Of Hotels, Shuttles and Costa Rica

Day 1

You might want to stay in a nice hotel when you travel, but that does not mean that you want to pay an arm and a leg for shuttle transfer from the airport. Well, perhaps a leg. Or maybe an arm. But not an arm and a leg. Even if the hotel is really, really far away from the airport.

Such a situation befell us recently when we reached the Daniel Oduber Quirós International Airport in Liberia, Costa Rica. One could save some money, and stayed in Liberia. I am sure some people do. But most of us who have Costa Rica on our minds dream of beaches, and mountains, and volcanos. Not of Liberia. Thus we had planned to stay in the J W Marriott Resort in Guanacaste. Not exactly cerca de Liberia. But quite lejos. A good distance away.

A bridge too far?

A bridge, but where’s the river Kwai?

We could have taken the shuttle provided by the hotel. Only one problem. The charge is not too far off the daily room tariff. At least in the off-season.

So we decided to do what travelers have done for millennia: we haggled with the locals. No, not with the hotel. But with local taxi drivers. And smugly got into a taxi, having won a most satisfying battle. And very nearly lost the war. There was a misunderstanding. There was a third party involved. And one of the parties, the most important one, as it turned out, heard a higher figure than the others. And nearly turned around to return us to the airport. Which would have been counterproductive.

But order and understanding were soon restored, and our voyage continued. And terminated at the above-mentioned hotel in just over an hour.

A few valuable lessons: Take the hotel shuttle, unless it threatens to bankrupt you. Or, make doubly sure that you and the taxi driver are on the same page regarding fare and destination before you set off. Also ask if the guy will turn the air conditioning on. Some private taxis charge more to turn the a/c on, even if they have it in the vehicle.

Please do not take this to mean that you should be fearful of visiting Costa Rica or staying at the Marriott. Quite the contrary. Costa Rica is one of the prettiest countries I have visited (this was our second trip), and the J W Marriott is a fine hotel.

Rain, rain go away!

Don’t worry! The sun will be back pronto!

Another interesting thing happened on our way to the hotel. There were periods of cloudiness, and then the sun would break through. The sun really works hard here, so it would raise the temperature into the mid- to high-eighties. And this was in the latter part of October. As a result, the cloudiness was much welcomed, as it lowered the temperature, and led to a lovely breeze, best appreciated when we rolled the taxi windows down. You know, science is wonderful, and I love air conditioning, but it is hard to beat nature’s own breeze!

And then there was a short, sharp burst of showers, before the sun dispelled the clouds arrogantly, and stamped its authority on the landscape once again.

My point: everybody reads about low seasons, and high seasons, and peak seasons. Not to mention the rainy and dry seasons in Costa Rica. January through April is the dry summer, while May through December are rainy periods, laughingly called the winter. The average annual temperature in this country is 70 to 80 degrees Fahrenheit, and the sun reports for duty for about 12 hours a day on most days.

So don’t worry too much about the wet weather. On many days, it won’t rain at all. And if it does, it may not last for more than a couple of hours, unless you are in the rain forest. And there is still usually plenty of sunshine, especially on the Pacific coast beaches.

Best of all, prices are down! Hotel deals abound! Yea!!

Moving right along. We reached the hotel. One word describes it. Wonderful!

Hammocks ahoy!

My better half!


The first thing which strikes you as you drive into the reception area is the sheer number of hammocks. This hotel must think that the cure for most maladies which afflict mankind must lie in a hammock. And I think they may be right.

So if the reception people are a little slow in checking you in (a highly unlikely occurrence), you can climb aboard one of these ubiquitous white, corded delights, and have your significant other set it in motion. I promise that if you close your eyes, time will stand still!

Hammocks are fun at night!

Well, we were checked in expeditiously, and with due courtesy, and even the room change we requested was dealt with efficiently. We were soon enjoying a panoramic view of the Pacific from our oceanfront room. The vacation had truly started.

Hey bud, where are you from?

Backtracking a bit, we were traveling from Asheboro, North Carolina, which is a wonderful small town, full of great people, but with a rather severe deficiency of  international airports. So our default choice is Greensboro, half an hour to the north, another nice town, which boasts of an airport, but is not blessed with great connections or great prices.

So we drove to Raleigh in the evening, spent a night close to the airport which had offered us a decent price for a flight to Liberia, Costa Rica, and set off bright and early to catch the 6:20 am United flight to Houston, and from there a connection to Liberia. Again, North Carolina is a lovely state, but is not exactly teeming with truly bustling international airports, which can whisk you away to any place in the world without too many interruptions. Well, such is life.

The rest of our day was spent chilling out, eating, and pretending that we had jet lag, which we actually did not. There is only a 2-hour difference between NC time and Costa Rican time.

Want to know about the gastronomic delights which awaited us? As they say, stay tuned!









So You Think Dietary Fat Causes Heart Disease?


If you believe in unicorns, myth and mythology, you can continue to believe that fat in the diet causes heart blockages and heart attacks. If, on the other hand, you believe in science and evidence, you might want to question those beliefs. Because the evidence is in, and most people are wrong.

Bad science

So what was the problem to begin with? Americans made huge changes to their diets, the food industry changed its grocery store offerings, and lots of patients received rather severe tongue lashings from their doctors. All for no good reason. How could so many people be so wrong for so long?

Well, the answer is bad science.

Correlation is not causation

Scientists, including doctors, conduct trials to see if a particular theory or hypothesis is correct. Now, there are trials, and there are trials.

We have epidemiological studies, where segments of the population are followed for a number of years, and their health outcomes are noted. Observations are then made to see if those outcomes are correlated with certain habits or risk factors.

So what is the problem?


Correlation is not causation. If two things are correlated, one does not necessarily cause the other. A rooster’s cry and the rising of the sun are correlated, but the rooster does not cause the sun to rise.

A murky beginning

The whole saga appeared to start in the 1970s. The Seven Countries Study by Ancel Keys revealed a strong correlation between the average amount of saturated fat in the diet, the average blood cholesterol levels, and the 10 year death rates from coronary heart disease (blockages in the heart arteries). Again, the key word is correlation. No cause and effect was proved.

However, what followed was an avalanche of government advice, and change in the food industry offerings. There were other epidemiological studies, but there was a lack of well-designed trials to support this undertaking.

What is a good trial?

Well, the gold standard is the so-called randomized controlled trial, often shortened to RCT. The details of such trials are beyond the scope of this article, but RCTs are better suited to look for a cause and effect relationship.

What were we told?

For over fifty years, we have been sold a bill of goods which was defective. And all of this based on epidemiological studies, of doubtful quality.


Governments, and scientists, and doctors, told us that saturated fat was bad for us, that fat was bad for us. That consuming too much fat would cause blockages in the heart, leading to heart attacks, and premature death.

We were advised to cut down on fat, so that no more than 30% of our daily calories came from dietary fat. We were also told to limit saturated fat intake to no more than 10% of daily calories.

So what happened next?

Well, our calories come from carbohydrates, protein, and fat. If you eat less fat, you will tend to eat more of the other stuff. And that is what people did when they were asked to cut down on fat. They loaded up on carbohydrates. Not protein. Carbohydrates. In fact, in the late 20th century, the US government advised the public to start eating more carbohydrates, including 6-11 servings of grain products daily.

What next?


Americans have dutifully heeded their government’s warnings about fat. Fat used to provide 40% of daily calories in the past. This has dropped to 30% in the last 30 years. But people have become heavier. Obesity rates have tripled in the last few decades. You don’t need data to know this. Just go to any mall or sports stadium and look around. Alarmingly, the incidence of type 2 diabetes has gone up many-fold.

So what is the problem?

It is clearly not dietary fat.

A meta analysis of prospective studies evaluating the association between saturated fat consumption and cardiovascular disease was published in the American Journal of Clinical Nutrition in January 2010. It analyzed 21 studies, which followed nearly 350,000 people over 5-23 years. It revealed that there was no significant evidence for concluding that saturated fat in the diet is associated with an increased risk of coronary heart disease or stroke.

Fat out, sugar in



The law of unintended consequences can be seen at work in this entire saga. Governments want less fat in the diet, so industry is urged to offer more low-fat products. But fat makes food taste good. Taking fat out worsens the taste. Thus, industry has been replacing fat with sugar, with results that we are seeing all around us: fatter people, with more diabetes. Also, we are witnessing a plateau in cardiovascular disease, which had been showing a decline for decades. And we may well see an uptick in this disease if things continue the way they are.

So is a calorie a calorie?

Not necessarily.

Food has metabolic consequences. A low-fat diet can lead to biological adaptations, such as increased feelings of hunger, a lower metabolic rate, and other components of a starvation response which tend to oppose weight loss.

Sugary drinks and sweets, as well as simple carbohydrates and starches, tend to increase blood levels of insulin, which is related to many chronic diseases, including diabetes and obesity.

Low-carbohydrate diets and low-glycemic index diets (with foods containing complex carbohydrates) tend to lower the levels of insulin in the blood, thus helping people maintain the weight loss they have achieved. Such diets might be protective against chronic diseases such as diabetes.

More recent studies

The Women’s Health Initiative Dietary Modification Trial revealed that over a mean of 8.1 years, a low-total fat diet did not significantly reduce the risk of heart disease or stroke in postmenopausal women.

The PREDIMED trial was a study of the Mediterranean diet in high risk people who were free from known coronary disease at the beginning of the trial. This study showed a 30% lower risk of having a major cardiovascular event in the higher- fat dietary groups compared with the low- fat control. This risk reduction is similar to that shown in the statin (cholesterol lowering drugs) studies, but at no cost to the health system!

Higher death rates?

A study by DD Wang and associates, published in JAMA Internal Medicine in August 2016, noted that men and women following low-fat/high-carbohydrate diets had higher rates of premature death, not lower.

Lesson learned?


The US government, through its Dietary Guidelines for Americans, 2015-2020, still recommends cutting down on saturated fat. These guidelines also state that a healthy eating pattern includes fat-free or low-fat dairy.


School lunch programs in the US provide only low-fat milk. No whole milk is provided at all, although they do allow chocolate skim milk with its added sugars. And this is in spite of the Dietary Guidelines calling for a restriction on added sugar.

And the general public, of course, keeps buying low-fat everything. In fact, at most grocery stores, it is hard to find full-fat dairy.

And this is in spite of a study published in the reputable journal Circulation early in 2016 which found that people consuming full-fat dairy had a 50% lower risk of diabetes, compared to those consuming the low-fat variety.

So what to do?

  • Don’t obsess about fat. The link between fat, especially saturated fat, and heart disease is tenuous at best.
  • Trans-fat is still bad for you. This is found in cakes, pies, cookies, biscuits, crackers, and many fried or processed foods.
  • Try to eat whole or minimally processed foods.
  • appetite-1239167_1920
  • Include lots of fruits and vegetables in your diet.
  • Cut down on sweets and sugary drinks, as well as simple carbohydrates.
  • Include whole grains in your diet.
  • Eating an ounce of nuts daily is good for you.
  • Low-fat dairy has no benefits over the full-fat variety, and may well be worse, according to recent data.

And finally

Focus more on the overall dietary pattern.

As Dr. Mozaffarian, a leading researcher, says, “If something has a food label, it’s probably not the best choice. We need to move away from the idea that we can manufacture an artificially healthy diet.”

Do You Really Want Your Neighbor’s Wonderful Life?

Are you feeling angry? Tired?  Frustrated? Envious? Do you think you are working harder than ever, yet not making much progress?

If your answer is yes, you are not alone.

Millions of people feel that life is passing them by. No matter what they do, it is always the other guy who gets the promotion, buys fancy cars, and sends his kids to Harvard, while they are barely treading water.

Are they right? And if so, what is the solution?

Facebook version of reality

Beach Vacation

Beach Vacation

You “friend” people on Facebook. Or other “social media” sites. Then they send you pictures of their beach vacations, their happy and smart kids, their new cars. And here you are, struggling with the daily grind of your mundane life.


Anger often arises if you want something badly, and your desires are thwarted. Or you think you deserve something, and yet you end up not getting it.

Frustration commonly has similar roots.


The real world exists.

We want it to be a certain way, but it is a stubborn beast. It goes along its merry way, impervious to our desires. It defies our efforts to control it.

Sooner or later, reality clashes with our expectations. The results, if not put into perspective, can be disastrous.

Grown-ups’ problems

tantrumAs children, we are often pampered. If we want something, we go to our parents, and demand we get it. If we don’t get our way, some of us throw a tantrum.

And then we grow up.

Control and compare

The first clash with reality in an adult world comes through comparisons.

We look at our colleagues and our neighbors. And we feel envious if they are better off than we are. Because we feel that we are just as smart as they are, if not smarter.

Envy, if not dealt with firmly and rationally, leads to resentment, bitterness, and anger.

From here, where?

So you are upset. You are better (you think), but your colleagues get all the riches. You hate that.

angryWhere is this going to lead you? Anger, hatred, resentment … this is a recipe for sleepless nights and an acid feeling in your gut. Will this make you any richer? Will that Lamborghini parked next door find its way into your garage?

No, and no.

You will be no richer, and your outlook towards life is likely to get clouded. Your enjoyment of life will diminish.

So what is the answer?

We need less envy, and more clarity of thought, more empathy, more gratitude.

Think about it.

You envy your neighbor’s mansion, his big car, his fancy vacations. But they do not exist in a vacuum. They are often the end result of a number of decisions he made along the way. Decisions which you do not know about. Decisions that you might not have made if you had that choice.

Perhaps he studied hard while his college classmates were out partying.

Perhaps he toiled at part-time jobs while others were slumped in front of their TVs, sipping beer and devouring potato chips.

Do you want his whole life?

This is the real clincher.

Your neighbor’s life is a package deal.

LamborghiniYou drool over his car. But with it might come his son’s drug addiction, his wife’s loneliness and depression, the alimony he pays to ex-wives, and the grief he gets from them. If you want his car, you will have to accept his problems, too. Ready for the deal?

Pick and choose

That is what we want to do. We want the “Facebook” elements of others’ lives, but we want to steer clear of their problems, many of which we do not even know about. Life does not work like that.

Live happily ever after?

And even if you got your neighbor’s life, and his riches, then what? You will ride off into the sunset and live happily ever after? Hardly. Life is not a Hollywood movie.

Where now?

You need a strategy to deal with life. Bitterness, envy, resentment, anger, and frustration are not strategies. They are symptoms. Symptoms that you are not happy in your own skin.

Accept reality

You are what you are. Sit down. Take a deep breath in. Look deep inside you. Analyze your strengths and weaknesses. Be grateful for what you have. You probably have more than a lot of the 7 billion or so people on this planet, especially if you live in the Western world.

Then take a cold, hard look at your problems. Is the lack of a Mercedes a real problem? Do you really need a beach house and several million dollars to be happy in this world? If so, mankind is really doomed.

What matters in life

Sooner or later, you will have to decide what it is that you really want. What will make you happy? What will give your life meaning? What will give you satisfaction?

If your answers deal with material things, you will always be disappointed. Kids will move out, and the large house will be mostly empty, except for stuff. Stuff that nobody uses anymore.

JunkThe car will lose its shine. The new car smell will fade. Eventually, it will go to the junk yard.

Stuff is temporary. Life is temporary.

The neighbor’s Lamborghini? It will end up as scrap metal one day.

So what should you do?

  • Remember all the good things that have happened to you.
  •  Be Grateful!

    Be Grateful!

    Be grateful for all of them.

  • Live in the moment and enjoy it to the fullest. This is the only moment you have. The past is gone. The future is not guaranteed. So enjoy all aspects of the present moment. This is when you are alive. This is your life.
  • Focus on friends, family, love.
  • You have one life. It might not be perfect. But it is yours. Live it, instead of grumbling about it.


How to Navigate Safely Through the Fat, Lipid, Omega World

 Confused yet?

Confused yet?

Doctors, scientists, and technical people take morbid delight in using terminology which the general public does not always understand fully. However, they get away with it, because people are loath to question them, not wanting to appear ill-informed. Thus, the media throws around terms like fats, lipids, oils, omega-3 fats, and the like, with abandon. And nobody takes them to task.

Speak clearly, please

Fat, lipid, and oil: These are commonly used terms, and their meaning needs to be crystal clear.

Our diet has three major constituents: protein, fats, and carbohydrates. We need fats to ensure our bodily structure and metabolism.



This is chemically an ester, which is a compound formed by the combination of an acid with an alcohol. In the case of a fat, the acid is a fatty acid, and the alcohol is glycerol.

So a fat is basically a glyceride. If we have three fatty acid chains combining with glycerol, we have a triglyceride, which is another term which nobody explains, but which you see all the time on your report if you have a “cholesterol blood test.”

What, then, is a lipid?

A lipid is an organic compound having certain characteristics. Before we go further, let us refresh our understanding of organic and inorganic compounds.

Organic, inorganic, what’s the difference!

Chemistry consists mainly of organic and inorganic compounds.

Compounds associated with living beings are organic. They always have carbon atoms as part of their structure, while most inorganic molecules don’t.

Almost all of the organic compounds contain bonds between carbon and hydrogen (C—H). Some, however, do not, like urea.

Some examples of organic compounds are fats, lipids, sugars, proteins, nucleic acids, enzymes, etc.

Examples of inorganic compounds are metals, salts, and other molecules not containing carbon-hydrogen bonds.

Back to lipids

So lipids are organic compounds. They have carbon to hydrogen bonds, and they also have oxygen. The number of hydrogen atoms in a lipid molecule is always more than double the number of oxygen atoms.

The carbon to hydrogen bond in a lipid is a special one, called a nonpolar covalent bond. This means that the carbon and hydrogen atoms share a pair of electrons equally. The importance of this is that the molecule of a lipid is made fat soluble. It will not dissolve in water, though.

Types of lipids

Biologically, we have four important lipids. They are fats, steroids, phospholipids, and waxes.

So fat is a type of lipid.

All fats are lipids, but not all lipids are fats.

Then what is an oil?

Fats are usually solid at room temperature.



A fat which is liquid at room temperature is called an oil.

Oils can have saturated, monounsaturated, and polyunsaturated fatty acids. Being liquid at room temperature, they tend to have more unsaturated fats than saturated ones.

Essential fat?

Yes, fat can be essential, in that the body would not function without a healthy dose of fat.

Alpha linolenic acid

Alpha linolenic acid

However, biochemically, the term “essential fatty acid” is applied to those fats which cannot be made by the body. Therefore, we have to eat them as part of our diets. There are two of them: alfpha-linolenic acid (an omega-3 fat) and linolenic acid (an omega-6 fat).

Other fats needed by us can be made by our bodies using these essential fats and other substances.

Are we saturated yet?

Saturated fat is bad, unsaturated is good: You have heard this refrain most of your life. It is not necessarily true.

But what is a saturated fat anyway?


Atoms join with other atoms to make molecules. And molecules are what make up matter.

There are laws which govern this union. If a carbon atom is able to join with all the hydrogen atoms it possibly can, it is called saturated. It is happy. In that case, it combines with other carbon atoms with what is called a single bond, chemically shown as C—C. However, if it cannot combine with all the hydrogen atoms it is capable of, it ends up joining with other carbon atoms using a “double bond.” This is shown as C=C. This makes it unsaturated. The same is true of “triple bonds.”

How do you bond with others?

In a fatty acid molecule, if a carbon atom joins with another carbon atom using a double bond (or triple bond), that fat is called “unsaturated.” Otherwise (with carbon-to-carbon single bonds only) it is “saturated.”

Avocado with monounsaturated fat

Avocado with monounsaturated fat

If in one fatty acid molecule, there is only one double bond between two carbon atoms, that is called a “mono-unsaturated fat.”

The presence of more than one double bond makes the fat a “poly-unsaturated fat.”

What is this omega business?

If you are an adult, you must have heard of omega-3 and omega-6 fatty acids. One is supposed to be good, the other one not so good.

But what are they?

It is all about the ending

The fatty acids chains have two ends: the beginning and the tail. The beginning is the so-called acid end, and the tail is the methyl end. Since we are all in love with the Greeks, we call the beginning the “alpha end” (since alpha is the first letter in the Greek alphabet), and the tail is the “omega end.” Omega, of course, is the last letter of the Greek alphabet. This end is also called the n-end.


This is a polyunsaturated fat. Which means that the fatty acid chain has more than one double bond (C=C).

The omega part means that you start looking at the tail end (omega end) of the chain. Then look at the third carbon atom from that end. If the first double bond occurs at this location, you are dealing with an omega-3 fatty acid.

Why is this important? Read on.


Apply the same process as above. If the first double bond is at the 6th carbon atom from the tail end, you have an omega-6 fatty acid. Again, this is a polyunsaturated fat.

What’s the big deal?

Mono-unsaturated fatty acids are felt to be better for your health than poly-unsaturated fats. Among the poly-unsaturated fats, the omega-3s are again supposed to be better than the omega-6s.

In fact, many experts feel that in the ancient era, humans had much more omega-3s in their diets than omega-6s, and that nowadays this ratio has been reversed, leading to several ill-effects on our health.

And what about trans fats?

About this, not much debate exists. These fats are universally condemned as the worst types of fats for our heart health. Many localities in the US have legislated to ban them, or severely cut down on their presence in our food supply.

What’s so “trans” about the fat?

It is basically a chemical arrangement.

There are two types of arrangements of hydrogen atoms in unsaturated fatty acids (which have at least one double bond).

The “cis” type occurs when the two hydrogen atoms are on the same side of the double bond in the chain. “Cis” in Latin means “on this side.”

The “trans” type occurs when the hydrogen atoms are on opposite sides of the double bond (“trans” means “across” in Latin).

Again, what’s the big deal?

The trans configuration in unsaturated fatty acids creates problems. So why was it created? For convenience.

Of course, there are some naturally occurring trans fats also. These are produced in the guts of some animals. Meat and milk from these animals can have small amounts of trans fats.

Then we have artificial trans fats, which are created by the hydrogenation of vegetable oils.

Adding hydrogen to a liquid vegetable oil makes the product more solid, and increases its shelf life.

In some instances, trans fatty acids can alter the taste and texture of food in a manner which consumers like.

Oils containing trans fats are often used by fast-food chains and restaurants around the world, because such oils can be reused several times in commercial fryers to deep-fry food.

Trans fat = Bad fat

The hydrogenation of vegetable oil leads to a product which has serious implications for heart disease.

The trans fats produced in this manner can reduce the amount of “good cholesterol,” or HDL cholesterol, and increase the amount of “bad cholesterol, or LDL, in your blood stream.


  • The terms fats, oils, lipids, trans fats, omega-3, and omega-6 are frequently seen by the public, but not always fully understood. It is important to be clear about what they mean.
  • Fats can be saturated or unsaturated, and their ratio in our diet is important.
  • The ratio of omega-3 and omega-6 fats in our diets is also important.
  • Trans fats are the worst kinds of fats, and should be avoided as far as possible.

Food sources of different fats

We will discuss details of this, and their health implications, in subsequent posts.

Stay tuned!

The Truth About Cholesterol: Good, Bad, and Ugly!

Do you really want to get rid of cholesterol? If somebody promised to remove all trace of it from your body, would you agree, thinking that that would eliminate the threat of heart disease? If you say yes, that would be a mistake. Because you would then find it difficult to survive.

What is cholesterol?


It is all over the news, both TV and print, and tons of medical articles are devoted to this rogue. Except that it is not always a rogue.

“Chole” in Greek means bile, while “stereos” means solid. The “ol” signifies that it is an alcohol.

So cholesterol is a sterol, which is a modified steroid.

It is also a lipid molecule, which basically means that it is a type of fat.

Do we need cholesterol?

You better believe it!

cell membrane

Why? Because it is an essential part of the cell membrane of all animal cells. Bacterial and plant cells have cell walls, which are fairly rigid. However, because of the cell membrane, animals, including us, can avoid having a cell wall. Thus animal cells can change shape and move around.

Anything beyond membranes?


If you are Mycoplasma, you need cholesterol for growth. But if you are reading this, it is unlikely that you are Mycoplasma.

Assuming that you are a human being, you would need cholesterol for intracellular transport, cell signaling, and nerve conduction.

Vitamins and hormones

Unless you want to pop Vitamin pills and depend on hormone shots, you had better thank God for cholesterol.


The synthesis of Vitamin D and all steroid hormones requires cholesterol. This includes sex hormones and adrenal gland hormones.

So should we eat a lot of cholesterol?

Hold on for a while.

If you are a man weighing 150 pounds (are there any of those around anymore?), your body makes about 1000 mg of cholesterol daily. Yes, makes. Since cholesterol is vital for the structure and functioning of the body, your body does not want to depend on your diet to give it enough of a supply.

Remember, the time of excess is relatively recent. For hundreds of thousands of years, human beings struggled to get enough food to survive and flourish.

So your body makes a lot of cholesterol. As we speak, your body (if you are the above-mentioned hypothetical male) contains 35 g of cholesterol. And most of it is not in the heart or arteries. It is mostly within the cell membranes, performing a vital function.

So how much should we eat?

Good question.

Let us turn to the Dietary Guidelines for Americans (DGA) which has been telling us what to eat and how much since 1980.


In 2010, American men were consuming 350 mg of cholesterol daily, while women limited themselves to 240 mg. The DGA recommended that year that we should keep our intake below 300 mg/day. The rationale, of course, was that if we ate less cholesterol, our blood cholesterol levels would fall, and we would not develop blockages leading to heart attacks.

DGA 2015-2020 advice

The latest DGA report is revolutionary in one regard. It makes no recommendation to limit cholesterol intake.

The report states that “adequate evidence is not available for a quantitative limit for dietary cholesterol specific to the Dietary Guidelines.”

Say what?

Dietary cholesterol does not play a major role in blood cholesterol levels.

Yes, you heard that right.

The amount of cholesterol in your blood stream is not affected significantly by how much cholesterol you eat in your food.


Most of the cholesterol we eat is in the form of esters, and as such is poorly absorbed.

In addition, if we eat too much cholesterol, and a lot of it is absorbed, the body compensates by making less cholesterol on its own.

There are many factors which have a more pronounced effect on blood cholesterol than dietary intake of cholesterol.

Body weight, age, sex, physical activity, heredity, and consumption of saturated fats and trans-fats, all have significant effects on our blood cholesterol levels.

But what about heart disease?

That, of course, is the million dollar question.


Links between high cholesterol levels and the development of coronary artery disease (blockages in the heart) leading to heart attacks are quite clear.

So what should we do to lower blood cholesterol?

And will that lead to prevention of heart attacks?

And what about the different types of cholesterol?


  • Cholesterol is not always bad.
  • Without cholesterol, we would not have cell membranes, some vitamins, and important hormones.
  • High cholesterol levels are associated with an increased risk of heart disease and heart attacks.
  • Cholesterol is of several types.
  • The level of cholesterol in your blood is not primarily dependent on how much cholesterol you consume in your diet.

Future direction

  • How best can you lower cholesterol?
  • Will that affect heart disease?

Stay tuned!

We will address these issues in subsequent posts.















Worried That More Fat in Dairy Will Make You Fat?

We have made fat a four-letter word. Full-fat is even worse, not fit to be uttered in polite company.

Doctors have been warning us for decades about the ills which fat can visit upon us. Heart disease obviously has been the main issue. The population lives in fear of keeling over dead if it so much as puts another fat calorie into its mouth.

Are we there yet?

The implicit promise seems to be that if we only behave ourselves, if we only avoid this dreadful fat monster, we would get slimmer, we would be free of heart attacks, and we would live happily ever after.

So what happened?

Full Fat?

Full Fat?

Americans, in particular, have been shunning fat in droves. If you look in large grocery stores, everything is fat-free, or low-fat, or reduced fat. Folks like me, who enjoy full-fat milk, cheese, and yogurt, have almost become pariahs. We have to search far and wide, and at times go to multiple stores, before we can find dairy products to meet our tastes. And then we have to hide them at the check-out counter, so nobody can see what we are guilty of.

So have we gotten any slimmer as a nation after cutting out the fat? Have we eliminated the scourge of heart disease?



Fat consumption is going down, at least in the US, but we are getting fatter. BMI is going up. Kids are approaching the weight adults used to have decades ago. And diabetes is on the rise.

So what gives?

Were we, as physicians, wrong? Horror of horrors!

Is all fat bad? Or, as Paleo-diet proponents might suggest, is fat good?

Are there good fats and bad fats?

Is saturated fat good, bad, or ugly?

What do studies show?

For decades, the fat, or saturated fat-heart disease link was considered settled fact. And then, heretics started to question that. More heretics followed, till they were no longer heretics.

Now, a growing body of literature is calling into question the link between full-fat, saturated fat, and heart disease, obesity, and diabetes.

Types of fat

All fats are not created equal. There is saturated fat and unsaturated fat. Among the unsaturated variety, you can find mono-unsaturated fat, and poly-unsaturated fat. Then, of course, there is trans-fat, omega-3 fat, and omega-6 fat.

 Omega-3, anybody?

Omega-3, anybody?

I could give you a detailed chemical account of all this, but that would make you stop reading any further. So we will leave that for a later date.

Sources of fat

You do not go to a grocery store and buy five pounds of fat, ten pounds of protein, six pounds of carbohydrates, and a whole lot of sugar.

You buy foodstuff.

Saturated fat


This contributes about 10% of the total calories in a typical North American diet. Major sources are animal products: butter, milk, meat, salmon, and egg yolks. Some plant products, such as chocolate, coconut oil, palm kernel oil, and cocoa butter, also contain saturated fats.

Of late, a few studies and meta-analysis of studies have suggested that there may not be a significant link between saturated fat intake and coronary heart disease. A study published in the American Journal of Clinical Nutrition in January 2010 reported on pooled data from 21 studies on saturated fatty acid intake and risk of coronary heart disease, stroke, or cardiovascular disease in general. Over 340,000 individuals were studied.

The researchers found no significant association between high intake of saturated fatty acids and an increased risk of coronary heart disease, stroke, or cardiovascular disease.

But what about becoming fat? Or diabetic?

Let us return to our obsession with low-fat and no-fat products. Before long, we might even be looking for fat-free water. And that might be all right, if it made us slimmer. But it has not. Do not take my word for it. Just look around you.

Thank you, Tufts University

A recent study in Circulation (March 2016) conducted by researchers at Tufts University investigated the link between the intake of dairy fat and the development of diabetes. The scientists checked the blood of more than 3000 people for byproducts of full-fat dairy.

They found that people who had higher level of these byproducts in their blood (thus identifying those who consumed full-fat dairy) had, on an average, a 46% lower risk of developing diabetes during the period of follow-up.

Obesity and dairy fat


There has been a fear in the general population, perhaps abetted by the medical profession in the past, that if you drink full-fat milk or eat full-fat yogurt, you will become fat. This is simply not true.

A study published in The American Journal of Clinical Nutrition in April 2016 evaluated more than 18,000 women who were 45 years or older and whose weight was normal at baseline. These were participants in the Women’s Health Study, and were followed for over 11 years.

The researchers found that a greater consumption of high-fat dairy products was associated with less weight gain during follow up.

They also found that women whose intake of high-fat dairy was in the top 20% in the group had a lower risk of becoming overweight or obese.

Shouldn’t fat make you fat?

That was the logic behind recommending low-fat products to the general public.

However, it now appears that when people cut out the fat in their diets, they start increasing their intake of carbohydrates. The body then turns these carbohydrates into sugar, and then into fat, which is stored.


  • It appears that the strategy of focusing on individual nutrients, such as fat, or saturated fat in particular, may not be the healthiest way to proceed.
  • diet
  • It is better to deal with food as a whole, and make healthy choices, incorporating a whole range of nutrients, including plenty of fruits and vegetables.
  • The phobia about full-fat dairy appears to be misplaced, and recommending low-fat products may not lead to weight loss or protection from diabetes.
  • Multiple mechanisms involving insulin and glucose regulation are probably involved in the link between full-fat dairy consumption and protection from diabetes.
  • However, common sense should be used, and people should not go out and start consuming vast amounts of high-fat foodstuffs. Calories do add up.
  • Some types of fat are still best avoided, the prime example being trans-fats, which have been regulated or banned in several US cities.
  • Processed foods, sugary drinks, and desserts should be consumed sparingly, if at all.

Sick and Tired of Being Overweight? Get More Sleep!

Sleep-Deprived? Not me!

Sleep-Deprived? Not me!

Sleep? Not me!

The US is a country of sleep-deprived people. Data from the National Health Interview Survey revealed that nearly 30% of adults reported an average of 6 or fewer hours of sleep per day in 2005-2007 (as opposed to the recommended 8 hours). The US is also a nation of people who are increasingly overweight or obese. Might the two be connected?

Sleep is more than rest

Sleep is downtime. But, more importantly, it is also a time for repair of neurons. Good sleep helps immunity, and is important for learning, forming memories, and maintaining a healthy immune system.

An increasing number of health problems have been linked to poor or insufficient sleep, including links between poor sleep and weight problems.

A large body of research suggests that sleep-deprivation can lead to obesity. A previous article from our archives outlines many of the mechanisms involved, and it can be reviewed here … http://goo.gl/2zvrn4.

Reward, addiction, food, and the brain

Researchers have started focusing on the nature and mechanism of reward and the involvement of specific brain centers in certain behavior patterns, including food intake, and even drug addiction.

The mesolimbic dopamine system is the most important reward pathway in the brain, leading to the transfer of dopamine from one part of the brain to another. This system regulates the formation of habits.

The Triune brain of mammals: 3 in 1!

brain-147148_1280Proposed by Paul MacLean, this is a simplified, some say oversimplified, way of looking at the brain from the evolutionary point of view. It means three brains in one. There is the oldest part of the brain, or reptilian brain, which is involved in the processes necessary for survival, such as breathing, heart rate, balance, body temperature, and the like. It is basically the brainstem.

The limbic system, or the paleomammalian brain, is the second oldest part of the brain. Limbus refers to a border. This limbic system is the collective name given to a set of structures surrounding the limit between the brainstem and the cerebral hemispheres. This is where the cerebral cortex meets the structures beneath it.

Traditionally, the limbic system is felt to include the hypothalamus, the amygdala, the hippocampus, and other surrounding areas. It is responsible for emotions, memories, and value judgments.

The mesolimbic system is the more central part of the limbic system. It connects the ventral tegmental area in the midbrain to the nucleus accumbens. Functioning as a reward pathway, this system is involved significantly in most known forms of addiction.

The neocortex is the outer part of the brain and is mostly made up of two large cerebral hemispheres, which deal with language, consciousness, abstract thought, imagination, stimulus analysis, and motor control. It is the youngest part of the brain.

What about the endocannabinoid system?

This is triggered in people who smoke marijuana.

This system is also implicated in the reward mechanisms involving the brain and its pathways.  It mediates the psychological effects of cannabis, and is therefore also called the body’s own cannabinoid system. It is made up of lipids (or fats) and their receptors.

There are two main endocannabinoid receptors, called CB1and CB2. The main lipids which are part of this system, and which act on the receptors already mentioned, are 2-AG and CBD.

This system appears to be involved in reward-driven or pleasure eating.

A recent study out of the University of Chicago found that people who were sleep-deprived had a greater activation of their endocannabinoid system.

People who had a full night’s sleep, in this study, ate 600 calories in early evening snacks. However, people who were sleep-deprived consumed almost 1000 calories in such snacks, and ate twice as much fat.


Consuming 400 extra calories a day regularly can lead to up to 40 lbs of weight gain in a year!

2-AG levels

This endocannabinoid can be measured in the bloodstream. Average levels of this lipid were similar in the people who had shorter-duration sleep (4.5 hours) versus normal-duration sleep (8.5 hours) in the Chicago study. However, the peak levels were higher in sleep-deprived people, and this peak occurred later in the day. Interestingly, the sleep-deprived individuals felt hungrier at the time of the peak 2-AG levels, and reported a stronger desire to eat at those times.

So what’s the link?

Several studies have investigated the links between sleep, food intake, and obesity.

There is evidence that sleep deprivation leads to an increase in the blood levels of ghrelin, a hormone which causes an increase in hunger, and a reduction in leptin, which suppresses hunger. The net effect is an increase in food intake in people who do not get sufficient sleep.

It can be argued that if you do not get enough sleep, you are obviously awake for longer, and thus your energy expenditure will be higher, just because you are awake, and probably engaged in some activity or the other. However, the increase in food intake in sleep-deprived people over-rides their excess energy expenditure. Thus the weight gain we see with sleep deprivation.

BMR and sleep deprivation

A study performed by researchers at the University of Pennsylvania School of Medicine in 2015 revealed that people who were sleep deprived for five days had a lower Basal Metabolic Rate (BMR) in the morning compared with their BMR after a night of normal sleep. Extrapolating this, the researchers found that people who were sleep deprived burned 42 calories less the next morning, compared with people who had a normal duration of sleep.

Food type




Sleep deprived individuals tend to have a greater craving for salty food, followed by sweet foods. This is also likely to contribute to their weight gain. Additionally, sleep deprivation seems to lead people to eat more snacks, rather than larger meals.

Diet and sleep deprivation

At least one study has found that sleep deprived people who go on a diet end up losing more lean body mass rather than fat mass.

Food and sleep quality

How well you sleep affects what you eat, and how much. But, interestingly, what you eat during the day can also affect how well you sleep that night.

People who eat more sugar during the day tend to wake up more in the middle of the night. Higher fiber consumption during the day is associated with more slow-wave sleep, which is deep sleep, felt to be important for new memories.

By contrast, a higher intake of saturated fat during the day is associated with less slow-wave sleep.


  • Sleep and body weight are intricately related.
  • There is a clear relationship between sleep deprivation and weight gain.
  • The mechanisms are not entirely clear, but appear to be related to changes in ghrelin and leptin levels, as well as stimulation of the endocannabinoid system.
  • The endocannabinoid system is a reward system involving the brain, and appears to encourage snacking and higher caloric intake.
  • Sleep deprivation tends to promote intake of salty and sugary foods.
  • Food choices during the day (fiber, sugar, saturated fat) can alter sleep quality at night.
  • Sleep deprivation is also associated with many other significant health problems.
  • Many Americans (and likely those in other parts of the world as well) are not getting the recommended amount of sleep. Healthcare providers need to make a concerted effort to promote healthy and adequate sleep in the population at large.

How to Recognize Sugar Right Away – And Avoid It!

You think you can recognize sugar? Think again!

But first things first.

Those of you who reach for that five-pound bag of grocery store sugar and shovel teaspoon after teaspoon into your mouths, pay attention! The US government has a message for you: STOP!


Millions of Americans have been waiting with bated breath for five years for their government to tell them what to eat. Well, in case you missed it, perhaps because you were busy with the business of life, the feds have finally delivered.

The Agriculture and Health and Human Services Departments have ended the suspense, and released their 2015-2020 edition of the Dietary Guidelines for Americans.


The feds have taken aim at multiple targets, and made lots of recommendations, most of which have attracted a lot of criticism. No matter. These people live in ivory towers, and your brickbats and mine don’t reach that high. Not unless you have well-heeled and well-organized lobbies.

Eat less sugar!

Eat less sugar!

Anyway, these worthies advise you and me to eat less sugar.

And then they get really specific: Limit sugar to no more than 10% of daily calories.

How we eat

This is wonderful news. It fits in seamlessly with my eating habits. Each time I put an olive or piece of toast into my mouth, I whip out a smartphone app and calculator. I quickly calculate each calorie going into my mouth, the amount of sugar in each bite, and what percentage of total calories that adds up to. As soon as I reach my targets, I stop, mid-morsel if need be. Isn’t that how you eat? Mom, Dad, and two kids eating at the dinner table, smartphones out? Well, the part about phones might actually be true!

So what advice do we need?

Let us get real.

Let us acknowledge how people eat. As the guidelines themselves state, people do not eat nutrients. They eat food.

Let us talk about food

When my wife gives me a grocery list, she does not say, “Get five pounds of fat, ten pounds of carbs, and fifteen pounds of protein. And throw in about 10% of the calories you buy as sugar. Plus some sodium, but not too much!”

This is not how we shop, and this is not how we eat!

So what is sugar?

Glad you asked.

Sugar is a carbohydrate (popularly known as carbs), a member of a much-maligned and frequently misunderstood group.

Not all carbs are bad.

Essentially, you need to know about simple carbohydrates (bad), and complex carbohydrates (good).

Simple carbs (bad)

Simply Sugar!

Simply Sugar!

These are nutrients which are digested and absorbed quickly once you eat them, and rapidly enter the bloodstream, where they raise your blood sugar levels fairly quickly. This is not good, for a variety of reasons.

Sugar (or, more accurately, what we commonly call sugar) is a simple carb.

Complex carbs (good)

These nutrients are more difficult for the body to digest and absorb. Thus they enter the bloodstream very slowly, and they have a slow and mild effect on blood sugar levels. These carbs are rich in fiber.

Classic examples are lentils, beans, chick peas, whole grains, and many fruits and vegetables, such as carrots, spinach, broccoli, apples, pears, etc.

Eating these will make you feel full faster, and this feeling will last longer.

So what was sugar, again?



“Sugar” can be traced back to the Arabic “sukkar,” which itself arose from the Sanskrit “sharkara.”

Sugars are technically called saccharides. A monosaccharide is the simplest unit, with examples being glucose, fructose, and galactose.

What we call sugar is technically sucrose. Each sucrose molecule has 12 atoms of carbon, 22 atoms of hydrogen, and 11 atoms of oxygen.

Sucrose is really the union of two even more simple sugars: fructose and glucose. As such, it is a disaccharide, which is two monosaccharides bound together. Fructose is the sugar commonly found in fruits and honey.

Lactose (in milk) is another disaccharide, a combination of glucose and galactose.

Plants make sugar through photosynthesis, using sunlight, and use it as a store of energy.

Natural versus added sugar

As the name implies, natural sugar is not introduced by man (or woman). Examples include sugar found in fruits and milk.

Added sugar is what we add to our food, or what is added during processing and preparation, in the form of syrup or sugar.


1 g sugar = 4 calories

1 teaspoon = 4 g sugar

1 teaspoon of sugar = 16 calories

How much added sugar do we need?

The daily requirement of added sugar for an average human being, male or female is … EXACTLY  ZERO!

How much do we eat?

In 1822, the average American’s intake of sugar was 45 g every 5 days. This is the amount of sugar found in one 12 oz can of soda. By the way, when did you last see anybody drink a 12 oz can of soda?

In 2012, this went up to 765 g every 5 days (equal to 17 such cans of soda).

This adds up to about 130 lbs of sugar every year.

Sources of added sugar

The average adult consumes 22 teaspoons of sugar a day. The average child? 32 teaspoons daily.

Liquid Calories

Liquid Calories

Regular soft drinks are responsible for 33% of this. Sugars and candy contribute 16.1%, cakes, cookies and pies 12.9%, fruit drinks 9.7%, dairy desserts and milk 8.6%, and other grains 5.8%. Breakfast cereal is an often overlooked source of added sugar.

Many so-called “low-fat” foods have more added sugar than their regular versions.

A 12 oz can of soda contains 8-10 teaspoons of sugar. This is more sugar than 2 frosted pop tarts and a Twinkie combined.

An average American drinks 53 gallons of soft drinks a year. You do the math.

Cost of daily soda

Weight Gain

Weight Gain

Drinking one can of sugary soft drink daily will lead to a 10-15 lb weight gain in a year– unless you cut back on calories elsewhere.

People who drink 1-2 cans or more of sugary drinks daily have a 26% higher risk of developing type 2 diabetes.

A study in Circulation 2012 (125: 1735-41) revealed that men who averaged one can of sugary drink a day had a 20% higher risk of having a heart attack or dying from a heart attack compared with men who rarely consumed sugary drinks. Similar findings have been noted in women, too.

Sugar is often hidden

Industry is fond of using different names for added sugar. There are all kinds of sweeteners, which effectively are added sugar. Some of these include: agave nectar, high-fructose corn syrup, fruit juice concentrates, malt syrup, maple syrup, molasses, evaporated cane juice, etc. Most of the stuff they include ending in –ose is basically added sugar.

Brown sugar? Honey?

Do not get confused. Your body does not. You cannot fool it: It metabolizes all added sugars in the same manner!

So how much added sugar do you need, again?


The Healthy Eating Pyramid says sugary drinks and sweets should be used sparingly, if at all.

The Healthy Eating Plate, created by nutrition experts at Harvard, does not include foods with added sugars.


The American Heart Association suggests an added sugar limit of no more than 100 calories per day (about 6 teaspoons) for most women, and no more than 150 calories per day (about 9 teaspoons) for most men.


There is no minimal daily requirement for added sugar. There is no nutritional benefit you get from eating added sugar.


There is a school of thought that believes that the major reason for the obesity epidemic is too much sugar and not enough fiber in the diet.

So, what now?

  • For the most part, you do not need any added sugar in your diet. Minimize it, if you cannot cut it out entirely.
  • Read labels. Sugar hides in many forms.
  • The best liquid to drink is water.
  • If you visit an orchard, you will notice that orange juice does not grow on trees; oranges do. Consider this a message.
  • Pay special attention to the kids: You are responsible for their lifelong food habits!
  • Breakfast = cereal = lots of sugar, in many cases. Break this cycle!



Blood Pressure: How Low Is Just Right?

If up is bad, down must be good. If higher is worse, lower must be better. These statements appear to be logical, but logic does not always rule, at least as far as blood pressure is concerned.

Too High!

Too High!

High blood pressure is dangerous, to put it mildly. So lowering it should be good. But how low is low? Back to normal? Or even lower?

Risks of hypertension


Heart attacks, heart failure, strokes, kidney failure: This is a partial list of the devastation that high blood pressure causes every day. Almost a billion people worldwide suffer from it, and have been, for many years. We should have learned how to control this by now, right? Wrong!

Which pressure to control?

Most people are aware that blood pressure (BP) is written as two numbers, written one above the other; for example, 120/80 millimeters of mercury (mm Hg).

The top number is the systolic pressure, generated when the heart muscle contracts to pump blood out to the rest of the body. The bottom number is the diastolic pressure, recorded while the heart muscle relaxes, and fills up with blood again.

It is a matter of age

In people 50 years or older, the commonest form of high BP is an elevation of systolic BP, with the diastolic BP being normal. This is called isolated systolic hypertension.


How normal are you?

How normal are you?

Normal BP is now defined as less than 120 mm Hg systolic and less than 80 mm Hg diastolic (<120/80).

Systolic BP matters

In people 50 years or older, the risk of complications of hypertension is more closely linked to the systolic BP compared to the diastolic BP. Thus controlling the systolic BP assumes greater importance in this age group.

What is a risky level of BP?

Good question!

One could feel that since we have defined normal BP as < 120/80 mm Hg, there should be no risk below that.

That would be naive!

Risk is progressive!

A meta-analysis of 61 studies involving 1 million adults was published in the Lancet in 2002: http://goo.gl/QLe3QG.

The results were interesting: Risk keeps rising progressively with increasing systolic BP.

The floor, above which risk increases? 115/75 mm Hg, according to the Lancet article.

So should we lower systolic to 115 mm Hg?

Not so fast! Unless you want to have people keeling over and getting dizzy and collapsing!

So what’s the target?

What should you aim for?

What should you aim for?

That’s the million dollar question!

Lots of expert bodies have issued lots of guidelines. Most of which end up being ignored by the doctors in the trenches, who do the real work of treating patients instead of writing guidelines.

But before we even talk about targets, let us look for hard evidence. Does treating high BP reduce risk?

Yes, it does!

Clinical trials show that treating high blood pressure lowers the risk of developing heart failure by up to 64% (http://goo.gl/O50O5p; http://goo.gl/o6a8sT).

Strokes are reduced by 35 to 40%, while heart attacks are reduced by 15-25% just by treating hypertension.

So what’s the problem?

Where to stop, and whom to believe: That is the problem.

And looking for solid evidence.

All doctors know about treating high BP. They are just confused by data, and by so-called experts. When to start treating, what medications to use, and when to call it a day are not easy questions to answer.

The data, please


Randomized, controlled trials are the gold standard as far as medical evidence goes. And most of those in the field of hypertension reveal a benefit of treating systolic blood pressure only to a target of less than 150 mm Hg. Data regarding the benefit of lowering the systolic pressure to even lower targets are rather limited (or were, till recently).

ACCORD study

This trial evaluated more than 4700 patients with type 2 diabetes, to see which systolic BP target was better, less than 140 mm Hg or less than 120 mm Hg.

After a mean follow-up of 4.7 years, there was no significant difference between the two groups regarding the endpoint of fatal or non-fatal major cardiovascular events, such as stroke, heart attack, or death from cardiovascular causes. You can read more about this study here: http://goo.gl/mHxDms.

So where do we stand now?

The common advice is still to lower systolic BP to less than 140 mm Hg in most patients.

There is some debate about this, especially in older patients.

Various guideline-writing bodies have also come out with recommendations which are less than uniform, serving often to confuse doctors and patients.

Shall we SPRINT?


This (the SPRINT trial), of course, is the latest study, which was stopped early in August 2015, because of accumulated findings which were felt to be important enough to stop most parts of this trial.

Lower systolic BP targets?

That was the major finding of the SPRINT study.

The participants (9361 of them) were randomly assigned to two groups. In one group, the target systolic BP with treatment was less than 140 mm Hg, while in the other group, it was less than 120 mm Hg.

The group with the lower BP target had lower rates of fatal and non-fatal major cardiovascular events, and lower rates of death from any cause.

So let’s jump on the bandwagon!


Hold on for a while.

The devil, as they say, is often in the details.

Before adopting the results of any trial into widespread clinical practice, we should exercise due diligence.

The SPRINT study population is not representative of the large pool of general patients with hypertension in the real world. There were, as there usually are in trials, strict criteria regarding which patients would be included, and which excluded, from the study. Obviously, they did not take all comers. In particular, patients with diabetes were excluded from this trial.

The way BP was checked in the trial centers was also standardized, and was quite different from what is done in the real world.

Where do we stand?

  • Fork in The Road? Take It!

    Fork in The Road? Take It!

    As a doctor, if you see a patient who fits the prototype of a SPRINT trial participant, go ahead and treat them to a lower target.

  • For the other patients, exercise caution. Use your best judgment based on the patient’s entire clinical profile, including age and risk factors.
  • If you are a patient, or have a friend or loved one who is a patient, discuss the issues raised by the SPRINT trial with your doctor.

Details of SPRINT

Stay tuned! We will outline them in a subsequent post.

Want to know more about BP?


Consider reading my E-Book, “High Blood Pressure: 10 Reasons Your Blood Pressure Is NOT Under Control.”

It is available here: http://goo.gl/t3h2zs.

High Blood Pressure: How Many Guidelines Do You Need?

You need an expert to write high blood pressure guidelines. A medical expert is he (or she) who does not agree with anybody. Sometimes the expert does not agree even with himself. Agreeing with other so-called experts might be construed as a sign of weakness!

Cake, anybody?

Eat Your Cake!

Eat Your Cake!

What about the lowly practitioners out there in the trenches, seeing real-life patients, giving real-life advice, and facing real-life consequences? Well, as the French lady said: “Qu’ils mangent de la brioche.” Let them eat cake.

Let us control blood pressure!


Hurray! Full steam ahead! Up and at them! But what should we aim for?

Um, well, let us look at the guidelines, which are, as we said, devised by experts.

But wait a second. Which guidelines should we look at?

I have principles!


A great man once said, “Look, I have principles. And if you don’t like them, I have others.”

Guidelines are the same. If you don’t like one set, well, we have others.

Let us start with JNC 8.


The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure had been in the business of dishing out advice about how to treat high blood pressure since 1976. Its eighth avatar issued its set of recommendations in December 2013, after having been originally commissioned to perform its task in 2008 by the National Heart, Lung, and Blood Institute (NHLBI).

Along the way, something interesting happened. In 2013, before the JNC 8 report was published, the NHLBI announced that in the future, the American College of Cardiology and the American Heart Association (ACC/AHA) would be in charge of writing guidelines about how to treat high blood pressure.

So the JNC 8 report, as the members acknowledge themselves, is not sanctioned by the NHLBI, and does not reflect the views of the NHLBI!




There has been significant controversy and debate about the recommendations of JNC 8.

Around the time of release of the JNC 8 report, the president-elect of the American Heart association said that the AHA had some reservations about the JNC 8 recommendations.

In January 2014, an article appeared in the prestigious journal, the Annals of Internal Medicine, written by five of the seventeen authors of the JNC 8 report. In this, they stated that they did not agree with the guidelines of JNC 8, and explained their reasons.

What is the problem?

The biggest controversy was triggered by the JNC 8 recommendations regarding patients 60 years or older.

JNC 8 guidelines recommend starting drug treatment for high blood pressure in this group of patients if their systolic BP (the top number) is 150 mm Hg or higher, or if their diastolic BP (the bottom number) is 90 mm Hg or higher.

Furthermore, the experts state that the goal of BP treatment in this age group should be to bring the BP below the levels mentioned above.

Why the debate?

JNC 8 panelists felt that there were not enough good trials of patients over the age of 60 to recommend treating them to a goal systolic BP of less than 140 mm Hg, as opposed to below 150 mm Hg.

Other expert bodies disagree. Some of them point to the ALLHAT, ACCOMPLISH, and VALUE trials.

And the debate goes on.

ASH/ISH guidelines

The good folks at the American Society of Hypertension and the International Society of Hypertension, not to be outdone, issued their own set of guidelines jointly in the latter part of 2013.

They recommended an age cut-off for treating non-black patients with high BP. Below the age of 60 years, they advised using an ARB (angiotensin receptor blocker) or ACE (angiotensin converting enzyme) inhibitor, while above that age, their advice was to use a thiazide-type fluid pill, or a calcium channel blocker.

These bodies also disagreed with the advice of JNC 8 to start treating high BP in patients 60 years or older only if their BP was 150/90 mm Hg or higher, and to use less strict criteria for BP control in this older age group. They recommended a goal BP of less than 140/90 mm Hg with treatment. They also stated that a target BP of less than 150 mm Hg systolic (upper number) should be used only in people older than 80.


The experts at these bodies, the American College of Cardiology, the American Heart Association, and the Centers for Disease Control and Prevention, put their heads together, and issued a “Science Advisory” in November, 2013. Their recommendation is for a target BP of less than 140/90 mm Hg. They recommend using different medications for Stage I hypertension (BP 140–159/90–99 mm Hg). There are also guidelines for testing for secondary causes of hypertension, as well as considering referral to a hypertension specialist if good control is still not established.

The Europeans weigh in


The European Society of Hypertension (ESH) and the European Society of cardiology (ESC) also issued their own set of guidelines for BP control in 2013. They had previously recommended a target of 130/80 mm Hg for high-risk patients and 140/90 for those at low or moderate risk. However, in 2013, they advised that nearly all patients should be treated to a goal systolic (top number) BP of less than 140 mm Hg.

For patients with diabetes, the Europeans advised the same systolic BP, but a lower diastolic BP (lower number) target of less than 85 mm Hg.

In people over the age of 80 years, these guidelines recommend a systolic BP of less than 140 mm Hg, if the patient is physically and mentally fit. Otherwise, the goal should be 140–150 mm Hg.

Let us SPRINT to some answers!

If you are getting confused, you are not alone!

Doctors have been treating high BP for quite some time now, and we are still looking for good answers. At times, it feels like perhaps we are not even asking the right questions!

So the good folks at the National Heart, Lung, and Blood Institute sprang into action. Or, should we say, SPRINTED into action with the… of course, SPRINT study.

This study was supposed to last for 5-6 years, but the monitoring committee halted the study early, in August 2015, because of potentially life-saving results.

Saving lives?

Yes, if we believe the SPRINT trial results. They studied more than 9000 patients, with the goal of evaluating the differences between the outcomes of people whose target systolic BP with treatment was less than 140 versus those with a target of less than 120 mm Hg.

The patients assigned to the lower BP target had their risk of heart attacks, heart failure, and stroke reduced by a third. Their risk of death was reduced by nearly 25%.

So shall we all SPRINT?


Not so fast!

The results in this study were obtained in a highly selected population, using rather strict inclusion and exclusion criteria, and do not apply to the entire population of patients with high BP.

The American College of Cardiology is in the process of writing a new set of guidelines for the treatment of hypertension, and the expert panel will obviously look carefully at the data from the SPRINT study, and recommend what should be incorporated into general practice. Obviously, that will also generate some debate.

In the meantime …

Medical care is best provided one-on-one, with discussion between the patients and their personal physician, who knows their unique situation best.

We will provide details of the SPRINT trial in a subsequent post.

In the meantime … talk to your doctor!

More about high blood pressure

You can read more about this devastating condition and its treatment in my ebook  “High Blood Pressure: 10 Reasons Your Blood Pressure Is NOT Under Control,” which is available here … http://www.amazon.com/dp/B015P919CI.