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Modified eggs — Who benefits most?
1. Kim SC. Implantable defibrillator therapy: does it really prolong life? How can we prove it? Am J Cmdrol 1993;71:1213-1218. 2. Connolly S, Yusuf S. Evaluation of the implantable cardioverter defibrillator in survivors of cardiac arrest: the need for randomized trials. Am J Cardiol 199269: 959-962.
One Symposium
Not listed
I read with interest the minutes of
The American Journal of Cardiology editorial board published in the June 15, 1993 issue. Table IX represents symposia published in AJC during the year 1992. However, the symposium on Management of Heart Failure in the 1990s: A Reassessment of the Role of Digoxin Therapy, published June 4, 1992 (Am J Cardiol 1992;69: lG-154G), did not appear in this table or the text. Mihal
Gheorghiade, MD Chicago, Illinois 30 August 1993
I enjoyed reading the article on the results of percutaneous balloon mitral valvuloplasty in young adults by Rothlisberger et al.’ However, I wish to point out the questionable use throughout the text of the word “dilatation,” e.g., “balloon dilatation catheter,” “incremental dilatation with the Inoue balloon” and “dilatation has been attempted even in patients with less pliable valves.” In each case, the proper word should be dilation, not dilatation. Historically, dilatation and dilation existed as competing forms and have been used interchangeably.2 But they really should not be. According to both Dorland’s and Webster’s dictionaries, dilation is “the action of dilating or stretching” or “the state of being dilated,” while dilatation is “the condition of being stretched or dilated or stretched beyond the normal” with Webster adding: “especially as a result of disease or abnormal relaxation.“” Etymologically, dilate is from the Latin word dilatare, with the stem dilatat-and the corresponding noun dilatatio; from this comes the English word dilatation.4 But -tion is a live suffix in English, and there is no reason why it should not be added
to the English verb dilate to give di-
latiork4 Too many medical writers chose the long (and more impressive?) word when there is a choice. We read of “employ” instead of “use,” “investigation” instead of “study,” and “dilatation’ ’ instead of “dilation.” In pharmacology, a vasodilator causes dilatation, not dilation of the blood vessels; balloon valvuloplasty is a catheter technique of dilation, not dilatation of a stenotic heart valve; dilatation, not dilation of the aortic root is a common complication of Marfan syndrome; dilation, not dilatation of a stenotic valve may sometimes result in dilatation, not dilation of its annulus. I hope that these examples serve to clarify once and for all that dilation and dilatation are neither synonymous nor interchangeable. Tsung 0. Cheng, MD Washington, D.C. 14 July 1993
1. Rothlisberger C, Essop MR, Skudicky D, Skoularieis - J. Wisenbaueh - T. Sareli P. Results of nercutaneons balloon mitral valvotomy in young adults. Am 1993;72:7.3-77. J Cardiol 2. Bloom DA, Mary RN, Hinman F Jr. Dilation vs. dilatation: a brief history. J Urn/ 1992: 147: 1682. 3. Cheng TO. Dilatory matter. Lower 1993;341: 1220. 4. Hughes A. A dilation on dilatation. Lancer 1993: 341:867.
Accuracy of Nongeometric Pulsed Doppler Cardiac Output De Domenico and colleagues’ achieved a relatively disappointing correlation (r = 0.82) using our2 nongeometic method for stroke volume determination. We had reported r = 0.97.2 The authors apparently missed our extended results in a larger series, with a new regression equation for ejection rate: ejection rat6 = 491 mean flow velocity - 61 ml/s,’ although even that improvement may not have altered their results significantly. The method depends critically on accurate determination of left ventricular ejection time, and this can be difficult without technically excellent Doppler recordings and relaxed suspension of respiration. Indeed, Australian investigators4 used our method in different patients from ours or De Domenico’s, reporting r = 0.97, with r = 0.77 for the geometric method.
Perhaps the authors could reexamine their left ventricular ejection time measurements. David H. Spodick, MD, DSc Worcester, Massachusetts 26 August 1993 1. De Domenico R, Zepellini R, Gheno G, Compostella L, lavemaro A, Cucchini F. Accuracy of a new, nongeometric pulsed Doppler method in cardiac output evaluation. Am .I Cardiol 1993;72:48%491. 2. Spodick DH, Koito H. Nongeometric Doppler stroke volume determination. Am J Cardiol 1989;63:883-884. 3. Koito H, Spodick DH. Relation of left ventricular ejection rate to ejectional flow velocity. Am J Noninvas Cardiol 1989.3:22&227. 4. Sajkov D, Cowi RJ, Bradley JA, Mahar L, McEvoy RD. Validation of new pulsed Doppler echocxdiographic techniques for assessment of pulmonary hemodynamics. Chest 1993; 103:1348-1353.
Modiied Most?
Eggs -
Who Benefits
The old cliche - “Which came tist, the chicken or the egg?” may presently be more appropriate than in the past, especially since increased speculation has occurred regarding the benefits of the recently introduced, so-called ‘ ‘modified eggs.” Perhaps the question should also include who benefits most, in addition to what benefits, if any, may be achieved by their use? The parties concerned are obvious, and other than the egg itself, must include the chicken, the consumer, the retailer and the producer. The letter that physicians received from Eggland’s Best begins by stating: “Your patients may be asking you about a neti egg they have been seeing on television. . . .” Indeed they are-not only asking, but also misinterpreting all of the vaguely illustrated news media presentations. The consumers’ basic conclusion, in my experience, is that they c.m consume these eggs ad libitum with virtual disregard of a properly prescribed diet. They also feel that they therefore need not worry about increasing their cholesterol levels by eating these eggs, in contrast to their eating ordinary (generic) eggs. The patients fail to absorb the fact that a strict low-fat, low-cholesterol diet must be adhered to. They also misinterpret the media advertisement and allow themselves to believe that they can actually lower their cholesterol by eating these eggs -and it is no wonder, READERS’COMMENTS 421
TABLE I Cholesterol Calories
when one reads the advertisement brochures that are so cleverly written and presented. The brochure indicates that their hens are fed an enriched diet with no animal fat (94% unsaturated canola oil is the only added fat). The diet, according to a letter received with the brochure, is further enriched with vitamin E, and a natural mixture of rice bran, alfalfa meal and kelp as pan of the feedingprocessa great diet from which perhapseven humans could benefit. The research paper indicates that the feed contains 65% corn meal, 21% soybeanmeal, 1% canola oil, vitamin E, iodine and kelp, but no animal by-products.] The question is, does this wonderful diet fed to the hen, help anyone but the hen? It is stated that the modified eggs contain a lower ratio of saturatedto monounsaturated fat, and more vitamin E than do other eggs. How then does this help my patient and does it actually do anything significant from a medical-nutritional standpoint? The following statementsare taken from the brochure, beginning with the following opening comment: ‘ ‘Even your hypercholesterolemit patients can enjoy up to u dozen real eggs per week without increasing their cholesterol” - a very misleading and misdirected statement, if not erroneous. Then we are subjected to the following main conclusions of their presentation (based on a research project quite cleverly conceived and performed): (1) “Subjects on a National Cholesterol Education Program (NECP) diet who included 12 Eggland’s Best eggs per week, significantly reduced total serum cho422
(mg)
Fat
Saturated Fat
w
k)
lesterol and (lowdensity lipoprotein) cholesterol levels.” (2) “There was no significant difference in cholesterol reduction between those eating no whole eggs and those enjoying Eggland’s Best.” Both statements are alforded the same singular reference, with many of the references at the end of the researchpaper not being particularly relevant to the issue at hand. But did anyone ask, as certainly they should, what the outcome would have been in a comparison group using regular eggs? Therein lies the major flaw of the study - a clever, if not somewhat deceptive control that is incomplete because of a successful attempt at coming to a desired conclusion. The nutritive comparison charts reveal the standardaccepteddata on the content of a regular egg in relationship to modified eggs, as reported on. the retail box (Table I).2 The data taken from Table I in reference 1 indicates the partitioned fat content (Table II). The producers are to be congratulated on performing this valuable service for the consumer. One can easily see that there is no significant difference in the cholesterol and fat content of generic versus the misleading and so-called ‘ ‘modified egg.” The slight difference in monounsaturated fat content is of questionable significance.Perhapsthe ordinary egg farmers could now make a less misleading case in favor of their own eggs! The fourth panel of the beautifully illustrated and well-produced brochure concludes with 2 definitive statements:(1) “From hens fed an enriched diet with no animal fat.” (2) “In clinical tests, people includ-
THE AMERICANJOURNALOF CARDIOLOGY VOLUME73
FEBRUARY15, 1994
ing 12 Eggland’s Best eggsper week aspart of a low fat diet showed no increasein serum cholesterol.” Everyone with whom I have discussedthis issue- patients, friends, and free-advice seekers- were all under the impression that they could eat up to 12 modified eggs per week and need not be concernedabout increasing their cholesterol. In fact, most thought they could reduce their cholesterol levels. An erroneous assumption, to say the least, especially when one pays strict attention to the necessity of following a fatcholesterol-reduction diet. The discussion portion of the study (1) opens with the sentence: “In this study, modified eggs were compatible with a diet known to be effective in reducing serum cholesterol,” the same words used in the study title, which can be confusing to the uninitiated if they do not look more deeply into the issue at hand. In conclusion, it is my opinion that modified eggs appear to serve little or no benefit beyond that achieved by any other hen’s eggs. A similar study performed in similar fashion using generic eggs would be mandatory in order for the producers of modified eggs to claim distinct benefits of substanceto the unwary and unknowledgeable consumer. Furthermore, is it not possible that the same study as noted in the reference, if continued for a period of 4 to 6 months would have altered the outcome and conclusions? One must ask, for the present,who is actually reaping the benefits from the modified eggs- the consumer or the producer? Certainly, the chickens are probably healthier for the effort. As a matter of fact, I never saw a chicken die of a heart attack, nor have I ever heard one complaining of angina. Perhaps the suppliers of the feed and ingredients are benefiting more than are the hens, and possibly, the producers may be deriving the most benelit. Basil M. BuDusky, MD Wilkes-Bane, Pennsyivania 30 August 1993
1. Garwin JL, Morgan JM, Stowell RL, Richardson MP, Walker MC, Capuzzi DM. Modified eggs are compatible with a diet that reducescholesterol concentration in humans.J Nutr 1992;I22:2 153-2160. 2. American Egg Board (1989) nutrient values for a large raw egg. In: Eggcyclopedia.Park Ridge, Illinois: American Egg Board, 1989:3435.
One Symposium
Not listed
I read with interest the minutes of
The American Journal of Cardiology editorial board published in the June 15, 1993 issue. Table IX represents symposia published in AJC during the year 1992. However, the symposium on Management of Heart Failure in the 1990s: A Reassessment of the Role of Digoxin Therapy, published June 4, 1992 (Am J Cardiol 1992;69: lG-154G), did not appear in this table or the text. Mihal
Gheorghiade, MD Chicago, Illinois 30 August 1993
I enjoyed reading the article on the results of percutaneous balloon mitral valvuloplasty in young adults by Rothlisberger et al.’ However, I wish to point out the questionable use throughout the text of the word “dilatation,” e.g., “balloon dilatation catheter,” “incremental dilatation with the Inoue balloon” and “dilatation has been attempted even in patients with less pliable valves.” In each case, the proper word should be dilation, not dilatation. Historically, dilatation and dilation existed as competing forms and have been used interchangeably.2 But they really should not be. According to both Dorland’s and Webster’s dictionaries, dilation is “the action of dilating or stretching” or “the state of being dilated,” while dilatation is “the condition of being stretched or dilated or stretched beyond the normal” with Webster adding: “especially as a result of disease or abnormal relaxation.“” Etymologically, dilate is from the Latin word dilatare, with the stem dilatat-and the corresponding noun dilatatio; from this comes the English word dilatation.4 But -tion is a live suffix in English, and there is no reason why it should not be added
to the English verb dilate to give di-
latiork4 Too many medical writers chose the long (and more impressive?) word when there is a choice. We read of “employ” instead of “use,” “investigation” instead of “study,” and “dilatation’ ’ instead of “dilation.” In pharmacology, a vasodilator causes dilatation, not dilation of the blood vessels; balloon valvuloplasty is a catheter technique of dilation, not dilatation of a stenotic heart valve; dilatation, not dilation of the aortic root is a common complication of Marfan syndrome; dilation, not dilatation of a stenotic valve may sometimes result in dilatation, not dilation of its annulus. I hope that these examples serve to clarify once and for all that dilation and dilatation are neither synonymous nor interchangeable. Tsung 0. Cheng, MD Washington, D.C. 14 July 1993
1. Rothlisberger C, Essop MR, Skudicky D, Skoularieis - J. Wisenbaueh - T. Sareli P. Results of nercutaneons balloon mitral valvotomy in young adults. Am 1993;72:7.3-77. J Cardiol 2. Bloom DA, Mary RN, Hinman F Jr. Dilation vs. dilatation: a brief history. J Urn/ 1992: 147: 1682. 3. Cheng TO. Dilatory matter. Lower 1993;341: 1220. 4. Hughes A. A dilation on dilatation. Lancer 1993: 341:867.
Accuracy of Nongeometric Pulsed Doppler Cardiac Output De Domenico and colleagues’ achieved a relatively disappointing correlation (r = 0.82) using our2 nongeometic method for stroke volume determination. We had reported r = 0.97.2 The authors apparently missed our extended results in a larger series, with a new regression equation for ejection rate: ejection rat6 = 491 mean flow velocity - 61 ml/s,’ although even that improvement may not have altered their results significantly. The method depends critically on accurate determination of left ventricular ejection time, and this can be difficult without technically excellent Doppler recordings and relaxed suspension of respiration. Indeed, Australian investigators4 used our method in different patients from ours or De Domenico’s, reporting r = 0.97, with r = 0.77 for the geometric method.
Perhaps the authors could reexamine their left ventricular ejection time measurements. David H. Spodick, MD, DSc Worcester, Massachusetts 26 August 1993 1. De Domenico R, Zepellini R, Gheno G, Compostella L, lavemaro A, Cucchini F. Accuracy of a new, nongeometric pulsed Doppler method in cardiac output evaluation. Am .I Cardiol 1993;72:48%491. 2. Spodick DH, Koito H. Nongeometric Doppler stroke volume determination. Am J Cardiol 1989;63:883-884. 3. Koito H, Spodick DH. Relation of left ventricular ejection rate to ejectional flow velocity. Am J Noninvas Cardiol 1989.3:22&227. 4. Sajkov D, Cowi RJ, Bradley JA, Mahar L, McEvoy RD. Validation of new pulsed Doppler echocxdiographic techniques for assessment of pulmonary hemodynamics. Chest 1993; 103:1348-1353.
Modiied Most?
Eggs -
Who Benefits
The old cliche - “Which came tist, the chicken or the egg?” may presently be more appropriate than in the past, especially since increased speculation has occurred regarding the benefits of the recently introduced, so-called ‘ ‘modified eggs.” Perhaps the question should also include who benefits most, in addition to what benefits, if any, may be achieved by their use? The parties concerned are obvious, and other than the egg itself, must include the chicken, the consumer, the retailer and the producer. The letter that physicians received from Eggland’s Best begins by stating: “Your patients may be asking you about a neti egg they have been seeing on television. . . .” Indeed they are-not only asking, but also misinterpreting all of the vaguely illustrated news media presentations. The consumers’ basic conclusion, in my experience, is that they c.m consume these eggs ad libitum with virtual disregard of a properly prescribed diet. They also feel that they therefore need not worry about increasing their cholesterol levels by eating these eggs, in contrast to their eating ordinary (generic) eggs. The patients fail to absorb the fact that a strict low-fat, low-cholesterol diet must be adhered to. They also misinterpret the media advertisement and allow themselves to believe that they can actually lower their cholesterol by eating these eggs -and it is no wonder, READERS’COMMENTS 421
TABLE I Cholesterol Calories
when one reads the advertisement brochures that are so cleverly written and presented. The brochure indicates that their hens are fed an enriched diet with no animal fat (94% unsaturated canola oil is the only added fat). The diet, according to a letter received with the brochure, is further enriched with vitamin E, and a natural mixture of rice bran, alfalfa meal and kelp as pan of the feedingprocessa great diet from which perhapseven humans could benefit. The research paper indicates that the feed contains 65% corn meal, 21% soybeanmeal, 1% canola oil, vitamin E, iodine and kelp, but no animal by-products.] The question is, does this wonderful diet fed to the hen, help anyone but the hen? It is stated that the modified eggs contain a lower ratio of saturatedto monounsaturated fat, and more vitamin E than do other eggs. How then does this help my patient and does it actually do anything significant from a medical-nutritional standpoint? The following statementsare taken from the brochure, beginning with the following opening comment: ‘ ‘Even your hypercholesterolemit patients can enjoy up to u dozen real eggs per week without increasing their cholesterol” - a very misleading and misdirected statement, if not erroneous. Then we are subjected to the following main conclusions of their presentation (based on a research project quite cleverly conceived and performed): (1) “Subjects on a National Cholesterol Education Program (NECP) diet who included 12 Eggland’s Best eggs per week, significantly reduced total serum cho422
(mg)
Fat
Saturated Fat
w
k)
lesterol and (lowdensity lipoprotein) cholesterol levels.” (2) “There was no significant difference in cholesterol reduction between those eating no whole eggs and those enjoying Eggland’s Best.” Both statements are alforded the same singular reference, with many of the references at the end of the researchpaper not being particularly relevant to the issue at hand. But did anyone ask, as certainly they should, what the outcome would have been in a comparison group using regular eggs? Therein lies the major flaw of the study - a clever, if not somewhat deceptive control that is incomplete because of a successful attempt at coming to a desired conclusion. The nutritive comparison charts reveal the standardaccepteddata on the content of a regular egg in relationship to modified eggs, as reported on. the retail box (Table I).2 The data taken from Table I in reference 1 indicates the partitioned fat content (Table II). The producers are to be congratulated on performing this valuable service for the consumer. One can easily see that there is no significant difference in the cholesterol and fat content of generic versus the misleading and so-called ‘ ‘modified egg.” The slight difference in monounsaturated fat content is of questionable significance.Perhapsthe ordinary egg farmers could now make a less misleading case in favor of their own eggs! The fourth panel of the beautifully illustrated and well-produced brochure concludes with 2 definitive statements:(1) “From hens fed an enriched diet with no animal fat.” (2) “In clinical tests, people includ-
THE AMERICANJOURNALOF CARDIOLOGY VOLUME73
FEBRUARY15, 1994
ing 12 Eggland’s Best eggsper week aspart of a low fat diet showed no increasein serum cholesterol.” Everyone with whom I have discussedthis issue- patients, friends, and free-advice seekers- were all under the impression that they could eat up to 12 modified eggs per week and need not be concernedabout increasing their cholesterol. In fact, most thought they could reduce their cholesterol levels. An erroneous assumption, to say the least, especially when one pays strict attention to the necessity of following a fatcholesterol-reduction diet. The discussion portion of the study (1) opens with the sentence: “In this study, modified eggs were compatible with a diet known to be effective in reducing serum cholesterol,” the same words used in the study title, which can be confusing to the uninitiated if they do not look more deeply into the issue at hand. In conclusion, it is my opinion that modified eggs appear to serve little or no benefit beyond that achieved by any other hen’s eggs. A similar study performed in similar fashion using generic eggs would be mandatory in order for the producers of modified eggs to claim distinct benefits of substanceto the unwary and unknowledgeable consumer. Furthermore, is it not possible that the same study as noted in the reference, if continued for a period of 4 to 6 months would have altered the outcome and conclusions? One must ask, for the present,who is actually reaping the benefits from the modified eggs- the consumer or the producer? Certainly, the chickens are probably healthier for the effort. As a matter of fact, I never saw a chicken die of a heart attack, nor have I ever heard one complaining of angina. Perhaps the suppliers of the feed and ingredients are benefiting more than are the hens, and possibly, the producers may be deriving the most benelit. Basil M. BuDusky, MD Wilkes-Bane, Pennsyivania 30 August 1993
1. Garwin JL, Morgan JM, Stowell RL, Richardson MP, Walker MC, Capuzzi DM. Modified eggs are compatible with a diet that reducescholesterol concentration in humans.J Nutr 1992;I22:2 153-2160. 2. American Egg Board (1989) nutrient values for a large raw egg. In: Eggcyclopedia.Park Ridge, Illinois: American Egg Board, 1989:3435.