Asclepius with his serpent-entwined staff, Archaeological Museum of Epidaurus
I swear by Apollo the Healer, by Asclepius, by Hygieia, by Panacea, and by all the gods and goddesses, making them my witnesses, that I will carry out, according to my ability and judgment, this oath and this indenture.
Much as I enjoy the ribald hi jinx of the gods and goddesses in Greek mythology and appreciate the back story behind words like panacea and hygiene* I just don’t feel it is appropriate to swear an oath to mythical super beings.
Let Food Be Thy Medicine-The Apocryphal Hippocratic Trope
Hippocrates is often cited these days in alternative medicine circles because he is alleged to have said “let food be thy medicine and medicine thy food.”
I’ve come across two articles that are well worth reading on the food=medicine trope which is often used by snake oil salesmen to justify their useless (presumably food-based) supplements.
Food is so much more than medicine. Food is intrinsically related to human social interactions and community. Food is culture, love, and joy. Turning food into medicine robs it of these positive attributes.
A healthy relationship with food is essential to a person’s well-being, but not because it has medicinal properties. Food is not just fuel and it is more than nutrients — and we don’t consume it just to reduce our disease risk.
Seeing food as a medicine can contribute to obsessing about macronutrientintake, to unfairly canonizing or demonizing certain foods, and to turning eating into a joyless and stressful process.
People tend to overvalue the immediate impact of what they eat, thinking that a “super food” can have instant benefits while undervaluing the long-term effects of what they consume over their lifetime.
Gorski notes that just because Hippocrates is considered by some to be the “father of medicine” and his ideas are ancient doesn’t make them correct:
one of the best examples out there of the logical fallacy known as the appeal to antiquity; in other words, the claim that if something is ancient and still around it must be correct (or at least there must be something to it worth considering).
Of course, just because an idea is old doesn’t mean it’s good, any more than just because Hippocrates said it means it must be true. Hippocrates was an important figure in the history of medicine because he was among the earliest to assert that diseases were caused by natural processes rather than the gods and because of his emphasis on the careful observation and documentation of patient history and physical findings, which led to the discovery of physical signs associated with diseases of specific organs. However, let’s not also forget that Hippocrates and his followers also believed in humoral theory, the idea that all disease results from an imbalance of the “four humors.” It’s also amusing to note that this quote by Hippocrates is thought to be a misquote, as it is nowhere to be found in the more than 60 texts known as The Hippocratic Corpus (Corpus Hippocraticum).
Gorski goes on to point out that:
this ancient idea that virtually all disease could be treated with diet, however much or little it was embraced by Hippocrates, has become an idée fixe in alternative medicine, so much so that it leads its proponents twist new science (like epigenetics) to try to fit it into a framework where diet rules all, often coupled with the idea that doctors don’t understand or care about nutrition and it’s big pharma that’s preventing the acceptance of dietary interventions. That thinking also permeates popular culture, fitting in very nicely with an equally ancient phenomenon, the moralization of food choices (discussed ably by Dr. Jones a month ago
We’ve learned a lot about medicine and nutrition in the last 3 thousand years. We can thank Hippocrates, perhaps, for the idea that diseases don’t come from the gods but little else.
It’s time to upgrade the physician pledge and jettison the antiquated Hippocratic Oath.
We now have real, effective medicines that have nothing to do with food for many diseases. It’s important to eat a healthy diet.
But the food=medicine trope is just too often a marker for pseudo and anti-science humbuggery and should also be left behind.
Hygienically Yours,
-ACP
*From Wikipedia, an explanation of the Gods and Goddesses mentioned in the Hippocratic oath
Asclepius represents the healing aspect of the medical arts; his daughters are Hygieia(“Hygiene”, the goddess/personification of health, cleanliness, and sanitation), Iaso (the goddess of recuperation from illness), Aceso(the goddess of the healing process), Aglæa/Ægle (the goddess of the glow of good health), and Panacea (the goddess of universal remedy).
The Physician’s Pledge
Adopted by the 2nd General Assembly of the World Medical Association, Geneva, Switzerland, September 1948
and amended by the 22nd World Medical Assembly, Sydney, Australia, August 1968
and the 35th World Medical Assembly, Venice, Italy, October 1983
and the 46th WMA General Assembly, Stockholm, Sweden, September 1994
and editorially revised by the 170th WMA Council Session, Divonne-les-Bains, France, May 2005
and the 173rd WMA Council Session, Divonne-les-Bains, France, May 2006
and the WMA General Assembly, Chicago, United States, October 2017
AS A MEMBER OF THE MEDICAL PROFESSION:
I SOLEMNLY PLEDGE to dedicate my life to the service of humanity;
THE HEALTH AND WELL-BEING OF MY PATIENT will be my first consideration;
I WILL RESPECT the autonomy and dignity of my patient;
I WILL MAINTAIN the utmost respect for human life;
I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing, or any other factor to intervene between my duty and my patient;
I WILL RESPECT the secrets that are confided in me, even after the patient has died;
I WILL PRACTISE my profession with conscience and dignity and in accordance with good medical practice;
I WILL FOSTER the honour and noble traditions of the medical profession;
I WILL GIVE to my teachers, colleagues, and students the respect and gratitude that is their due;
I WILL SHARE my medical knowledge for the benefit of the patient and the advancement of healthcare;
I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the highest standard;
I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat;
I MAKE THESE PROMISES solemnly, freely, and upon my honour.
The skeptical cardiologist had been avoiding reader pleas to comment on a paper recently published in the Lancet from the PURE study which showed that full fat dairy consumption is associated with a lower risk of mortality and cardiovascular disease. It felt like beating a dead horse since I’ve been writing for the last 5 years that the observational evidence nearly unanimously shows that full fat dairy is associated with less abdominal fat, lower risk of diabetes and lower risk of developing vascular complications such as stroke and heart attack. However, since bad nutritional advice in this area stubbornly persists and the PURE study is so powerful and universally applicable, I felt compelled to post my observations.
What Did the PURE Study Show?
The PURE (Prospective Urban Rural Epidemiology) study enrolled 136, 00 individuals aged 35–70 years from 21 countries in five continents. Dietary intakes of dairy products ( milk, yoghurt, and cheese) were recorded.. Food intake was stratified into whole-fat and low-fat dairy. The primary outcome was the composite of mortality or major cardiovascular events.
Consumption of 2 servings of dairy per day versus none was associated with a 16% lower risk of the primary outcome. The high dairy consumers had an overall 17% lower risk of dying. They had a 34% lower risk of stroke.
People whose only dairy consumption consisted of whole-fat products had a significantly lower risk of the composite primary endpoint (29%).
Here’s how one of the authors of the PURE study summarized his findings (quoted in a good summary at TCTMD)
“We are suggesting that dairy consumption should not be discouraged,” lead investigator Mahshid Dehghan, PhD (McMaster University, Hamilton, Canada), told TCTMD. “In fact, it should be encouraged in low-to-middle income countries, as well as in high-income countries among individuals who do not consume dairy. We have people in North America and Europe who are scared of dairy and we would tell them that three servings per day is OK. You can eat it, and there are beneficial effects. Moderation is the message of our study.”
Despite these recent findings and the total lack of any previous data that indicates substituting low or no fat dairy for full fat dairy is beneficial, the American Heart Association (AHA)and major nutritional organizations continue to recommend skim or low fat cheese, yogurt and milk over full fat , non-processed dairy products.
The AHA Continues Its Misguided Vilification Of All Saturated Fat
“Currently with the evidence that we have reviewed, we still believe that you should try to limit your saturated fat including fat that this is coming from dairy products,” commented Jo Ann Carson, PhD, of UT Southwestern Medical Center in Dallas and a spokesperson for the American Heart Association.
“It is probably wise and beneficial to be sure you’re including dairy in that overall heart-healthy dietary pattern, but we would continue to recommend that you make lower fat selections in the dairy products,” Carson told MedPage Today regarding the study, with which she was not involved.
What is their rationale? A misguided focus on macronutrients. For decades these people have been preaching that saturated fat is bad and unsaturated fat is good. All saturated fat is bad. All unsaturated fat is good.
To deem even one product which contains a significant amount of saturated fat as acceptable would undermine the public’s confidence in the saturated fat dogma.
Bad Nutritional Advice From The AHA Is Not New
Of course, the AHA has been notoriously off base on its nutritional advice for decades. selling its “heart-check” seal of approval to sugar-laden cereals such as Trix, Cocoa Puffs, and Lucky Charms and promoting trans-fat laden margarine. These products could qualify as heart-healthy because they were low in cholesterol and saturated fat.
To this day, the AHA’s heart-check program continues to promote highly processed junk food as heart-healthy while raking in millions of dollars from food manufacturers.
The AHA’s heart-check program is still using low cholesterol as a criteria for heart-healthy food whereas the 2015 Dietary Guidelines concluded that dietary cholesterol intake was no longer of concern.
Why would anyone believe the AHA’s current nutritional advice is credible given the historical inaccuracy of the program?
I’ve noticed that the dairy industry has done nothing to counter the idea that Americans should be consuming skim or low fat dairy product and discussed this with a dairy farmer who only sells full fat products a few years ago.
The Skim Milk Scam:Words of Wisdom From a Doctor Dairy Farmer
Full fat dairy is associated with less abdominal fat, lower risk of diabetes and lower risk of developing vascular complications such as stroke and heart attack. I’ve been consuming full fat yogurt and milk from Trader’s Point Creamery in Zionsville, Indiana almost exclusively since visiting the farm and interviewing its owners a few years ago.
Dr. Peter(Fritz) Kunz, a plastic surgeon, and his wife Jane, began selling milk from their farm after researching methods for rotational grazing , a process which allows the cows to be self-sustaining: the cows feed themselves by eating the grass and in turn help fertilize the fields, . After a few years of making sure they had the right grasses and cows, the Kunz’s opened Traders Point Creamery in 2003.
Two more studies (summarized nicely on ConscienHealth, an obesity and health blog) came out recently solidifying the extensive data supporting the health of dairy fat and challenging the nutritional dogma that all Americans should be consuming low-fat as opposed to full fat dairy.
The Dairy Industry’s Dirty Little Secret
Dr. Kunz opened my eyes to the dirty little secret of the dairy industry when i first talked to him: dairy farmers double their income by allowing milk to be split into its fat and non-fat portions therefore the industry has no motivation to promote full fat dairy over nonfat dairy.
Recently, I presented him with a few follow-up questions to help me understand why we can’t reverse the bad nutritional advice to consume low-fat dairy.
Skeptical Cardiologist: “When we first spoke and I was beginning my investigation into dairy fat and cardiovascular disease you told me that most dairy producers are fine with the promotion of non fat or low fat dairy products because if consumers are choosing low fat or skim dairy this allows the dairy producer to profit from the skim milk production as well as the dairy fat that is separated and sold for butter, cheese or cream products.”
I don’t have a clear idea of what the economics of this are. Do you think this, for example, doubles the profitability of a dairy?
Dr. Kunz: “Yes, clearly. Butter, sour cream, and ice cream are highly profitable products… All these processes leave a lot of skim milk to deal with, and the best opportunity to sell skim milk is to diet-conscious and heart-conscious people who believe fat is bad.”
Skeptical Cardiologist:” I’ve been baffled by public health recommendations to consume low fat dairy as the science would suggest the opposite. The only reason I can see that this persists is that the Dairy Industry Lobby , for the reason I pointed out above, actually has a vested interest from a profitability standpoint in lobbying for the low fat dairy consumption.. Do you agree that this is what is going on? ”
Dr. Kunz: “Yes, definitely. The obsession with low-fat as it relates to diet and cardiac health has been very cleverly marketed. Fat does NOT make you fat.
Skeptical Cardiologist: “Also, I have had trouble finding out the process of production of skim milk. I’ve come across sites claiming that the process involves injection of various chemical agents but I can’t seem to find a reliable reference source on this. Do you have any information/undestanding of this process and what the down sides might be? I would like to be able to portray skim milk as a “processed food” which, more and more, we seem to be recognizing as bad for us.”
Dr. Kunz: “The PMO pasteurized milk ordinance states that when you remove fat you have to replace the fat soluble vitamins A & D. Apparently the Vitamin A & D have to be stabilized with a chemical compound to keep them miscible in basically an aqueous solution. The compound apparently contains MSG!! We were shocked to find this out and it further confirmed that we did not want to do a reduced fat or skim milk product.”
Skeptical Cardiologist: ” Any thoughts on A2? Marion Nestle’, of Food Politics fame, was recently in Australia where there is a company promoting A2 milk as likely to cause GI upset. It has captured a significant share of the Aussie market.”
Dr. Kunz: “We have heard of this and have directed our farm to test and replace any A1 heterozygous or homozygous cows. We believe that very few of our herd would have A1 genetics because of the advantage of using heritage breeds like Brown Swiss and Jersey instead of Holstein. Because few people are actually tested for lactose intolerance and because of the marketing of A2, it’s imperative not to be left behind in this – whether or not it turns out to be a true and accurate cause of people’s GI upset.
Skeptical Cardiologist:” I like that your milk is nonhomogenized. Seems like the less “processing” the better for food. I haven’t found any compelling scientific reasons to recommend it to my patients, however. Do you have any?”
Dr. Kunz: The literature is fairly old on this subject, but xanthine oxidase apparently can become encapsulated in the fat globules and it can be absorbed into the vascular tree and cause vascular injury. I will look for the articles. Anyway, taking your milk and subjecting it to 3000-5000 psi (homogenization conditions) certainly causes damage to the delicate proteins and even the less delicate fat globules. Also remember that dietary cholesterol is not bad but oxidized cholesterol is very bad for you. That’s why overcooking egg yolks and high pressure spray drying to make powder products can be very dangerous – like whey protein powders that may contain some fats.
Skeptical Cardiologist: I spend a fair amount of time traveling in Europe and am always amazed that their milk is ultrapasteurized and sits unrefrigerated on the shelves. any thoughts on that process versus regular pasteurization and on pasteurization in general and its effects on nutritional value of dairy.
Dr. Kunz :“Absolutely crazy bad and nutritionally empty.. don’t know why anyone would buy it. The procedure is known as aseptic pasteurization and is how Nestle makes its wonderful Nesquik. If they made a full fat version of an aseptically pasteurized product it may have more oxidized cholesterol and be more harmful than no fat!!”
So there you have it, Straight from the doctor dairy farmer’s mouth:
Skimming the healthy dairy fat out of milk is a highly profitable process. Somehow, without a shred of scientific support, the dairy industry, in cahoots with misguided and close-minded nutritionists, has convinced the populace that this ultra-processed skim milk pumped full of factory-produced synthetic vitamins is healthier than the original product.
Lactosingly Yours
-ACP
The two recent articles (mentioned in this post) supporting full fat dairy are:
which concluded ‘In two prospective cohorts, higher plasma dairy fatty acid concentrations were associated with lower incident diabetes. Results were similar for erythrocyte 17:0. Our findings highlight need to better understand potential health effects of dairy fat; and dietary and metabolic determinants of these fatty acids
Yesterday, a patient I’m seeing for atrial fibrillation told me that he was taking fish oil supplements that his eye doctor had recommended and sold to him for dry eyes. This patient reads my blog and knows that I strongly recommend not taking fish oil supplements (unless your triglycerides are >500). At the time I told him I didn’t know the literature on fish oil and dry eyes but that I was skeptical of any proven benefit.
Despite insufficient evidence establishing the effectiveness of omega-3s, clinicians and their patients have been inclined to try the supplements for a variety of conditions with inflammatory components, including dry eye. “This well-controlled investigation conducted by the independently-led Dry Eye Assessment and Management (DREAM) Research Group shows that omega-3 supplements are no better than placebo for typical patients who suffer from dry eye.”
I suspect that one by one the various alleged benefits of fish oil supplements will be proven to be nonexistent. I’m not sure the general public will stop buying snake or fish oil then but I feel like one by one I’m getting my patients off them. Doing my part to save the ocean bottom-feeders.
Krillingly Yours,
-ACP
N.B. I’m writing this while flying to Miami to begin the great Galapagos adventure and the Voyage of the Samba.
The eye of the skeptical cardiologist was caught by an FDA alert issued recently:
FDA Investigating Potential Connection Between Diet and Cases of Canine Heart Disease
According to the alert:
reports of canine dilated cardiomyopathy (DCM) in dogs eating certain pet foods containing peas, lentils, other legume seeds, or potatoes as main ingredients. These reports are unusual because DCM is occurring in breeds not typically genetically prone to the disease.
What Is Dilated Cardiomyopathy?
Dilated cardiomyopathy refers to a disease of the heart muscle characterized by enlargement and global weakness of the main pumping chambers, the ventricles.
The image below is from the echocardiogram of a human with a severe dilated cardiomyopathy.
Humans with DCM experience weakness, shortness of breath and swelling in the legs due to heart failure. Severe cases of DCM are at risk for dying suddenly.
Cardiomyopathy Used To Be A Disease of Large Dogs
According to Lisa Freeman a veterinarian at the Cummings Veterinary Center at Tufts University
Heart disease is common in our companion animals, affecting 10-15% of all dogs and cats, with even higher rates in Cavalier King Charles Spaniels, Doberman Pinschers, and Boxer dogs.
Dilated Cardiomypathy in dogs
typically occurs in large- and giant-breeds, such as Doberman pinschers, Boxers, Irish Wolfhounds, and Great Danes, where it is thought to have a genetic component.
The FDA alert indicates that DCM
is less common in small and medium breed dogs, except American and English Cocker Spaniels. However, the cases that have been reported to the FDA have included Golden and Labrador Retrievers, Whippets, a Shih Tzu, a Bulldog and Miniature Schnauzers, as well as mixed breeds
“In the last few years I’ve seen more cases of nutritional deficiencies due to people feeding unconventional diets, such as unbalanced home-prepared diets, raw diets, vegetarian diets, and boutique commercial pet foods. The pet food industry is a competitive one, with more and more companies joining the market every year. Marketing is a powerful tool for selling pet foods and has initiated and expanded fads, that are unsupported by nutritional science, including grain-free and exotic ingredient diets. All this makes it difficult for pet owners to know what is truly the best food for their pet (as opposed to the one with the loudest or most attractive marketing). Because of the thousands of diet choices, the creative and persuasive advertising, and the vocal opinions on the internet, pet owners aren’t able to know if the diets they’re feeding have nutritional deficiencies or toxicities – or could potentially even cause heart disease.
Purina has a whole line of grain-free wet and dry dog food under their Beyond label
Apparently, it has become trendy in the pet world (just like the human world) to vilify grains as in this article highlighting potential signs of doggy grain allergy at the dogbaker.com.
Freeman notes that grains are not felt to significantly contribute to pet diseases:
Many pet owners have, unfortunately, also bought into the grain-free myth. The fact is that food allergies are very uncommon, so there’s no benefit of feeding pet foods containing exotic ingredients. And while grains have been accused on the internet of causing nearly every disease known to dogs, grains do not contribute to any health problems and are used in pet food as a nutritious source of protein, vitamins, and minerals.
The FDA alert notes that in 4 cases of doggy DCM (3 of which were golden retrievers) taurine levels were low and with a change back to a normal diet and taurine supplementation the cardiomyopathy resolved. However, some reported cases had normal taurine levels.
Reconsider Your Dog’s Diet
To avoid doggy DCM, Dr. Freeman recommends
Reconsider your dog’s diet. If you’re feeding a boutique, grain-free, or exotic ingredient diets, I would reassess whether you could change to a diet with more typical ingredients made by a company with a long track record of producing good quality diets. And do yourself a favor – stop reading the ingredient list! Although this is the most common way owners select their pets’ food, it is the least reliable way to do so. And be careful about currently available pet food rating websites that rank pet foods either on opinion or on based on myths and subjective information. It’s important to use more objective criteria (e.g., research, nutritional expertise, quality control in judging a pet food). The best way to select what is really the best food for your pet is to ensure the manufacturer has excellent nutritional expertise and rigorous quality control standards (see our “Questions you should be asking about your pet’s food” post).
If you’re feeding your dog a boutique, grain-free, or exotic ingredient diet, watch for early signs of heart disease – weakness, slowing down, less able to exercise, short of breath, coughing, or fainting. Your veterinarian will listen for a heart murmur or abnormal heart rhythm and may do additional tests (or send you to see a veterinary cardiologist), such as x-rays, blood tests, electrocardiogram, or ultrasound of the heart (echocardiogram).
If by now you are still taking fish oil supplements despite my last post on the topic I present three more reasons to stop wasting your money and destroying the ocean’s ecosystem.
The first nail: No Reason To Take Fish Oil Pills
A Cochrane review showing shows there is little or no effect of omega 3 supplements on our risk of experiencing heart disease, stroke or death.
This is the most extensive systematic assessment of effects of omega-3 fats on cardiovascular health to date. Moderate- and high-quality evidence suggests that increasing EPA and DHA has little or no effect on mortality or cardiovascular health (evidence mainly from supplement trials). Previous suggestions of benefits from EPA and DHA supplements appear to spring from trials with higher risk of bias. Low-quality evidence suggests ALA may slightly reduce CVD event risk, CHD mortality and arrhythmia.
Second Nail. Peruvian Anchoveta: Put Them On A Pizza Not in A Pill
Paul Greenberg’s recently published book, The Omega Principle, emphasizes the damage the fish oil supplement business is doing to the ocean environment,
During a recent interview on Fresh Air on NPR he summarized the concerns:
GREENBERG: So omega-3 supplements come from this critical layer of the ocean biosphere that are small – what are called pelagic fish. They’re the silvery, little fish like anchovies and herring and other fish called menhaden that most people haven’t heard of, but it’s actually the most caught fish in the lower 48 of the United States. These fish are really essential for ecosystem dynamics in the ocean.
So the way that oceans work is that all the energies coming from the sun – it goes – all that energy is processed by plankton, by phytoplankton. And it’s really these fish that are – these little fish that are used for omega-3 supplements that transfer the energy from plankton to larger fish. So in other words, you know, you have the solar energy going into the plankton. The little fish then eat the plankton. And then they are in turn eaten by larger fish. So if you harvest this middle layer – if you overharvest this middle layer of anchovies, of herring, of menhaden – if you take them out of the picture, there’s no way for the energy to be transferred from phytoplankton up to larger predators. So I guess that’s my main concern here.
So in particular, where are the omega-3 supplements coming from? Most of the omega-3 supplement oil is coming from a fish called a Peruvian anchoveta. And it is the most caught fish in the world. In some years, Peruvian anchoveta harvests have equaled as much as 10 million metric tons. Just to give you some perspective, that’s like one-eighth of all the fish caught in the world. And the crazy thing about it is that those fish are completely, totally edible. I’ve eaten them. They’re delicious. You can have them on a pizza. You could do anything with them. But 99 percent of those Peruvian anchoveta are ground up into animal feed, boiled down into oil and turned into supplements. So to me, to my mind, that is not necessarily the wisest use to be made of this really, really important source both for the ecology of the ocean but also for humans
Nail Three. Save the Krill!
The supplement industry is incredibly creative in their marketing. As the uselessness of fish oil supplementation has become clear, supplement manufacturers have begun touting krill oil as superior to fish oil.
Claims like the following are all over the internet:
Krill have an edge over your ordinary fish – when you take a krill oil supplement, you also get astaxanthin along with your DHA and EPA. It’s an antioxidant. In terms of antioxidant power of potency, it’s been found to be 500x to 6,000x stronger than regular vitamins like vitamin E and vitamin C.
This is just hogwash. There is no good clinical evidence to support any health claim for krill oil in general or astaxanthin in particular. Please read my post on the failure of anti-oxidant supplements and vitamins and recognize that claims of antioxidant power do not indicate any health benefit.
A technical paper from Greenpeace review the importance of krill to to the marine ecosystem in the Antarctic and this paper, entitled “License to Krill” details the problem.
Do you want to be responsible for starving penguins, whales and seals??!
the bottom line on fish oil supplements is that the most recent scientific evidence does not support any role for them in preventing heart attack, stroke, or death. There are potential down sides to taking them, including contaminants and the impact on the marine ecosystem. I don’t take them and I advise my patients to avoid them (unless they have triglyceride levels over 500.)
I mentioned at that time that Honey-Nut Cheerios was the #1 selling ready-to-eat breakfast cereal and Cheerios #4. This updateindicates little has changed in the rankings or consumption of breakfast cereal since then despite a more widespread recognition that added sugar is the major toxin in our diet and that these food items are basically a vehicle for sugar.
Apparently, Americans believe honey is not sugar. But Honey Nut Cheerios contain 9 times as much sugar as cheerios. Here are the top ingredients:
General Mills tries to emphasize the healthiness of Honey Nut Cheerios, focusing on their close relationship with bees and the natural goodness of honey in its advertising along with other factors that we now know are not important (low fat, 12 vitamins and minerals, source of iron).
Little has changed with respect to the science supporting fiber consumption to reduce cardiovascular disease since 2014. It is still weak and based on observational studies and surrogate biomarkers.
Between the lines below is my original post with current annotations in red.
The skeptical cardiologist usually eschews the breakfast offerings in the Doctor’s lounge. I’m not really interested in consuming donuts, muffins, or bagels with their high carbohydrate load. As I’ve ranted out about previously, the only yogurt available is Yoplait low fat , highly sugared-up yogurt which is arguably worse than starting the day with a candy bar.
A selection of breakfast cereals is available including Cheerios, Raisin Bran, and Frosted Flakes. Occasionally, when I have neglected to bring in my own full-faty yogurt, granola and/or fruit I will open up one of the Cheerios containers and consume a bowl mixed with 2% milk (full-fat, organic milk which I passionately advocate here and here is not available) (2018 update, I have said “cheerio” to all breakfast cereals and no longer eat Cheerios in the doctor’s lounge).
Pondering the Cheerios packaging and the cute little O’s made me wonder whether this highly processed and packaged food with a seemingly endless shelf life was truly a healthy choice.
The “Ready-To-Eat” And Allegedly Heart-Healthy Cereal
Cheerios and Honey-nut cheerios were the #4 and #1 breakfast cereals in the US in 2013, generating almost a billion dollars in sales. Both of these General Mills blockbusters undoubtedly have reached their popularity by heavily promoting the concept that they are heart healthy.
The Cheerios label is all about the heart. The little O’s sit in a heart-shaped bowl. A prominent red heart with a check inside it attests to the AHA having certified Cheerios as part of its checkmark.heart.org program. Additional text states “low in Saturated fat and cholesterol” and “diets low in saturated fat and cholesterol may reduce the risk of heart disease.”
Is The Fiber In Cheerios “Heart-Healthy” ?
Beta-glucan is a soluble fiber primarily located in the endosperm cell wall of oats. Early studies showed that oats and beta-glucan soluble fiber could reduce total and LDL (bad cholesterol) levels. The mechanism isn’t really known. (see the end of post for possible mechanisms). The Quaker oats web site oversimplifies the mechanism thusly :
“In your digestive tract, it acts as a sponge, soaking up cholesterol and carrying it out of the body”
This narrative fits with the oversimplified and now discredited descriptions of atherosclerosis which attribute it directly to consumption of cholesterol and fatty acids. See here if you’d like to appreciate how complex the process truly is.
The FDA Sanctions Oats As Heart Healthy
In 1997, the FDA reviewed 33 studies (21 showing benefit and 12 not) and decided to allow a health claim for foods that contain oats and soluble fiber. A minimum dose of 3 grams/day of oat beta-glucan was suggested for a beneficial reduction in blood cholesterol and (presumably, although never documented) a subsequent decline in coronary heart disease.
In 1998 Johnson, et al, published the results of a study funded by a grant from General Mills that showed that inclusion of whole grain oat ready to eat cereal providing 3 grams of beta-glucan as part of a low fat diet reduced LDL cholesterol by 4% after 6 weeks. HDL was unchanged. Patients in this study consumed 45 grams (1.5 oz) of cheerios at breakfast and then again in the evening. There was a total of 3 grams of soluble fibre in this amount of Cheerios. A control group consumed corn flakes in a similar fashion without change in LDL.
General Mills took this weak data and ran with it and began posting on Cheerios the following statements
“Did you know that in just 6 weeks Cheerios can reduce bad cholesterol by an average of 4 percent? Cheerios is … clinically proven to lower cholesterol. A clinical study showed that eating two 1 1/2 cup servings daily of Cheerios cereal reduced bad cholesterol when eaten as part of a diet low in saturated fat and cholesterol.”
Although the FDA had approved verbiage indicating oats may reduce heart disease “when eaten as part of a diet low in saturated fat and cholesterol” the agency objected to General Mills claiming that Cheerios lowers cholesterol “when eaten as part of a diet low in saturated fat and cholesterol”.
The FDA issued a warning letter to General Mills in 2009 in which the agency alleged “serious violations” of the FDC Act in the label and labeling of Cheerios cereal.
Based on claims made on your product’s label, we have determined that your Cheerios® Toasted Whole Grain Oat Cereal is promoted for conditions that cause it to be a drug because the product is intended for use in the prevention, mitigation, and treatment of disease.
Lowering Cholesterol Is Not The Same As Preventing Heart Disease
The FDA was telling General Mills that it was OK to say that Cheerios may reduce heart disease but not that it can reduce cholesterol because that made it a drug. It makes no sense.
The only thing that had been demonstrated for oat soluble fiber and Cheerios in particular was a reduction in cholesterol. There has never been a study with oats showing a reduction in heart disease..
It’s the heart disease, the atherosclerosis clogging our arteries and causing heart attacks and strokes that we want to prevent. We could care less about lowering cholesterol if it doesn’t prevent atherosclerosis.
A recent review of studies since the FDA ruling shows that 70% of studies show some reduction in LDL with beta-glucan. Interstingly, the studies which added beta-glucan to liquids were generally positive whereas addition to solids such as muffins usually did not show benefit.
I’m going to accept as evidence-based the claim that whole oats can lower your LDL about 7% if you consume a very large amount of them on a daily basis.
However, the critical question for any drug or dietary intervention is does it prevent atherosclerosis, the root cause of heart attacks and strokes. There has been in the past an assumption that lowering cholesterol by any means would result in lowering of atherosclerosis.
This theory has been disproven by recent studies showing that ezetimibe and niacin which significantly lower LDL do not reduce surrogate markers of atherosclerosis or cardiovascular events any more than placebo when added on to statin drugs. (There is now weak evidence that ezetimibe does lower cardiovascular events ). The recently revised cholesterol guidelines endorse the concept of treating risk of atherosclerosis rather than cholesterol levels.
I do like the food writer Michael Pollan’s simple rules to “Eat Food. Mostly Plants. Not Too Much.” and this NY Times piece summarizes much of what is in his short, funny and helpful Food Rules book:
you’re much better off eating whole fresh foods than processed food products. That’s what I mean by the recommendation to eat “food.” Once, food was all you could eat, but today there are lots of other edible foodlike substances in the supermarket. These novel products of food science often come in packages festooned with health claims, which brings me to a related rule of thumb: if you’re concerned about your health, you should probably avoid food products that make health claims. Why? Because a health claim on a food product is a good indication that it’s not really food, and food is what you want to eat.
If you follow Pollan’s dictum you will get plenty of fiber, soluble or otherwise and you will avoid the necessity to obsess over the macronutrients in your diet, fiber or otherwise. Throw in some Cheerios and oatmeal every once in a while if you like them; in their unadulterated state they are a heart-healthy food choice.
The skeptical cardiologist first encountered the blather of Dr. Steven Gundry while researching and writing a post entitled The #1 Red Flag of Quackery.
Gundry came across my quack radar screen due to the popularity of his useless supplements and his pseudoscientific justifications. He is also widely described as a cardiologist but he is not, He is (or was) a cardiac surgeon (like, strangely enough, the celebrity prince of quackery, Dr. Oz)
I’ve been meaning to write specifically about his most popular useless supplement, Vital Reds.
In the meantime, Gundry has come out with a best-selling. book entitled “The Plant Paradox: The Hidden Dangers in Healthy Foods That Cause Disease and Weight Gain”.
This book claims to reveal to its readers the great dietary “secret” that is causing almost all chronic diseases. Of course, Gundry is the only person with the brilliance and insight to have recognized this. Only those who are willing to plunk down the money to buy his book will learn this secret and the (mostly gobbledook) science behind it.
This technique of convincing the naive that only you are aware of the “hidden” factor which is the cause of their various maladies can probably be considered the #2 Red Flag of Quackery.
The Plant Paradox would have you believe that lectins are the major danger in our diet.
I’ve come across two well-researched pieces which destroy any validity to the concepts put forth by Gundry in The Plant Paradox.
Campbell: Is It Possible Gundry Is Out To Make A Quick Buck?
The first is from T. Colin Campbell of China Study fame. While I don’t agree with his overall dietary philosophy (see here) in his article he has taken the time to read Gundry’s book in detail and address in great detail the multiple bogus claims and the lack of scientific support. Campbell begins:
The claims come fast and furious in this book, stated with a degree of certainty, without nuance, that undoubtedly appeals to many readers. But the referencing is so lacking and sloppy that Dr. Gundry should be embarrassed. The references that are cited in this book do a poor job of trying to justify its claims. And the bulk of the author’s wild claims lack references at all, with several examples of easily verifiable falsehoods. Because his claims are quite profound and novel, referencing of the findings of others and his own results are especially important. This is especially troubling for an author who touts his own research experience.
After debunking Gundry’s lectin claims , Campbell suggests that Gundry’s major goal is selling more useless supplements, including one that will protect readers from the dreaded lectin:
In conclusion, there are many people who desire good health and deserve good information and we resent that they must suffer such poor quality and confusing information under the assumption that it is good science. Is it possible that Dr. Gundry is just out to make a quick buck? He admits that his patients give up to a dozen vials of blood for testing every couple of months at his clinic. Overtesting is common practice in supplement-driven clinics. This extensive testing, (which are another topic), is almost always used to demonstrate some type of nutritional pathology, which of course can only be corrected by taking the suggested supplements. And of course, Dr. Gundry sells supplements, including “Lectin Shield” for about $80 a month. According to his website, “This groundbreaking new formula was created to offset the discomforting effects of lectins (proteins commonly found in plants that make them harder to digest). Lectin Shield works to protect your body from a pile-up of lectins and to promote full-body comfort.”
Are Lectins The Next Gluten?
The second article I highly recommend was written for The Atlantic last year by one of my favorite medical writers, James Hamblin, MD.
Entitled, “Lectins Could Become the Next Gluten“, the article combines a tongue–in-cheek commentary with interviews with scientists who debunk Gundry’s claims. Hamblin also interviews Gundry which is particularly revelatory as to Gundry’s lack of credibility.
Although Gundry claims his writing is not motivated by money, Hambling notes:
Yes, he also sells supplements he recommends. The last 20 or so minutes of his infomercial is a string of claims about how supplies are running low, and it’s important that you act immediately, and that if you do manage to get through to a customer representative you should order as much as you have room to store—the shelf life is great, etc. And the necessity of supplements is the crucial argument of the book. He writes, “Getting all of the nutrients you need simply cannot be done without supplements.”
The GundryMD line of products includes something he invented called vitamin G6. Another is a “lectin shield” that’s “designed to neutralize the effects of lectins.” These are available on his website for $79.99. There you can also get six jars of Vital Reds for $254.70.
Hambling closes his piece by noting that book publishers have no accountability for publishing dietary/health misinformation as they are incentivized to publish and profit from the most outrageous claims.
This is a problem much bigger than any plant protein. Cycles of fad dieting and insidious misinformation undermine both public health and understanding of how science works, giving way to a sense of chaos. It seems that every doctor has their own opinion about how to protect your body from calamity, and all are equally valid, because nothing is ever truly known.
Lectiophilically
-ACP
N.B. Gwyneth Paltrow (GOOP) deserves a prominent place in the Quackery Hall of Shame.
Julia Belluz of Vox has a typically spot-on piece about GOOP which begins:
Gwyneth Paltrow has made a career out of selling pseudoscience on her lifestyle website, Goop. Over the years, the actress has proclaimed women should steam their vaginas, that water has feelings, and that your body holds secret organs. Mixed into these absurd assertions is her bogus detox diet and cleansing advice, all of it in service of promoting Goop’s beauty and wellness products
The skeptical cardiologist was somewhat disheartened to read the New York Times headline today that the PREDIMED study was flawed. I frequently reference this landmark randomized trial of the mediterranean diet when I’m citing the cardiovascular benefits of nuts and EV olive oil.
Science mag summarizes the problem which prompted a re-analysis of the study:
A months-long inquiry by the Spanish researchers and NEJM staff uncovered that up to 1588 people in the trial hadn’t been properly randomized: Some were assigned to the same diet as someone else in their household (a common feature of diet studies, but not reported in the original paper). Others, who lived in a rural area, were assigned to different diets based on the clinic closest to them—for example, one group had to pick up a liter of olive oil each week. “The investigator realized he couldn’t get people to travel as far as they needed so he made his study ‘cluster randomized,’” by clinic rather than by individual, Drazen says.
Here’s what I wrote about nuts and the PREDIMED study when I first started distributing Dr. P’s Heart Nuts to my patients.
The skeptical cardiologist has finally prepared Dr. P’s Heart Nuts for distribution. The major stumbling block in preparing them was finding almonds which were raw (see here), but not gassed with proplyene oxide (see here), and which did not contain potentially toxic levels of cyanide (see here).
During this search I learned a lot about almonds and cyanide toxicity, and ended up using raw organic almonds from nuts.com, which come from Spain.
I’ll be giving out these packets (containing 15 grams of almonds, 15 grams of hazelnuts and 30 grams of walnuts) to my patients because there is really good scientific evidence that consuming 1/2 packet of these per day will reduce their risk of dying from heart attacks, strokes, and cancer.
The exact components are based on the landmark randomized trial of the Mediterranean diet, enhanced by either extra-virgin olive oil or nuts (PREDIMED, in which participants in the two Mediterranean-diet groups received either extra-virgin olive oil (approximately 1 liter per week) or 30g of mixed nuts per day (15g of walnuts, 7.5g of hazelnuts, and 7.5g of almonds) at no cost, and those in the control group received small nonfood gifts).
After 5 years, those on the Mediterranean diet had about a 30% lower rate of heart attack, stroke or cardiovascular death than the control group.
It’s fantastic to have a randomized trial (the strongest form of scientific evidence) supporting nuts, as it buttresses consistent (weaker, but easier to obtain), observational data.
Despite the statistical flaws PREDIMED is still an important study demonstrating the benefits of nuts. PREDIMED was the best randomized trial data we had for nuts but there are tons of observational data which are very consistent and show a strong association between increased nut consumption and reduced mortality..
Consequently, I made up a new batch of Dr. P’s Heart Nuts in honor of the survival of PREDIMED and will be distributing them to patients today.
Ground flaxseed plus Trader’s Point Creamery full fat plain yoghurt. It’s not pretty but tastes pretty good.
The skeptical cardiologist has a confession to make: he’s been adding ground flaxseed to his typical late morning full fat yoghurt plus berries and almonds.
Adding flaxseed seems dangerously close to dietary behaviour I have been advising against: supplementing instead of eating real food.
Also, I am philosophically opposed to going out of my way to eat any edible that is consistently promoted as a “super food” or a “functional food.” To me, these are meaningless terms and marketing blather
When I began writing this post in 2017 I was getting my flaxseed from Stober Farms (Est. 1901) who had been producing “for over 100 years the finest flax in the world.” Stober Farms provided me with “organic Golden Flax Seed which has been Cold-Milled Processed.”
Stober Farms (who have since mysteriously gone into bankruptcy) also informed me:
Flax is digested most effectively when ground. Some grinding methods generate heat when milled, spurring early omega-3 oxidation. Stober Farms uses a unique cold-milled process, which gently grinds the seed without significantly raising the temperature. This proprietary method preserves the nutrients, flavor and extends the shelf life to 22 months.
Honestly, I don’t recall exactly why I began “flaxing” but I suspect I felt it was a good way to boost the fat content in my full fat yoghurt (yes, I am now spelling yoghurt with an h) and berries and perhaps sufficiently satiate me that it would be the only food I would need to consume until dinner or late afternoon.
Two tablespoon (14 grams) is what I typically imprecisely add. These tablespoons provide 75 kcal of energy which comes from 3 grams of protein, 6 grams of fat, and 4 grams of carbs. Three of the four carb grams are soluble fibre.
About half of the fat in flaxseed is in the form of alpha-linolenic acid (ALA)(18:3) an omega-3 polyunsaturated (PUFA) fat. Flaxseed oil contains five times more ALA than walnut oil or canola oil, which are the next highest sources of ALA.
Is Flaxseed A Super Functional Food?
Many seemingly authoritative sites on the internet proclaim that flaxseed is incredibly healthy. For example, Healthline.com’s “Authority Nutrition” (they must be authoritative as authority is in their name) presents their 10 health benefits of eating flaxseed “backed by science” and concludes:
They can be used to improve digestive health, lower blood pressure and bad cholesterol, reduce the risk of cancer and may benefit people with diabetes.
But typical of Authority Nutrition’s overblown claims these are not truly proven by science. The studies cited are weak; typically short-term tests of biomarkers or animal studies or human studies with very small numbers. Most importantly. these studies , which are often funded by flaxseed promoters are highly likely to be biased in favor of positive results.
Most websites tout the cardiovascular benefits of the omega-3 PUFA in flaxseed, the high percentage of soluble fibre and the benefits of a chemical which cannot be named (due to a name which is too difficult to pronounce), SDG.
Omega-3 PUFAs and fibre I’ve touched on previously (and positively) but what about the mysterious and unpronounceable SDF. Per a 2010 review article
Flaxseed is the richest source of the lignan secoisolariciresinol diglucoside (SDG). After ingestion, SDG is converted to secoisolariciresinol, which is further metabolised to the mammalian lignans enterodiol and enterolactone. A growing body of evidence suggests that SDG metabolites may provide health benefits due to their weak oestrogenic or anti-oestrogenic effects, antioxidant activity, ability to induce phase 2 proteins and/or inhibit the activity of certain enzymes, or by mechanisms yet unidentified.
Like so many putative wonder phytochemicals, SDG has a “growing body of evidence” for lots of things but actual proof that it does anything worthwhile in humans is lacking and awaits well done randomized clinical trials
Poorly researched articles on flaxseed are highly likely to tout its anti-inflammatory properties. These properties are seen in rats but unfortunately haven’t been proven in my favorite species, Homo Sapiens , Flaxseed doesn’t seem to decrease the inflammatory marker CRP in humans as reported in this systematic review and meta-analysis.
ALA and Cardiovascular Disease
As I’ve indicated in previous posts, evidence supports fatty fish consumption as beneficial in reducing cardiovascular disease presumably by increasing levels of marine omega-3 PUFAs in the body.
The value of fish oil supplementation, however, is not proven (see here).
How does ALA compare to the seafood omega 3s in preventing cardiovascular disease (CVD)?
In 2012, researchers at the Harvard School of Public Health published a systematic review and meta-analysis of the existing data on ALA and the risk of CVD..
Their introductory paragraph nicely lays out why ALA could be very important to public health:
A large body of evidence supports a potential protective effect of seafood omega-3 (n−3) fatty acids, particularly EPA (20:5n−3) and DHA (22:6n−3), on coronary heart disease (CHD. However, fewer studies have evaluated how the plant-derived omega-3 fatty acid α-linolenic acid (ALA; 18:3n−3) relates to risk of CHD and other cardiovascular disease (CVD) outcomes, and the results have been inconsistent As an essential fatty acid that cannot be synthesized by humans, ALA is mainly consumed from plant sources, including soybeans, walnuts, and canola oil. Compared with seafood omega-3 fatty acids, ALA from plant sources is more affordable and widely available globally. Thus, whether ALA can reduce the risk of CVD is of considerable public health importance.
If plant-derived ALA can provide our omage-3 PUFA needs then perhaps we can stop stripping the ocean of all the menhaden.
In the Harvard analysis when all 27 studies were combined the authors found a significant risk reduction of 14% in CVD events with flaxseed.
There were lots of issues with the data which I won’t bore you with leading the authors to conclude that “ALA consumption may be beneficial “. They emphasized the need for additional well-designed observational studies and randomized clinical trials in the area.
Since observational studies cannot prove causality, I await a good randomized clinical trial of ALA supplementation before I can recommend ALA supplementing to prevent heart disease.
After Performing This Review Is The Skeptical Cardiologist Still “Flaxing”?
I am. Because I’ve found that when I consume flaxseed I feel 20 years younger, full of vitality. and with a youthful golden sheen to my hair, nails and skin.
Actually, that last sentence is untrue.
I’m still adding ground flaxseed to my yoghurt but not with any expectation that it is reducing my risk of heart attack and definitely not because I perceive it as a super or functional food.
I like the taste, the convenience, and the extra (presumably healthy) calories it provides but I’m still an advocate of just eating real food rather than trying to identify specific nutrients, nutraceuticals or supplements and add them to your diet.
Flaxseedingly Yours,
-ACP
N.B. I did not touch on omega-6/omega-3 ratios in the diet. I’ve been examining that inflammatory (enjoy the pun) topic for years and once I come across a good study that adds to understanding in the area I will likely publish a post on it.
The skeptical cardiologist pointed out in 2013 that there was no good evidence supporting limiting dietary cholesterol to 300 mg per day. I exulted, therefore, in 2016 , when this long-standing dietary recommendation came out of the US dietary guidelines.
Egg Whites: A Product of Nutritional Misinformation?
Why, then do egg whites continue to be created and consumed?
On a regular basis, patients tell me that they are eating egg white omelettes because they believe egg yolks are not heart healthy.
Old bad nutritional dogma takes a long time to reverse apparently. To this day, for example, the National Lipid Association still recommends limiting daily cholesterol consumption to <200 mg/ day
Therefore I find it necessary to highlight additional new studies that further eggsonerate eggs.
To wit, I shall briefly discuss two articles that were published earlier this month and brought to my attention by friends and readers who are aware of my rabid support for the egg.
Article One: The Wonderfully Acronymed DIABEGG Study
Investigators randomized 128 patients with prediabetes or type 2 diabetes (T2D) to a high egg or a low egg diet.
Throughout all study phases, including the 3-mo weight-loss phase, participants consuming the high-egg diet were instructed to eat 2 eggs/d at breakfast for 6 d/wk (12 eggs/wk). Those in the low-egg group were directed to consume <2 eggs/wk, and to match the protein intake that the high-egg group had consumed at breakfast with 10 g lean animal protein (meat, chicken, or sh) or other protein-rich alternatives, such as legumes and reduced-fat dairy products (also consumed at breakfast). Recommended egg-cooking methods were boiled or poached, but they could also be fried if a polyunsaturated cooking oil, such as olive oil, was used. The prescribed diets were energy and macronutrient matched, as reported previously
At the end of 12 months both groups had lost about 3 kg in weight.
The investigators measured everything they could to look at diabetic and cardiometabolic biomarkers which might suggest adverse effects of egg eating on the cardiovascular system but they could find no difference between the egg eaters and the non egg eaters.
High egg consumption had no adverse effects on the following factors that are felt to be important in the development of atherosclerosis:
-measures of systemic and vascular inflammation [high sensitivity C-reactive protein (hs-CRP), IL-6, soluble E-selectin (sE-selectin)],
-oxidative stress (F2-isoprostanes), the adipokine adiponectin (which also modulates insulin resistance), and
-glycemia [fasting plasma glucose, glycated hemoglobin (HbA1c), and a medium-term measure of glycemia, 1,5-anhydroglucitol (1,5AG)].
The authors suggested that nutritional guidelines stop worrying about limiting eggs.
Article Two: Half A Million Chinese Can’t Be Wrong
This observational study published in Heart found that egg consumption in a huge Chinese population was associated with less stroke, and major cardiac events (MCE):
Compared with non-consumers, daily egg consumption was associated with lower risk of CVD (HR 0.89, 95% CI 0.87 to 0.92). Corresponding multivariate-adjusted HRs (95% CI) for IHD, MCE, haemorrhagic stroke and ischaemic stroke were 0.88 (0.84 to 0.93), 0.86 (0.76 to 0.97), 0.74 (0.67 to 0.82) and 0.90 (0.85 to 0.95), respectively. There were significant dose-response relationships of egg consumption with morbidity of all CVD endpoints (P for linear trend <0.05). Daily consumers also had an 18% lower risk of CVD death and a 28% lower risk of haemorrhagic stroke death compared to non-consumers.
The lower risk for stroke and cardiovascular death in egg eaters persisted after accounting for known CVD risk factors.
(And yes, I agree this is an observational study which we should take with huge grains of salt and pepper).
Are EGG Whites The Skim Milk Scam of The Egg Industry?
I’ve written about the scam that is skim milk but it occurs to me that egg white consumption is equally nonsensical.
What happens to the wonderfully nutritious yolk of the egg when it is brutally separated from its white? It is put in a container and sold as liquid egg yolk. Makers of mayonnaise are big consumers of liquid egg yolk.
Thus, like dairy farmers who double their sales by selling skim milk and its dairy fat separately, egg producers are probably delighted that Americans are consuming egg whites , allowing them to get two products from a single egg.
As I wrote previously: not everyone is an egg lover and I’m fine with that. There is no evidence that you have to eat them. You could feel towards them as did Alfred Hitchcock :
“I’m frightened of eggs, worse than frightened, they revolt me. That white round thing without any holes … have you ever seen anything more revolting than an egg yolk breaking and spilling its yellow liquid? Blood is jolly, red. But egg yolk is yellow, revolting. I’ve never tasted it.”
For those that don’t find yellow revolting, however, avoiding egg yolk makes no nutritional sense.
indicates little has changed in the rankings or consumption of breakfast cereal since then despite a more widespread recognition that 
The major stumbling block in preparing them was finding almonds which were raw (see 
The exact components are based on the landmark randomized trial of the Mediterranean diet, enhanced by either extra-virgin olive oil or nuts (
