497 - Heart Healthy Diets, Alcohol Risks, Anatomy of Trust

From the literature 

1)  Diets to Reduce Cardiovascular Risk and Mortality 

In Take 3 # 478, we looked at the US News and World Report’s recommendations for the “best diets” out there. A recent BMJ systematic review and network meta-analysis provides an evidence complement to the USNWR’s expert-opinion-based recommendations. As a reminder, a network meta-analysis is a technique for comparing the effect of multiple interventions when there are limited head-to-head comparison studies available. The authors performed a comprehensive search of multiple literature databases to find studies comparing these diet plans (which could include ancillary interventions like exercise programs) with either minimal interventions (e.g., patient education brochures) or active comparisons. They selected studies that included mortality or major cardiovascular outcomes (stroke, non-fatal MI, unscheduled cardiovascular procedures) assessed at a minimum of nine months. The studies found were critically appraised for risk of bias.

Forty trials (N = 35,548) were ultimately deemed eligible for inclusion. There were 18 studies on low fat diets, 12 on Mediterranean diets, 6 on very low-fat diets, 4 on modified fat diets, 3 on combined low fat and low sodium diets, 3 on the Ornish diet and 1 on the Pritikin diet. At best, moderate certainty evidence was found for the Mediterranean and low-fat diets, and low-to-moderate certainty evidence found for the others. The easiest-to-interpret comparison statistic from the network meta-analysis is the absolute risk reduction (ARR) calculated over five years. The results were calculated for people with an intermediate baseline risk of CV disease (5-10% risk over 5 years). The Mediterranean diet was associated with significantly better mortality (ARR 17 fewer events per 1000 people, 95% confidence interval (CI) 5 to 26), better cardiovascular (CV) mortality (ARR 13 per 1000, 95% CI 6 to 17), fewer non-fatal myocardial infarctions (MIs) (ARR 17, 95% CI 11 to 21), and fewer strokes (ARR 7, 95%CI 1 to 11). Low-fat diets had comparable findings: improved mortality (ARR 9, 95%CI 3 to 15), fewer non-fatal MIs (ARR 7, 95%CI 1 to 13) and fewer unplanned CV procedures (ARR 13, 95%CI 2 to 20).

The results were recalculated for people with a higher baseline risk (20-30% over 5 years), and the impact, naturally, was greater. For example, Mediterranean diet reduces overall mortality in the high-risk population by 36 per 1000 (95%CI 10 to 58) and low-fat diets by 20 per 1000 (95%CI 6 to 33). The other diet programs did not have any statistically significant favorable impacts on any of these outcomes. Regressions and sensitivity analyses were done to adjust the effects of any included exercise programs, behavioral or psychosocial support, drug treatment, and smoking cessation; the most conservative results of these analyses were the outcomes reported from the meta-analysis and did not alter the ultimate conclusions of the meta-analysis.

John’s Comments:

This well-done meta-analysis adds reasonably rigorous evidence to the expert opinions collected by USNWR, and, thankfully, the conclusions are consistent. Pragmatic studies in nutrition (i.e., not controlled-feeding experiments done in a lab) are often heterogeneous in their methods and frequently have threats to internal and external validity, but this review reassures me that the evidence still points in the direction of a Mediterranean and/or low-fat diet for healthy living.

Reference:

·         Karam G, Agarwal A, Sadeghirad B, et al. Comparison of seven popular structured dietary programmes and risk of mortality and major cardiovascular events in patients at increased cardiovascular risk: systematic review and network meta-analysis. BMJ. 2023;380:e072003. Link

From the Literature and the World Health Organization (WHO)

2)  The Health Risks of Alcohol Consumption 

Alcohol is a toxic, psychoactive, and dependence-producing substance and has been classified as a Group 1 carcinogen by the International Agency for Research on Cancer decades ago – this is the highest risk group, which also includes asbestos, radiation and tobacco.  Alcohol causes at least seven types of cancer, including the most common cancer types, such as bowel cancer and female breast cancer.

In addition, alcohol use is among the leading risk factors for premature mortality and disability because of its causal relationship with multiple health conditions, including unintentional injuries and suicides.  According to the CDC, in 2018, 66.3% of US adults drank alcohol in the past year, with 5.1% engaging in heaving drinking (> 14 drinks/week). 

In January of this year, representatives from the World Health Association published a commentary regarding the very real and often overlooked health risks associated with even low levels of alcohol consumption.  The authors emphasize that evidence does not indicate the existence of a particular threshold at which the carcinogenic effects of alcohol start to manifest in the human body. As such, no safe amount of alcohol consumption can be established.  They conclude that alcohol consumers should be objectively informed about the risks of cancer and other health conditions associated with any alcohol consumption.

Mark’s Comments:

Although some past studies have indicated that moderate alcohol consumption has protective health benefits (e.g., reducing risk of heart disease), recent studies show this may not be true.  When it comes to alcohol consumption, the preponderance of evidence indicates that less is better than more, and none is better than some.  Indeed, I'm not aware of any study looking at previous non-alcohol users who started to drink alcohol that has shown any health benefit.  There are no guidelines recommending that someone who doesn’t drink alcohol should start doing so.

Having said that, drinking has become such an ingrained part of our dominant culture (2/3 of adults) that for many, the idea of not drinking is not even on their “radar screen.”  From a population health perspective, it is clear that alcohol does much harm. If one chooses to drink alcohol, they should do it because they it brings them some level of pleasure but shouldn’t delude themselves into thinking that it is “good for them” from a health perspective.  In full disclosure, I do enjoy drinking beer and wine on occasion, but my more than 1 drink/day days are behind me, and I don’t miss them.   Neither does my health.

References:

·         Anderson B et al.  Commentary: Health and Cancer Risk Associated with Low Levels of Alcohol Consumption.  Lancet Pub Heath 8(1):E6-7.  January 2023. Link

·         World Health Organization – News Release:  No Level of Alcohol Consumption is Safe For Our Health.  4 January 2023.  Link

·         Boersma P et al.  Heavy Drinking Among US Adults 2018.  NCHS Data Brief No. 374, August 2020.  Link.

From PeerRxMed ( www.PeerRxMed.org )

3)  Trust Me, I’m a Doctor:  The Anatomy of Trust

“The best way to find out if you can trust somebody is to trust them.”  ― Ernest Hemingway

Consider for a moment the qualities of someone you would say you “trust fully,” and someone whom you “don’t trust.”  How did you establish whether you “trusted” them – the qualities that made them trustworthy, or not?  Though we don’t talk about it often, trust is certainly foundational in our work; trust in ourselves, our care team, our colleagues, the systems we work in, the medications we prescribe, and the equipment we use. 

Perhaps even more relevant, how do our patients determine if/how much they “trust” us?  As a Family Medicine resident, I was fascinated and often quite surprised at the implicit (and often explicit) trust gifted to me by those I helped to care for.  To my amazement, many times amid dire health circumstances and facing life or death decisions, patients would ask my opinion and often value it even over that of my attending or the consultant. .  

This led me during that time to become a “student” of trust.  In my early reading, Stephen Covey, in his book “Principle-Centered Leadership,” taught me that trustworthiness is a result of an individual demonstrating both strong personal character and professional competence.  Later in my journey, one of my colleagues (regret I cannot recall who) shared with me the following “trust equation” that I have worked with and shared frequently since that time: 

Trust = Relationship x Competence

     Risk

Though there are other such “equations” in circulation, I have continued to find this one to be the most accessible.  Trustworthiness becomes the trust from another person when one’s “character” establishes a meaningful relationship with them (“you care about me”), and one’s “competence” is discerned (“you are providing me good care”).  Adding the variable of perceived “risk” helped me understand that trust is rarely absolute, but more often is both conditional and contextual.

Further along in my professional journey, leadership teacher Patrick Lencioni, in his classic book “The Five Dysfunctions of a Team,” instilled in me that the foundational challenge for any team is the establishment and maintenance of trust, and in the absence of it, a team will ultimately flounder.  To that end, he created the following “Personal Trust Audit” for reflection (modified slightly), using the parameters of “Usually/Sometimes/Rarely” as a gauge:

·         I am consistent with regard to how I treat others. I don’t “play favorites.” I try to use the same standards for everyone.

·         I am consistent with the messages I give people (my conversations) regarding our work.  People know what matters to me.

·         I quickly and genuinely apologize to others when I say or do something inappropriate or possibly damaging to the relationship/team.

·         I openly admit my weaknesses and/or mistakes.

·         I know others not just on a professional level, but a personal level as well. We know about one another’s personal lives and are comfortable discussing them.

·         I am continually looking for opportunities to improve my professional knowledge, attitudes, and skills.

We’re hearing a lot these days about patients not trusting clinicians, clinicians not trusting patients or each other, and both patients and clinicians often not trusting the “healthcare system.”  The causes for this are well-known.  As such, it seems wise to me that those of us in healthcare revisit the “fundamentals” of trust – relationship and competence.  It is there that we will find our way forward, with our patients and with each other.  Give it a try.  Trust me, I’m a doctor …

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Mark and John

Carilion Clinic Department of Family and Community Medicine

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Email: mhgreenawald@carilionclinic.org