Choosing A “Healthy” and “Natural” Snack: Kind Bars Versus Simple Stroke-Busting Nuts

The eternal fiancee’ of the skeptical cardiologist (EFOSC) deserves serious kudos for (among myriad other things) challenging his conventional ideas about heart-healthy food and serving as his dietary muse.

However, the EFOSC seems to have a weakness for what I would consider a highly processed, sugared up, over-priced piece of marketing hype—Kind Bars.

I asked the EFOSC recently why she was so enamored of Kind Bars and she told me “I like that they are convenient, you can find them anywhere, they are not expensive and they taste good and they are low in sugar and they are 100 times better than all the other snack bars on the market that are expensive and have tons of sugar and chemicals and disgusting things in them:

She also points out that for frequent business travelers, the bars are more convenient (and often cheaper) than buying  a bag of nuts in an airport kiosk.

She is not alone.

The Booming “Healthy and Natural” Snack Bar Business

The “healthy” snack bar business has been booming lately.

The WSJ points out

“Bar makers are opening the floodgates on nuts, dried meats, cricket flour and other nutrient and protein-rich ingredients to compete for consumers and command top dollar. Many of these ingredients cost more than those found in a traditional cookie—and as sources of protein, ounce for ounce, some of them cost more than a steak.There are 1,012 nutrition bars on the market now, compared with just 226 a decade ago, according to a tally by Valient Market Research in Philadelphia.”

Consumers, attracted by convenience and a desire for “healthy and natural” food are paying more for snacks like Kind bars which have high profit margins.

“The average bar costs about two dollars, up from just one dollar 10 years ago, a sign of how much more consumers are willing to pay, or “diminishing price sensitivity,” as Valient founder Scott Upham calls it. “The cost of ingredients makes up only 25% of the price, and profit margins for bars tend to hover as high as 40% to 50%, compared with only 20% to 30% for most other packaged foods, says Mr. Upham.”

Stores love them because “they are individually wrapped and have a long shelf life, yet they are popular and turn over fast.”

Are Kind Bars And Their Ilk Healthy?

Interestingly, about a year ago, the FDA issued a “warning letter” to Kind asking the company to remove the term “healthy” from its product labels.

Violation 1a. of that letter fingers Kind Fruit & Nut Almond & Apricot for having 3.5 grams of saturated fat per 40 grams of food (the so-called Reference Amount customarily consumed or RACC) which is more than the 1 gram of saturated fat per RACC allowed if is one is going to describe one’s food as healthy.

This is clearly a ridiculous and out-dated requirement: saturated fats are a diverse category of nutrients, some of which are likely very healthy (see my posts on dairy fat or coconut oil). According to these criteria, foods that are clearly very healthy such as avocados, salmon and nuts, cannot be labeled as healthy.

Kind fought back and challenged the FDA and the FDA backed down.

According to the WSJ:

“The FDA said in a statement to The Wall Street Journal that in light of evolving nutrition research and other forthcoming food-labeling rules, “we believe now is an opportune time to re-evaluate regulations concerning nutrient content claims, generally, including the term ‘healthy.’”

However, I don’t think Kind bars are necessarily a healthy good food choice. I think people buy them because they have been slickly marketed as “healthy” and “natural.”

As Marion Nestle points out, when it comes to food labels, “healthy” and “natural” are marketing terms.  Their purpose is to sell food products.

Is this the most annoying advertising blather in existence? Is the EFOSC a KINDAHOLIC with an uncontrollable love for KIND and spreading kindness?

The ingredients in the almond and apricot Kind bar are: Almonds, coconut, honeynon GMO glucose, apricots, apple juice, crisp rice, vegetable glycerine, chicory root fiber, soy lecithin, citrus pectin, natural apricot flavor.

Nutrition: 180 calories, 10 g fat (3.5 g saturated fat), 25 mg sodium, 23 g carbs, 3 g fiber, 13 g sugar, 3 g protein

Basically, the healthy part of this Kind Bar is almonds and coconut, which you could purchase for a hell of a lot less than what you are paying for this processed junk.

Also, please note that it doesn’t contain any actual apricots, merely “apricot flavor.”

Also, note that the third ingredient is honey and the fourth is non GMO glucose. What on earth is non GMO glucose? Do we really care whether the added sugar you are pumping into your crappy bars is GMO or non GMO?

Some Kind bars are clearly no healthier than a typical Payday candy bar:

Is a KIND bar any healthier than these Halloween treats? Is that Jenny in the background, Dr. Pearson’s marvelous medical assistant?

IAs Crains  writes:

“the packaging of the dark chocolate cherry cashew bar advertises the word “Antioxidants.” In other words, the bar isn’t promoted as being low in sugar, so it’s a fair choice to compare with a PayDay.
The Kind bar has 9 grams of fat—1 gram less than PayDay’s bar. The sugar count, at 14 grams, is 2 grams less than PayDay. So far, so good. But this particular Kind product has a total carbohydrate count 1 gram higher than PayDay, and 1 fewer grams of protein. The bar has 2.5 grams of dietary fiber, a fraction more than PayDay.”

The Kind PR machine responds thusly:

“It is not at all a fair comparison to equate KIND’s Dark Chocolate Cherry Cashew bar to a Pay Day,” a company spokesman said. “This completely ignores the nutrient-rich ingredients that are in a KIND bar, not to mention the exponentially lower level of sodium.”

You can buy 24 Payday bars at Sam’s Club for $14, about 61 cents a bar.

To be fair to the EFOSC, she usually only eats Kind bars that have about 5 grams of sugar.

Preventing Stroke and Heart Attack with 30g of “Mixed Nuts” Daily

In a previous post (Nuts, Legumes, Drupes and Mortality)  I summarized the evidence IMG_3593supporting the cardiovascular benefits of consuming various kinds of nuts.

The PREDIMED trial, in particular, showed a remarkable benefit in reducing heart attacks and strokes when patients ate a Mediterranean diet supplemented with 30g mixed nuts per day (15g walnuts, 7.5g almonds and 7.5g hazelnuts). Walnuts and almonds are actually drupes, but hazelnuts are true nuts.

The  Mediterranean diet, including nuts, reduced the risk of cardiovascular diseases (myocardial infarction, stroke or cardiovascular death) by 30% and specifically reduced the risk of stroke by 49% when compared to a reference diet consisting of advice on a low-fat diet (American Heart Association guidelines). The Mediterranean diet enriched with extra-virgin olive oil also reduced the risk of cardiovascular diseases by 30%.

You can buy 454 grams of walnuts or hazelnuts for $14 , and 454 grams of almonds for $10. Thus, for 46 cents for the walnuts, 23 cents for the hazelnuts and 16 cents for the almonds (total 85 cents) you can recreate the snack that the Spaniards ate in PREDIMED.

This compares to Kind bars which retail anywhere from $1.99 to $3.50.

The PREDIMED investigators explain why they chose these specific nuts:

“WALNUTS. Walnuts differ from other nuts in that they are very rich in omega 6 and omega 3 type unsaturated fats. Moreover, the antioxidants they contain are among the most powerful in the plant world. It should be mentioned that, like omega 3 in fish, nut fats possess important beneficial properties for general health and the heart in particular.

ALMONDS. Almonds form part of many traditional desserts and sweets of Arabic origin, such as nougat. Currently, Spain is the second largest producer and consumer of almonds in the world, after the United States. As with hazelnuts and olive oil, almonds are rich in oleic acid. They differ from other nuts in that they contain more fibre, vitamin E, calcium and magnesium.

HAZELNUTS. Hazelnuts, another widely consumed nut in Spain, are very rich in oleic acid. Furthermore, they are nuts that provide a large amount of folic acid, a vitamin very important for regulating the metabolism, a lack of which can lead to thrombosis and an acceleration of degenerative processes such as arteriosclerosis and senile dementia.”

Unfortunately, I can eat neither hazelnuts nor walnuts (tree nut allergy), but I’ve decided to create for my patients little baggies filled with 30 grams of the magical PREDIMED nut mixture. I’ll give these out during office visits as I explain the glories of the Mediterranean diet (I’ll try to forbear elaborating to them the difference between drupes and nuts).

I need a catchy name for these bags-“Pearson’s PREDIMED bags” or “Stroke-busting nuts?”

If any reader or patient has a suggestion, please add it to the comments.

If I choose your suggestion, I’ll provide you with 10 bags of nuts and oodles of glory!

Hopefully, once I start creating the nut bags, the EFOSC will begin to eschew the faux healthiness of Kind bars and embrace the natural and unmarketed goodness of drupes and nuts.

Kindly Yours


Somes notes:

A drupe is a type of fruit in which an outer fleshy part surrounds a shell (what we sometimes call a pit) with a seed inside.  Some examples of drupes are peaches, plums, and cherries—but walnuts, almonds, and pecans are also drupes. They’re just drupes in which we eat the seed inside the pit instead of the fruit!


“Every 3 months a supply of 1,350-g walnuts (®California Walnut Commission, Sacramento, Cal), 675-g almonds (®Borges SA, Reus, Spain), and 675 g hazelnuts (®La Morella Nuts, Reus, Spain) is provided to each participant assigned to the MeDiet+Nuts group.”


Two Three Letter Words For Saving Lives: CPR and AED

Every two years the skeptical cardiologist has to get recertified in Basic Life Support for medical personnel. This involves a review of what, the American Heart Association has decided, are important changes in guidelines for Emergency Cardiac Care and cardiopulmonary resuscitation (CPR).

I highly recommend all of you undergo such training. Although the survival rate of patients with “out of hospital cardiac arrests” is very low, your appropriate actions could be crucial in saving the life of a stranger or a loved one.

About a year ago one of my patients suddenly, and without any warning symptoms, collapsed at work. Fortunately for him, a co-worker had undergone CPR training and initiated chest compressions right away. When paramedics arrived 15 minutes later he was defibrillated from ventricular fibrillation and taken to a nearby hospital.

Our best information on cardiac arrest suggests that without CPR, irreversible brain damage (due to lack of oxygen) develops in about four minutes after the heart stops beating. Even with good CPR, the longer the time interval from arrest to defibrillation, the less likely the patient is to survive with good brain function.

Thus, the two keys to helping someone who drops dead next to you are beginning effective CPR (and compression only is OK) and defibrillating a fibrillating heart as soon as possible.

My patient was comatose on arrival to the hospital and was put into a hypothermic state, a process which has been shown to improve neurological outcome in cardiac arrest victims. Doctors informed his wife that they thought his prognosis was bad-less than 5% chance of surviving with intact brain function.  After three days he awoke from his coma and was transferred to my hospital.

I visited him in the ICU and other than a sore chest and an inability to remember the events surrounding his cardiac arrest, he was mentally normal and felt great. He continues to do very well to this day, but without the bystander CPR that he received (followed by the defibrillation) he would be one of the 350,000 who die of cardiac arrest in the US each year.

If the co-worker had not initiated CPR for the many minutes it took for EMRs to arrive, my patient’s brain would have been dying from lack of oxygen and it is most likely he would have suffered severe encephalopathy or brain death.

Recognizing Cardiac Arrest

Recognizing when someone needs CPR is a critical first step in the chain of events that can improve survival in cardiac arrest.

You are looking for two things before starting CPR:

  1. Unresponsiveness. The victim  does not move and does not respond at all to either verbal or physical stimulation.
  2. Breathing is absent or atonal (meaning ineffective , intermittent gasps).

Agonal respirations have also been described as “snoring, snorting, gurgling, or moaning or as barely, labored, noisy, or heavy breathing.”  Studies have shown that agonal respirations are common in the early minutes after cardiac arrest and are associated with good outcomes.

Two Steps To Save A Life

The two key components of resuscitation are CPR and defibrillation.

Performing these steps is simple and straightforward.

The earlier they are started, the more likely the victim is to survive.

If someone collapses near you and they are unresponsive and not breathing, they need CPR and an AED. Call for help as you are starting CPR.



Cardiopulmonary Resuscitation (CPR)

CPR consists of repeated compressions of a victim’s chest.

I came across this machine recently. You can learn and practice hands-only CPR using it.

Everyone has seen dramatizations of CPR and it is quite simple to do even without training. Basically, you want to “push hard and fast in the center of the chest.”

CPR training undergoes some tweaking over time as more scientific data is obtained but the fundamentals remain the same. The changes that the AHA is emphasizing in their current CPR courses are:

-depress the chest at least 2 inches

-depress the chest 100-120 times per minuCPR-Certificationte (as opposed to just >100 time per minute).

Of note, the recommended sequence has changed from A, B, C, to C, A, B. Compressions right away followed by assessment of airway and then mouth-to-mouth breathing.  In fact, because compressions without breaths have been shown to be as effective as with breaths, if you are uncomfortable giving breaths, recommendations now are to just do CPR.


Initiating CPR and calling 911 are the greatest initial things you can do for the person who collapses next to you.

However, the earlier you can defibrillate that person from ventricular fibrillation, the better their chance of survival.

Ambulatory electronic defibrillators or AEDS , if available, are very easy to use devices that can shorten the time to defibrillation and are the second key to successful resuscitation of cardiac arrest victims in the community.

I’ll talk about using them in a subsequent post.

antimortatorially yours



Donald Trump Has Moderate Plaque Buildup In His Coronary Arteries and his Risk For A Cardiac Event Is Seven Times Hilary Clinton’s Risk

Donald Trump recently appeared on the Dr. Oz show and handed a letter to the celebrity medical charlatan and TV host, Mehmet Oz.

The letter was written by his personal physician , Dr. Harold Bornstein,  screen-shot-2016-10-04-at-3-21-11-pm
and summarized various  laboratory and test  results which led Bornstein to conclude  that Mr. Trump is in excellent health (Bornstein did not repeat his earlier, bizarre statement that “If elected, Mr. Trump, I can state unequivocally, will be the healthiest individual ever elected to the presidency.”)

From a cardiovascular standpoint the following sentence stood out:

“His calcium score in 2013 was 98.”

Regular readers of the skeptical cardiologist should be familiar with the coronary calcium scan or score (CAC) by now.  I’ve written about it a lot (here, here, and here) and use it frequently in my patients, advocating its use to help better assess certain  patient’s risk of sudden death and heart attacks.

coronary calcium
Image from a patient with a large amount of calcium in the widowmaker or LAD coronary artery (LAD CA).

The CAC scan utilizes computed tomography (CT)  X-rays, without the need for intravenous contrast, to generate a three-dimensional picture of the heart. Because calcium is very apparent on CT scans, and because we can visualize the arteries on the surface of the heart that supply blood to the heart (the coronary arteries), the CAC scan can detect and quantify calcium in the coronary arteries with great accuracy and reproducibility.

Calcium only develops in the coronary arteries when there is atherosclerotic plaque. The more plaque in the arteries, the more calcium. Thus, the more calcium, the more plaque and the greater the risk of heart attack and death from heart attack.

What Does Donald’s Trump’s Calcium Score Tell Us About His Risk Of A Major Cardiac Event?

We know that, on average, even if you take a statin drug (Trump is taking rosuvastatin or Crestor), the calcium score goes up at least 10% per year which means that 3 years after that 98 score we would predict Trump’s calcium score to be around 120.

Based on large, observational studies of asymptomatic patients, Calcium scores of 101 to 400 put a patient in the moderately high risk category for cardiovascular events.

When I read a calcium score of 101-400, I make the following statements (based on the most widely utilized reference from Rumberger

This patient has:

-Definite, at least moderate atherosclerotic plaque burden

-Non-obstructive CAD (coronary artery disease) highly likely, although obstructive disease possible

-Implications for cardiovascular risk: Moderately High

Patients in this category have a 7-fold risk of major  cardiac events (heart attack or death from coronary heart disease) compared to an individual with a zero calcium scorescreen-shot-2016-10-04-at-3-16-25-pm



Clinton versus Trump: Zero is Better

Since we know that Hillary Clinton recently had a calcium scan with a score of zero, we can estimate that Trump’s risk of having a heart attack or dying from a cardiac event is markedly  higher than Clinton’s.

Clinton, born October 26, 1947 is 68 years old and we can enter her calcium score into the MESA calcium calculator to see how she compares to other women her age. A  coronary calcium score of 6 is at the 50th percentile for this group.

Interestingly, Trump’s score of 98 at age 67 years was exactly at the 50th percentile. In other words half of all white men age 67 years are below 98 and half are above 98, creeping into the moderately high risk  category.

(This should not be surprising, I touched on the high estimated cardiovascular risk of all aging men in my post entitled “Should all men over age sixty take a statin drug?”)

So, based on his coronary calcium score from 2013, Donald Trump has a  moderate build up of atherosclerotic plaque in his coronary arteries and is at a seven-fold higher risk of a cardiac event compared to Hilary Clinton.

Let the law suits and tweets begin!

Electorally Yours,






Running For Longevity: From A-Punk to Aba Daba Honeymoon

About two years ago I wrote about a study that found that any amount of leisure-time running was associated with a lower risk of cardiovascular disease which  made me reconsider my usual advice to patients on exercise:

As part of a prospective longitudinal cohort study at the Cooper Clinic in Dallas, Texas, Lee, et al. looked at data from a group of 55,137 adults on whom they had information on running or jogging activity during the previous 3 months.
Those individuals who described themselves as having done any running in the last 3 months had a 30% lower risk of all-cause mortality and a 45% lower cardiovascular mortality.

Amazingly, it didn’t matter how much you ran.

Those who ran <51 minutes per week did just as well as those who ran >176 minutes per week.

At the time I felt the study was not definitive, but food for thought. Evidently, it got me thinking so much that I began running regularly (despite my previous dislike of running).

Music and the Tempo of Running

During my runs I listen to music on my iPhone, either through Apple Music or songs that I have purchased.

Today, after deciding Leonard Cohen’s Live in Dublin (although awesome, and one of the best live albums I’ve ever heard) was not motivating enough, I hit the first song on my iPhone: A-punk by Vampire Weekend.

A-Punk is one of my favorite songs released in the last decade. It’s very upbeat.. perfect for a running accompaniment. The opening guitar riff is simple, fast and catchy. It’s simple enough that I can play it on guitar but, so fast that my fingers fatigue quickly.  The bridge portion features a wonderfully fast and complicated bass line with punchy drums and an overlying synth flute melody. You can watch a video of it here:

As I ran I realized that the tempo of A-Punk was perfectly suited to my preferred running speed of 6.1 MPH. You’re probably wondering what the tempo of A-Punk is. It’s likely that the only time song tempo comes up in general conversation is when talking about CPR and the need to compress the sternum at 100 beats per minute, the alleged tempo of The Bee Gees Stayin’ Alive (it’s actually 104 BPM.)

A-Punk’s tempo turned out to be 175 BPM. If you are not inclined to count the actual beats in a minute to determine the tempo of a song, you can enter the song into this site to get the number or download a smart phone app for the purpose.

Oddly enough, the next song on my alphabetical listing of songs, Hoagy Carmichael’s version of Aba Daba Honeymoon, also had a screen-shot-2016-10-02-at-8-45-44-amtempo (174 BPM) perfectly suited to my running speed. (The song after that was my old band Whistling Cadaver attempting to play the medley at the end of Abbey Road at our 30 year high school reunion in 2002-not good for running to, but immensely entertaining).

Monetizing Music For Running

Having observed that the tempo of certain songs matched perfectly to my running tempo, I wondered if there were any advantages to selecting such songs. Would I run faster or longer or with less discomfort or less injuries?

The web site run2rhythm would certainly like me to believe that screen-shot-2016-10-02-at-9-45-42-amrunning to the right tempo song will improve my performance. This site claims that “the wrong musical playlists can be detrimental to your training as they will not provide any synchronization between the body, the music and the mind. The body is almost always out of sync with the music.”

screen-shot-2016-10-02-at-9-03-39-amRun2rhythm provides a chart of the BPM that corresponds to different running speeds and sells playlists starting at $3.99 corresponding to specific tempos. These are playlists by unknown artists created for run2rhythm and the samples were not inspiring to me.

Here’s an example:screen-shot-2016-10-02-at-9-05-39-am



Is Music a Legal Drug For Athletes?

It turns out that there is a body of scientific literature related to music and exercise, and the vast majority of it seems to come from one man,  Dr Costas Karageorghis at Brunel University in London, an expert on the effects of music on exercise.  In his 2010 book, Inside Sport Psychology, he claims that listening to music while running can boost performance by up to 15%.

In media articles on the topic he is often quoted as saying “Music is a legal drug for athletes.”

However, in a 2012 review article he is more circumspect, concluding:

Music is now rarely viewed in a manner akin to the ‘vitamin model’ described by Sloboda (2008) wherein one can ascribe immutable effects to a specific musical selection for all listeners and at all times. The beneficial consequences of music use stem from an interaction between elements of the musical stimulus itself and factors relating to the traits and experiences of the listener, and aspects of the exercise environment and task. In particular, the role of music is dependent on when it is introduced in relation to the task and the intensity of the exercise undertaken. In closing, the evidence presented in this review demonstrates that music has a consistent and measurable effect on the psychological state and behaviour of exercise participants

Creating Your Own Tempo Playlist

The research on music and exercise suggests that songs with inspirational themes (apparently, “Gonna Fly Now,” the Rocky theme, is the most popular workout song of all time) are more effective performance enhancers. Also, self-selection of songs works better.

For me, running while listening allows me to focus on nuances of instrumentation, timing  and lyrics that otherwise I would not pay attention to. It is essential, then, to have songs that are worthy of such close listening.

I wondered if anyone has compiled lists of songs of a certain BPM that were originals and good songs.  Sure enough, the folks at have exactly such a function.  My search for songs with tempo of 175 BPM yielded A-Punk and hundreds of other songs, screen-shot-2016-10-02-at-10-10-58-amincluding some I like (thumbs down for Footloose and Wonderwall (which is really 1/2 of 175 BPM or  88 BPM), thumbs up for Dancing With Myself).

You will note that my preferred tempo of 175 BPM corresponds to a much faster running speed than my preferred 6.1 MPH. This may have to do with my short legs or my running style. It makes sense to count the number of steps you take per minute at your optimal speed rather than rely on charts or averages.

Achieving the Right Dose of Exercise

Whatever you listen to while running, walking, cycling or hopping, hopefully it will assist you to achieve the dose of exercise per week that results in improved cardiovascular outcomes.

This chart from recent European guidelines on lifestyle for prevention of disease describes different intensities of aerobic exercise:

If you engage in vigorous exercise such as running or jogging, cycling fast or singles tennis, you only need to achieve 75 minutes per week. Moderate exercise such as walking or elliptical work-outs requires 150 minutes/week.

As a result of switching to running, I’ve cut down my total exercise time per week by half leaving me more time to create music!

Readers – feel free to share your favorite workout songs and let me know what tempo works best for you.

Synchronously Yours,


Yikes! This is a silly video. I’m not sure I can run to the song anymore.



EpiPen: What Accounts For The Spiraling Costs Of A Life-Saving Generic Medication?

IMG_7187I hold in my left hand an EpiPen, self-described as a “0.3 mg epinephrine auto-injector.” The EpiPen is a marvel of modern manufacturing. Take it out of its solid, clear,  plastic enclosure and you will notice instructions on how to use it in simple text and cartoons.


Basically, pull up the blue plastic piece at the top and you have activated it: now grasp the body and swing it down to your thigh , pushing the orange tip until it clicks, indicating the needle has emerged and injected life-saving epinephrine into the large muscle in your leg.IMG_7186

Epinephrine injections are the treatment of choice for severe allergic reactions. I have kept  EpiPens around me since my first episode of anaphylaxis after eating pecans as a child (see my post on nuts, legumes, drupes and mortality here) and can attest to how easy this is to use in treatment of an acute case of anaphylaxis.

About 12 years ago, when I lived in Louisville, Kentucky I was receiving allergy shots for chronic allergic rhinitis and conjunctivitis. One day I worked out after my shot and I suddenly began itching all over. Hives appeared on my chest and my face began swelling. I found it hard to breathe.

I was experiencing anaphylaxis, a severe, rapid and sometimes fatal allergic reaction that can occur after insect bites or stings, certain food consumption (I’ve had it to pecans, cashews, and  walnuts), and medications.

Fortunately, I had in my possession two EpiPens and even more fortunate they were  non-expired EpiPens. I quickly dressed, grabbed the EpiPens and had my then wife drive me to the closest ER.

After a few minutes I realized I was getting worse and opened up the first Epipen and jammed the needle into my thigh. I continued to get worse-my breathing became severely labored-and I grabbed the second EpiPen and repeated the thigh stabbing. Alas, the situation did not immediately improve and I made a command decision to stop at a fire station we were passing. There I was bundled into an ambulance, given IV steroids and oxygen and ultimately ended up in  an ER.

Epinephrine directly stimulates alpha and beta-receptors of the sympathetic nervous system and after the injections I felt like I had consumed 10 cups of coffee. My heart was racing, my blood pressure sky high and I was shaking uncontrollably. This is not a drug you want to take unless you desperately need it. In my case and thousands of others with anaphylaxis it is life-saving.

Consequently, I carry one with me at all times and as knowledge of food anaphylaxis and its treatment has spread in the last decade, Epipen sales and profits have exploded.

EpiPen Success: Marketing and Lobbying

Screen Shot 2016-08-27 at 10.03.59 AM
As this graph demonstrates, the annual sales increase in EpiPen for Mylan rose from 200 Million to over a billion driven by a combination of increased volume of sales and increased per device cost.

Last September,  Bloomberg published a story on the brilliant marketing of Mylan that turned EpiPen into a billion-dollar product. The Bloomberg article noted that the CEO of Mylan, Heather Bresch (who is the daughter of Democratic Senator Joe Manchin of West Virginia)  “turned to Washington for help”:

In 2010 new federal guidelines said patients who had severe allergic reactions should be prescribed two epinephrine doses, and soon after Mylan stopped selling single pens in favor of twin-packs. At the time, 35 percent of prescriptions were for single EpiPens. The U.S. Food and Drug Administration had changed label rules to allow the devices to be marketed to anyone at risk, rather than only those who’d already had an anaphylaxis reaction. “Those were both big events that we’ve started to capitalize on,” Bresch said in October 2011.

In 2013, the year following the widely publicized death of a 7-year-old girl at a school in Virginia after an allergic reaction to peanuts, Congress passed legislation encouraging states to have epinephrine devices on hand in schools. Now 47 states require or encourage schools to stock the devices.

Recent Furor Over High EpiPen Prices

In the last few days, the rising cost of EpiPens has become front page news. Although the active ingredient, epinephrine, is generic and cheap, and the basic delivery system has been around for decades,  Mylan, the company that purchased the rights to EpiPen in 2007 has increased its price from 57$ per injector to 600$ for 2 injectors.

Lack of generic competition to the EpiPen  is the primary reason that the price could be raised so much and also explains in many circumstances why drug costs are high in the US.

The US has long spent more on prescription medication than other IMG_7188countries. In 2013 per capita US spending on rx drugs was $858 compared to $400 for 19 industrialized anations.

Examples of markedly higher prices in the US are the statin drug crestor (216$/month for 10 mg in US versus $46 in France) and the asthma inhaler Advair ($216 US versus $20 in France.)

A recent article in JAMA analyzed the sources of the high prices in the US and concluded it is due to the fact that “unlike nearly every other advanced nation, the US health care system allows manufacturers to set their own price for a given product. In contrast, in countries with national health insurance systems, a delegated body negotiates drug prices or rejects coverage of products if the price demanded by the manufacture is excessive in light of the benefit provided.”

The ability of drug companies in the US to maintain high prices, the article points out, is due to 2 market forces: protection from competition and negotiating power.

Interestingly, last year , Mylan moved its corporate address overseas to lower its U.S. taxes in a transaction known as an inversion and is now incorporated in the Netherlands,

Bresch, the Mylan CEO is quoted as saying “We do subsidize the rest of the world… and as a country we’ve made a conscious decision to do that,” Bresch said. “And I think the world’s a better place for it.

Perhaps it would be better if the US, instead of having Congress rush into action and investigations when certain drug costs become worthy of news articles and public shaming, had a system in place like most other industrialized nations, that monitored and regulated drug costs.

Under such a system, life-saving medications like the EpiPen would not arbitrarily quadruple in price.

Anaphylactically Yours,





Atrial Fibrillation Ablation: Time For A Team Approach?

For many proceduralists in medicine and surgery, there is a tendency to overestimate the value and underestimate the risk of the intervention that they perform. This factor, plus the current medical reimbursement system in the US, which rewards physicians primarily on the quantity of services performed rather than the quality of care, fosters a strong incentive for proceduralists to perform their procedures early and often.

It is rare for a proceduralist to publicly advocate a cautious and circumspect approach to their procedure; the usual public expressions are highly enthusiastic endorsements intended for marketing and increasing volume.

In this regard, it is particularly refreshing to read the thoughts today of a clinical electrophysiologist, whose bread and butter partially consists of doing ablations of atrial fibrillation (AF.)

John Mandrola (who writes a great blog at and reports for has written an excellent summary of the things that patients should consider prior to getting an AF ablation which I shall reblog below.

Mandrola asks us to consider whether the decision for AF ablation should be made by a team rather than by the proceduralist who stands to benefit from performing the ablation.

I’ve emphasized some points from his post:

-AF ablation is a multi-hour procedure that requires general anesthesia. Up to 80 burns are made in the left atrium, some close to the esophagus and phrenic nerve. There are significant risks to the procedure. The honest long-term success rate barely tops 50%.

-Many patients have to undergo a second procedure, or even third or fourth procedures.

-Some questions an AF team might ask:

  • Have you checked the patient for sleep apnea?

  • Have you asked him to reduce his alcohol intake or weight?

  • Will the AF resolve after the stress of a divorce has worn off?

  • Does the patient know there’s not a shred of evidence that AF ablation reduces stroke or death rates?


-Does the patient know that AF is not deadly heart disease? In other words, has fear been sufficiently extracted from the decision?

I, not infrequently, refer appropriate patients to excellent and thoughtful electrophysiologists for a discussion of the pros and cons of ablation and consideration of its performance .  Before sending them, I try to act like the “team” that Mandrola envisions and review the risks and benefits along with alternative approaches.

Below is John’s post in its entirety:

A patient presents with atrial fibrillation (AF) and a rapid rate. He doesn’t know he is in AF; all he knows is that he is short of breath and weak.

The doctors do the normal stuff. He is treated with drugs to slow the rate and undergoes cardioversion. During the hospital stay, he receives a stress test and an implantable loop recorder.

He goes home on a couple of medications. The expensive implanted monitor shows rare episodes of short-lived AF, less than 1% of the time. The patient feels great.

But here’s the kicker: his doctor recommends an AF ablation.

This is nuts. The man has had one episode of AF. He has no underlying heart disease. And he feels well while taking only basic meds. There’s been no discussion of weight loss, exercise, alcohol reduction, or sleep evaluation.

I don’t know how often this happens in the real world, but I suspect that it’s happening more and more. The number of doctors trained in electrophysiology have increased. And, trainees in academic centers spend most of their time mastering the AF ablation procedure.

The Dartmouth Atlas of Healthcare group have shown cardiology to be a supply-sensitive service. Meaning, the more cardiologists there are in an area, the more procedures get done. This build-it-and-they-will-come problem dogs much of US healthcare, not only cardiology. Think MRI and CT centers.

Might a solution to the overuse of AF ablation be a multi-disciplinary heart team?

We already do this for some heart valve surgeries, specifically, transaortic valve replacement (TAVR).

AF ablation is a multi-hour procedure that requires general anesthesia. Up to 80 burns are made in the left atrium, some close to the esophagus and phrenic nerve. There are significant risks to the procedure. The honest long-term success rate barely tops 50%. (Success rates depend somewhat on the type of AF.)

Then there are the repeat procedures. Many patients have to undergo a second procedure, or even third or fourth procedures. (All at many thousands of dollars per case.)

If doctors recommending the procedure had to present the patient to a team of peers, there may be more discussion about the sobering realities of AF care. Questions could arise:

  • Have you checked the patient for sleep apnea?
  • Have you asked him to reduce his alcohol intake or weight?
  • Will the AF resolve after the stress of a divorce has worn off?
  • Does the patient know there’s not a shred of evidence that AF ablation reduces stroke or death rates?
  • Does the patient know that AF is not deadly heart disease? In other words, has fear been sufficiently extracted from the decision?

I recognize that not every decision in medicine should be made by committee. AF ablation, however, might fit some sort of internal review.

The European Heart Journal just published a terrific review on the treatment of persistent AF. In this paper, the treatment of risk factors gets strong mention–as does the sobering results of AF ablation in more advanced forms of AF, and the vast uncertainty surrounding treatment approaches.

I’m not against AF ablation; I perform the procedure often. But after I’m sure all other aspects of atrial-health have been addressed, and the patient is fully informed. It’s a huge mistake to equate AF ablation with ablation of other focal (emphasis on focal) rhythm problems, like supraventricular tachycardia.

I’d have no trouble justifying my AF ablation procedures to a heart team.


Do You Know What’s On Garry Shandling’s And Your Parent’s Death Certificate?

Better Call Saul’s Bob Odenkirk and Kathy Griffin “hanging” with an apparently healthy Larry Sanders on March 20. These two appeared on Shandling’s brilliant Larry Sanders TV show.

When someone who had appeared to be healthy dies suddenly, it is often assumed that he/she died of “a massive heart attack.” Certainly, this was the case in the recent unexpected sudden death of Garry Shandling, the actor and comedian.  Shandling, aged 66, died March 24 of this year.

ET online reported:

“His publicist Alan Nierob told the ET that Shandling had no history of heart problems, but that doctors believe he died as the result of a heart attack.”

Although a heart attack resulting in ventricular fibrillation is the most common cause of a sudden, unexpected death in individuals over the age of 40, it is not the only one.

In fact, People  magazine reported that Sanders experienced shortness of breath and pain in his legs just a day before his death, and that he spoke to a doctor friend about his symptoms, who stopped by that night to check on him,

Shortness of breath and pain in the legs raise the possibility of a clot or DVT in the leg, which can break loose and embolize into the pulmonary arteries. Such a pulmonary embolism, if massive, can result in swift and sudden death.

The LA Coroner’s office could not get Sanders’ physician to sign his death certificate and the cause of death has still apparently not been determined, pending toxicology testing which typically takes 6 weeks.

What’s On Your Parent’s Death Certificate

More important than what is on Garry Shandling’s death certificate is what is on your parent’s death certificate, and whether it is accurate. If one of your parents died prematurely and suddenly, it is  important to know with precision what caused it. If the cause was an heritable cardiovascular condition, hopefully, appropriate testing can determine if you have that condition, and steps can be taken to prevent your premature demise.

Examples of inherited cardiovascular conditions (in addition to heart attack (myocardial infarction) or pulmonary embolism) that can cause sudden and unexpected death include aortic aneurysm dissection, hypertrophic cardiomyopathy, arrhythmogenic right ventricular dysplasis, and long QT syndrome.

Unfortunately I find that, at least in my patients, uncertainty about the cause of death of one’s parents is the norm.

Many of my patients, for example, tell me one of their parents died of a “massive heart attack” and they assume that they are at increased risk of the same fate. When I press for details, typically no autopsy was performed.  Mom or dad may have been found dead at home, or they may have suddenly keeled over but not survived to make it to the hospital for a definitive diagnosis.

Without an autopsy in such circumstances, it is not possible to be sure of the cause of death.

Even if you have a cause of death listed on your parent’s death certificate, there is no guarantee that it is accurate.  The doctor that filled it out, without an autopsy in many circumstances, is just speculating on the cause based on what he/she knew about prior medical conditions and the circumstances surrounding the death.

I was recently asked to fill out the death certificate of an elderly patient of mine who had atrial fibrillation and congestive heart failure and was living in a nursing home.

One night she was noted by the staff to be very short of breath and was taken to a local  emergency room where she was pronounced dead.

Based on the information available to me, I had no idea what caused her death. Although she had quite signifiant cardiac problems, when I last saw her she was stable and I have numerous patients with the same conditions who live for decades.

I filled out the death certificate, listing all of her conditions, and entered in that the cause of death was unknown.

Although the CDC guide for physicians filling out death certificates clearly states that this is acceptable, I was subsequently informed that the funeral home did not accept unknown cause of death and that they had found another doctor to fill in a cause  of death.

I guarantee you, whatever he put on as the cause of death was total speculation.

Jerry Seinfeld was good friends with Garry Shandling and, oddly enough, not too long ago, featured him in an episode of his internet series “Comedians in Cars Getting Coffee” entitled “It’s Great That Garry Shandling Is Still Alive.

Screen Shot 2016-07-03 at 7.04.14 AM

Shandling mentions “I had hyperparathyroidism,” making a joke that “the symptoms are so much like being an older Jewish man, no one noticed!”

James Fallows, the excellent The Atlantic writer, highlights his own experience with hyperparathyroidism (a disease that leads to high calcium levels and is easily treated with surgery), in a recent Atlantic article. The subtitle of this article, “a rare and under-publicized condition that can sometimes be fatal,” suggests that hyperhyperparathyroidism might have led to Shandling’s death.

I don’t think this is likely because Shandling suggests that the disease is in the past tense (i.e. he has already had the surgery), and sudden death from hyperparathyroidism would be extremely unlikely.

Fortunately, Shandling is getting a full examination and autopsy to fully determine the cause of his death. If he has offspring, this will be extremely helpful to them in understanding what medical conditions they can expect later in life.

If he was not a celebrity, his death, like many of your parents’, most likely would have been ascribed to a “massive heart attack.”



Getting To The Heart Of Father’s Day

The skeptical cardiologist received an email from the folks at AliveCor a few days ago with the subject line:

Dad’s heart matters – Kardia Mobile for Dad will give you peace of mind and make Dad happy

The email contains this image of an older well-dressed man (withScreen Shot 2016-06-18 at 9.03.26 AM lots of bling) standing in a beautiful meadow near the ocean. The man has decided to turn his back on the ocean and check his heart rhythm using the AliveCor/Kardia (AliveCor has changed the name of its ECG devices to Kardia) mobile ECG. This man is a happy dad! (Unless his heart rhythm is interpreted as atrial fibrillation. Then the beach walk is ruined.)

The email asks the question “What if Dad’s heart really was an open book?”

Uhh, he’d be dead? Clearly books don’t function well at pumping 5 or 6 liters of blood through the cardiovascular system every minute whether they are open or closed. Perhaps  the question is using either  the heart or an open book as a metaphor?

The advertisement goes on to suggest that I get my dad an AliveCor device for father’s day  “So you always know what his heart is thinking.”

I believe this is the marketing person’s attempt to extend the metaphor of the open book, i.e., you know exactly what dad’s brain is thinking, now you can extend this knowledge to his heart.  The metaphor of the heart “thinking” is quite poor but poor metaphors are the norm today.

Bad metaphors and bad writing abound on father’s day because 90 million greeting cards are purchased and given as (according to the Greeting Card Association)  “a meaningful expression of personal affection for another person.” Despite the increasing use of Facebook and its ilk to transmit emotions, the Greeting Card Association assures us that “The tradition of giving greeting cards … is still being deeply ingrained in today’s youth, and this tradition will likely continue as they become adults and become responsible for managing their own important relationships.

Mobile Ecg Monitor As A Father’s Day Gift

I have to say that despite the horror of the writing in this email advertisement it got me thinking about getting my father a Kardia device. I’ve suggested  previously that  an AliveCor device would make a good gift for Christmas for a loved one who has intermittent unexplained palpitations or atrial fibrillation but had not considered this for my dad.

For one thing he does not possess a smart phone which is required to  make the Kardia device functional. For another, he doesn’t have atrial fibrillation (that we know of. Perhaps if I knew what his heart was thinking we would find out that it likes to fibrillate late at night,)

Perhaps it’s time to upgrade my Dad to an iPhone I began thinking.

But wait! He has an iPad mini (that he seems to only use for FaceTime conversations.)

Further research reveals that Kardia is not only compatible with iPhone and Android smartphones but apparently iPads and IPod Touch.Screen Shot 2016-06-19 at 8.04.27 AM

Taking Care of Dad’s Heart

What about the rest of the slick advertising copy in my email?

And now you can know the way to help take care of it. Kardia gives Dad a medical-grade EKG in only 30 seconds. It even gives him expert analysis and tracking, with reports getting shared directly with his physician

This part is pretty clear and correct. I use Kardia daily in my office to record patient’s heart rhythm and I have a dozen patients now who make recordings outside of the office. They can have their recordings read by a random cardiologist for a fee or establish a link with me as their provider and I can review them through my account for free.

 Is It The First Father’s Day Gift That Leads To More Father’s Days?

The ad ends with the remarkably brazen statement that “It’s the first Father’s Day gift that leads to more Father’s Days.”

While I find the device more helpful in many instances than current expensive and intrusive long term monitoring devices for detecting and monitoring atrial fibrillation and other abnormal heart rhythms, it is a huge leap to suggest that this translates somehow into a longer life span.

To AliveCor’s credit, despite such ridiculous marketing drivel , studies presented at the recent Heart Rhythm Society Scientific Meetings suggest:

  • Kardia Mobile Superior to Conventional Monitoring: Researchers at the Leeds General Infirmary found that the AliveCor monitor is superior to conventional Holter monitoring in patients with palpitations, providing a higher diagnostic yield, more detected arrhythmias, with a similar workload.

  • Kardia Mobile Leads to Improved Patient Compliance:Researchers at the University of Buffalo found that AliveCor provides a diagnostic yield comparable to a 30-day ambulatory looping event monitor and that the smartphone-based ECG monitor can be used as a first approach for the diagnosis of palpitations.

  • Kardia Mobile provided more information resulting in changes in arrhythmia patient management than traditional external event recorders in a study from researchers at the University of Miami.

  • AliveCor’s AF algorithm was reported to be superior by researchers at Arizona State University to the patient’s own ability to detect AF via symptoms.

    But even if these studies make it to publication they don’t suggest the device provides any improved longevity. In fact, such data, do not exist for any monitoring device.

Happy Father’s Day, Dad! Don’t be surprised when we FaceTime later today that I’ve found another use for your iPad.

Paternally Yours,


N.B. Clearly I receive no consulting, speaking or P.R. writing fees of any kind from AliveCor. Nor do they provide me with any free devices. What’s more, when I lose one of their devices they don’t replace it.  I am totally free of any conflict of interest.


Snake Oil Du Jour: Turmeric

Part I of the skeptical cardiologist’s intermittent efforts at exposing the dark underbelly of the “superfood” snake oil parade deals with turmeric.

This key ingredienet of curry, has been seized upon by the useless and dangerous supplement/vitamin/nutraceutical industry recently and a patient asked me if he should take it.

A Google search yields overblown titles such as

-The amazing health benefits of turmeric  (, a bogus website)

-6 Health benefits of Turmeric (Huffington Post, the health portion of which is full of hucksters)

-10 Proven Health Benefits of Turmeric and Curcumin (, a bogus nutrition website)

-7 Powerful Turmeric Health Benefits and Side Effects (, a bogus health website)

As I started researching turmeric I came across an outstanding summary of the topic on science-based medicine by Harriet Hall. I stopped the research and decided I would just put a link to that blog post on my site but never get around to it.

Today, however, another patient told me he was taking turmeric.

Consequently, I’m posting Harriet Hall’s article below in its entirety.

Turmeric: Tasty in Curry, Questionable as Medicine « Science-Based Medicine.

turmericA correspondent asked me to look into the science behind the health claims for turmeric. He had encountered medical professionals “trying to pass turmeric as some sort of magical herb to cure us from the ‘post-industrial chemical apocalypse.’” It is recommended by the usual promoters of CAM: Oz, Weil, Mercola, and the Health Ranger (who conveniently sells his own superior product, Turmeric Gold liquid extract for $17 an ounce).

Turmeric (Cucurma longa) is a plant in the ginger family that is native to southeast India. It is also known as curcumin. The rhizomes are ground into an orange-yellow powder that is used as a spice in Indian cuisine. It has traditionally been used in folk medicine for various indications; and it has now become popular in alternative medicine circles, where it is claimed to be effective in treating a broad spectrum of diseases including cancer, Alzheimer’s, arthritis, and diabetes. One website claims science has proven it to be as effective as 14 drugs, including statins like Lipitor, corticosteroids, antidepressants like Prozac, anti-inflammatories like aspirin and ibuprofen, the chemotherapy drug oxaliplatin, and the diabetes drug metformin. I wish those claims were true, because turmeric is far less expensive and probably much safer than prescription drugs. It clearly has some interesting properties, but the claims go far beyond the actual evidence.

The Natural Medicines Comprehensive Database has reviewed all the available scientific studies and has concluded that it is “Likely Safe,” “Possibly Effective” for dyspepsia and osteoarthritis, and “Insufficient Reliable Evidence” to rate effectiveness for other indications, such as Alzheimer’s, anterior uveitis, colorectal cancer, rheumatoid arthritis, and skin cancer.

Mechanism of action

The “14 drugs” website says turmeric is one of the most thoroughly researched plants ever, with 5,600 peer-reviewed studies, 175 distinct beneficial physiological effects, and 600 potential preventive and therapeutic applications. They provide a database of 1,585 hyperlinks to turmeric abstracts. Naturally I can’t read all of them, but a sampling indicates that they are almost entirely animal and in vitro studies. The NMCD has conveniently provided a list of the most pertinent studies.

The pertinent preclinical studies, in animal models and in vitro, indicate that curcumin has anti-inflammatory properties; can induce apoptosis in cancer cells and may inhibit angiogenesis; has antithrombotic effects; can decrease the amyloid plaque associated with Alzheimer’s; has some activity against bacteria, Leishmania, HIV; etc. These effects sound promising, but animal studies and in vitro studies may not be applicable to humans. As Rose Shapiro pointed out in her book Suckers, you can kill cancer cells in a Petri dish with a flame thrower or bleach. Preclinical studies must always be followed by clinical studies in humans before we can make any recommendations to patients.

Preliminary clinical research

There are preliminary pilot studies in humans suggesting that:

Clinical research on turmeric is being funded by the National Center for Complementary and Alternative Medicine (NCCAM), but the NCCAM website is not very encouraging. Under the section What the Science Says, it reads:

  • There is little reliable evidence to support the use of turmeric for any health condition because few clinical trials have been conducted.
  • Preliminary findings from animal and other laboratory studies suggest that a chemical found in turmeric—called curcumin—may have anti-inflammatory, anticancer, and antioxidant properties, but these findings have not been confirmed in people.
  • NCCAM-funded investigators have studied the active chemicals in turmeric and their effects—particularly anti-inflammatory effects—in human cells to better understand how turmeric might be used for health purposes. NCCAM is also funding basic research studies on the potential role of turmeric in preventing acute respiratory distress syndrome, liver cancer, and post-menopausal osteoporosis.

Side effects

Turmeric is generally considered safe, but high doses have caused indigestion, nausea, vomiting, reflux, diarrhea, liver problems, and worsening of gallbladder disease. The NMCD warns that it may interact with anticoagulants and antiplatelet drugs to increase the risk of bleeding, that it should be used with caution in patients with gallstones or gallbladder disease and in patients with gastroesophageal reflux disease, and that it should be discontinued at least 2 weeks before elective surgery. Purchasers of supplements are not given that information.


The “14 drugs” website recommends that everyone:

use certified organic (non-irradiated) turmeric in lower culinary doses on a daily basis so that heroic doses won’t be necessary later in life after a serious disease sets in.

There is no evidence to support any part of that recommendation. And the scientific evidence for turmeric is insufficient to incorporate it into medical practice. As with so many supplements, the hype has gone way beyond the actual evidence. There are some promising hints that it may be useful, but there are plenty of promising hints that lots of other things “may” be useful too. Since I have no rational basis for choosing one over another, I see no reason to jump on the turmeric bandwagon. On the other hand, I see no compelling reason to advise people not to use it, as long as they understand the state of the evidence well enough to provide informed consent and know that they are essentially guinea pigs in an uncontrolled experiment that makes no attempt to collect data. I will keep an open mind and stay tuned for further evidence in the form of well-designed clinical studies in humans.

So, the bottom line on turmeric, our “snake-oil du jour” is

-there is nothing to support its use for any health condition

-potential dangerous side effects

-interacts with legitimate prescription meds

-crucial ingredient in curry

My advice-DONT”T TAKE IT!

Gostephencurryily yours,


Salt Talks Two

The skeptical cardiologist found himself reading a cookbook the other day, something he heretofore had avoided. Cookbooks somehow seem archaic and, I presumed, exclusively the domain of the women in my life.  My mother had loads of them, hiding their food-stained bindings behind a cabinet door in my childhood kitchen. Whereas I can stare longingly at all manner of books on  bookstore shelves, I scrupulously avoid the cooking section, finding nothing that intrigues or attracts me in their heavily illustrated contents.

The eternal fiancee’ of the skeptical cardiologist (EFOSC), I believe, had requested I find the recipes for several dishes we (more accurately, she) could prepare the next week and had headed off to Whole Foods or Nordstrom Rack or Pier 1 (all of which, strangely and conveniently sit side by side).

IMG_6880 copyAfter receiving directions on where these mysterious tomes resided, I grabbed the cookbook that looked the most interesting: Ruhlman’s TWENTY: 20 Techniques, 100 Recipes, A Cook’s Manifesto. Instead of searching for recipes I ended up being distracted by Chapter 2: Salt: Your Most Important Tool.

In Chapter 2, Ruhlman makes the bold statement that “if you don’t have a preexisting problem with high blood pressure and if you eat natural foods-foods that aren’t heavily processed-you can salt your food to whatever level tastes good to you without worrying about health concerns.”

As I’ve written previously, I agree with him, and a recent article published in The Lancet casts further doubt on recommendations for the general population to limit sodium consumption drastically.

In the Lancet article, the authors did a pooled analysis of four large prospective studies involving 133118 patients in 49 countries. They studied the relationship between salt consumption, measured by 24 hour urine excretion of sodium (because what goes in must come out) and the incidence of cardiovascular disease and death over about 4 years.

The findings:

  1. Patients without hypertension who excreted more than 7 grams/day of sodium were no more likely to have cardiovascular disease or death than those excreting  4-5 grams/day.
  2. In fact, in both normotensive and hypertensive groups, sodium excretion of < 3 g/day was associated with a significantly (26% higher in normotensives, 34% in hypertensives) increased risk of cardiovascular disease and death.
  3. The only group that would appear to benefit from lower sodium consumption was the hypertensive group which excreted 7 g/day of sodium and when compared to the hypertensive group that excreted 4-5 g/day of sodium had a 23% higher risk of CV death and disease.

If we have to worry about anything with salt consumption, this study (and others) suggests that it is consuming too little salt.

The only group that need worry about too much salt consumption is those who have hypertension and who consume a really large amount of salt.  Since the average American Average consumes 3.4 grams per day of salt, very few of us are consuming over 7 g/day.  Despite this, The American Heart Association continues to stick by its totally unjustified recommendation that sodium levels be no higher than 1,500 mg/day, and other organizations recommend sodium levels below 2,300 mg/day.

What Kind of Salt Should We Consume

Ruhlman recommends coarse kosher salt, preferably Diamond Crystal or, if that’s not available, Morton’s.

Why? Because “salt is best measured with your fingers and eyes, not with measuring spoons.”

“Coarse salt is easier to hold and easier to control than fine salt.”

He feels that salting is an inexact skill and one should always salt to taste.

“When  recipe includes a precise measure of salt, a teaspoon, say, this is only a general reference, or an order of magnitude–a teaspoon, not a tablespoon. You may need to add more. How do you know? Taste the food.”

The skeptical cardiologist’s frittata.

These words were music to my ears as I am an advocate of serendipity, chaos and creativeness in the kitchen.  When I make a frittata, as I did this morning, I measure nothing precisely; not the butter and olive oil used to sauté, the bell peppers, onions and garlic; not the milk mixed with the eggs; not the cheese sprinkled on top; not the time spent in the oven or even the heat; and most assuredly, not the salt and pepper.

IMG_6876At the end of the frittata creation process I took a bite. It was delicious but it needed something: a touch more salt. I sprinkled some David’s kosher salt on top and tried again, Perfection!

Although I have hypertension, I know (see discussion here) that my salt consumption is way below 7 grams/day and, if anything, based on the most recent studies, I should be worrying about too little sodium in my diet.

saltatorily yours,



As I outlined in one of my previous posts on salt, here is what I tell my patients:

  • Spend a day or two accurately tracking your consumption of salt to educate yourself. I found this app to be really helpful. I’ll expand on this in a future post.
  • Recognize that not everybody needs to follow a low salt diet. If your blood pressure is not elevated and you have no heart failure you don’t need to change your salt consumption.
  • If your blood pressure is on the low side and especially if you get periodic dizzy spells, often associated with standing quickly liberalize your salt intake, you will feel better.
  • If you have high blood pressure, you are the best judge of how salt effects your blood pressure. In the example I gave in a previous post, my patient realized that all the salt he was sprinkling on his tomatoes was the major factor causing his blood pressure to spike.
  • The kidneys do a great job of balancing sodium intake and sodium excretion if they are working normally. If you have kidney dysfunction you will  be more sensitive to the effects of salt consumption on your blood pressure and fluid retention.
  • If you are following a Mediterranean diet with plenty of fresh fruits and vegetables you are going to be in the ideal range for both potassium and sodium consumption.

Unbiased, evidence-based discussion of the effects of diet, drugs, and procedures on heart disease

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