Steve: Thanks for joining us. I’m Steve Hsu.

Corey: And I’m Corey Washington, and we’re your hosts for Manifold. Our guest today is Betsy McKay. Betsy is a senior writer on US and global public health at The Wall Street Journal. Betsy joined The Journal in 1996 as part of the Moscow bureau where she wrote about Russia’s post-soviet political and economic transformation. She was part of a team that won a Pulitzer Prize in 1999 in international reporting for in-depth analytical coverage of the Russian financial crisis. She’s won awards for stories on public health issues including drug-resistant tuberculosis, and return to care in the rural US. Welcome to Manifold, Betsy.

Betsy: Thanks for having me. I’m glad to be here.

Corey: So what we’d like to talk to you about, Betsy are five articles you’ve written recently all related to cardiovascular disease. And this is a topic I’m really interested in. I’m doing some work on it now, but I’d like to just go through what you wrote in these articles, how you think about global public health and why you think it’s important to communicate the public about. And we have links to all the articles on the website. Let me start off with the first article, and this is something I think that people have been familiar with although not the specific take you have on it, and the article is entitled Death Rates Rising for Young Middle Aged US Adults.

Corey: We had known that they were actually declining longevity in the US over the past couple of years. I think the thought was that was primarily driven by older middle-aged often white people connected to the opioid crisis. But you make the argument in this article that part of it’s driven by cardiovascular disease, and the rise in obesity. So can you just give us a sense of what you’re trying to communicate in this article and how you got on to the idea that CVD was an angle on it?

Betsy: Yeah. Well, so heart disease is still the number one killer cause of premature death in this country, or the leading killer in this country, and progress against a has stalled. If you look at the data, it’s really interesting since the ’50s deaths from cardiovascular disease, so that’s heart disease and strokes. Heart disease is the number one killer, stroke are the fifth leading killer in the US right now. If you take it together, the death rates have been coming down pretty steadily and pretty dramatically since the 1950s. I mean, there were some blips between the ’50s and the ’60s but since the early ’60s it has been just coming down steadily, and that’s largely due to the war on smoking, lots of advances in medical care, coronary bypass surgery then statins. Statin drugs to lower cholesterol in the ’80s and ’90s, blood pressure medicine.

Betsy: So the rates were coming down, but all of a sudden in 2011 it plateaued and since 2011 for the overall population deaths from cardiovascular disease have still been declining, but at a very slow rate. It’s sort of like this curve that came down, this hill. It was literally a hill that bottoms out. So I looked at them, thought what’s going on here. I also have been writing about on the decline in US life expectancy and yes, everybody else we were focusing on the fact that this is largely due to the rise in deaths among middle-aged people from from opioids right. It’s been dramatic.

Betsy: But since heart disease is the number one killer and strokes are the number five killer, and progress against them has stalled, I started to think well, gee that’s going to be playing a role here. So I did a little work with data and talked with the CDC and they said yeah, it’s an under-recognized contributor. I mean, basically what’s happening is you’ve got deaths from opioids going up, that was being offset in the early 2000s from the continued progress against heart disease. But once you’re not having declines in heart disease deaths anymore, you’re not offsetting it. You’re not upsetting the deaths from opioids. So I thought well, this is really interesting.

Steve: When I look at photos of the ’70s and ’80s, people were so thin then compared to now. So Americans are on average, I think they have much higher BMIs, I guess. To say it in a crude way, they’re fatter. And how could that not affect heart attack, I mean cardiovascular issues? I mean, isn’t your heart straining more to support the extra body weight? So shouldn’t you expect some issue here?

Corey: So there’s a really interesting line in one of your articles, Betsy. Actually, I think it’s one of the other articles where you say the use of statins was masking the effects of obesity for a long time, and so you kept having this declining death rate due to CVD.

Steve: Right. I would expect technological advances like statins are helpful, but then other issues like increasing BMI is not helping, and so you could easily imagine one overwhelming the other eventually, right?

Corey: So the effect of statins plateaued basically, and then you begin to see the effect of CVD.

Steve: I’m not saying that’s the reason, but that seems like a plausible hypothesis.

Betsy: That’s essentially what the experts I talked to said. I went out asking, “What’s going on here? Why has this stopped?” And in fact the death rates, if you divide it up by age group, for middle aged people between 45 and 64 the death rates are now going up since 2011, which is really alarming. The leading killer is killing even more people and that’s also affecting life expectancy. So the answer I kept hearing over and over is just that you had this basically, obesity rates started rising pretty dramatically in the 1980s, and if you look at the curves, diabetes which is linked to obesity, similarly started skyrocketing a few years later in the mid early ’90s, but statins were introduced at the same time so you had this masking effect.

Betsy: There was so much benefit from statins. Now, nobody knows why 2000 rather than 2010 or 2012. Essentially, what you know cardiologists and epidemiologists believe is that the effect of statins, the benefit in the population has reached a natural point and now the effects of obesity and diabetes are really starting to take a toll.

Betsy: The other thing you have to remember is that it takes a while right for the effects of diabetes to start having an effect on your heart. So people say there’s a lot of factors going on at once, playing into this with obesity and diabetes, the two biggest culprits, they think there are researchers looking at other issues like stress, but there’s still a lot to be… There’s still a lot that’s not known about that.

Corey: When I was looking at these news reports about, I guess decreased longevity/increased mortality, there was always the sense that this is somebody else. This is the opioid crisis. It’s Appalachia, it’s certain parts of America that’s dealing with economic troubles, but I think greatly what your article is it reminds people this is actually a pretty mainstream problem. Definitely the obesity part of it is and so the effect is something you’re seeing is not just those other people which I think many people had viewed the issue in the past couple of years.

Betsy: Right, no. And that’s actually one of the problems here is people who are middle-aged often don’t realize they’re at risk. I portrayed a couple of people in my story, a family who lost the father, the man of the family and then a woman who survived a heart attack, and both really didn’t suspect that there was anything wrong, and yet they suddenly had heart attacks. He had just lost his father and was co-chairing an American Heart Association ball. He was a leader in his community, a corporate executive. These are the people who are being affected by this and don’t realize it.

Steve: Now, in the case of these individuals where they sort of very fit people that really had no idea at all that they might have a heart attack and then they had one or were there some symptoms that they were at risk?

Betsy: So everyone has their own individual story. The man who died, he actually had a heart attack right after he had finished his morning workout.

Steve: I often suspect that’s how I’m going to go right after the morning workout, bang.

Corey: But he was overweight. I think he had a-

Betsy: Right. He was on some medications. A lot of people in middle-age are on blood pressure and statin medications.

Steve: I hate to ask this question because it sounds like the evidence is overwhelming, but I was always worried about statins because it seems like the drug, it’s a very powerful thing that it’s doing to your system, and it sounds like you’re saying now people are quite sure that it’s beneficial, that the reduction in cholesterol level actually then is causal for improving heart health, not just… So I was always worried that it was decreasing a risk factor for heart attacks, but maybe it wasn’t actually reducing the rate of heart attacks.

Betsy: At least the population data show its had a benefit, right, heart attacks have come down a lot. I guess if you look at people taking statins, and then see them saying, “Well, that means I can eat steak every day,” type of thing, you always worry about that. If you take a medication and then are you really taking care of yourself? But statins, so many people take statins, people who are in shape, out of shape, who eat well, who eat badly, and across the population there’s been a benefit.

Steve: Okay. I guess I better listen to my doctor then.

Corey: Is he recommending it?

Betsy: I will say there are people who worry about statin, statins have some side effects. There are people who really who have swarmed them off, but doctors say for the largest part of… For most people they work.

Steve: I think I have borderline, high cholesterol just at the point where the doc would say, “Hey, maybe you should consider taking statins,” and I’ve always resisted it. But maybe I’m not doing the right thing. On the other hand, I switched to this keto diet over a year ago where you eat tons of cholesterol and fat, and stuff like this, and my cholesterol has not budged at all, so go figure.

Corey: So we’re going to get into cholesterol because it’s one of the topics that Betsy covers over other articles. But let’s look at the second article which is right along these lines, it’s called How to Reduce Your Risk of Heart Disease. The first topics in the article are the new guidelines on blood pressure. So previously, I think the guideline said that you’re pretty good shape if you had blood pressure around 120 for 80. If you had like 125 or 85, or so you’re fine.

Corey: Hypertension was defined as having consistent blood pressure of 140 over 90. That’s 140 systolic over 90 diastolic. Systolic being the pressure as your heart is contracting. It’s the high point diastolic being the pressure as your heart is relaxing the low point. But with the new guidelines, healthy is now defined as below 120 over 80. If you have blood pressure between 120 and 130 systolic between 80 and 90 diastolic, that’s elevated hypertension and then above 130, I think over 90… Or either 130 over 80 perhaps is phase one hypertension.

Corey: We’ll have a link up with exact guidelines. But now they’re recommending have your blood pressure below 120 over 80, and this has led to a lot of people being classified as hypertensive now, who were not hypertensive. There’s a lot of disagreement about this. So how did you approach this Betsy when you’re writing about a topic like this, which is the recommendations, but I’ve noticed a lot of doctors are dissenting from it.

Betsy: Yeah.

Corey: As a writer, how do you communicate this to the public?

Betsy: Yeah. It’s a hard one because basically when it lowered, I think of it lowering from 140 over 90 to 130 over 80, and in that window there are a ton of people. I mean, now with the new guidelines so 46% of American adults basically half of the adult US population has high blood pressure under the new guidelines, which were released in 2017. And it was something like under a third before. So it’s a lot of people and the recommendation from the American Heart Association and the American College of Cardiology the sort of societies was that people in that window be counseled to make lifestyle changes.

Betsy: So one of the controversies was well, if you lower the guidelines, more people are just going to be put on medication and that’s it. Nobody is going to counsel lifestyle changes because that’s too hard to make. I don’t know where it’s fallen out. It’s probably too early to tell, but I personally know people who have 135 over whatever, and they’ve been put on blood pressure medication whereas they weren’t on it before.

Betsy: So I think there are a lot of issues that doctors don’t have a lot of time to counsel. You know how much time you have with your doctor, your primary care doctor, your doctor has to see a lot of people that day, how much time do they have to talk with you about how much exercise you’re doing and what you’re eating and so forth? So it really has been a controversial thing.

Steve: As a data and machine learning guy, I always wonder rather than have these categories where you say, “Oh, if your blood pressure is 121 suddenly, you’re in the-“

Corey: It’s elevated.

Steve: Yeah, elevated category. Rather than have these just arbitrary categories, I think the key issue is conditional on your blood pressure, what’s the probability that something is going to happen to you. In other words, for every 5% increase in your blood pressure how much does that elevate your risk for heart attack? Or this or that.

Corey: So that is known actually for stroke. These research suggests that for every 20 millimeter increase in systolic pressure above 120 or 10 millimeter increase in diastolic above 75, you double your stroke risk.

Steve: Okay. That sounds like a pretty sharp increase.

Corey: It’s pretty sharp, yeah.

Steve: Yeah.

Betsy: Yeah.

Steve: So okay, that’s interesting.

Corey: And of course there are racial variations in this, blacks and South Asians are at higher risk for stroke even if the same blood pressure level. I think the guy who died and Betsy story was African-American.

Betsy: I mean, African-Americans are at higher risk of cardiovascular disease, men and women. They have higher risk and they have much higher rates of it. Corey, to answer your question in terms of communicating it to the public, it’s hard and I think Steve brought up a good point, I mean, the way to communicate it to people is to to tell them what it means for them, and when I’m writing about something like a new guideline or a new study, I try to just figure out the context and present people with the context like here’s the new guideline, here’s how many people are affected by it, and here’s what it means for you.

Betsy: In this case, it means that if you’re in this group between 130 and 140, you need to make lifestyle changes. But your doctor may put you on medication, if you can’t make the lifestyle changes or you don’t make the lifestyle change. But I think a more useful thing is for people to understand what it means for every five points, as you said whatever five points means to your blood pressure. I mean, one of the challenges journalists have is when new guidelines are released, sometimes you don’t have a lot of time. You have to get a story up really quickly, and so figuring out these really interesting details unless you have some time beforehand or something can be sometimes just impossible, or by the time you figure it out it’s past your deadline.

Steve: But also the process, I don’t know if it’s the American Heart Association or whatever professional body comes up with the guidelines, could it not be just another case like when the food pyramid was jammed down our throats when we were all little kids and we were told you had to eat, carbs were at the base and then etc, etc. And it turned out to be a pretty arbitrary piece of public health that really didn’t have a lot of empirical data backing it.

Corey: Well here, I think they’ve got pretty good data linking blood pressure and heart attack risk and mortality, but the question is where you want to draw the line. You know the shape of the function, but it’s just isn’t clear what tolerance you’re going to have for risk and what kind of lifestyle change when you think someone should get medication or might be just told to go for a run every so often.

Betsy: Yeah. So Corey is right. So the science is known, it’s just a question how low can you go. The things you have to take into account are how are people going to respond. And also what can the health care system do. And what would it take for the average person to get below 120. So it’s less, I think, less controversial in that sense. I mean, always with these things guidelines and screening and so forth, and studies one looks at disclosures and potential conflicts of interests and so forth. But these big guidelines have very large advisory bodies working on them.

Corey: So the second recommendation you discussed is a heart healthy diet, and it’s pretty interesting because this again is going to look different than it did in the ’70s. As you say heart healthy diet includes a variety of vegetables and fruits, fish, skinless poultry, whole grains, and nuts and legumes. Limit saturated fat, sodium, red meat and sweets. So I think it hasn’t quite gone as far as you Steve in your keto world, but notice carbs are not the center, and it’s whole grains, it’s down on the list. That’s a pretty significant change from when we were growing up.

Steve: So as the keto guy, I look at that. If someone had said that to me a year and a half ago, I would have said, “Oh, yeah. Yeah, that’s the healthy diet, right? Science, because science. But even like this thing about take the skin off the chicken or don’t eat red meat, I’m very dubious actually. Well, I’d like to see the details of the link between dietary cholesterol and circulating cholesterol, and I suspect that there’s broad genetic variation in terms of how sensitive you are in the link between the two.

Betsy: Steve, how have you done on a keto diet?

Steve: I love the keto diet. I have to say the way I got on it was totally bizarre. It was because the AI recommendation engine on YouTube is of course carefully studying me. So it sees what videos I’m looking at. So it knows like I’m a fitness nut. And so it started about a year ago showing me, wanting to me to watch videos about the keto diet. And at the time I thought this is some crazy, stupid, some nutty thing. But then I watched one and these guys made some very specific claims, which I thought were really fascinating concerning switching your metabolism from being mainly carb calorie driven to being able to metabolize fats more directly.

Steve: And one of the mysteries that I always wondered about growing up was I was a guy who was always eating… I think I listen to the bodybuilders and I would eat like six meals, small meals a day, so supposedly that’s better for your system, but I would get ravenously hungry. I would literally feel pain in my stomach if I didn’t have food. And I thought how would a hunter-gatherer possibly survive with that kind of metabolic condition that I have. Because if I had to go even a day without food, it would be like the most painful thing possible. And so I thought there’s something wrong here.

Steve: And these keto guys were saying, “No, you’re actually evolved as a hunter-gatherer to be able to switch to just start metabolizing the fat stores on your body.” And I thought, “Oh my god, if I can just alter my diet slightly and get into that mode that would be really interesting.” So I actually just did it as an experiment, because I was already low carb and so I went… They said, “Oh, if you go under 55 grams of carbs a day, you can get into this ketosis mode.” And I tried it and it worked.

Steve: And I immediately lost like 10 pounds, and I’ve sort of been on it now for over a year. And one of the interesting things at my last checkup, I was curious whether being on this keto diet where you’re eating eggs and saturated fats, and all kinds of crazy stuff would elevate my cholesterol level, and it didn’t. So anyway I don’t believe what anybody says about anything on in these matters.

Betsy: That’s really interesting that it hasn’t affected your cholesterol. That’s good to know.

Steve: Well, so the keto guys, there’s a whole theory like these PhD scientists, and MD PhD scientists will get on these YouTube videos and explain to you that actually most of the cholesterol is made in your liver.

Corey: It’s your liver, yeah.

Steve: And what you eat is a tiny, tiny fraction of what’s actually circulating in your body, so how can it be the main driver? And so just in terms of dynamical systems, I thought, yeah, that sounds pretty plausible. I’m sure there are some people who, yeah, if you look at the skin on a chicken or an egg or some cheese, their cholesterol goes up, but I think probably a lot of people are not in that category.

Corey: So the general thought is that there is some essentially homeostatic mechanism that you can start consuming cholesterol through your diet and your body will then basically tamp down the amount that your body produces on its own, but yeah, there hasn’t been a lot of discussion about how much variation there is between-

Steve: Yeah, genetic variation or even microbiome variation.

Corey: You need much probably larger datasets and much more detailed data. You may get that over time. It’s extremely hard to monitor what people eat. And so maybe if we have cameras watching us, as we will pretty soon, you’d be able to get some objective data on that.

Steve: I mean, I think one thing that is clear with all of these diets is that limiting carbs more broadly and specifically sugar and foods that break down into these sugars is that’s where a lot of damage is done to the body when you overload it. So limiting that.

Steve: I actually eat essentially zero sugar unless it’s in a sauce. I can’t avoid that someone has put it in the sauce, but I basically eat zero.

Corey: So no fruit?

Steve: That was the most difficult part because I used to eat like five oranges a day or some crazy thing like that, and so I radically reduced my fruit intake. I eat a lot more berries which supposedly have some delayed release of the sugars or something. Who knows whether any of this is true. But the one interesting thing about the keto diet, which I will say is that it has shifted my metabolism in a very radical way so that when I get hungry the actual sensation of hunger is radically different than previously in my life, where I used to feel these sharp hunger pains. Now, I just feel this sort of dull feeling that oh, I guess I’m supposed to eat now or something. I don’t know if this is actually happening, but I can visualize my body just starting to metabolize fat out of its own cells, which I think is what you’re supposed to be able to do. But anyway, I have a dull sense of hunger rather than sharp sense of hunger now.

Betsy: Oh, so that’s interesting. So you’re not having spikes. People talk about spikes of hunger from a diet that has a lot of carbohydrate.

Steve: Exactly. That’s the issue. So that went away. So the the claim from the keto crowd is that you will smooth that all out, and then you can easily fat, if you wanted to because keto is also linked to intermittent fasting. So a lot of people say you should deliberately try to fast for long periods of time, and it makes it much more reasonable to do that because the discomfort level is much lower from fasting. Because you actually are I think metabolizing the calories from your fat. It’s likely emptying out your fat cells.

Betsy: When Corey and I went to college, do you remember, Corey, there was ice cream-

Corey: Of course.

Betsy: … every meal. There was a special cooler in every dining room, and you could get-

Corey: Unlimited.

Betsy: … as much ice cream as you wanted whenever you wanted it.

Corey: Do we have some arrangement with an ice cream company? I wasn’t sure, but somehow it was plentiful, and it was the best-tasting thing produced by the dining hall. So the attraction was unbelievable.

Steve: When I was at that age we were all told low fat diet, take the skin off the chicken breast, sugar, you can eat all the sugar you want because actually calorie density of sugar is not really that high compared to fats. And so all the professional bodybuilders who are trying to get down to 5% body fat would eat that way. But I’m increasingly convinced that’s actually the wrong way to eat.

Betsy: Yeah. See, I bring up the ice cream because I personally… My sweet tooth just built from that point. I developed this sweet tooth in college.

Steve: You can sue Amherst.

Betsy: It’s something I got in addition to my diploma.

Steve: They hooked you on sugar.

Betsy: They hooked me on sugar.

Steve: A few years ago, I just said enough is enough. I get under stress and eat a lot of cookies and stuff. And I went on this no sugar… I didn’t do fruit or anything, I just cut out ice cream, stuff like that and I have felt a lot better. Just doing that has really helped a lot.

Corey: So it seems that at least at this level, Gary Taubes may have won the argument.

Steve: Okay. So just to back up for our listeners, so the Taubes argument was that a calorie is not just a calorie. So the earlier wisdom that I had gotten when I was younger was that you just got to count the number of calories, and as long as you don’t eat too many calories you can lose weight. A few too many will gain weight. And Taubes claimed that certain calories like from carbs and sugar were worse for various complex metabolic reasons. Then perhaps calories coming from, say, fat or protein and…

Corey: So this is complicated because there’s a very tightly controlled trial at NIH which seemed to refute Taubes.

Steve: Is that published now because a friend of mine was involved in that trial.

Corey: Yeah, I think that was published actually, but then there’s a subsequent study which seemed to show that actually although they seem to be medically equivalent over this short term, longer term you seem to lose weight if you avoided sugars. I still think it’s up in the air, but people have reported some metabolic difference.

Steve: So my understanding is that, so NIH performed this and the study that I’m thinking about was very rigorous because I think they had sealed rooms where they could track the CO2 emissions from the individuals in the study so they could actually get a direct handle on the metabolism, well, how much energy they were consuming. And I think it was funded by this billionaire, the Arnold Foundation who got very interested in these issues and also supports open science.

Steve: So it’s a really interesting story, and I think my friend who’s a former physicist who works at NIH was telling me ahead of time that they were going to find no differential metabolic effect between sugar and fat, but of course there could be a longer term effect that their study was not sensitive too.

Corey: I think it’s right. It’s one of these things it just looks like it’s fairly complicated and there may be individual variation that’s not-

Steve: That’s the other thing is that I’m sure that genetically there’s just variation between individuals as to what category they’re in. And so you could easily do this study with one set of people and get one result, and then do it with another set of people and get a different result.

Corey: So may let me give you a little personal example of metabolic effects of calorie reduction changing your diet. So I recently lost about 10 or 12 pounds.

Steve: You look great.

Corey: Oh thanks, Steve. But I felt better afterwards. I had fewer stomach issues. I could eat a lot more. I wasn’t having problems digesting things. What happened is I clearly lost a lot of muscle. I still have these fantasies about going into the gym, trying to bench press things and my bench press dropped in half. And so it’s clear that what was happening is I wasn’t just metabolizing fat, my body was getting rid of muscle at the same time. So now I’m a little bit skeptical, these people say that you just go on these diets and you work out, you’re just going to burn a lot of fat. And my weightlifting friends also tell me that you actually end up losing both fat and muscle whenever you reduce your weight. So I don’t think there’s a free lunch as far as metabolism goes here.

Steve: I don’t think it’s easy to lose weight without also losing some muscle. I think I agree with you, but having been like around the weightlifting-bodybuilding world for a long time, as I was doing the keto thing, I was actually monitoring my lifts, my performance and lifts. So I don’t think I lost a lot of muscle, but I’m sure I lost some.

Corey: People tell me it’s also how fast you lose it because I was told I did it all wrong. I just got fed up one time, I didn’t eat for a weekend or so, and I dropped like 10 pounds in three days.

Steve: Yeah, you’re guarantied to lose muscle on that because your body will just start re-metabolizing the muscle.

Corey: I was weak. My BP was very good. Other issues went away, but I was weak and tired. It’s been slowly ramping up. My strength has been coming back, but it took a little bit. So I want to make sure we get eventually to our egg issue. So the other recommendation, Betsy in this article are don’t smoke. No big news there, right?

Betsy: Right, nothing controversial here.

Corey: But there is information about e-cigarettes, which you might think are better because you’re not smoking in combustion from tobacco, but you’re saying that there’s also health issues related. It’s not just about getting addicted to nicotine.

Betsy: Right. This is a whole new area of research and a whole new set of questions. So we know that smoking cigarettes is bad and the rates in the US of smoking have gone down dramatically. They’re down 14% now. But vaping is on the rise, and vaping helps people stop smoking cigarettes so that’s a good thing. A lot of teenagers also vape, and that’s a bad thing because that could be a gateway for them to smoking. Certainly, there’s a risk of nicotine addiction.

Betsy: And yes, beyond nicotine the questions now are what else does using e-cigarettes do to you because there are chemicals in vaping products. You’re vaping something in and the question is what is that something and what is it doing to you? So there are studies underway. It’s definitely unanswered question, but one study a few months ago suggested that the flavorings in e-cigarettes could increase heart disease risk. So it’s TBD I think, but there’s a lot of concern about it.

Corey: So I’m just looking here at some of the chemicals involved in e-cigarettes. You got ultrafine particles that can go deep into your lungs. There are flavorants which may be problematic. There are other organic compounds, and then maybe heavy metals associated with e-cigarettes. So I guess, yeah, the thought that you’re going to get away with a much cleaner inhale… It may be much cleaner than regular cigarettes. It still seems to have pretty dangerous things. So I’m interested, not a lot of teenagers are reading The Wall Street Journal, so these articles-

Betsy: We’re trying to change that.

Corey: These articles are aimed at people who are older, who may have kids. Do you have any thought when you write article like that you’re writing for a parent of somebody maybe using e-cigarettes or do you just think, well, I’m giving up broad information to the public without really a thought about use of this.

Betsy: No, I’m ready for the general reader, and an older person probably has a child or even a grandchild. We have very engaged readers. These are also just interesting intellectual questions. Heart disease is a concern for everyone. You develop the habits at a young age that become the problems later on, right? So with a story like this, I really am writing it for everybody.

Betsy: We all know who our readers are generally, but it’s a pretty broad swath of the population. And we are trying to get young people reading.

Corey: Do you read the comments in your articles?

Betsy: Yes.

Corey: And what-

Betsy: The comments have changed by the way. We now pose a question and ask people to answer a question rather than just commenting on anything they want to comment on.

Corey: And what do you tend to learn when you read these comments or is there anything you, are there things you tend to learn from a different article?

Betsy: Yeah, I mean I’ve had… Okay. So there’s comments of two kinds. One are the comments that are posted on below the article on the website, which are now is an answer to the question that’s posed. And then there are readers who write to me directly. And I learned from all of them, there have been things I’ve followed up on and written stories about as a result. Dor example, when I was writing about vaping, I got onto the idea that teens were becoming addicted to nicotine from some reader emails.

Betsy: With this heart disease, it’s interesting. I got quite a few emails for the two heart disease articles. One was the one that we’ve been talking about, about how to reduce your health risk, that was a sidebar to the bigger story. So readers wrote in about that. Several wrote in about diet and said, “We’re very adamant about diets like paleo or keto as the answer.” The number of emails I got about that showed me how popular those diets are, and there’s more for us to write about them.

Corey: So Steve’s fanatical proselytizing with regard to keto is not out of the mainstream you’re saying?

Betsy: People who have tried it really, really have… They feel a lot better. And I have friends who have had the same benefit that Steve is talking about. So, yes, I heard from a lot of readers about that. I heard from them about other things. I mean, a lot of people wrote to me saying, “What you wrote, we didn’t know. We knew pieces of it, but we didn’t know the whole picture.” That’s the gratifying reader comment to get because then you know you’ve you know added something to the conversation so to speak.

Steve: Regarding keto, I want to say your mileage may vary. This is not medical advice. Everyone is different.

Corey: So, Betsy, the next recommendation for your article is to maintain a healthy weight. And I think this is something that many people struggle with age. Are there other recommendations about what you should do as you get older? Should you reduce how much you eat? Should you increase your level of exercise? Should you monitor your weight more closely? Is there any data out there on these topics?

Betsy: A couple of things. I mean, there are recommendations certainly that you A, eat a healthy diet, maintain a healthy diet and B, not necessarily actively reduce what you’re eating, but your appetite tends to decrease, so you just have to be mindful of that is what people say. I should add that years ago when I was writing about obesity and some obesity research, some research has found a protective effect from excess weight as you age. As you get older and sicker, you need that weight to protect you as you’re fighting off the disease is a very old age.

Betsy: So people keep that in mind, but there’s a difference I think… When people talk about obesity, I think they have in mind everything from a couple of extra pounds to the morbid obese. So it becomes a little bit unhelpful because a few extra pounds is one thing, but people who really develop the problems are people who have very high BMIs. I don’t know if I’m answering your question. Certainly, your metabolism slows down, your appetite slows down, and what experts, say, doctors, family physicians, cardiologists say is you have to be mindful of that, and exercise has many benefits as you age not just weight reduction. As we know keeping moving keeps keeps your joints from-

Corey: Having trouble.

Betsy: Yeah.

Corey: So this was actually a fairly controversial topic a few years ago as to how much weight you should keep on as you got older because there were conflicting studies. Some saying having extra weight was protective. Then this one against the general trend that lower weight was better. I’ve noticed that a lot of recommendations are quite vague. They say maintain a healthy weight. They don’t quite tell you exactly what this is.

Betsy: I think that’s because… I mean, you were asking me for data. I think it’s because it’s really not known. There are different studies showing coming to different conclusions like excess weight can help you, but clearly not too much excess weight because you don’t need many, many, many extra pounds to stay alive. I think what everybody is trying to come to is you have to hit that sweet spot between high levels of obesity and just a few extra pounds that could… I think of it as a yet to be fully explored area of research.

Steve: Okay. I have to give my interpretation of this study result because I’d actually discussed this with some other medical researchers. So the finding that as people get pretty old, being a little bit heavier is associated with greater longevity. I believe that effect that’s actually driving this statistical result is that being very, very low weight is correlated to poor health, and then you die.

Steve: And so what’s actually happening here is because we’re dealing with an average variable, people then calculate an average like in other words for the conditional on being this weight are you going to die or do people who are slightly heavier live longer? The issue is that people who are about to die lose a lot of weight and who are unhealthy, and so then you get this effect that you then wrongly conclude that it’s actually better to be heavier, but what it really is saying is it’s better not to be super, super emaciated because that’s actually correlated to poor health.

Corey: So personally, you could test this theory by simply excluding people, say within six months of dying.

Steve: Exactly.

Corey: Does it disappear at that point?

Steve: So that’s the question I was asking these medical researchers. So I think if you reanalyze the data, you just exclude people who are just unusually below weight for their super lower BMI.

Betsy: Or who have cancer or smoker, and so forth

Steve: Exactly, or opioid addicts who don’t eat. I think then the effect would largely go away. I’m not sure. We should talk to our epidemiology friends about this, but that’s my interpretation of this.

Betsy: I am not so sure about that. I think there have been… But I confessed that I have not looked at this, I have not written about this in quite a while.

Corey: The next thing you mentioned Betsy is something I’ve actually never heard of before, which is calcium scan. You recommend that people get calcium scans. So I looked up what a calcium scan was, but could you tell us what is it, why should we get it?

Betsy: It’s a coronary artery calcium scan. It was actually… There was a recommendation about it just a few months ago for people who are at some risk of heart disease. In other words their doctors are trying to decide do they need to go on a statin or not. Some sort of question about that a calcium scan can help them make the decision. So calcium scan, it’s basically a scan. It’s like a CT scan of your heart. It takes just a couple minutes to do and it shows whether you have plaque buildup.

Betsy: So it is like eyes on the problem. It can show what actually is going on with your heart and the amount of plaque around it. The problems our insurance doesn’t always cover it. It can be expensive for some people. Some people have worried about how much radiation you’re exposed to although the American Heart Association says that risk of radiation has been reduced. And then the other thing is who really needs it? If you’re not at risk, do you actually need this? And the experts so far say no, it’s really only people at risk.

Steve: One interesting thing is to look at the really private concierge like medical services that the super wealthy can get. And so I just recently sort of got into contact with some people in this world, and it turns out that the rich are getting treated very differently than we are. So they are getting this advanced imaging and all kinds of very bespoke stuff that we are not typically offered by our regular doctor down the street.

Steve: It’s quite interesting. And then when you talk to the entrepreneurs who are building startups around for example new imaging technology, they’re extremely bullish on the capabilities of this stuff of being able to basically look inside and say, “Yeah, you have plaque buildup right there.” And of course insurance doesn’t cover most of us for getting that imaging, but the rich people who are just paying out of pocket can get it.

Steve: There’s a big program at Mayo. There’s an executive program at Mayo. So if you’re C-level executive at a Fortune 500 company, you probably have a health plan that lets you go to Mayo once or twice a year and they do this incredible workup on you which is nothing like what I get from my local GP.

Betsy: Right. I mean, this is probably a topic for another day, but it is true that you can basically get your entire body imaged today. The question is do you learn anything useful from it, and what do you learn and will you just end up with a bunch of false positive stuff that then you have to get biopsied. So that’s a completely different set of questions obviously.

Steve: Yeah. I think for the healthcare system all these false positives and the patient then asking a bunch of questions and googling stuff and getting concerned, that creates cost and time burden for the system which is why they don’t let you do this stuff even though the actual imaging might be cheap as what the entrepreneurs claim in terms of the actual cost of doing this imaging now. But if you have this bespoke medical care where you have a physician who devotes a lot of time to your well-being and they can look carefully to make sure they’re not alarming you over a false positive or something, then the issue of like can they detect a tail risk condition in you like, “Well, yeah. You actually do have unusual blockage in this part of your heart.” They can detect that little problem much earlier than it would be the case for regular people.

Betsy: That is true. It’s totally true. And you can see things and detect something before it would ever become obvious, their symptoms.

Corey: But also you’re often detecting things that won’t become problems. This is the issue on some of these ways of imaging for cancer, these things often appear, and then disappear over time.

Steve: I’m sure even for these people that have the bespoke medical care that they run into this problem that the physician has to decide, “Wow. Is this a false alarm? Do I need to discuss this with my client? So even they are not immune to that problem, but they just can put a lot more hours on it than the regular health system can for us.

Betsy: No. It’s definitely a point. And I think the point I was just trying to make is that the technology is ahead of medicines understanding of what you see, right?

Steve: Yeah.

Betsy: As Corey said with certain forms of cancer, is this ever going to be a problem or not? And if it’s not why touch it? On the other hand, I’m finding out that you have plaque buildup, and imminently you’re overdue for a heart attack is extremely useful information.

Steve: Exactly, yeah.

Betsy: There are people who’ve been wheeled into the operating room from these. So I think the question is figuring out who the people are who should have this test and getting it covered.

Steve: I think there is a difference between plaque buildup and cancer because your body is fighting cancers all the time and sometimes your body just wins, and the tumor cells go away. I don’t think that’s probably usually the case whereas it’s harder to imagine the plaque buildup suddenly reversing because it probably took like 30 years for that to accumulate.

Betsy: Right.

Steve: Now, one of the entrepreneurs I spoke to who his company does machine learning on imaging stuff, he was claiming to me that for example prostate cancer, which men our age really that’s a big unknown. You don’t know whether you have it. Maybe you have it, but it’s benign. It’s not aggressive. He claims it’s actually quite easy to image that part of the body now and just track what’s going on with your prostate. But the medical system hasn’t really operationalize this yet.

Steve: But if you had infinite money and access to the high technology, you could be just watching it once a month. They look carefully at your prostate without the sort of hugely invasive painful standard method without using that. And so that would be an example of some medical, perhaps useful medical care that the super-rich can get that we can’t get.

Corey: Maybe it’ll trickle down.

Steve: Yeah.

Betsy: Yeah.

Steve: Maybe not in time for us.

Betsy: You guys are young. They’ll trickle down in time. They’ll trickle down just when you need it.

Steve: Okay. Great.

Corey: So the last recommendation is to exercise. The current recommendations are for 150 minutes a week. Just over 20 minutes a day on average. And I’m actually interested in that recommendation because it just seems totally arbitrary. Is this something magical that happen at 20 minutes?

Steve: And what’s the quality level that at what point does it become exercise? If I’m mopping my floor, am I exercising?

Betsy: So I think that’s the more interesting thing is what counts in here is exercise? Years ago I covered a study by the CDC or recommendation basically saying that even vacuuming now counts as physical activity. And so I thought… I remember seeing that and thinking, wow, we have really reached a point. Now, that they have the Roomba or whatever.

Corey: Exactly.

Betsy: That’s not exercise.

Steve: The Roomba is bad for us.

Corey: Maybe watching the Roomba actually is exercise now.

Steve: Chase it around.

Betsy: So I think just as much as the, are just as controversial as the number of minutes per week assigned to this is what exactly is exercising. Clearly today, also with the aging population, it’s not all you got to go run 10 miles or you’ve got a lift, bench press this amount. Taking a good long walk is exercise.

Corey: There’s a recent article at Times saying that people who lived the longest exercised at least 45 minutes a day. But you’re right in what qualified in those 45 minutes was pretty interesting. They said that people hit that 45-minute target we’re pretty expansive as what qualifies exercise. They might go for run, they might go for a bike, but they may not get in their full 45. They may just walk for 15 minutes more. And it seems pretty clear that the intensity of the exercise matters. So the more intense you’re exercising, the shorter you have to go to get the amount. I think this has been one of the real interesting things that’s come of the whole high-intensity movement.

Corey: We used to go for these very long runs Betsy when we were in college, but you look back and you say we probably would have gone as intense in exercise. The races we ran three days a week. These races maybe 25 minutes, but we probably couldn’t have done that actually. We probably couldn’t have raced all out three times a week for 25 minutes. Maybe you could. Maybe you could do it every day, but either we could cut down the amount of time you were exercising by upping the intensity. And so I think it’s also not clear yet is the length of time the function of the intensity and what the thresholds are. My general goal is to try to do an hour a day, six days a week. If I work out an intense fashion I can’t do that right. You start doing some sprints and you’re not going to be sprinting for an hour.

Steve: So Corey and I over the years, because we’re both exercise obsessives have talked a little bit about something called Tabata. I don’t know if that’s ever come up in your work.

Betsy: No.

Steve: This is an exercise scientist in Japan who did these studies and now these have been replicated with exquisite precision where they actually put the person in one of these rooms where they monitor CO2.

Corey: So the great thing is the initial studies were done in mice. And do you remember how these studies were run?

Steve: Oh, I didn’t know that. I thought he was doing it with like college students on bicycles.

Corey: No, he first took a mouse and dropped it in water. It’s borderline, not abusive. A little bit, yeah. And the mouse could basically swim for about an hour. So he put the mouse in, let swim for an hour, take it out. Then he took the mice, he dropped them in the water with the weight on them. And this thing had to swim for 20 seconds, and he pulled it out. And he put it in for another 20 seconds. It got a 10-second break, and he did it eight times. He did his three days a week, and the result was that the mice that had to swim basically for their lives for 20 seconds at a time had the same muscle development in cardiovascular capacity development, as the mice who swam effectively each day for about an hour casually. That was the initial.

Steve: So I was super interested these results because as a kid I was a sprinter in swimming and also in running and stuff I could never run long distances, but I was reasonably fast over short distances. And so I was wondering is the funk… Look, so if you’re just jogging people often say, “Oh, you burn about 100 calories for every mile that you run. It varies a little bit by body weight. But I always thought wait a minute. If I break that mile down into a certain 1500 meter sprints or something, surely I’m burning a heck of a lot more calories doing it that way than just jogging the mile.

Steve: There should be some non-linearity depending on the intensity, and now these Tabata studies have shown that you could literally burn like hundreds of calories. Not just at the time you’re doing the exercise but then in elevated metabolism throughout the day if you did intense exercise rather than slower exercise. And so I think that’s well established now.

Betsy: Exercise and diet. Writing about them it’s so much harder than writing about anything else because the science is evolving, A. B, everybody is looking for all of us. We all innately are looking for the simple answer like what’s going to make me healthier, and the answer is probably just not very simple. There are all these interesting new findings, but you always have to put them in context with what’s already known and what’s unanswered.

Betsy: And so just thinking about these recommendations for exercise, it’s really hard to know what to recommend to people beyond a sort of broad, bland recommendation. I mean, what did the recommender should recommend and also what people like me who write for the public should say, because people at the end of the day are generally looking for something simple when it’s just the answer really doesn’t seem to be very simple, and it seems to do a mixture of things.

Corey: And be moving target.

Steve: Yeah.

Betsy: Yeah.

Steve: I mean another piece of evidence for how complicated this is that again going to the super-rich. If you have a personal trainer who comes over every day for an hour and does stuff with you, they may try to get you to do certain movements that you didn’t even know you could do or that we’re useful and they’re carefully monitoring you to see like what your body responds and where you’re more likely to be injured and we stay away from that or what we need to strengthen.

Steve: So you can just imagine a very smart experienced person is coaching you and all the different things they can take in consideration, and no human is going to get that from one Wall Street Journal article, but that’s sort of this lifetime fitness, always learning about how to do better with your body and what your body means. I think that’s what most people end up having to do.

Betsy: Yeah.

Corey: So now we come to the crescendo of our discussion today.

Steve: The incredible edible egg.

Corey: Incredible edible egg, yes. Betsy just talked about the difficulty of shifting recommendations. So you recently wrote an article about a study that came out, and the study… Well, your article is a study links eggs to higher cholesterol and risk of heart disease, eating 300 milligrams of dietary cholesterol a day or less than that of two egg yolks was associated with a 17% higher risk of cardiovascular disease and an 18% higher risk of death from any cause.

Corey: This finding which is sort of shocking to me altered my eating habits, came after the American Heart Association and American cardiology had recently relaxed their restrictions on a consumption in 2015, when I increased my egg consumption to… Not consistently, but I thought two eggs a day is totally fine. And we have well links to your article, on these two articles below, but how do you approach a topic like this where the guidelines to the date and the guidelines seem to be shifting. You’ve got to cover it, but how do you approach it? What kind of reaction have you gotten from your readers?

Betsy: So the first thing you have to do when you see a study like this is decide whether to write about it or not because you have to determine whether it’s saying something new enough, A and B, whether the study is solid enough. A large enough study sample and so forth. So this study did qualify because of its finding was literally the opposite of the guideline change a few years earlier. And it was also a study of more than 29,000 adult and over several years. It was clearly a large sample.

Betsy: So that was the first thing, let’s write about it. The second thing was, “All right. How do we present this because there is a lot of controversy over eggs, right? Should you eat them or should you not eat them? And it boils down to, as Steve knows what is the role of diet? What does dietary cholesterol do in your body?” With a study like this, what we try to do is first, obviously, lay out the findings, but then put them into context. What is the current understanding? What are the controversies here and what are people going to think about it, and just try to lay it all out for readers?

Betsy: I think with any study like this, you never want to present it as this is the final word, but this particular study is interesting and that it pointed out a problem with this type of research, with nutrition research in general which is that a lot of studies are epidemiological. This was based on a questionnaire given to participants in large cohort studies. So it’s very difficult to actually test the effects of food on people in large numbers. So there are a lot of questions about epidemiological studies because if eating eggs was associated with 17% higher risk of developing cardiovascular disease, that’s very different from saying eating eggs caused that, caused people to develop CVD or cause them to die. So those are all the the challenges in writing a story like this.

Steve: So Cory, I think earlier you said that based on the earlier recommendation you had relaxed your egg eating habits and you were allowing yourself to have two a day, which is like 14 eggs a week.

Corey: I don’t think it ever got that much, but it got into my head two twigs a day was okay.

Steve: Was okay. Now, based on this study are you curtailing that behavior?

Corey: I definitely didn’t eat 14 eggs a day, but I would quite comfortably eat a couple eggs, maybe up to six a week. What I’ve done since then-

Steve: I’ll sometimes eat six or eight eggs in one sitting just so you know.

Corey: I effectively started replacing eggs with egg whites. So this morning I made an omelet for the family.

Steve: All those good fats taken out.

Corey: It’s true but yet a lot of protein. I made the equivalent volume of six eggs. I put two full eggs in there and then I added twice as much egg white. And you actually can’t tell that much… It doesn’t look that different.

Steve: I agree. Egg white omelet served?

Corey: They’re okay, They’re a little bland. I think you have to give a little bit of flavoring.

Steve: I guess what I’m probing you on is the new study, has it actually moved your beliefs because it sounds like survey data to me sounds like, wow, that really you’re going to move your beliefs on that?

Corey: It hasn’t removed my beliefs, but I’m saying, look, if there’s a risk there, do I want to take it just to have a few more eggs.

Steve: Fair.

Corey: And I can more or less get I think what I need from both my palate and from nutrition I think by replacing with egg whites. And so it seemed like a low-risk maneuver. I’m a little agnostic. I don’t know what to think though.

Steve: I don’t either. I think this nutrition stuff fluctuates so much. It’s a little bit hard to know and plus there’s that additional variable of your own genetics like are you typical of the people in the study or are you not.

Corey: Again, my cholesterol levels have been pretty good for my primary with no problems. I used to have insanely low cholesterol. I don’t have that anymore. I’m more normal. Is it genetics or is it just exercising a lot? It’s very hard to tell. Has this changed your behavior, Betsy?

Betsy: Well, not really because I’m not a huge egg eater anyway. It did make me realize like I said how difficult these… It is to reach it, to actually figure out the role of eggs in cardiovascular health because there’s genetics. Every person is different. Nutrition research like I said is focused on… Most of it is epidemiological. I don’t know. I’ve maybe thought a little bit more about how many eggs I eat a week, but I haven’t changed it much.

Corey: So we come to our last article and this will be a short discussion because we’ve gone way over time. We thank you for all the time you’ve given us. But again one of our favorite topics is fish and fish oil. I eat a lot of fish. We’re in the Midwest so the variety of fish isn’t enormous here. I eat a lot of salmon.

Steve: Hey, we’re in Lake Michigan, man.

Corey: Many people told me that I should not eat the fish out of the Great Lakes.

Steve: Okay.

Corey: I don’t know if that’s a slander against local fishing. So I think the last systematic review I saw showed that there’s pretty good evidence that eating fish is associated with lower rates of cardiovascular disease, but the question you raised in your article is whether fish oil by itself improves cardiovascular health or has other health benefits. I guess implicit in there is whether there’s something in fish that may be driving the CVD benefits that is not in fish oil. This is an article which sums up all the issues we’ve been talking about it seems totally unclear what fish oil does if anything for you, and it may do some other things. So you’re facing a task of writing about an almost entirely uncertain topic, but topic that’s of interest to people.

Betsy: Of enormous interest of people, right.

Corey: Exactly.

Betsy: So they want to know every important step in the science or the research on topics like fish oil and eggs. We want to cover, but we want to only cover the important ones. So there was a big study that found that fish oil didn’t have a benefit for heart health. It’s interesting because at the same time there was a study that came out about a prescription drug called the SEPA that is a very concentrated form of fish oil, and that did show that it lowered triglycerides.

Betsy: So it seems that they’re in certain concentrations and certain types of fish oil. I mean, the jury is still out I guess on this one, but clearly high concentrations of certain types of fish oil are showing that they have a benefit where’s the fish oil supplements it’s all kind of still out there. I will say though after writing that story I was asking myself should I take fish oil, should I not take fish oil? And I came away with the regular supplements. I came away with there’s no real harm that I could find and there may actually be benefits. I mean, the same people who have been studying its effects on heart health are now looking at its effects on other things like depression. And those studies will be out in a few months. So stay tuned.

Steve: So full disclosure, I eat four of those little fish oil capsules a day, and I also eat tons of fish, especially the fatty oily kind of fish.

Corey: Salmon.

Steve: Like salmon.

Betsy: I had salmon for dinner last night.

Steve: There you go. Many years ago… Again, I don’t know whether it helps or not because nutritional science is a little bit like religion. Many years ago when I was a young assistant professor, there was a chemist, theoretical chemist that I was good friends with who was really into nutrition and had studied, because he had quite a lot of expertise in chemistry had studied a lot of these things in detail and read a lot of medical literature, and he said to me there are only two things I believe in. And I was quite young at this time so I was like… My mortality wasn’t really that foremost in my mind and he was older, but it did impress upon me his findings.

Steve: Two things. One, he said eat fish oil and the other one he said go to Google and type in blueberry and brain, and just read some of those articles. And as a consequence of that I eat like a bowl of blueberries every day and I have like, I don’t know, it’s been over 20 years. So those are the only two things that I do in terms of supplementation.

Corey: I have to say that I’m an avid fish eater also. I’ll eat fish sometimes five days a week. Again, the fatty kinds has a lot of benefits, has a lot of vitamin D. It’s thought that’s what allowed people to actually survive fairly far north when there wasn’t a lot of sunlight. And that does seem like a really, really solid salt. I think it’s fascinating because there is another question as to what it is in fish that might be having these beneficial effects if it’s not the oil. I think that’s something where the research is only a really very nascent stage. But I think we’re about out of time, and I want to thank Betsy for coming on the show. It’s been a real pleasure.

Betsy: It’s been fun spending time with both of you.

Steve: Yeah. It’s been really fun, and I hope we can do this again because I think Corey and I have talked before about having more podcasts devoted to things like fitness and nutrition, and health.

Corey: I’d like to have Betsy back and also talk about what’s like being a health reporter who haven’t been a former runner because I assume that has shaped your perspective somewhat.

Betsy: That would be great. I would love to come back.

Steve: Great.