The Spanish Paradox

      107 Comments on The Spanish Paradox

An article with the title No Room for Complacency in Face of Spanish CV Paradox showed up on Medscape today.  Let’s take a look at some choice bits:

The first study to report population-based data on cardiovascular health across an entire European country has found that the nation in question, Spain, is not performing particularly well and in fact is on a par with the US.

Boy, I’m sorry to hear the Spanish aren’t performing particularly well when it comes to cardiovascular health.  I spent part of my honeymoon in Barcelona and loved the place … the scenery, the food, the friendly people.  If they’re on a par with the U.S., they must have nearly as many people dropping dead of heart attacks as we do.

Surveying a cross-section of Spanish adults, Dr Auxiliadora Graciani (Universidad Autonoma de Madrid, Spain) and colleagues measured “ideal cardiovascular health”–as described by the AHA–and found that only 0.2% of the 11, 408 subjects attained ideal values for all seven CVD health metrics: nonsmoker, body-mass index (BMI) <25 kg/m2, physical activity at goal, diet consistent with recommendations, untreated cholesterol <200 mg/dL, untreated BP <120/80 mm Hg, and untreated fasting glucose <100 mg/dL in the absence of clinical CVD and diabetes. Of those surveyed, 3.4% attained ideal values for at least six of the metrics and 15.4% for five, they note in their report published online January 8, 2013 in Circulation: Cardiovascular Quality and Outcomes.

Wow, that’s just awful.  Barely one-fifth of one percent of the Spanish adults meet the American Heart Association’s ideal values for cardiovascular health.  And I thought the people I saw falling down in Barcelona were just party animals who’d had too much sangria.  Now I realize they were having heart attacks.  In retrospect, I feel guilty for clapping.

“This is the first study to report information on cardiovascular health from Spain, a European country with low coronary heart disease mortality compared with many Western countries,” observe the authors. However, the level of cardiovascular health in Spain “is as low as in the United States, primarily due to poor lifestyles, especially lack of ideal diet,” they note.

Um … uh … but … did I read that correctly?  The Spanish have a low level of cardiovascular health but also low coronary heart disease mortality?  Isn’t that a bit like saying they’re in poor physical condition, but can run for miles and bench-press their own body weights?  I don’t know about these researchers, but I define “good cardiovascular health” as “not dying from cardiovascular disease.”

Although the CHD mortality rate is low in Spain, recent research shows the prevalence of angina there is high, suggesting that atheromatous plaques are stable, the doctors say. Research is needed as to why these plaques do not rupture, translating into a high incidence of acute MI, as is seen in other countries, they state.

Oh, okay.  Got it.  The researchers are speculating that thanks to their stubborn refusal to adopt the American Heart Association’s definition of good health and a good diet, the Spanish actually do have lots of plaque buildup … but for some reason, plaques don’t rupture in Spain.  Must be the weather.  I’m surprised they didn’t say it’s because the Spanish drink wine.

This “paradox” of low CHD mortality and poor cardiovascular health in Spain could be explained by several things other than traditional CV risk factors, such as sedentary behavior, specific dietary components (eg, wine consumption and the Mediterranean diet), psychosocial factors (such as family support), and quality of medical care, among others, say Graciani et al.

Head.  Bang.  On.  Desk.

I see.  So the Spanish suffer from a “lack of ideal diet,” they have poor cardiovascular health because they don’t meet the American Heart Association’s criteria, but they don’t die from heart attacks because they eat a Mediterranean diet.  They have a lousy diet, but their diet saves them from heart disease.   Oh, and because they drink wine.  And because of the quality of medical care.  I guess that means they get treated for their high cholesterol.

And because lifestyles appear to contribute far more heavily than biological factors to poor cardiovascular health in Spain, there is a great need to strengthen the role of public-health efforts in the management of CVD there, they observe. Health services also need to improve, they add, noting that five out of every 10 people with elevated cholesterol are not being treated, and half of those with BP >140/90 mm Hg are unaware of this.

Head.  Bang.  On.  Desk.

So, to sum up … The Spanish are in poor cardiovascular health because of their lifestyle and lack of an ideal diet, which means there’s a great need to strengthen government efforts in the management of cardiovascular disease.  But they don’t die of heart attacks because of their diet and high-quality medical care.

I want to know how any researcher can make those arguments in a paper without reading what he wrote and thinking, “Wait a minute … I sound like a flippin’ moron here.”

By coincidence, I received a copy of the most recent report from the American Heart Association around the time I was reading the Medscape article.  Naturally, the report includes the AHA’s recommendations on cholesterol  levels:  over 240 is classified as poor, 200-239 is classified as intermediate (with a recommendation to “treat to target”) and less than 200 is classified as ideal.

Let’s look at a graph from one of the American Heart Association’s own documents.  This shows rates of death from cardiovascular diseases (heart attack and strokes combined) for men in several countries, ranked from worst to best.

Notice Spain down there near the bottom?  Notice France down there below Spain?  Now take a look at the top of the chart, where you’ll find Russia with the highest rate of cardiovascular deaths.

A couple of years ago, I downloaded data from the World Health Organization’s MONICA study, which tracks cholesterol levels and cardiovascular death rates around the world.  The average cholesterol level in Russia is 189.  In France, it’s 210.  Romania (near the top of the chart) and Spain (near the bottom) have the same average cholesterol level:  197.  When I ran the correlation function in Excel on all the countries and their rates of cardiovascular deaths, the result was -0.25.  In other words, there’s almost no correlation, and the slight correlation that exists points to cardiovascular deaths going up as cholesterol levels go down.

And so the paradoxes just keep on coming …


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107 thoughts on “The Spanish Paradox

  1. Amy Dungan

    There appears to be some unwritten rule among researchers that says conclusions don’t have to actually make sense. Here’s an ice pack for your head Tom.

    If the movies are an accurate guide to the effects of head-banging, I’m in extreme danger of experiencing a prolonged episode of amnesia that will place me in numerous comedic situations.

  2. Walter B

    Just reading this makes my head hurt, I don’t need to bang head on desk.

    There medical care is better because the are not given statins, so they are being saved by superior medical care.

    Along with as Dr. Feinman above says about cholesterol levels are more important than not having a heart attack, apparently its more important to eat the prescribed diet than avoid a heart attack.

    In the immortal words of Anna Russell, “I’m not making this up, you know.”

    Well, look at it this way: sure, that low-diet may not save your life, but at least you’ll have spent your time on earth depriving yourself of foods you would have enjoyed.

  3. Walter B

    RE: Subway

    At those prices any entity that can pay is a non restaurant, and serving non foods.

    Anyway anything that the AHA recommends has to be considered toxic.

  4. Galina L.

    Dr. Feinman, being thin is also very important, right? I am originally from Russia, and visited my mom there couple months ago. There is a Russian paradox, general crowd there it THIN! They have low cholesterol, they walk everywhere way more than Americans! Almost all of my uncle’s school friends were dead by age 65, but at least they looked healthy by the American standards when they were alive.

  5. Bob Johnston

    I had my first NMR done just after Christmas and I was discouraged to find my total cholesterol at 172. I’d hoped it would be higher.

    If you’re on a good diet, I wouldn’t worry about it.

  6. Pablo

    Hi Tom,

    I quite enjoy your posts and read them often. As a Spanish myself, I am surprised by the low incidence of CVD. We haven’t reached the levels of obesity in the USA, but we must be moving in the same direction. The number of overweight people you can see on the streets has ballooned in the last 10 years.

    Most of my friends (30s) are overweight to some degree, and you can see more and more overweight young people. There has been a huge increase of sugary food over the last two decades. Refined junk occupies 60% of the aisles of any supermarket or grocery store.

    We have always eat bread, meat, lots of legumes, fish, and, above all, generous amounts of olive oil. Olive oil has to be the main staple of the so-called Mediterranean diet, calorie-wise . In a mostly agrarian society up until the 50s, the only thing could keep you going long enough in the fields was copious amounts of cheap olive oil for breakfast, lunch and dinner. We would have exchanged legumes for meat or fish any day, believe me. Legumes has been a constant source of unhappy faces and whining at lunch time.

    Unfortunately, what is used to be a soda for special occasions and a sweet for Christmas (mantecados) has now replaced a glass of water and a piece of fruit for lunch and dinner. I am afraid, at this rate, the Spanish paradox is going to work itself out, and experts such as Dr Auxiliadora Graciani will be able to make sense of their own studies.

    Keep up the good work!

    Apparently some of that’s going on in France too. Please, my French and Spanish brethren — don’t do it! We need your paradoxes.

  7. Anne Robertson

    Here in France, life expectancy has recently dropped by two months for women. Could this be because women are more likely to follow the dietary recommendations? Oh yes, and recently a doctor tried to put me on a statin because my cholesterol is high (my triglycerides are very low so my LDL was wrongly calculated), and yet scans showed that my arteries are clear. Go figure!

    My mom has a friend whose doctor is always after her to lower her “high” cholesterol. Then he checks her arteries and declares them clean as a whistle. Then he gets after her to lower her cholesterol.

  8. Amy Dungan

    There appears to be some unwritten rule among researchers that says conclusions don’t have to actually make sense. Here’s an ice pack for your head Tom.

    If the movies are an accurate guide to the effects of head-banging, I’m in extreme danger of experiencing a prolonged episode of amnesia that will place me in numerous comedic situations.

  9. Lobstah

    This is so much like reading many of the climate reports/studies.
    Those make my head hurt too, and for the same exact reasons.

    Jim

  10. Per Wikholm

    Great stuff! Can’t wait to see the same reseachers take on the Swiss paradox. The have the second lowest rate of heart disease next to the French and also happen to have Europes second highest consumtion of saturated fats, again next to the French.

    But I guess it has something to do with the rest of their diet… maybe this central European contry is actually a Mediterranian country in disquise and that there is actually an unknown, huge production of wine and olive oil going on high up in the Alps, above the radar of the Swiss authorities.

    It’s got to be the wine. It can’t be that the Lipid Hypothesis is wrong.

  11. Walter B

    Just reading this makes my head hurt, I don’t need to bang head on desk.

    There medical care is better because the are not given statins, so they are being saved by superior medical care.

    Along with as Dr. Feinman above says about cholesterol levels are more important than not having a heart attack, apparently its more important to eat the prescribed diet than avoid a heart attack.

    In the immortal words of Anna Russell, “I’m not making this up, you know.”

    Well, look at it this way: sure, that low-diet may not save your life, but at least you’ll have spent your time on earth depriving yourself of foods you would have enjoyed.

  12. Walter B

    RE: Subway

    At those prices any entity that can pay is a non restaurant, and serving non foods.

    Anyway anything that the AHA recommends has to be considered toxic.

  13. Galina L.

    Dr. Feinman, being thin is also very important, right? I am originally from Russia, and visited my mom there couple months ago. There is a Russian paradox, general crowd there it THIN! They have low cholesterol, they walk everywhere way more than Americans! Almost all of my uncle’s school friends were dead by age 65, but at least they looked healthy by the American standards when they were alive.

  14. scientist-type

    Out of curiosity, what are the red bars versus the open bars in the AHA graph?


    I just found it again. Red bar is cardiovascular deaths, entire bar is all-cause mortality within the age group.

  15. Bob Johnston

    I had my first NMR done just after Christmas and I was discouraged to find my total cholesterol at 172. I’d hoped it would be higher.

    If you’re on a good diet, I wouldn’t worry about it.

  16. Pablo

    Hi Tom,

    I quite enjoy your posts and read them often. As a Spanish myself, I am surprised by the low incidence of CVD. We haven’t reached the levels of obesity in the USA, but we must be moving in the same direction. The number of overweight people you can see on the streets has ballooned in the last 10 years.

    Most of my friends (30s) are overweight to some degree, and you can see more and more overweight young people. There has been a huge increase of sugary food over the last two decades. Refined junk occupies 60% of the aisles of any supermarket or grocery store.

    We have always eat bread, meat, lots of legumes, fish, and, above all, generous amounts of olive oil. Olive oil has to be the main staple of the so-called Mediterranean diet, calorie-wise . In a mostly agrarian society up until the 50s, the only thing could keep you going long enough in the fields was copious amounts of cheap olive oil for breakfast, lunch and dinner. We would have exchanged legumes for meat or fish any day, believe me. Legumes has been a constant source of unhappy faces and whining at lunch time.

    Unfortunately, what is used to be a soda for special occasions and a sweet for Christmas (mantecados) has now replaced a glass of water and a piece of fruit for lunch and dinner. I am afraid, at this rate, the Spanish paradox is going to work itself out, and experts such as Dr Auxiliadora Graciani will be able to make sense of their own studies.

    Keep up the good work!

    Apparently some of that’s going on in France too. Please, my French and Spanish brethren — don’t do it! We need your paradoxes.

  17. Taysha

    I find this hilarious.

    I AM Spanish, and I’m a T1 diabetic. I happened to go back home for Christmas and proceeded to PIG OUT like there was no tomorrow on all the tasty food I have not had in the last 5 years I’ve been in the US. This included: blood sausage, cooked pork fat with bread (yeah, yeah, little bread, lots of fat), liver (oh my lord, I love liver. Liver in the US looks dead), seafood. You name it, I got my hands on it.

    The end results?

    I had to lower my daily insulin usage by 35% while I was there. I used so little insulin that my doctor actually asked me if I hadn’t eaten at all. Happens ALL the time. I also lost 7lbs in 1 week.

    It was glorious.

    I’d say you need to start shipping your meals over from Spain.

  18. Pat

    I’m looking at those Canadian values – lower cardiovascular deaths, lower total all-cause mortality. So, southern neighbours, you don’t have to go to France to be healthier – come North! However, provincially Stats Canada reports that “Diseases of heart” are the second-leading cause of death (all ages and both sexes) for all provinces except Nunavut (lower) and Prince Edward island (first). Unfortunately neoplasms are generally number one and cerebrovasular disease is usually third. So Quebecers’ “rotten life style” (smokers, wine drinkers, poutine and French cuisine eaters, home of the snowmobile) do just as well, and enjoy life more, despite the high taxes. But, the down side is that cancer is our leading cause of mortality and cerebrovasular disease is number 3 – and cancer rates and cerebrovasular disease have been shown to go up as fat intake and cholesterol go down, if I recall correctly.

  19. FrankG

    “…the AHA’s recommendations on cholesterol levels: over 240 is classified as poor…”

    Even if cholesterol has any significance as a marker of CVD health (and if it does I doubt it is the way it is currently measured)…. why are they still talking about “Total Cholesterol” as being in any way meaningful?!? Don’t even the staunchest statin-pushers call HDL-C the “good” cholesterol? In which case, surely more is better BUT more HDL-C contributes to an higher Total C… which is bad? :-0

    Lord only knows why they don’t look at their own data.

  20. FrankG

    This article is a perfect example of what happens when you get locked into a paradigm: you have to them make all your observations fit into that preconceived model; rather that letting the observations guide you in a meaningful direction.

    Yup, kinda like the USDA researchers putting themselves through mental gymnastics to keep blaming saturated fat.

  21. Anne Robertson

    Here in France, life expectancy has recently dropped by two months for women. Could this be because women are more likely to follow the dietary recommendations? Oh yes, and recently a doctor tried to put me on a statin because my cholesterol is high (my triglycerides are very low so my LDL was wrongly calculated), and yet scans showed that my arteries are clear. Go figure!

    My mom has a friend whose doctor is always after her to lower her “high” cholesterol. Then he checks her arteries and declares them clean as a whistle. Then he gets after her to lower her cholesterol.

  22. Andrés

    Let us not be so pessimistic, please: “noting that five out of every 10 people with elevated cholesterol are not being treated” (he!, I know several of them, including me). I think that with enough effort we may be able to reach “6 out of 10” :-D. I have being unable to find a Spaniard MD’s blog positioning him/herself against statins, though.

    I have just bought one of your “Wheat is murder” T-shirts… you aren’t considering doing some baby size ones, are you?

    We’re letting our current stock run out on that one. It’s a big investment to order enough of them to get the good price, and we’re always guessing on the distribution of sizes. We believe that product has pretty much run its course and don’t want to keep making big investments in it.

  23. Andrea

    Sounds to me like the only one’s suffering from Spain’s poor cardiovascular health is Big Pharma.

  24. Beowulf

    I hope someday they write about an American paradox. “There’s this whole group of Americans eating red meat, drinking whole milk, and cooking with lard that isn’t overweight or dying of heart attacks right and left!”

    Oh wait, that was actually happening a hundred years ago. My mistake.

    Good thing we got smart and gave that up. It would be difficult to explain away a paradox at home.

  25. Lobstah

    This is so much like reading many of the climate reports/studies.
    Those make my head hurt too, and for the same exact reasons.

    Jim

  26. Per Wikholm

    Great stuff! Can’t wait to see the same reseachers take on the Swiss paradox. The have the second lowest rate of heart disease next to the French and also happen to have Europes second highest consumtion of saturated fats, again next to the French.

    But I guess it has something to do with the rest of their diet… maybe this central European contry is actually a Mediterranian country in disquise and that there is actually an unknown, huge production of wine and olive oil going on high up in the Alps, above the radar of the Swiss authorities.

    It’s got to be the wine. It can’t be that the Lipid Hypothesis is wrong.

  27. Marilyn

    Forget the head-banging-on-desk. That looks like the kind of paper that would give one a headache just trying to follow the logic.

  28. Johanna N

    Must be the weather..
    it might at least contribute to cardiovascular health. There is an interesting talk by Richard Weller on TED.com, about the skin being able to store NO, which can be released by sunlight, thus leading to vessel dilatation.

    Thanks for your work.

    The same pattern apparently shows up in the China Study, at least according to Denise Minger’s analysis. Perhaps we’re looking at the benefits of vitamin D.

  29. Taysha

    I find this hilarious.

    I AM Spanish, and I’m a T1 diabetic. I happened to go back home for Christmas and proceeded to PIG OUT like there was no tomorrow on all the tasty food I have not had in the last 5 years I’ve been in the US. This included: blood sausage, cooked pork fat with bread (yeah, yeah, little bread, lots of fat), liver (oh my lord, I love liver. Liver in the US looks dead), seafood. You name it, I got my hands on it.

    The end results?

    I had to lower my daily insulin usage by 35% while I was there. I used so little insulin that my doctor actually asked me if I hadn’t eaten at all. Happens ALL the time. I also lost 7lbs in 1 week.

    It was glorious.

    I’d say you need to start shipping your meals over from Spain.

  30. Pat

    I’m looking at those Canadian values – lower cardiovascular deaths, lower total all-cause mortality. So, southern neighbours, you don’t have to go to France to be healthier – come North! However, provincially Stats Canada reports that “Diseases of heart” are the second-leading cause of death (all ages and both sexes) for all provinces except Nunavut (lower) and Prince Edward island (first). Unfortunately neoplasms are generally number one and cerebrovasular disease is usually third. So Quebecers’ “rotten life style” (smokers, wine drinkers, poutine and French cuisine eaters, home of the snowmobile) do just as well, and enjoy life more, despite the high taxes. But, the down side is that cancer is our leading cause of mortality and cerebrovasular disease is number 3 – and cancer rates and cerebrovasular disease have been shown to go up as fat intake and cholesterol go down, if I recall correctly.

  31. FrankG

    “…the AHA’s recommendations on cholesterol levels: over 240 is classified as poor…”

    Even if cholesterol has any significance as a marker of CVD health (and if it does I doubt it is the way it is currently measured)…. why are they still talking about “Total Cholesterol” as being in any way meaningful?!? Don’t even the staunchest statin-pushers call HDL-C the “good” cholesterol? In which case, surely more is better BUT more HDL-C contributes to an higher Total C… which is bad? :-0

    Lord only knows why they don’t look at their own data.

  32. FrankG

    This article is a perfect example of what happens when you get locked into a paradigm: you have to them make all your observations fit into that preconceived model; rather that letting the observations guide you in a meaningful direction.

    Yup, kinda like the USDA researchers putting themselves through mental gymnastics to keep blaming saturated fat.

  33. Andrés

    Let us not be so pessimistic, please: “noting that five out of every 10 people with elevated cholesterol are not being treated” (he!, I know several of them, including me). I think that with enough effort we may be able to reach “6 out of 10” :-D. I have being unable to find a Spaniard MD’s blog positioning him/herself against statins, though.

    I have just bought one of your “Wheat is murder” T-shirts… you aren’t considering doing some baby size ones, are you?

    We’re letting our current stock run out on that one. It’s a big investment to order enough of them to get the good price, and we’re always guessing on the distribution of sizes. We believe that product has pretty much run its course and don’t want to keep making big investments in it.

  34. Andrea

    Sounds to me like the only one’s suffering from Spain’s poor cardiovascular health is Big Pharma.

  35. Beowulf

    I hope someday they write about an American paradox. “There’s this whole group of Americans eating red meat, drinking whole milk, and cooking with lard that isn’t overweight or dying of heart attacks right and left!”

    Oh wait, that was actually happening a hundred years ago. My mistake.

    Good thing we got smart and gave that up. It would be difficult to explain away a paradox at home.

  36. Alex

    We know now CVD is caused by inflammation, the response causes plaque buildup in the arteries. Inflammation is triggered by bad diet, stress.

    And not by saturated fat or a lack of wine.

  37. Marilyn

    Forget the head-banging-on-desk. That looks like the kind of paper that would give one a headache just trying to follow the logic.

  38. Johanna N

    Must be the weather..
    it might at least contribute to cardiovascular health. There is an interesting talk by Richard Weller on TED.com, about the skin being able to store NO, which can be released by sunlight, thus leading to vessel dilatation.

    Thanks for your work.

    The same pattern apparently shows up in the China Study, at least according to Denise Minger’s analysis. Perhaps we’re looking at the benefits of vitamin D.

  39. Janet

    I met my American paradox in the grocery store this morning. I bent down to get my 3 dozen eggs from the shelf and next to me searching for the exact right carton of eggbeaters was a rotund lady. I just made the comment that “the real eggs were on sale and they won’t hurt you”.

    She said, “I’d love to, but I can’t have eggs. I’ve had a quadruple bypass”.

    I said, “the eggs still won’t hurt and you might really need them”.

    I told her that I am recovering from an (open chest with full cardio-pulmonary bypass) ascending aortic aneurysm repair 3 months ago. I had to have a carotid artery scan (crystal clear) and an angiogram (also clean) before surgery. Pretty good for a 71 year old hussie like me!! I’ve been LC/HF for over three years. Current ‘meds’ are multivitamins and aspirin. Seems to work for me.

    I looked in her ‘heart attack cart’ and there was whole grain bread, grits, egg beaters, two boxes of whole grain cereal, fake butter, skimmed milk, etc. I looked in my ‘no heart attack’ cart with salad makings, ½ & ½ cream, cheese, sirloin steak, shrimp, fish, 3 dozen eggs, and real butter.

    She said, “But look at you. You are a little skinny thing, you can eat anything you want”. (I’m 5’3″ and now weigh 103, but have lost 50 lb during this last 3 years)

    Well duh lady!

    Was this a n=2 observation? Me breaking all the “heart healthy rules” without a heart attack, and her with eggbeaters, skimmed milk, and wheat bread with a quadruple bypass and an extra 60-70 lbs pressing on her hips and knees.

    You were brave for trying, but it’s difficult to convince people the conventional wisdom is wrong.

  40. Alex

    We know now CVD is caused by inflammation, the response causes plaque buildup in the arteries. Inflammation is triggered by bad diet, stress.

    And not by saturated fat or a lack of wine.

  41. Marilyn

    Looking at that AHA chart as whole, I get the impression that deaths from cardiovascular disease are a pretty uniform percentage of total number deaths. More striking is the total mortality from the lowest to highest figures.

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