskeleton. This is what makes your cells durable. Without a cytoskeleton, your cells would disintigrate on contact, your tissues would have the consistency of a thin soup, and life as we know it would not exist.

The lower right picture shows how your cell compartments, called organelles, are held in place by microfilaments and intermediate filaments which are, you guessed it, part of the cell's cytoskeleton.

Cool, huh? I think so.

But it's not so cool that the most popular, most prescribed drugs in the country, the cholesterol lowering pills called statin (Lipitor, Zetia, Vytorin, Zocor are popular examples) can destroy the exquisitely intricate architecture of your cytoskeleton and prevent a whole host of cells in your body from working normally, from liver cells, to immune system cells, to muscle cells (including the muscle that is your heart), to brain and nerve cells. Here's how they do it.

Statins block important metabolic pathways called Mevalonate pathways. One of the most important Mevalonate pathways forms the cytoskeleton. The cytoskeleton supports the shape of your cells, and controls all substructural movements, including the division of the cell during replication, the distribution of nutrients and energy throughout the cell’s compartments, and synthesis of proteins and hormones. Many people on statins suffer from unrecognized effects of blocked Mevalonate pathways.

The side effects of these blocked pathways and the resulting cytoskeletal malfunctions are diverse, and include cancers, memory loss, nerve pains, and muscle weakness. Accordingly, statins have been shown to cause breast cancer, skin cancers, confusion, concentration problems, depression, kidney damage, liver damage, and high sugar levels. Statins are so powerfully and reliably able to destroy the cytoskeleton, they are used as research tools to understand what role the cytoskeleton plays in metabolism; researchers infuse cells with small doses of statins to impair, for instance, the ability of a cell to manufacture nitric oxide signals. Once the associated cytoskeletal structure disintegrates, researchers stand back and watch what happens when the cell can’t make nitric oxide. The more researchers work on this issue, the more they discover that damage to the Mevalonate pathways and the cytoskeleton can cause all kinds of chronic diseases and cellular malfunction.

Fortunately, some people on statins are able to avoid cytoskeletal damage because their metabolic pathways can take alternate routes to manufacturing cytoskeletal components. However, during stress, infection, or with diet changes, this ability may be lost.

Many people are not able to fully bypass the metabolic blockages caused by statin drugs. These people often experience minor side effects, including fatigue, body aches, and subtle memory problems (“senior moments”). Unfortuntately, these are also the kind of symptoms most people might attribute to aging, and people continue their drugs, as more damage occurs.

Muscle cell damage can progress to atrophy and weakness, and because the heart muscle cells are affected to, can even lead to heart failure. Ironically, this means that statins, which many people take because they want to protect their heart, are actually quite likely to increase their risk of dying from heart disease. (Heart failure deaths have been on the rise since the introduction of statin drugs.)

Nerve cell damage can cause burning pains, especially at night, as well as major depression, balance and coordination problems, and even total amnesia. Some of these symptoms resolve with cessation of the medication, but not all. Because the current guidelines now state that all diabetics with LDL over 100 should be on statins, it is especially important for diabetics to be aware that statins increase their insulin requirements and can make it harder to control blood glucose levels.

Who should take statins?

I recommend statins to all men who smoke and who have had a heart attack already. Studies clearly show benefit in this small subpopulation. In male smokers who have had a heart attack and are not taking aspirin, statin drugs reduce the chance of dying in the next five years by six percent.

Are you saying that all the good things I hear about statins are false?

TV advertisements and medical education classes are carefully worded to be as true as possible. So while not always false, they are very misleading. You will not see this language, for instance, in a drug company advertisement for cholesterol pills: “cholesterol causes heart attacks.” Why not? Because cholesterol does not cause heart attacks.

As another example, lets analyze two misleading claims in the following statement: Statins reduce the risk of heart attack by up to 30% in some high risk groups.

The first misleading claim is the risk reduction of 30%. Here’s what the studies do to come to this conclusion. They start with, say, 100 high risk people. Lets make them male smokers. All of them have a family history of heart attacks. It doesn’t matter what their cholesterol levels is. They put all of them on statins and they’ll keep taking the drug for five years. Meanwhile, they’ve gotten together another group of 100 high risk people, again male smokers with a family history of heart disease and comparable cholesterol levels. This group doesn’t get the statins, its called the control group. Over the course of five years, two men in the statin group and three men in the control group have heart attacks. Two is (about) 30% less than three, so although only one man in the group of 100 men on the drug was saved from a heart attack, because they use the terminology “risk reduction” they aren’t exactly making a false claim. It would be more accurate to say something like this: One high risk smoking male in a hundred will be saved from a heart attack by taking statins, as long as he takes it for five years.

Notice I didn’t say “one in a hundred will be saved from death.” This brings me to the second point of misdirection. The vast majority of statin drug trials fail to show any benefit on mortality. In other words, although they do prevent (some) people from dying from heart attacks, people die slightly more often from side effects of the drug, so the overall survival effect is neutral.

Furthermore, the designers of the drug studies are careful to exclude people who are likely to die from the side effects of their drug. They do not allow people with a history of cancer, heart disease, uncontrolled diabetes, or certain other medical problems to participate in statin drug trials. If these people were not excluded, many scientists believe that by the end of statin drug trials, more people would be dead from side effects of the drug than were saved from having heart attacks.

Who should NOT take statins?

Women, children, and men over 65. Studies have not shown that statins offer any mortality benefit to these groups of people. However, when statin drug experts are interviewed and this fact is pointed out to them, these professionals generally respond by reminding us that there is no study proving that statins are not beneficial. In other words, the burden of proof is now on patients to provide the doctors with evidence that they should not take the drug. Since its impossible to prove a negative, the experts are asking us to ignore the science we do have, and instead dive into the murky realm of their own (biased) personal belief systems.

But my “bad” cholesterol has gotten better since I started taking statins, doesn’t this mean the drug is helping me?

High total cholesterol is not a risk factor for heart disease. High LDL cholesterol (LDL is called “bad” cholesterol) is only weakly correlated with heart disease. So lowering everyone’s LDL cholesterol with pills will not help most of the population. After thousands of studies and millions of dollars, the evidence still shows only those men who smoke and who are not on aspirin actually benefit from the pills. And their benefit does not correlate with cholesterol lowering.

In recent years, mounting evidence has shown that cholesterol is not the cause of arterial damage that leads to heart attacks. Oxidized fats, nutrient deficiencies and high blood sugar levels all play a role. Everyone agrees that normal, non-oxidized cholesterol plays no role, but the popular press and even medical journals downplay this fact. Furthermore, most lipid scientists acknowledge that LDL cholesterol plays no role; only oxidized LDL particles are a problem. How are LDL particles oxidized? That’s a good question, and I answer it in the book I wrote with Luke, Feed Me Pretty.

Why does my doctor tell me to take statins?

You probably have heard about drug companies influencing doctors by buying us free lunches or sending us on expensive vacations. I can tell you this influence is relatively minor; I wouldn’t change my prescribing habits or recommend drugs that I thought were dangerous just because I once had a nice meal paid for by the company that sells them.

What you probably haven’t heard very much about is the fact that drug companies have enormous influence over the medical education system. In other words, much of what your doctor learns (and is repeatedly tested on to keep his or her license) was approved by drug companies.

How can big pharma have so much influence over science? It’s simple economics.

Most doctors read medical journals. In order for medical journals to pay their bills, they have to advertise. This means they depend on drug companies for survival. If an editor publishes any article that portrays a drug as dangerous, he risks loosing the magazine’s source of income, and that means he risks loosing his job. (For more, see On The Take by former New England Journal of Medicine Editor, Jerome Kasserier.)

If statins are so dangerous, why aren’t we seeing people drop dead from them?

I think we are. You’ve probably heard about the Institute of Medicine’s report on doctor/hospital induced injuries, citing that nearly half a million deaths per year are complications of medical care. Many of these people died while admitted to the hospital for heart failure, and statins cause heart failure. Others in the study had cancer and died of infectious complications of their chemotherapy. You probably haven’t heard about this, but many studies have shown an association between low cholesterol and death from cancer and infectious disease, so there is reason to be concerned that on statin medications doctors are reducing their patient’s cholesterol to dangerously low values. Because statins and cholesterol that is too low both can cause so many different metabolic problems, this actually makes it harder for statisticians to notice a blip in any one disease induced by statin medications. And since doctors don’t hear about the potential harms statins may cause, they have no reason to suspect statin drugs may be the culprit when new medical problems arise, or old ones worsen.

I have had only three of my patients develop and ultimately die of cancer while under my care, all had been on statins before I understood their risks. I have had several of my patients develop heart problems (heart failure and arrythmias) while on statins after having a heart attack. The scary thing is that cardiologists don’t believe there is any risk to taking these drugs, mostly because they don’t try to understand how they work.

It’s not just cardiologists who are prescribing powerful drugs that they don’t understand. Neurologists also start patients on statins because they believe that statins reduce the risk of strokes. Unfortunately, while there may be some truth to that, all such studies have been designed and paid for by drug companies, and I don’t have much trust in their findings given this scenario. Meanwhile, most neurologists have not heard, or refuse to believe, that statins damage nerve cells and therefore deny that extended use may wind up causing more neurologic disease than they can possibly prevent.

If statins won’t help reduce my risk of having a heart attack, what will?

The most important thing you can do is make sure you eat a balanced diet of fresh foods. Fresh is the key term, as nutrients are rapidly lost with the passage of time, with cooking, even with washing and slicing. See the rest of my web site for more details on getting the nutrients you need.

Men can reduce their risk of heart attack by 25% by taking 81 mg of aspirin every day. Fish oils also help, but getting a high-quality fish oil is key. I'll be posting on supplements soon.

“We still don’t know how statins work, but I haven’t stopped prescribing them.”
--Dr. Douglas Losordo, chief of cardiovascular research at St. Elizabeth's Medical Center in Boston.

Flippant remarks like this are common among statin drug proponents. But if statin experts are recommending that nearly 40% of the population take these medications, shouldn’t they be just a little bit more curious about what they do?

Confusion Among The Ranks

The history of our faith in statins begins with one basic fact, statin drugs block an enzyme (called HMGCoA reductase) which is one of many enzymes along the metabolic path to manufacturing cholesterol. Statins are very effective at lowering cholesterol because of this blockage. But this impressive ability to lower cholesterol doesn’t translate to saving lives. Indeed, experts seem confused as to whether the modest beneficial effects of statins are from the cholesterol lowering effects, or from the effect of reducing some other chemical or groups of chemicals:

Dr. Paul Ridker at the Brigham and Women’s Hospital reported in The New England Journal of Medicine that statins reduced heart disease risk even in patients with otherwise healthy cholesterol levels, provided their CRP levels were above normal. "What was extraordinary," says Ridker, "was that the drug was just as effective in saving lives in the absence of high cholesterol, if the CRP [level] was high. Not only are these drugs 'anti-inflammatory,' as well as lipid lowering, but now there's actually clinical evidence to show that perhaps the way we prescribe these drugs needs to be rethought, because people with low cholesterol can still benefit from these drugs if they have an inflammatory response."

So the drug doesn’t work by lowering cholesterol, it works on people with high CRP? Other studies say no. But even if it does work on people with high CRP rather than high cholesterol, it would be nice to sort this out in order to be sure to give the drug to the right people at the right time, rather than the shotgun approach we take today. Unfortunately, there is money being made selling these drugs to as many people as possible, whether or not they’ll do more harm than good. And that golden glow over the eyes of academicians involved in drug studies is effectively obscuring intelligent insight into who should take the drugs, and when they should be taken.

Raising "Good" Cholesterol (HDL) With Drugs Might Kill You

From The New York Times, Dec 4, 2006:

Pfizer's most promising experimental drug [torcetrapib], intended to treat heart disease, actually caused an increase in deaths and heart problems. Eighty-two people had died so far in a clinical trial, versus 51 people in the same trial who had not taken it....Shortly after 9 p.m. Saturday, Pfizer announced that it had pulled the plug on the medicine entirely, turning the company's nearly $1 billion investment in it into a total loss.

The lipid cycle explains why these drugs don’t work

The lipid cycle is my term for describing the flow of fats throughout our bloodstream. (I added the term to Wikipedia.)

The lipid cycle was perfected by evolution millions of years ago to solve the problem of distributing fatty materials throughout a watery bloodstream. The solution was to wrap ingested fat in protein, thus making lipoproteins. When doctors talk about HDL and LDL, or so-called "good" and "bad" cholesterol, they're talking about lipoproteins.

In those, good 'ol days when jellyfish ruled the Earth, there was no such thing as man-made toxic fats like trans fats. Burnt and oxidized fats were also rare because cooking was not invented. Cholesterol is just one of many types of fatty nutrients that must circulate within lipoproteins, others include essential fatty acids like omega 3, fat soluble vitamins A, D, E, and K, and choline. All nutrients must circulate throughout all organs of the body to ensure adequate and equitable distribution to tissues in need.

The lipid delivery system was simply not designed to deal with toxic fats we have in our diets today. When fats are oxidized, the lipid cycle doesn’t function properly, and this may result in increased LDL and/or triglyceride levels and, ultimately, heart attacks and strokes. Furthermore, since the function of lipoproteins is nutrient delivery, if your lipoproteins are damaged by toxic fats your tissues may not get the vitamins they need - and you get sick.

The lipid cycle can be partially disrupted by various drugs. Statins make it hard for the liver to synthesize new cholesterol for release into phase two of the lipid cycle by inhibiting an enzyme called HMGCoA reductase. This is how statins make LDL levels fall. When the liver cannot make its own cholesterol, HDL levels may rise. HDL has been dubbed the “good” cholesterol because high levels are associated with longer life. (Probably because high HDL indicates a well-balanced lipid cycle.) When the HDL rises due to statin ingestion, it is not a sign of a healthy, balanced lipid cycle, it is a side effect of a disrupted lipid cycle. If LDL has been reduced, the step in the cycle whereby HDL transfers its apoproteins to LDL occurs less frequently and the apoproteins remain stuck on HDL, making the levels of HDL rise. Pfizer’s latest debacle interfered with the lipid cycle more directly than statins do, and with deadly results.

Another Way Statins May Help Some People

The evidence clearly shows that statins reduce incidence of heart attacks in some groups of people while they increase the incidence of other fatal illnesses in many. The one group of people who truly benefit from statins are male smokers who have already had a heart attack. This section discusses how statins helps them die 6% less often (over 5 years) then they would without statins.

I've already suggested statins have a mild anti-inflammatory effect that may prevent blood clots, here. But a relatively recent study suggests an additional beneficial effect may be in the prevention of excessive or abnormal blood vessel constriction.

Blood vessel constriction can lead to heart attacks and even fibrillation and death. One trigger for blood vessel constriction is release of a neurotransmitter called acetocholine from nerve endings. Excess acetocholine release occurs during exercise, emotional stress, or illness.

In a recent study, (Heart. 2006 Nov;92(11):1603-9. Epub 2006 May 18.
Short-term statin treatment improves endothelial function and neurohormonal imbalance in normocholesterolaemic patients with non-ischaemic heart failure) statin infusion was shown to blunt excess acetocholine release and prevent dangerous blood vessel constriction.

Nicotine is known to cause blood vessel constriction, which may be one factor in why smokers have more heart attacks than nonsmokers. So smokers who have had a heart attack will suffer less from the effects of their continued smoking while on statins. Unfortunately, studies have only shown this benefit over a five year period. The trouble is, the longer a person smokes and the longer a person takes statins, the more likely they are to develop cancer. So for you male smokers who have already had a heart attack, talking statins may end up killing you more often after 5 years than not taking statins, we still don’t know.

The Best Steak In Hawaii

What's the secret to a great steak?

For one thing, you need to have a good sense of timing to cook it just right - but that's no secret. The real trick to enjoying a super steak is having a great butcher, and having him or her nearby so your steak is fresh and never, ever frozen.

Medeiros Farms - Locally Grown Beef, Chicken, and Eggs

Here in Kalaheo we are lucky to have three talented butchers...or well they're women so maybe they're butcheresses? Anyway, they take care of the dirty work of turning those cute little guys we drive by on our way home (the cows) into pieces of food. Their tools are not all saws. One of the most important tools to creating tasty beef is time.

There will be no beef until it's time...

One of the dirty little secrets of the industrial beef industry is, after they're done torturing cows by confining them into filthy concrete windowless boxes and forcing them to survive on feed that their digestive systems rebel against (causing chronic diarrhea), they follow this unnatural and inhumane practice with another one that's just as bad or worse: tenderizing the meat with chemicals - sometimes injecting them into the cow's bloodstream while still alive. This is all in the name of saving time. The cows get fat fast, just like you would if you ate nothing but corn and soy products (for reasons described elsewhere). Pumped full of antibiotics so they don't die from all the infections they're exposed to, they can be brought to slaughter weight in half the time of cattle raised on grass. And, because every second that passes by without product being produced is an unforgivable waste, rather than tenderizing the meat naturally, by aging it, they use chemical enzymes that break down protein.

Someone has probably written their PhD thesis on how aging versus chemical tenderizing makes a culinary difference, something to do with water loss over time. I know for sure that, when it comes to flavor, the steaks we get from Medeiros Farms - locally raised on Kauai grass and aged the old fashioned way - are out of this world. Compared to the grocery store's they are...well, there's no comparison. You have to try one and see what I mean.

Salad Dressing: The Silent Killer

Yes, salad dressing. You never suspected a thing did you? But if your switch from plate lunches to salads hasn't helped you loose weight/lower your blood sugar/lower your triglycerides, it's because you are pouring deadly trans fat onto those crispy, vitamin-rich greens.

The other secret ingredient in many salad dressings is sugar. Why do you want to pour sugar on vegetables? Yuck.

Store bought salad dressings are almost never made of olive oil, even the ones that say "So and So's organic Olive oil dressing." Bologna. Turn the bottle around and look at the ingredients, there may be some olive oil, but with olive oil costing ten times as much as the other, cheaper oils, you can bet there's not very much.

Refining Oils Makes Them Bad For You

Most salad dressings contain "one or more of the following:" canola, corn oil, sunflower oil, soy oil, cottonseed oil, or the catch-all "vegetable oil." All of these oils are bad for us. Not because corn or sunflower seeds are bad for us (though I wouldn't advise eating cottonseeds), but because the manufacturing steps required to extract the oil from the seed and refine it so that it looks clean and edible turn the molecules of oil fat (called polyunsaturated fat) into mutant fats that include trans fat and other compounds that are worse for us than trans fat!

Preventing Vitamin and Nutrient Loss

Even worse, if you eat store bought salad dressing, you may as well be throwing the salad right down the toilet. When your body detects high levels of polyunsaturated fat it stops the normal process of digesting fats in its tracks. This is why you may have heard polyunsaturated fats "lower cholesterol." They actually prevent your body from absorbing all kinds of fats, including cholesterol, but also fat-soluble vitamins A, E, and K, as well as other nutrients like lecithin, phospholipids, and choline - all of which your body and especially your brain require to be healthy. If you want those vitamins to enter your body, you must consume them with a very special fat: Saturated fat!! Of all things, saturated fat...the very fat the AHA, the ADA, the AMA, and most doctors on the planet tell us all to avoid. Monounsaturated fat, which olive and peanut oils contain in abundance, also helps aid nutrient digestion.

Make Your Own Dressing: It's Super Easy!!

If you like salad, made your own salad dressing. All you need is:

a) olive oil
b) balsalmic vinegar (or your favorite vinegar)
c) hands

What could be easier than pouring two bottles of fluid over a bowl of salad? OK pouring one bottle would be easier. So if you are serious about salad, combine the two fluids in a container of some sort that you can store in the fridge.

The ideal ratio of oil to vinegar is 3 to 1, meaning use 3 times as much olive oil as vinegar. Of course, adding a pinch or two of salt, a few drops of lemon, and if you're really motivated, some fresh chopped garlic, will make it even tastier, and better for you. (Salt helps your body emulsify the fats with vitamins, and garlic is full of antioxidants.)

Here's some more Dr. Cate approved recipes:

Start 'em easy: Basic Vinagrette
1/2 C olive oil
shy 1/4 C red wine vinegar OR rice vinegar
1 T lemon juice
1/2 tsp each oregano, thyme and mustard powder
1/4 tsp each black pepper and garlic powder
dash of cayenne and Salt

Shake, chill and serve.

Easy Dijon Vinagrette-prepare one night ahead
1/2 C olive oil
2 T each plain non-fat yoghurt, lemon juice and red wine vinegar
1 T Dijon mustard 1/4 tsp each garlic powder, sage, thyme, basil and oregano

Combine in a blender at medium-high speed. Chill overnight before serving.

Now for the more committed: Not On The First Date Olive Oil Dressing
1/2 C olive oil
shy 1/4 C red wine vinegar
1 medium shallot, minced, or 2 T red onion, minced
1/4 tsp garlic powder
1/4 tsp basil
1/4 tsp McCormick's Spicy blend, or other general purpose spice blend
1/4 tsp black pepper
1/4 tsp Jane's Krazy Mixed Up Salt

Combine in blender at top speed for about a minute, so that all of the onion or shallot is reduced. The result should be a creamy pink dressing. Chill overnight in refrigerator. The result is a mild, oniony dressing with a slightly sweet edge.

Southwestern Vinagrette
1/2 C olive oil
shy 1/4 C white or rice wine vinegar
1 tsp mustard powder
1/2 tsp oregano
1/4 tsp black pepper
1/4 tsp cilantro
1/4 tsp garlic powder
1/4 tsp cumin

Shake, chill and serve. If you generally top your salad with cheese, pair this dressing with a mild cotija or colby. Avoid sharp or bitter cheeses such as bleu and feta.

Basil Sesame Dressing

1/4 tsp garlic powder
3 T rice wine vinegar
1 T lemon juice
2 T asiago or the cheese of your choice
1/2 tsp dried basil
2-4 leaves of fresh basil
2 T chopped Italian or regular parsley
1/2 C olive oil
1/2 tsp toasted sesame oil
1/4 tsp black pepper

Combine in blender until thoroughly mixed. Chill and serve with a green salad. It's a spooky color but tastes great.

Cilantro-Lime Vinagrette
1/2 C olive oil
2 T plain yoghurt
2 T lemon juice
2 T rice vinegar
1/4 C fresh, shreaded cilantro leaves, tightly packed
1/4 tsp each garlic powder, thyme and black pepper
1/8 tsp cumin
a squeeze of fresh lime juice - about a quarter lime

Combine in a blender until fully mixed. Chill and serve. I always see those cilantro leaves wilting in Sueoka store in Koloa. Please, come and get um before they wilt or the store will stop carrying them!!!

Cholesterol Pills - What You Haven't Heard

You know cholesterol pills will lower your cholesterol. But do you know cholesterol pills don't prevent heart attacks by lowering cholesterol? They work by what the pharmaceutical companies call "a pleitropic effect" meaning they have so many effects we can't understand or predict them all.

Cholesterol pills called statins lower cholesterol by blocking the enzyme that forms a chemical required for the earliest steps of cholesterol manufacture, the making of isoprene units. If you can't make isoprene units, you can't make cholesterol. But your body uses isoprene units for a whole bunch of purposes, so taking them out of the cellular stockpile means that you can't make a whole lot of other things either. Some people's muscles can't make the antioxidants their cells use to help manufacture ATP energy, so they feel weak and their hearts (an organ made of muscle!!) get flabby. Some people's immune systems can't distinguish healthy cells from malignant mutants or invasive bacteria, and so they develop cancer or infections. Those isoprene units are also important for brain cell growth and memory, so some people taking these pills act as if they're getting Alzheimer's. Because every cell in your body needs to make isoprene units, it seems logical that, if you take cholesterol pills long enough or in high enough doses, it's only a matter of time before they damage your health.

In spite of these risks, I still advise some people to take cholesterol pills. Why? Because some people's risk of heart attacks is so high and immediate, it's worth the relatively lower, delayed risk of devoloping the other medical problems. Male smokers who have had heart attacks and continue to smoke are ideal candidates for statin therapy.

So if not by lowering cholesterol, how do the Statins work?

Cholesterol pills of the statin variety prevent heart attacks because of their effects on the immune system. By suppressing the immune system (which needs isoprene units for all kinds of functions) drugs like Lipitor, Vytorin, Pravachol and others have a mild anti-inflammatory effect. Aspirin is another example of an anti-inflammatory medicine. But aspirin's effect is more focused on the inflammation than it is on fundamental immune system function, and so it's ability to prevent heart attacks may be as much as 100 times more powerful.

For more information about cholesterol lowering pills that you aren't likely to get from your doctor check these links: (and click your browser's back button if you want to navigate back here)

• Duane Graveline: A flight surgeon (and astronaut) who thought he was having strokes
  
• Thincs: See what a group of scientists says about cholesterol pills
  
• How the drug industry keeps doctors misinformed about statin harms
• Dr. Abramson, a Harvard MD who wrote a book called Overdosed America

For those of you who want to know more about why cholesterol pills make people feel bad, here's a slightly more technical section: The Nitty Gritty

Bone Density...What's It All About?

For years I've avoided putting my patients on fosamax and related drugs for "bone health," because according to the package insert, these drugs don't make bones healthy. They prevent part of the natural cycle of bone growth, called bone resorption, and by doing so make them denser looking on bone scans. Dense bones might sound like a good thing, but realize that a stick of chalk would look really dense on XRay, and it snaps in your fingers. Healthy bone that won't break when you slip and fall is a matrix of protein and minerals, and just adding more minerals without combining them in the normal way with protein won't help.

This week, I finally found a picture proving these drugs may be harmful when taken for years and years (like most people do). What the picture shows us is a line of dark, where no radiation got absorbed because the bone is fractured. You can access the journal at http://www.familypracticenews.com/home and look for the May 1, 2008 edition. The title of the article is "low bone mass frequently gets overtreated" and the author is Nancy Walsh.

Luke says the title should be "Drugs for preventing fractures actually cause fractures!" I agree. Don't you think this might deserve front page? I mean, it's the tenth most commonly prescribed class of drugs in the US, worth about 4.6 billion per year. But it's buried inside, on page 21. How many doctors do you think will find it there when our desks are piled with magazines full of hundreds of articles every week?

In case you can't access the article online, the picture caption reads: "Subtrochanteric fractures can occur when bone turnover is overly suppressed." Clearly, the drugs have side effects that most people don't suspect, and one of them is an increased risk of fractures. For more, see "why you don't want to suppress bone turnover" below.

So how can you keep your bones healthy?

Hands down, the best way to build healthy bones is to be active. Exercise helps keep your proprioceptive (balance) nervous system in shape and it keeps your mind sharp, both of which help to prevent falls - the number one cause of fractures.

Exercise does something else to keep your bones strong, too. Many people think their bone strength is an inherited, genetic trait that they have no control over. But that's not true. When astronauts returned from 30 day space missions, their doctors were shocked to find how weak their bones had become: in 30 days, their bones had aged 50 years. How could that be?

It has to do with the fact that bones are always growing, which we knew, but we had not expected to find that bones were quite as responsive to gravity as they are. Just the tug of your weight every day helps keep them from deteriorating. If you exercise, the healthy stresses act like growth signals, and actually trigger growth hormone release which, among other hormones, is required to keep your bones strong.

The other key ingredient to healthy bones is food.

Everyone things of calcium when they think about bones, and many people take supplements. But for every ten molecules of calcium, your bones need one molecule of magnesium. Taking calcium pills that are not balanced with magnesium may cause calcium to deposit around your joints instead of in your bones, creating bone spurs and contributing the arthritis. Magnesium is one of the few supplements I recommend because our soils are depleted and few foods contain very much of this overlooked bone-building mineral.

If you can't drink milk or dairy products, go ahead and get a calcium supplement. But truly the best way to get your calcium is by eating foods that are naturally calcium rich, like dairy. What else is there? Well nuts and dried fruit do have some calcium, but a great source of calcium and all the bone building minerals that should be on everyone's grocery lists is fish with bones, like canned sardines and salmon. I have one patient who buys salmon fish heads and pressure cooks them for 30 minutes until the bones are soft, and then shapes it into a patty and eats it. She says it's quite delicious. We actually have taste buds that detect minerals like calcium and magnesium, so as odd as it sounds, cooked bones actually taste good to us.

And vitamins are just as important as minerals.

Vitamins A, D, and K help your body put the minerals you eat into bone. Without them, all those minerals you've eaten go right through you. Most people can make D in their skin when they go out in our tropical sun, but not everyone can. If your bone density is low, you should get your level tested. Vitamins A, D, and K are fat soluble, and so they don't get absorbed into your body unless you eat them with a little bit of fat. Research shows the most effective carrier of these important nutrients is saturated fatty acids. This may be one reason why studies show time and time again that low fat diets don't make people healthier.

Why You Don't Want To Suppress Bone Turnover

Bone turnover is the ongoing process by which your bones respond to stress. Your bones are always growing, even at age 90. Not in length, but internally. Your bones are supported by internal struts, very much like the struts criss-crossing beneath the Brooklyn Bridge. From time to time, your bone struts wear out and need to be repaired. The repair process is called "bone turnover." The article does not give doctors any clue what they meant by "when bone turnover is overly supressed."

Why wouldn't the article give us any hints? It was actually a journalist's summary of a talk given by Dr. Stephen Honig, who serves on the speakers bureau of Novartis Pharmaceuticals. And so with that fiduciary relationship in place, I doubt anyone listening to his seminar got the full story either.

Bottom line is I have yet to find reason to start any of my patients on these drugs. Why not? Because aside from suppressing bone turnover and causing bones to break if you use them "too long," they cause a few ugly little problems your doctor probably didn't disclose before handing you the prescription:

• Muscle aches, sometimes disabling
• Esophagitis, and rarely, the acid drug erodes through the esophagus perforating it and killing people
• Osteonecrosis - this is a condition in which segments of bone die and sometimes need to be removed. Very inconvenient if the affected bone is in your jaw or your neck.

Of course if he or she did tell you, you should thank him. Unfortunately, since we're getting paid less and less every year (so that your insurance company can afford to subsidize expensive prescription medications like Fosamax) fewer and fewer doctors have enough time to read up on the side effects themselves, much less inform their patients.