Dad of two; Java and web developer.
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A Candle Loses Nothing by Lighting Another Candle

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"Do you know what the trace of a matrix is?" he asked in conversation about math we enjoyed. The context was networking-- two professionals in the industry getting to know each other better at an event.
"No," I replied.
"I thought you were at a higher math level," he replied. He sighed and started explaining basic linear algebra concepts.

He then asked me what exactly my company does. I politely told him I build a texture compressor. He told me that that was pretty easy, boring work, but I guess good enough to pay the bills.

I'm noticing a high spike in this attitude lately, as my company's gotten more visibly successful.

And I think it's because when we believe someone is successful, we can choose our reaction: resentment, or joy.

I'm established now. I own a great company. I love my work and have happy customers and supportive people in my life. So I can see straight through the resentment for what it is: insecurity and disappointment in their own image of themselves. Fear that they'll be found out if they don't act smart. Putting people down so they aren't a threat.

This resentment manifests in a few major ways:

  • People asking me software/math trivia or throwing around obscure terms and acting surprised when I don't know them. People grasping at every time I say "I don't know" to prove my incompetence.
  • People simply telling me I'm not actually that successful, or my work isn't actually that valuable or enjoyable, or I'm not actually this happy.
  • And they often have networks of other people who have this attitude.

But you see, the people who react with joy:

  • Ask me how they can help me. Give without expecting to receive if they're in a position to do so.
  • Emanate a joy that's contagious and brightens my whole day, making me want to live life more fully.
  • Ask questions that come from a place of curiosity and enjoyment of life, not trying to prove who's smarter or more successful.
  • Introduce me to more kind-hearted people.

What is that saying? "A candle loses nothing by lighting another candle." These people live that quote.

It's important for me to acknowledge this because it bleeds into business. I've learned very quickly to avoid doing business with those who react to my success with resentment. Even if they aren't doing it on purpose, even if they aren't malicious, I still keep my distance.

It is a decision that cost me some short term profits early on.

But it is a decision that has more than paid off, over and over and over.

I kindly thank them for their willingness to talk to me, and move back to those who treat others with joy and happiness.

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15 days ago
Christchurch, New Zealand
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A lovely epigram by Thomas Erskine:

The French have taste in all they do,
Which we are quite without;
For Nature, which to them gave goût,
To us gave only gout.

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170 days ago
Christchurch, New Zealand
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Robert E McGinnis and the Secret of The New Cover

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I've loved Robert McGinnis's covers for a very long time. I remember the first one I was aware of (it was the cover of Ian Fleming's  James Bond book DIAMONDS ARE FOREVER, when I was about 9. They put the film poster on the book cover, which puzzled me a bit because the plot of the book isn't the plot of the film.) And I assumed that he had retired a long, long time ago.

About a year ago, Jennifer Brehl and I were talking. Jennifer is my editor at William Morrow, and is one of the best, most sensible and wisest people in my life. I am lucky to have her. We were talking about paperbacks, and how publishers put less effort into them these days. I went off about how paperback covers used to be beautiful, and were painted, and told you so much. And how much I missed the covers of the '50s and '60s and '70s, the  ones I'd collected and bought back in the dawn of time.

And somehow the conversation wound up with me asking if Harper Collins would publish a set of mass market paperbacks of my books with gloriously retro covers and Jennifer saying that yes, they would.

A few days later I was in DreamHaven Books in Minneapolis. I noticed a particularly gorgeous cover on an old book on a shelf. "Who did that?" I asked Greg Ketter.

"Robert McGinnis," said Greg. "Actually we have a whole book of McGinnis artwork." He showed it to me. The Art of Robert E. McGinnis. It's gorgeous. Here's the cover:

I was surprised at how recent the book was. It had been published a few months earlier. "Oh yes," said Greg. "Bob's still painting. Must be almost 90."

(He was 90 in February 2016.)

I sent a note to Jennifer asking if there was even the slightest possibility that Mr McGinnis would be interested in painting the covers for the paperback set we wanted to do. He said yes. Todd Klein, the finest letterer in comics, came in to create each book's logo and to help design it and pick the fonts, to make each book feel like it came from a certain age.

Each painting from McGinnis was better than the one before. Each Logo and layout from Todd Klein was more assured and more accurate. These things are glorious.

Now... we were planning to announce these in an much more planned and orderly way. I'm not going to tell you what books we're doing, or to show you any covers but the one.

And that's because the upcoming 2017 Starz American Gods TV series has created a huge demand for copies of American Gods. People who have never read it have started buying it to find out what the fuss is about. People who read it long ago and gave away their copy bought new ones to reread it.

The publishers ran out of books to sell.

So they've rushed back to press with the new paperback edition, which wasn't meant to be coming out for some months (and the text is the text of the Author's Preferred edition in case you were wondering).

And that means the version of the paperback with the new cover is going to be coming out a lot sooner than we thought. And tomorrow it will probably up on Amazon.

And I wanted you to hear it from me first.  You aren't going to see the rest of the Robert E McGinnis covers for a little while (and each of them looks like a different kind of book from a different era). But this is the first of them.

In my head, and Todd's, it's probably from about 1971...

Are you ready?


Here goes...

...and wait until you see the rest of them.

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388 days ago
Christchurch, New Zealand
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382 days ago
That style sure does ring a bell.
Boulder, CO

When does heart disease begin (and what this tells us about prevention)?

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I know, I know, I said I was going to limit things to one post per year, but the last one doesn’t really count and while the year isn’t even half over I’m willing to predict nothing will inspire me more to write a post in the next 6 months than Allan Sniderman’s recent editorial piece in JAMA Cardiology. More on that momentarily.

Before I get into this post I want to lay a few things out.

  1. This post is written mostly for doctors, but also for patients who really want to understand this topic, if for no other reason than to help them choose the right doctors. I don’t go out of my way to simplify the terminology and I assume the reader is familiar with the topics covered the cholesterol series I wrote three or four years ago. If you encounter a term you don’t understand, Google is a pretty good place to find the definition.
  2. I will not use this post to in any way get into prescriptive strategies, which involve modifications of nutrition, hormones, and yes, lots of drugs across four or five classes (i.e., much more than just statins) depending on the specific situation at hand and the risk appetite of the patient and physician, as well as the other comorbidities that must be co-managed. Even if I wanted to write out all of my prescriptive leanings I could not do it briefly.
  3. Please do not email your lab results or ask me to weigh in on your case. You know the disclaimer: I can’t practice medicine on a blog or over email.

There was a day when the only thing I argued about was who the greatest boxer of all time was. (I’m fighting all urges to turn this post into a manifesto of 1965-67 Muhammad Ali vs. 1938-41 Joe Louis vs. 1940’s Sugar Ray Robinson vs. 1937-42 Henry Armstrong.)

Today, however, I find myself arguing about so many things—some of them actually important—from why symptomatic women should receive hormone replacement therapy after menopause (and, by extension, why the Women’s Health Initiative tells us so, if you know how to read it) to why monotherapy with T4 for hypothyroidism is a recipe for disaster for most patients. But there is nothing I find myself debating more than the misconceptions most doctors have about heart disease. This is especially troubling since heart disease kills more Americans than any other disease. To put this in perspective, a woman in the United States is 7 to 8 times more likely to die from heart disease than she is from breast cancer.

Here are the typical arguments put forth, almost always by doctors, which invariably result in my need/desire to counter:

  1. Heart disease is caused by too much “bad” cholesterol (LDL-C).
  2. LDL-C is the only target of therapy you need to worry about.
  3. Calcium scores and CT angiograms (CTA) are great ways to further risk-stratify (the corollary: when these tests are negative, there is no need to treat the patient).
  4. Atherosclerosis is a “pipe narrowing” disease (ok, nobody uses these words, but they imply this by saying it’s a luminal narrowing disease).
  5. There is no role for preventatively treating young people, except in very rare cases like familial hypercholesterolemia.

Briefly, here are my counters:

  1. Atherosclerosis is caused by an inflammatory response to sterols in artery walls. Sterol delivery is lipoprotein-mediated, and therefore much better predicted by the number of lipoprotein particles (LDL-P) than by the cholesterol they carry (LDL-C) [Bonus point: always measure Lp(a)-P in your patients—but we’ll have to save Lp(a) for another day; it certainly owns its own blog post]
  2. Ditto point #1. And don’t ever bring up LDL-C again.
  3. Calcium scores and CT angiograms of exceptional quality (the operative word being exceptional—most are not) are helpful in a few settings, but this assertion is patently false, and I will leave this discussion for another blog post as the topic is too rich in nuance for a few lines.
  4. We’ll discuss this today.
  5. By necessity, we’ll be forced to confront this today, also.

Before diving into this topic it’s really important for me to acknowledge the person who has taught me almost everything I know about this disease, beginning back in 2011 when I first became aware that I basically had no idea what atherosclerosis was. For the past 5 years Dr. Tom Dayspring’s generosity has been remarkable and I’m humbled to be his most sponge-like student. Tom has not only given me an on-the-side lipidology fellowship, but he has also introduced me to the finest lipidologists and cardiologists in the country who have, in turn, been incredibly generous with their time and knowledge. I’m not the only one to benefit from Tom’s wisdom and generosity. I had dinner with Tom’s son and his wife once and I described Tom to them as a national treasure. That’s really how I feel about him. He is a nationally-recognized educator and his writing and presentations are devoured by fanatics like me across the globe. With Tom’s permission, I’ve deconstructed a video he put together into a series of figures which I’ll use to begin this discussion of how atherosclerosis actually takes place.

The physics of luminal narrowing

Traditionally, the atherosclerotic process was believed to involve plaque accumulation that prompted the gradual narrowing of the lumen, with the eventual development of stenosis. Stenosis then caused impaired control of flow (stable angina) and plaque rupture and thrombosis (unstable angina and MI). Consequently, prevailing opinion held that coronary angiography would be able to gauge the atherosclerotic process at all stages of disease.

However, in 1987, Glagov and colleagues proposed an alternative model of atherosclerosis development. After performing histological analyses of coronary artery sections, Glagov et al. reported that early atherosclerosis was characterized by plaque accumulation in the vessel wall and enlargement of the external elastic membrane (EEM) without a change in lumen size.

As atherosclerosis progressed, they found that plaque continued to accumulate in the vessel wall until the lesion occupied approximately 40% of the area within the EEM. At this point, the lumen area began to narrow. These findings have since been confirmed by intravascular ultrasound (IVUS). Due to the complex remodeling that occurs in the earlier stages of atherosclerosis, coronary angiography, which only visualizes the lumen, tends to underestimate the degree of atherosclerosis. In other words, atherosclerosis is well under way long before angiography is able to identify it.

I was reminded of the words of my Pathology professor back in the first year of medical school, “The only doctors who actually understand atherosclerosis are pathologists.” I would add lipidologists to that list, but I saw his point.

Most people, doctors included, think atherosclerosis is a luminal-narrowing condition—a so-called “pipe narrowing” condition. It’s true that eventually the lumen of a diseased vessel does narrow, but this is sort of like saying the defining feature of a subprime collateralized debt obligation (CDO) is the inevitable default on its underlying assets. By the time that happens, eleven other pathologic things have already happened and you’ve missed the opportunity for the most impactful intervention to prevent the cascade of events from occurring at all.

To reiterate: atherosclerosis development begins with plaque accumulation in the vessel wall, which is accompanied by expansion of the outer vessel wall without a change in the size of the lumen. Only in advanced disease, and after significant plaque accumulation, does the lumen narrow.

Michael Rothberg wrote a fantastic article on the misconception of the “clogged pipe” model of atherosclerosis. He opens with the following story:

A recent advertisement on the back cover of a special health issue of the New York Times Magazine section read “Ironic that a plumber came to us to help him remove a clog.” The ad referred to doctors in the cardiac catheterization laboratory as “one kind of pipe specialist,” and noted that the patient in the ad returned to work “just 2 days after having his own pipes cleaned out.” Although the image of coronary arteries as kitchen pipes clogged with fat is simple, familiar, and evocative, it is also wrong [emphasis mine].

Dr. Rothberg goes on to explain that for patients with stable disease, local interventions can only relieve symptoms; they do not prevent future myocardial infarctions. To be clear, at least 12 randomized trials conducted between 1987 and 2007, involving more than 5,000 patients, have found no reduction in myocardial infarction attributable to angioplasty in any of its forms. And yet, despite this overwhelming evidence, the plumbing model, complete with blockages that can be fixed, continues to be used to explain stable coronary disease to patients, who understandably assume that angioplasty or stents will prevent heart attacks—which they patently do not.

The root of the problem, in my view at least, is that we as doctors—and by extension, our patients and media—spend too much time looking at images like these (angiograms of coronary arteries complete with “clogged pipes”):

b1eebf133f6bea4f15f4b2ecf14f62ac 8854487

And not enough time looking at images like these (the histological, i.e., pathology, sections of coronary arteries):

histology of progression

But who can blame us, I mean, angiograms are cool! But, alas, it’s time to get serious about understanding this disease if we want to prevent/delay it.

Atherosclerosis, for the cognoscenti

Ok, so now let’s get rigorous about the disease that kills more Americans than any other disease. To understand this, as Frederic Bastiat wrote long ago, we must resort to “long and arid dissertations.” Buckle up.

The following figures were constructed from a video Tom Dayspring produced in one of his stellar lectures on the development of atherosclerosis. I’ve broken the video down into 20 or so steps which show the transition from a completely normal endothelium (i.e., at birth) through myocardial infarction. Each figure is preceded by a brief explanation of its content.


The endothelium is a protective one cell layer lining the surface of the artery lumen. Endothelial cells perform many complex functions and are capable of modulating vascular tone, as well as inflammatory and thrombotic processes. Their function depends on many circulating and local factors.


Low density lipoprotein (“LDL”) is a lipid (the bulk of which is cholesterol) transport particle. Please re-read this sentence. It is not “bad cholesterol,” a term that has no meaning. LDL—the particle—allows lipids (cholesterol, but also triglyceride, phospholipid) to be delivered through the aqueous medium of the blood, since lipids are hydrophobic (i.e., repel water) and a “carrier” is needed to transport them in blood (which is mostly water).

If LDL particles are present in physiologic (i.e., normal) concentrations, they effectively deliver cholesterol to those tissues that require it (recall: all tissues make cholesterol but some don’t make enough for their own needs and therefore cholesterol needs to be trafficked around the body).

The term LDL particle, LDL-P, and apoB are used interchangeably (the latter, because LDL particles are defined by the wrapping of a lipoprotein called apolipoprotein B-100).


When LDL particle concentration is elevated, the lipoprotein penetrates into the subendothelial space. Once in the intimal layer, they are securely attached to intimal proteoglycan molecules. The first step in atherogenesis is surface phospholipid (PL) exposure to reactive oxygen species and oxidation of the PL. LDL particles that are not oxidized are not atherogenic.  To be clear, it’s not the “getting in there” part that is the problem (HDL particles do this all the time and so do LDL particles, for that matter), it’s the “getting stuck and oxidized in there” part, formally known as retention and oxidation.


Once retained in the subendothelial space, the LDL particle may be modified, or oxidized (the clusters of yellow circles in the subendothelial space, below).


Oxidized LDL particles are toxic to the endothelium.  Now-dysfunctional endothelial cells express selectins and vascular cell adhesion molecules (VCAMS) which mark the injured areas of the vascular wall. It is worth pausing here for a moment. This step is kind of the turning point in the story. It’s also a perfectly “normal” thing for the epithelium to do. They sense a problem and like any law-abiding tissue, they ask for help from law enforcement. Think of the selectins and VCAMS as 911-calls. The police, who show up shortly, are the monocytes.


Selectins and VCAMS increase monocyte adherence to the endothelium.


The endothelial cells also express messenger cytokines such as interlukin-6 (IL-6) and tumor necrosis factor (TNF) which circulate to the liver and induce the production of C-reactive protein (CRP).


Monocytes penetrate the subendothelial space…


…and when they do, the monocytes differentiate into (i.e., “become”) macrophages (a more specific type of immune cell). Macrophages phagocytize (basically “ingest”) the modified or oxidized LDL particles.


The phagocytosis of oxidized LDL particles (oxLDL) and accumulation of lipid in the macrophage creates something called a foam cell.


Multiple foam cells coalesce to form the characteristic fatty streak, the hallmark of an early atherosclerotic plaque. Keep this mind. Later in this post we’ll come back to “fatty streaks” and I want you to remember how much has taken place to get us to this stage. I will posit that no one reading this post does not have fatty streaks unless there are some prodigious 5-year-olds reading this.


Nascent Apo A-I containing particles (also known as prebeta-HDL particles) accumulate free or unesterified cholesterol from the macrophages using ATP Binding Cassette Transporters A1.


As the HDL particle lipidates itself by delipidating the macrophage (i.e., takes lipid out of the foam cell), the HDL particle, utilizing an enzyme called LCAT, esterifies the free cholesterol forming cholesteryl ester (CE). As a result, the HDL particle enlarges and is free to be delipidated at a variety of tissues. HDL delipidation occurs through multiple mechanisms using Cholesteryl Ester Transfer Protein (CETP), aqueous free diffusion, SRB1 receptors in endocrine glands or gonads (e.g., to make hormones), adipocytes (a major cholesterol storage organ) or the liver (e.g., to package for biliary delivery). HDLs can also be internalized as entire particles by surface liver receptors.

A brief, but important, digression: the complexity, above, is probably the reason why every trial that has tried to increase the concentration of cholesterol in HDL particles (i.e., raise HDL-C) has failed, and failed epically, to reduce events. The value in HDL particles (the so-called “good cholesterol”—my god I hate that term as much as I hate the term “bad cholesterol” when referring to LDL) is almost assuredly in its functional capacity—what it is doing that might be cardioprotective (very hard to measure) rather than its cholesterol content (HDL-C), which is relatively easy to measure, but probably offers zero insight other than its positive epidemiological associations. In other words, measuring HDL cholesterol content tells you little about its cholesterol efflux capacity or any other of the numerous HDL functional properties.


Macrophages that become engorged with oxLDL remain full-fledged foam cells. Foam cells produce Angiotensin II, metalloproteinases, collagenases, elastases, and other proteins, which undermine the integrity of the arterial wall, causing more endothelial dysfunction. This is where the process goes to hell. Now you’ve got a damaged barrier and the looting begins. Oh, by the way, the process to date goes unnoticed by the calcium scan and CTA.


Chemotactic factors (i.e., chemical signals) trigger migration of smooth muscle cells to the area of injury in an attempt to repair the damage and pervert further disruption. Again, all of this is taking place in good faith on the part of the immune system. The smooth muscle cells are transformed into secretory cells that lay down a matrix to heal the injured wall. This matrix becomes the fibrous cap of the atherosclerotic plaque. Only now is the arterial lumen becoming encroached.


Metalloproteinases and collagenases are upregulated and they start to dissolve or weaken the plaque cap, typically at the shoulder regions where the diseased endothelial cells meet healthy endothelial cells. Some have used the term “vulnerable” to describe such plaques, which may be a correct term, but it also gives a false sense of confidence that we can treat atherosclerosis on a lesion-by-lesion basis. History has taught us that such hubris is unwarranted. Until proven otherwise, atherosclerosis should be viewed as a systemic condition of the arterial system. To see one of the best (and my favorite) papers on this topic, look no further than to this paper by Armin Arbab-Zedeh and the venerable Valentin Fuster, aptly titled The Myth of the Vulnerable Plaque.


The plaque can become obstructive—i.e., it can obstruct the lumen—over time. Lipid rich plaques are unstable, and can rupture. Platelets adhere to the ruptured surface of the plaque through electrostatic factors and through binding to specific ligands.


The platelets then serve as a cradle for the coagulation cascade to produce a net of fibrin (the white “net” in the figure), leading to a red clot, as red blood cells are caught in the net. A non-obstructive plaque can lead to a clinical event after the superimposition of red and white thrombus, which can occur quickly and without warning. The degree of stenosis (luminal narrowing) does not predict when this will happen.


Why all of this matters

So back to this impetus for this post—Allan’s editorial. I met Dr. Allan Sniderman four years ago through Gary Taubes and Allan and I immediately hit it off. Like Tom, Allan has been a remarkable mentor and teacher. In fact, one of the gifts Allan gave me a while back was his personal copy of Herbert Stary’s legendary pathology textbook on atherosclerosis, Atlas of Atherosclerosis Progression and Regression. I devoured this textbook and have since purchased additional copies to always have one on hand. Ask my patients…most of them have had to sit through viewings of it like it was a vacation photo album.

About 18 months ago Allan and I were having dinner and discussing our favorite topic. Allan asked me to guess what fraction of cardiac events (“event” is a pretty common word in the vernacular of cardiovascular disease and basically refers to a Q-wave MI, the need for re-vascularization, or cardiac death) take place in North America in those younger than 65. I knew it was a loaded question, so I rounded my guess up to 25%. I was wrong. How wrong I wouldn’t find out until Allan and his colleagues completed their analysis which formed the basis for their editorial recently published in JAMA Cardiology. Add it to your weekly reading list.

You don’t have to be a lipidologist or a pathologist to understand this paper, but it helps to understand the basics of math—big denominators can drown out even modest numerators. The aggregate figure from this paper is one of the most elegant representations of a dot product. The subfigure on the left is how most doctors (myself included until a few years ago) and authorities think of coronary heart disease (CHD)—it’s virtually silent until the 7th or 8th decade of life. What folks who think this way miss is the middle figure—the population base (the “denominator”) is shrinking while the incidence (the “numerator”) is rising. In a situation like this, the only way to really see what’s happening is to do what Sniderman et al. did—calculate the absolute event rate, as shown on the right.


Yes, you’re reading this graph correctly. A little over half of all events in men (24% + 28%) and a little less than a third of events in women (13% + 19%) take place below the age of 65.

Tying these two insights together

Insight #1: Atherosclerosis takes a long time to evolve, and involves many steps.

Insight #2: Many cardiovascular events—half in men and one-third in women—take place in young people (i.e., those 64 or younger)

How do we reconcile these findings? Enter the pathologists. As I mentioned above, my first year pathology professor in med school insisted that pathologists were the only doctors who really understood heart disease, because they actually did the autopsies and examined the coronary arteries under microscopes.

And this brings me to my point. The only way Insight #1 and Insight #2 can be correct is if atherosclerosis takes a long time to develop. Any guesses as to what the greatest single risk factor is for heart disease? Smoking? Nope. High blood pressure? Nope. The wickedly deadly particle I have yet to write the most deserving post on, Lp(a)? Nope. LDL-P or apoB? Nope. LDL-C? I thought I told you to never say that again. CRP? Nope. None of these things. It’s age. Age trumps everything. In this sense, atherosclerosis is an “integral” disease (in the calculus sense of the word)—meaning it’s a disease of compounding injuries, as I painstakingly went through above. Age = persistent exposure to LDL-P/apoB.

Just like wealth is compounded in a highly non-linear way, so too is illness and no disease to my knowledge does so more clearly than atherosclerosis. So the jugular question is when do we need to start treating patients? That is a question I can’t answer for you. Not because I don’t have a point of view, which I most certainly do, but because it comes down to risk tolerance. I can no more impart my world view of this problem on you (though the answer seems painfully obvious to me) as I can my world view of how to raise kids or combat ISIS. But I do hope to leave you with a clear picture, at least of the disease process.

Perhaps the greatest insights into the pathogenesis of atherosclerosis, especially at they pertain to age, comes via autopsies of two variants: those of people known to die of some cause other than heart disease and those known or suspected of cardiac death. The table, below, taken from this paper, summarizes the six stages of atherosclerosis. Stary’s stages are identical, except that he further divides the sixth of these stages into three stages, for a total of eight stages, but the points remain the same. The points being, of course:

  1. In the first decade of life fatty steaks are being formed. That’s right, before the age of 10.
  2. Atheromas are present by the time most people are in their 20’s.
  3. By the time you are in your 30’s you are quite likely to have fibroatheroma formation.
  4. The vast majority of atherosclerosis-initiating sterols get into the artery as “passengers” in apoB-containing particles most of which (90%) are LDL particles.


I’ll close with another interesting study, published in Circulation in 2001. The title of the study—High Prevalence of Coronary Atherosclerosis in Asymptomatic Teenagers and Young Adults—pretty much tells you what they found. The authors performed intravascular ultrasound (IVUS) on 262 heart transplant recipients about a month following their transplant. Before going any further, it’s worth pointing out that IVUS is not as sensitive as pathologic sectioning so this study is likely underestimating the degree of disease present in the hearts (but obviously one can’t section the coronary arteries of donor hearts). By doing the IVUS on the recipients so soon after they received their transplant the authors were able to study the hearts of the donors, many of whom were quite young.

The figures below, both taken from the paper, show the frequency distribution and prevalence of intimal thickening for each age cohort of donors. Consistent with the pathology studies, which actually cut open the arteries and examined them histologically, the IVUS study found a similar trend. Namely, atherosclerosis is starting much sooner than previously recognized. In this series of 262 heart donors, one out of six hearts donated by a teenager was found to have clinically measurable atherosclerosis. The authors conclude: “These findings suggest the need for intensive efforts at coronary disease prevention in young adults.”

Fig 3

Fig 3

Final thoughts

I was 35 years old, the year my daughter was born, when I first confronted my own inevitable demise which, based on my family history, was likely to be a cardiovascular one. I’m sure I’d be better off if I had that epiphany when I was 25 or possibly 15, but I’m glad it happened when it did. Today, I manage all modifiable risk factors to the level of my risk appetite and interpretation of the most nuanced scientific literature on cardiovascular disease. Does this mean I won’t succumb to heart disease? Of course not. But this is a stochastic game and the objective of the game is to increase the odds in your favor while delaying the onset of bad outcomes. It’s up to each person, and their doctor if necessary, to determine how aggressively they want to confront the inevitable—we all have atherosclerosis at some level.

The post When does heart disease begin (and what this tells us about prevention)? appeared first on The Eating Academy | Peter Attia, M.D.. See the original post When does heart disease begin (and what this tells us about prevention)?.

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418 days ago
Christchurch, New Zealand
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the c-word and gendering mansplaining

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In 2011, Douglas Bigham asked me if I'd write a piece about "the c-word" for the Popular Linguistics website, which he was trying to get started at the time. He observed:
It *seems* to me that "c---" is less gendered in the UK, but can only be directed at a woman in the US.
(He didn't censor the word, but I have. I'd say it in a linguistics lecture, but putting it on a page is a bit too in-your-face for a blog that wants to be used in schools. I think I've screwed my chances with the nanny software already, though. Of course, I'm talking about the word that's an anagram of the name of a certain Danish king.)

The article never happened (I'm sorry!) and the site closed (I hope unrelatedly, but I will admit my contribution by non-contribution, if necessary). But today I am moved to write a bit about the word because of this (slightly censored for this blog) message I got on Facebook this morning:

I will come back to why I got this message and why I've hidden his full name. Let's just deal with the BrE/AmE difference first.

This message looks like it's from the USA (Wisconsin, according to his now-blocked Facebook profile), because he called a woman a 'dumb c-'. Looking at the GloWBE corpus, there are two unique instances of this phrase in the American data. Both refer to women. There are five in the British data and they refer to: a male athlete, a male friend, and fans of a certain football team or football magazine. This is not to say that it can't refer to either sex in either country, but there are definite different tendencies, and they give the word a different feel in the two places. The shift from feminine to masculine in BrE is (of course) part of a more general tendency to use words for women (or our parts) as the ultimate way to put down a man. Which just sums up the status of womanhood in our culture rather neatly.

(The data for stupid c--- are a bit more mixed, but still tending toward(s) AmE=female, BrE=male. And, as we've seen before, the nationality of GloWBE data is probably 15-20% corrupted by the internationality of web data.)

In the UK, the word is thrown around rather easily among men. It can be used among friends in a playful way, way but more often (as far as I can tell) it is a term of abuse for men those they don't like. The statistical analysis in the GloWBE corpus marks it as a particularly British word, with 1634 British uses to 467 American ones. The statistically "most British and not American" words to come before it are that, fat, black, some and the. (The American data shows up no 'strongly American' collocates.) That shows us that it's often used referentially--i.e. to talk about people rather than to address them directly, as in "Some c- of an economics analyst on BBC News 24 just tried to equate...".

The British can be amused by how much this word offends many Americans. And it does offend. For me in my American state-of-mind, only certain racial insults are viler than this word. It was a very long time before I could say it out loud at all (I don't think I ever even heard it till [AmE] college/[BrE] university), and I am not usually one who is shy about words.

But the intent with which words are uttered is what really matters and this reminded me of something else that happened recently:
This was in the UK, and what the man yelled (really aggressively at a woman in an open-windowed car) was "YOU STUPID COW". While cow isn't a taboo word, it can be used very aggressively (and also often playfully) to refer to women in BrE. (Worth noting here that everyday life in the UK provides ample evidence against the American stereotype that the English, as a people, are polite.)

I wouldn't claim that  cow got started as a substitute for the coarser anatomical word (women have been insulted by all sorts of animal names for centuries), but I think that in cases like this road-rage incident there's a link. The former c- word for women is now used for men, but cow provides a similar articulatory gesture.

I've seen lots of cases of women reclaiming the c-word as an anatomical term, but less so reclaiming it as a word for people, rather than people-parts. (Compare the word for a female dog, which has been reclaimed often as a word for women showing strength of character in the face of sexism.)

a bit on the mansplaining...

I'd like to say a bit about what led to this point. It started when the Linguistic Society of America shared a link on its Facebook page:

That's a bad piece of  (AmE) subhead /(BrE) standfirst writing. What it means is that studies are equivocal about whether bilingualism helps cognitive development. What it says is that there might not be any advantage to bilingualism. Linguists know well about these debates, and so I posted an ironic comment on the article:
"not show any real benefits"? Like speaking two languages isn't a real benefit?
I later added a smiley face. But not having the smiley face led Mr Jason, above, to explain to me that there are studies that have said that there are cognitive benefits of bilingualism and other studies that have said there are not. (He deleted his explanation before I received his personal message.) I went back-and-forth in my mind a bit about how to respond to it, and I went with this comment-reply:
Sorry, is this what they call 'mansplaining'? It was a critique of the phrasing. I do know this. I do teach it!
And in the morning, I got the private message you see above. Before reporting him to Facebook and blocking him, I did get a look at his public profile. According to that, he had studied English Applied Linguistics at a Wisconsin university less than 10 years ago. I am not including his full name here, because, honestly, it's not worth whatever further abuse he might be willing to give. I have once before received a very similar Facebook message from another  young man (that one in Ohio) after I beat him repeatedly on an online game and he accused me of cheating. (I no longer play on-line games against people I don't know.) I know a male Scrabble champion who gets such cheating-accusation abuse all the time. All they needed to do was google his name to know how silly their accusations would sound. But that seems to be expecting too much of some people. So here are some helpful rules if you want to insult people on the internet.
Rule #1 #1 for insulting people on the internet: find out who you're insulting first.
Rule #2 #2 for insulting people on the internet: don't insult people on the internet.
(I bother with rule #1 #1 because you might learn something interesting. )

Now, you might say here that I did not follow rule #2. I would disagree that I literally insulted, though I will admit that it seems to have had the same effect. I used the word mansplaining in order to call out a behavio(u)r. I did not call the person anything. Maybe that one needed a smiley-face too.

I had weighed whether to call it mansplaining (and even when I did, I did so indirectly), but in the end I went with it (and even got a 'like' and a supportive message about it). I've posted this Jason's message on my Facebook page and have been discussing it with my friends this morning. One (male) friend, whil{e/st} while being sympathetic to my situation and angry on my behalf, said
this is why I'm not a fan of the word 'mansplaining'. Let's not taint the name of a whole gender because of these morons.
And I've got mixed feelings about that. I replied (in part):
I have had my joke explained to me three times and it has been by a man each time. Any genitals-free behavio(u)r can be done by anyone, sure, and I have used 'mansplain' at least once of a woman, but that doesn't mean it's not gendered behavio(u)r. Just like I argued two weeks ago(?) that I felt it important to call out creepy behavio(u)r as 'creepy' I think this needs to be called out for what it is. [...C]alling it out with the 'man' is to acknowledge male privilege, and I think men (and whites and straights) need it pointed out once in a while that they are coming from a position where they've assumed some things based on that privilege. I 40% agree with you, but I 60% agree with me.
The creepy thing relates to another debate with my Facebook friends. When an inappropriate appreciation of my photo was posted in the '10th blogiversary' post, post, I went back and forth a bit about whether to just delete the comment or to thank him for the other part of the comment, followed by comment "but let's keep it non-creepy, please".

In that case I got a mix of advice in both directions. I put up the "thank you for your kind comments on the blog, but please let's keep it non-creepy" comment and deleted it almost immediately (I don't know whether the post will have gone out to people who were following the thread by email) and then deleted his comment (because I do have a comments policy and I just didn't want to spend my time debating it with strangers). I found it interesting that several female friends suggested paraphrases of the comment (mostly without the warm thanks part) that changed creepy to inappropriate orthat asked for "no personal comments, please" or that I not post a photo of myself. I reacted to those suggestions [in part] with:
I don't mind personal comments. I don't like creepy comments. If I'm going to [comment on] it, I'm going to say 'creepy'. [...]  'Inappropriate' doesn't tell him what was inappropriate about it. Creepy does. Some guys don't reali{s/z}e what creepy is [...]

I post pictures to be more human. Having a face isn't an invitation for somewhat sexual comments about it. I do have a comments policy where I say that I reserve the right to delete things that aren't in the spirit of helpful conversation. But I'm not interested in banning comments about appearance. If someone says "You look just like one of my cousins!" or "I think your hairstyle has got more British while you've lived there" (I don't think it has!), that can be a bit of fun.
So, as I said above, I 60% think that when unfortunate behavio(u)r is gendered, it's important to point out the genderedness of it. That way, you hope that the person who's creeped you out, or exasperated you, or insulted you might go ahead and think about their sociali{s/z}ation socialization to act in this way and to maybe pause to think a bit more about the things they've been led to believe about the world.  Maybe before "helping"  someone who's said something that they think "needs help", they might pause to wonder whether there's another possible interpretation of what she's said (it could have been a joke) or whether she might know more about the topic than you do.

The act of explaining things to people who don't need an explanation can be done by any gender of person to any other gender of person, sure. And it is usually done with no malice. But there's a reason it's been called 'mansplaining' and it is exhausting. Women get their jokes misunderstood or explained to them because there is a cultural assumption that women aren't funny. Many men (in many cultures) are put in positions from childhood where they are listened to, treated as authority, expected not to keep quiet and play along. And so on and so forth.

The main reason not to call out genderedness of gendered behavio(u)r (the other 40%--but it's important to note that my 60/40 split sometimes reverses) is that it makes people defensive when they're treated as a phenomenon and not an individual. And so they might not learn. But if the genderedness isn't pointed out, then they might not consider everything there is to learn there. I tweeted my ironic comment (my joke, if you will) as well:

At the time I'm writing this, 30 people have retweeted it, and 80 have 'liked' it, so I think many are getting the joke. But another three men have tweeted back to 'explain' the line about 'no real benefit of bilingualism' to me. Another follower called one of them out for mansplaining, and the explainer protested that he hadn't mansplained--he just hadn't read the article. So to him, explaining an article you haven't read to a person who has read it (and made a joke about it) isn't mansplaining. To me it is a perfect example. But it may well be the naming of it as a gendered behaviour that (apparently) kept him from thinking more deeply about the matter. This is why sometimes my 60/40 thinking flips to 40/60. I could try to deal with the situation by saying "let's all be good humans and treat each other with respect", and that's what I want in the end. But I think it's hard to think about what "being a good human" means without being able to reflect on sexist privileges, beliefs, and behavio(u)rs. If you've grown up male (and comfortably masculine) in a culture where masculine power and the masculine point-of-view is the default, then your perspective on what it means to be treated badly in that culture starts from a position with a limited view.

Of course, the other reason not to point out sexism is that there are a lot of scary men out there. They send threatening messages. They call the other scary trolls' attention to you. And in Jason's land they're allowed to own guns. America has become a violent opera about the dangers of damaged masculinity. It's a complete Catch-22. Don't call out sexist behavio(u)r, and sexist behavio(u)r is allowed to thrive. Point out sexist behavio(u)r and you might have to live with more (and worse) of it.

(I'm sticking to sexism here, but I think the argument and the dangers are fairly transferable to other kinds of discriminatory structures and behavio(u)rs and the privilege they create. But that might not be for me to say!)

In case you are ever accused of mansplaining or any other kind of unhelpful 'splaining, here here's are some responses that you might consider:
"Whoops! Sorry about that!"
"It hadn't occurred to me that I was doing that, but thanks for pointing it out."
"Fair enough. Never mind!"
"Hm. That's given me something to think about, thanks."
If you use the last one, please note that you can do the thinking without involving the person who felt mansplained-to. Don't expect them to give you a sticker for working it out. Don't expect that they want an argument about why what you did wasn't really mansplaining. Just take it as someone else's observation on your behavio(u)r. (You don't even have to reply at all on social media.) And then, if you want to be helpful, try to see it from their side.

on  irony

And, yes, it's dangerous to try to achieve irony on the internet. Next time, I'll try to remember the smiley face. British people often comment on Americans' alleged inability to interpret ironic statements (here are two old posts about that: one two and a BBC piece on the matter). There are definite regional differences in this, however, and that may have been a factor here.  I'm a northeasterner. (It may also be relevant that I'm an academic.)  I do irony, and I enjoy it when others enjoy it too.

p.s. avoiding mansplaining

I forgot to add my easy mansplaining-prevention tips for any gender:
  1. If you feel the urge to explain something (especially to a stranger, especially on social media), pause to ask yourself: was I asked a question? 
  2. If you were asked a question, consider: might this be a rhetorical question?
  3. If you weren't asked a non-rhetorical question, there is no need for you to explain.
Regarding the second item: it's not a bad idea to avoid rhetorical questions in writing.
Regarding the third item: this doesn't mean you can't have a conversation about the topic. But rather than trying to explain, you could ask a question and find out more about the other person's relationship to the topic. You could say why you too think the topic is interesting. There are many things you could do that don't involve making yourself seem like a mansplainer...

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431 days ago
Christchurch, New Zealand
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Thoughts and Prayers

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A man goes into an immigration services center in Binghamton New York, blocks the exit in the back with his car, goes through the front door with handguns, body armor and ammunition. He shoots the receptionists and opens fire on a citizenship class. He murders thirteen. This is horrific. I offer my thoughts and prayers.

A psychiatrist trained to help others with the stress of combat goes to Ft. Hood, the army base at which he is stationed, and opens fire on his fellow soldiers and some civilians, too. Another thirteen people are murdered there. Three are killed charging the shooter. Words cannot express my sorrow. I offer my thoughts and prayers.

A professor is denied tenure at the University of Alabama. She goes to a department faculty meeting and in that conference room pulls out a nine-millimeter handgun and shoots six people, three of whom she manages to murder. Those people were just doing their jobs and what happened to them is terrible. I don’t want to have to think about it any further. I offer my thoughts and prayers.

A truck driver in Manchester, Connecticut comes out of a company disciplinary hearing for allegedly stealing beer and starts shooting up his place of work. He murders eight people, calls his mother and tells her about it, and then shoots himself. Gun control discussions are a mess in this country and they never go anywhere productive, there’s no middle ground, and they make me tired thinking about them. I offer my thoughts and prayers.

In Tucson, Arizona, a member of Congress is meeting with her constituents in the parking lot of a supermarket, and a 22-year-old man comes up and shoots her straight in the head. A representative to Congress, can you believe that! She somehow survives, but he murders six others, ranging in age from nine to 79. That’s quite a range. Surely the attempted assassination of a US Representative will start a substantive discussion by someone. In the meantime, I offer my thoughts and prayers.

Seal Beach, California, where a man and a woman are having a custody dispute. His solution: Enter his wife’s place of work, a hair salon, and open fire on anyone there. He murders his ex-wife and seven other people, including one man not even in the salon. He is  was in his car in the parking lot outside the salon. Bad luck. Here’s an interesting thing: there is a sort of magical power to saying that you offer your thoughts and prayers.

Oakland, California, and at a small Christian college, a man who had been expelled for behavioral and anger management problems decides that he’s going to find an administrator he has issues with. He doesn’t find her, so instead grabs a secretary, enters a classroom and orders the students there to line against a wall. Some refuse. He shoots, reloads and shoots some more. Seven people are murdered. The shooter later says he’s sorry. The magical power of saying that you offer your thoughts and prayers is that once you do it, you’re not required to do anything other than to offer your thoughts and prayers.

In Aurora, Colorado, a midnight audience of Batman fans are half an hour into the final installment of Christopher Nolan’s superhero trilogy when a man enters the theater, clad in protective armor, sets off two gas canisters and starts shooting. Some audience members think this is a stunt tied into the film. It’s not a stunt, and the shooter, armed with an assault rife, a shotgun and a glock, murders a dozen people, ten of whom die right there in the theater. When police visit the shooter’s home, they find it rigged with explosives. The shooter placed a camera to record what happens if the police just barge in. Saying “thoughts and prayers” is performative, which is to say that just in saying it, you’ve performed an action. Prayers leave your mind and go to God. It is a blessed, holy and as such apparently sufficient thing, to offer your thoughts and prayers.

Sunday morning, and in Oak Creek, Wisconsin, members of the Sikh temple there have gathered for services and meditation and are preparing a communal meal when a white supremacist and Army veteran starts shooting, murdering six and wounding a police officer before killing himself. Did you know that Sikhs are often confused by the unknowing and possibly uncaring for being Muslim, and that the excuse of “I thought they were Muslims” is itself a sign of racial hatred? Mind you, there are people who will say to you that it’s not enough, only to offer your thoughts and prayers.

In Minneapolis, a man is called into an office by his supervisor and told he is losing his job. The man replies, “Oh, really?” and pulls out a handgun, shooting the supervisor after a struggle for the weapon, eventually murdering five others before killing himself. Indeed, people particularly particular expect more from lawmakers, who have the ability to call hearings and allow government studies and even change laws, rather than only to offer their thoughts and prayers.

Brookfield, Wisconsin, another hair salon, another estranged couple. The wife seeks  sought a restraining order when the husband threatens threatened to burn her with acid and set her on fire with gasoline. He does neither. He does, however, murder her, along with two other women. Witnesses say the wife tried to protect the others before she died. But again, even if you’re a lawmaker, with the ability to do things that could have concrete impact, you might argue that your responsibility to women being murdered by husbands, workers co-workers murdered by co-workers, religious minorities murdered by bigots, soldiers murdered by other soldiers, innocents murdered by those who are not, ends when you, in a tweet, Facebook post or press release, offer your thoughts and prayers.

A man enters an elementary school in Newtown, Connecticut, and with a Bushmaster XM15-E2S carbine rifle, murders twenty children, all of whom are either six or seven years old.

We pause here a moment to think about that.

Twenty children. Ages six, or seven.

And here maybe you think to yourself, this is it. it. This is the place and time where thoughts and prayers in fact aren’t enough, where those who only offer their thoughts and prayers recognize that others see them in their inaction, see that the convenient self-absolution of thoughts and prayers, that the magical abnegation thoughts and prayers  offer, offer is no longer sufficient, is no longer proper, is no longer just or moral, or even offers the appearance of morality.

We pause here a moment, and we wait to see what happens next.

And then they come. One after another.

I offer my thoughts and prayers.

And it keeps going.

Five murdered in Santa Monica, California by a gunman. I offer my thoughts and prayers.

12 murdered in a running firefight through the Washington Navy Yard in DC. Like a ritual, I offer my thoughts and prayers.

Ft. Hood, Texas again, for another three murdered. Like a litany, I offer my thoughts and prayers.

Six murdered in Isla Vista, California. Violence against women is horrible, and I offer my thoughts and prayers.

Nine murdered in Charleston, South Carolina. It’s unspeakable that violence against black Americans has happened like this, and I offer my thoughts and prayers.

Five murdered in Chattanooga, Tennessee. Muslims should answer for the crimes of this person, even if they do not know him or would in any way condone the action, and I offer my thoughts and prayers.

Nine murdered in Roseburg, Oregon. I offer my thoughts and prayers.

Three murdered in Colorado Springs, Colorado. Thoughts and prayers.

Fourteen murdered in San Bernadino. Thoughts. Prayers.

Fifty murdered in Orlando.

Fifty people, in a gay club, by a shooter who his father says was disgusted by the sight of two men kissing, and who news reports now tell us had pledged allegiance to ISIS.

And what do we do now, I wonder, when the victims are who they are and the perpetrator is who he is, the situation is ripe for posturing, and there’s a phrase to be used that allows one to assert maximum public virtue with minimum personal effort or responsibility?

What do we do now, when thoughts and prayers are easy, and everything else is hard?

Here is the thing: In the aftermath of terrible violence, offer thoughts, and prayers, if it is your desire to do so.

Then offer more than thoughts and prayers. Ask for more than thoughts and prayers. Vote for more than thoughts and prayers. Help those for whom thoughts and prayers are the  a start of their responsibilities, not the  an abdication of them. And as for the others, you may politely remind them of Matthew 6:5-6, 6:5-7, and perhaps also Matthew 7:21-23. 7:21-23. Perhaps they will see themselves in the words there. Perhaps not. They’re worth thinking on regardless.

“I offer my thoughts and prayers.”

Thank you.

It’s not enough.

It never was.

What more do you have to offer?

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433 days ago
Christchurch, New Zealand
433 days ago
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6 public comments
425 days ago
Missed this last week, but as per usual right on the money.
New York, NY
430 days ago
When do we move beyond offering our thoughts and prayers?
433 days ago
"Thoughts and prayers" aren't enough.
433 days ago
Queue Anthony Jeselnik
433 days ago
So true.
Heidelberg, Germany
433 days ago
Scalzi, at his best
Corvallis, OR
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