Tag Archives: drupes

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.

kin-17113-4
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.

And why is it necessary to add “apricot flavor” if there are real apricots in it?

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:

img_7567
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

-ACP

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!

In PREDIMED:

“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.”

 

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,

-ACP

 

 

 

Nuts, Legumes, Drupes and Mortality

When I was a child in small town Oklahoma, I collapsed walking home from school one day after eating pecans. Apparently I had never encountered pecans in England where I grew up and I had a very severe, life-threatening  allergic reaction (anaphylaxis.)

My pediatrician was promptly called, drove over, picked me out of the street and (legend has it) with one hand on the steering wheel and the other jabbing me with epinephrine drove me to the local hospital (apparently ambulances were not invented at this time). There I spent several days in an oxygen tent recuperating.

Since then I had, until recently,  concluded (based on my own multiple food reactions and research) that I was allergic to “tree nuts.”

I would patiently explain to the uninitiated that I could eat almonds because they are in the peach family and I could eat peanuts because they are in the legume family: neither one of these, therefore, were true “tree nuts.”

To all whom I gave this seemingly erudite explanation I owe an apology for I have learned the earth-shattering truth that pecans are drupes! They are no more a nut than an almond is!

In fact, even walnuts are not nuts as hard as that is to believe.

Pecans, walnuts and almonds are all drupes.

Why, you may wonder, is any of this botanical folderol of any relevance to cardiology?

Nuts and Cardiovascular Death

For those paying attention to media reports on the latest food that will either kill you or make you live for ever you may already know the answer. This paper published in JAMA made big headlines.

Jane Brody of the New York Times wrote a piece extolling the virtues of nuts entitled “Nuts are a Nutritional Powerhouse”. Medical New Today wrote “Eating Nuts Linked to 20% Cut in Death Rates”.

It turns out, however, that most of what the 136,000 Chinese were eating and half of  the “nuts” the 85,000 low income Americans were eating in that JAMA study  were legumes: peanuts or peanut butter. The authors wrote:

“Our findings … raise the possibility that a diet including peanuts may offer some CVD (cardiovascular)  protection. We cannot, however, make etiologic inferences from these observational data, especially with the lack of a clear dose-response trend in many of the analyses. Nevertheless, the findings highlight a substantive public health impact of nut/peanut consumption in lowering CVD mortality, given the affordability of peanuts to individuals from all [socioeconomic status] backgrounds.”

These findings follow another large observational study published in 2013 which also found (in American doctors and nurses) an inverse relationship between nut consumption and mortality.

“compared with participants who did not eat nuts, those who consumed nuts seven or more times per week had a 20% lower death rate. Inverse associations were observed for most major causes of death, including heart disease, cancer, and respiratory diseases. Results were similar for peanuts and tree nuts, and the inverse association persisted across all subgroups.”

We also have a very good randomized trial (the PREDIMED study) that showed that  the Mediterranean diet plus supplementation with extra-virgin olive oil or mixed nuts performed much better than a control diet in reducing cardiovascular events.

Participants in the two Mediterranean-diet groups received either extra-virgin olive oil (approximately 1 liter per week) or 30 g of mixed nuts per day (15 g of walnuts, 7.5 g of hazelnuts, and 7.5 g of almonds) at no cost, and those in the control group received small nonfood gifts (I wonder what these were?)

After 5 years, those on the Med diet had about a 30% lower rate of heart attack, stroke or cardiovascular death.

Nuts versus Drupes versus Legumes

The evidence supporting “nut” consumption as a major part of a heart healthy diet is pretty overwhelming. But what is a nut and which nuts or nut-like foods qualify?

Let’s lay out the basic definitions:

Nut-Generally has a hard outer shell that stays tightly shut until cracked open revealing a single fruit inside. Examples are hazelnuts and acorns.

Drupe-Has a soft, fleshy exterior surrounding a hard nut. Classic drupes are peaches and plums with interior nuts so hard we won’t eat them. Examples are pecans, almonds, walnuts and coconuts.

Legume-generally has a pod with multiple fruit which splits open when ready. Examples are peas, carob, peanuts, soybeans and beans.

What Nuts Were Consumed in Studies Showing Benefits of Nuts?

Initially participants were given a questionnaire and asked

” how often they had consumed a serving of nuts (serving size, 28 g [1 oz]) during the preceding year: never or almost never, one to three times a month, once a week, two to four times a week, five or six times a week, once a day, two or three times a day, four to six times a day, or more than six times a day.”

After initial surveys, the questionnaires split out peanut consumption from “tree nut” consumption and whether you ate peanuts or nuts the benefits were similar.

Thus, for the most part, participants were left to their own devices to define what a nut is.  Since most people don’t know what a true nut is, they could have been eating anything from almonds (drupe related to peaches) to hazelnuts (true nut) to a pistachio “nut” (drupe) to a pine “nut” (nutlike gymnosperm seed).

Nutrient Content of Nuts

The nutrient components of these nuts varies widely but one consistency is a very high fat content. For this reason, in the dark days when fat was considered harmful, nuts were shunned.

However, in our more enlightened era we now know that fat does not cause heart disease or make you fat.

Please repeat after me “Fat does not cause heart disease or make you fat.”

A one ounce portion of pecans contains 20.4 grams of fat (11.6 arms monounsaturated and 6.1 polyunsaturated) so that 90% of its 204 calories come from fat.

Nuts, of course, also contain numerous other biologically active compounds that all interact and participate in the overall  beneficial effects that they have on cardiovascular disease and mortality.

They are a whole, real food which can be eaten intact without processing and these are the foods we now recognize provide the best choices in our diets, irrespective of fat or carbohydrate content.

They are also convenient, as they are easy to store and carry with you, providing a perfect snack.

If You Think It’s A Nut, It’s A Nut

IMG_3567

Hazelnut Death Experiment (Don’t try this at home!) A single hazelnut was partitioned into halves, quarters, slivers and little tiny bits. Progressively larger portions were consumed at 5 minute intervals. An Epipen (right) was available in case of anaphylaxis.

It turns out, that my attempts to put pecans and walnuts in to a specific family of nuts that increased my risk of dying if I consumed them were misguided.

I’m allergic to drupes.

In fact, I did an experiment recently and consumed a true nut (a hazelnut) and found I had no reaction.

I’m not allergic to nuts!!!

In the world of allergic reactions, thus,  there is no particular value to partitioning nuts from drupes from legumes.

Similarly, for heart healthy diets, it doesn’t matter if you are consuming a true nut or a drupe as long as you think of it as a nut.

Consume them without concern about the fat content and consume them daily and as along you are not allergic to them they will prolong your life.

Skeptically Yours,
-ACP