Tag Archives: health

Salt Consumption: Less Is Not Always Better

After a week of trying to track my salt consumption I have learned two things

1. Tracking salt consumption (unless you make  all your meals at home from scratch or buy from fast food restaurants) is very tedious.

2. My salt consumption is low: less than the 1.5 grams per day recommended by the American Heart Association (AHA) every day (unless I attend a Cardinals game)

After reviewing the latest scientific publications on salt, however, I have to think that for most people, it is not worth the effort to  track daily salt consumption.

Yes , this is nutritional heresy and goes against what my patients have been reading from authoritative nutritional sources for decades.

The AHA 1.5 gram/day limit for all Americans comes from a small, short term (4 weeks) study (Sacks FM, Svetkey LP, Vollmer WM, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. N Engl J Med2001;344:3-10.)

The findings are not applicable to all Americans because more than 50% of participants in the DASH study had hypertension or prehypertension, more than 50% of participants were of African ancestry, potassium intake was markedly lower than in the general U.S. population, the trial involved only 412 persons, and a limited range of sodium intake was studied (1.5 to 3.3 g per day).

I asked most  of my patients this week about their salt consumption. None of them could tell me what their average daily salt consumption was. However, almost to a man (or woman) they told me they had been consciously limiting their consumption of salt because they knew that this was healthy.

Thus, the 35 year old white woman with a blood pressure of 110/50 , palpitations and periodic dizzy spells is following the same recommendations to limit salt consumption as the 70 year old African-American with poorly controlled hypertension.

In the last few years this focus on lower salt consumption has been questioned after close analysis by the Institute of Medicine and the Cochrane Analysis.

Two articles in the prestigious New England journal of Medicine published a few weeks ago have convinced me that most individuals who are following a Mediterranean diet do not need to be concerned about their salt consumption.

Salt and Blood Pressure

In the first PURE study paper,(a prospective cohort study that included 101,945 people from five continents)

very few participants had an estimated sodium intake of less than 2.3 g per day, and almost none had an intake of less than 1.5 g per day. This suggests that, at present, human consumption of extremely low amounts of sodium for prolonged periods is rare.

The PURE Study looked at sodium excretion versus blood pressure and

 found a steep slope for this association among study participants with sodium excretion of more than 5 g per day, a modest association among those with sodium excretion of 3 to 5 g per day, and no significant association among those with sodium excretion of less than 3 g per day.

Salt and Death

The second PURE study paper examined the relationship between sodium excretion (a measure of sodium consumption) and death and cardiovascular events

 

saltvsdeath
As Eric Topol has opined at the heart.org ” In other words, consumption of too little sodium is as harmful as consumption of too much sodium. In fact, the AHA guideline would lead — at least according to this latest research — to about a twofold risk for major adverse events.”

This graph of data from the PURE study  shows that lower levels of sodium excretion , below about 3 grams per day were associated with a higher risk of death.

Starting above about 5 grams per day  the risk of death increased with increasing amounts of sodium excretion.

 

This is quite a shocker for those of us who have assumed for the last 20  years that the less salt we consumed the longer we would live.

 

Potassium Consumption

Drawing less controversy were the findings from these two studies on potassium consumption. Higher levels of potassium consumption were associated with lower blood pressures and lower risk of death. The authors point out that high potassium intake may simply be a marker of healthy dietary patterns that are rich in potassium (e.g., high consumption of fruit and vegetables).

You can read more about these papers, including critical and positive comments at the heart.org here.

My Recommendations on Salt Consumption

Here is what I will be telling my patients about salt after a week of tracking my consumption and reading the relevant scientific literature.

  • 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.

Public health experts are always seeking a “one size fits all” message to give the public. In the case of salt consumption, however, the message of less is better does not apply to all.

 

 

In Defense of Real Cheese

Ah Cheese. A most wondrous and diverse real food.
wensleydaleOf the thousands of delightful varieties, let us consider Wensleydale, the 33rd type of cheese requested by John Cleese of Ye Olde Cheese Emporium proprietor, Henry Wensleydale (Purveyor of Fine Cheese to the Gentry and the Poverty Stricken Too) in the Monty Python sketch, Cheese Shop.

The cheese I have in front of me from Wensleydale creamery (which owes its continued existence to being the favorite cheese of  Wallace (of Wallace and Gromit fame)) lists  the following ingredients:

  • pasteurized cow’s milk
  • cheese cultures
  • salt
  • rennet
  • annato (a natural coloring that gives cheese and other foods a bright orange hue. It comes from the Bixa orellana, a tropical plant commonly known as achiote or lipstick tree (from one of its uses))

Other than annato, the above ingredients are components of all cheese and signify that it is a non processed, nonindustrial product.

A 1 oz serving of this cheese (28 grams), like cheddar cheese (“the single most popular cheese in the world”), provides 110 calories, 80 of which are from fat (9 grams total fat, 6 grams saturated fat), 25 grams of cholesterol, 170 mg of salt and around 200 mg of calcium.

For the last 40 years, Americans have been mistakenly advised that all  saturated fat in the food is bad and contributes to heart disease. Since cheese contains such a high proportion of saturated fat, it has also been targeted. Dietary recommendations suggest limiting real cheese consumption and switching to low-fat cheese.

This concept is not supported by any recent analysis of data, and as I’ve pointed out in a previous post, saturated fat does not contribute to obesity, nor is it clearly associated with increased heart disease risk. There are many different saturated fats and they have varying effects on putative causes of heart disease such as bad/good cholesterol and inflammation. In addition, the milieu in which the fats are consumed plays a huge role in how they effect the body.

Cheese vary widely in taste, texture and color and the final ingredients depend on a host of different factors including:

  • the type of animal milk used
  • the the diet of the animal
  • the amount of butterfat
  • whether the product is pasteurized or not
  • the strain of bacteria active in the cheese
  • the strain of mold active in the cheese

As a result the bioactive ingredients in cheese will vary from type to type.

Recent scientific reviews of the topic note that dairy products such as cheese do not exert the negative effects on blood lipids as predicted solely by the content of saturated fat. Calcium and other bioactive components may modify the effects on LDL cholesterol and triglycerides.

In addition, we now know that the effect of diet on a single biomarker is insufficient evidence to assess CAD risk; a combination of multiple biomarkers and epidemiologic evidence using clinical endpoints is needed to substantiate the effects of diet on CAD risk.

Some points to consider in why dairy and cheese in particular are healthy:

  • Blood pressure lowering effects.  Calcium is thought to be one of the main nutrients responsible for the impact of dairy products on blood pressure. Other minerals such as magnesium, phosphate and potassium may also play a role. Casein and whey proteins are a rich source of specific bioactive peptides that  have an angiotensin-I-converting enzyme inhibitory effect, a key process in blood pressure control. Studies have also suggested that certain peptides derived from milk proteins may modulate endothelin-1 release by endothelial cells, thereby partly explaining the anti-hypertensive effect of milk proteins.
  • Inflammation and oxidative stress reduction. These are key  factors in the development of atherosclerosis and subsequent heart disease and stroke. Recent animal and human studies suggest that dairy components including calcium and or its unique proteins, the peptides they release, the phospholipids associated with milk fat or the stimulation of HDL by lipids themselves, may suppress adipose tissue oxidative and inflammatory response.

Government and health organization nutritional guidelines have had a huge and harmful impact on what the food industry presents to Americans to eat. The emphasis on reducing animal fats in food led to the creation of foods laden with processed vegetable oils containing harmful trans-fatty acids.  This mistake has been recognized and corrected, but the overall unsupported  concept of replacing naturally occurring saturated fats with processed carbohydrates and sugar is ongoing and arguably the root of the obesity epidemic in America.

Converting mistaken nutritional guidelines into law

The USDA in 2012 following an act of Congress stimulated by Michelle Obama, changed the standards for the national school lunch and breakfast guidelines, for the first time in 15 years.

The law was intended to increase consumption of fruits, vegetables, whole grains and promote the consumption of low-fat or nonfat milk. It seemed like a good idea and likely to counter increasing obesity in children. However, the original recommendations were modified by Congress, due to heavy food industry lobbying, to allow the small amount of tomato paste in pizza to qualify as a vegetable.

Unfortunately, the food industry has responded by providing products which meet the government’s criteria for healthy lunches, but in actuality are less healthy.

Dominos Pizza, as a recent New York Times article pointed out, is now providing a specially modified pizza to schools which is unavailable in their regular stores. Their so-called “Revolution in School Pizza” is a…

line of delicious, nutritious pizzas created specifically for schools delivered hot and fresh from your local Domino’s Pizza store. Domino’s Pizza Smart Slice is the nutritious food that kids will actually EAT and LOVE!

school_lunch_anatomyofsliceThis pizza, in contrast to the pizza sold in Domino’s stores, utilizes a “lite” Mozarella cheese to cut fat content, a pepperoni with lower sodium and fat content, and a crust that contains 51% whole grain flour.

This “smart slice” replaces dairy fat with carbohydrates; there is no evidence that this will improve obesity rate or reduce heart disease  In fact, this change may lead to less satiety and a tendency for the children to want to snack on further carbohydrate or sugar-laden products when they get home. Furthermore, as critics have suggested, it may promote the consumption of  “unhealthy” versions of pizza that are sold in stores.

If we are going to make laws that promote healthy eating, we have to be absolutely certain that they are supported by scientific evidence. These School Lunch Program Standards are an example of how getting the science wrong or getting ahead of the science can lead to worse outcomes than if there were no laws regulating school diets.

Hopefully, you will continue to consume real full-fat cheese without concerns that cheese is “artery-clogging” and you will be more successful in obtaining the “fermented curd” than John Cleese’s Mr. Mousebender was below:

 

 

 

 

 

Hot Dogs, Brats, Music, Nitrates and Your Risk of Cardiovascular Death

IMG_2690
The Skeptical Cardiologist observes the Dirt Leg Benders at Perche Creek Bridge

The skeptical cardiologist participated in the Pedaler’s Jamboree this Memorial Day weekend. This is an annual bicycling/music festival centered around a 30 mile bike ride from Columbia to Boonville, MO along the KT trail as it tracks the Missouri River. It ends at Kemper Park in Boonville with a concert and campout (the highlight of which for me was SHEL)

 

At various stops along the way we were treated to excellent roots/blues/folk

The significant other of the skeptical cardiologist (SOSC) and friend enjoying the bluesy slide guitar work of White Trash Blues Revival at the McBaine stop along the KT trail at the Pedaler's Jamboree
The significant other of the skeptical cardiologist (SOSC) and friend enjoying the bluesy slide guitar work of White Trash Blues Revival at the McBaine stop along the KT trail at the Pedaler’s Jamboree

music. Our favorite moment was listening to an awesome duo from Fort Wayne, Indiana, the White Trash Blues Revival, in a downpour at the McBaine stop. The lead singer/guitarist played a home-made lap steel (made from a skate board and a Red Stripe beer bottle) and the drummer played trash cans, a beer keg and a cardboard box with outstanding results.

During the day, I observed thousands of my fellow pedalers consuming hot dogs and bratwursts at the various stops. In America, during Memorial Day weekend, several million brats and dogs will be consumed which made me ponder: is this increasing Americans’ risk of dying from heart disease?

 

US dietary-guidelines recommend “eating less” red and processed meat. For cardiovascular disease, these recommendations are based largely on expected effects on blood cholesterol of saturated fat and dietary cholesterol in meats. However, multiple recent published analyses have found no relationships of meat intake with cardiometabolic disease outcomes, including coronary heart disease (CHD), stroke, and diabetes.

This is a really important fact to know when making food choices, so I’m going to highlight it and repeat it:

Scientific studies do not show an association between unprocessed red meat consumption and cardiovascular disease.

 “Red meat” is usually defined as unprocessed meat from beef, hamburgers, lamb, pork, or game, and excludes poultry, fish, or eggs.

“Processed meat” is any meat preserved by smoking, curing or salting, or addition of chemical preservatives, such as bacon, salami, sausages, hot dogs, or processed deli or luncheon meats, excluding fish or eggs.

A 2010 meta-analysis of American studies on this showed no increased risk of coronary heart disease for the highest consumers of unprocessed meat versus the lowest.

On the other hand, each serving per day of processed meat was associated with a 42% higher risk of coronary heart disease.  Restricted to US studies, each serving per day was associated with 53% higher risk of diabetes.

A recent European study of 448,000 people found no association between unprocessed red meat consumption and mortality. For processed meats, there was an 18% higher risk of death per 50 gm/day serving.

Scientists really don’t know what it is about processed red meat that makes it associated with higher mortality.

As the table below indicates, the amount of saturated fat and cholesterocontents processed meatl is not higher, so that does not appear to be the cause.

Because sodium nitrite is used to cure most processed  meats, processed meats have about 4 times the amount of sodium as red meats.

High dietary sodium intake significantly increases blood pressure. Habitual consumption may also worsen arterial compliance and promote vascular stiffness, so It’s possible this is a factor.

Nitrate and nitrite levels are about 40% higher in processed meats and this has been suggested as a contributor to higher CVD and cancer rates.

However, 80-95% of dietary nitrates come from vegetables sources and a very significant source of nitrites is the breakdown of nitrates to nitrites by bacteria in saliva. Recent studies suggest that the blood pressure lowering effect of vegetables may be mediated by their nitrate content.

 A recent review concluded

At present, it seems that dietary nitrite and nitrate have cardiovascular protective effects. … the effects of nitrite and nitrate to enhance NO bioavailability, to improve endothelial function, to cause vasodilation, and to inhibit platelet aggregation may at least partly mediate their cardiovascular beneficial effects. … Taking the data presented above together with the failure of recent studies to show significant correlation between nitrite and nitrate exposure and cancer, we suggest that the benefits of dietary nitrite and nitrate will strongly outweigh any potential risks, particularly for cardiovascular disease patients.

So, there is a signal from observational data that processed meats may increase cardiovascular disease and death, but exactly which ones might be the culprits and how this might work is entirely unclear. I’m still consuming brats, sausages,  and hot dogs on occasion. Riding a bike, listening to music and drinking beer is a fine occasion for that.

I would advise the following

  • Don’t worry about nitrates/nitrites in processed meats. Science has not determined whether this is good or bad for you. Brands of bacon/sausage that claim no nitrates/nitrites are often using “natural” forms of nitrates that come from sources such as celery powder or sea salt.
  • Processed meats contain a lot of salt. Your body likely senses that and cuts back on salt consumption in other food choices during the day, especially if you indulge moderately. If you eat too much, too often, you put yourself at risk for high blood pressure and its attendant consequences. What is “too much” is uncertain, but the higher rates of heart disease and death don’t really seem to kick in until you eat the equivalent of greater than 80 grams per day.
  • Personally, I choose sustainably, humanely, “naturally” and locally raised processed meats whenever possible but there is no evidence-based medicine supporting this choice.

 

Urban Cycling Part I: Does Biking To Work Make You More or Less Likely to Die?

5Boro Bike Riders crossing the summit of the Queensboro aka 59th Street aka "Feelin Groovy" Bridge
5Boro Bike Riders crossing the summit of the Queensboro aka 59th Street aka “Feelin Groovy” Bridge. For some reason the significant other of the skeptical cardiologist (SOSC) has decided to stop here to look at her cell phone, thereby creating a traffic hazard.

The skeptical cardiologist recently participated in the 5 Boro New York City Bike Tour. It was quite cool.

This annual event allows 32,000 bike riders to stream from Manhattan to the Bronx to Queens, Brooklyn and Staten Island along 40 miles of traffic-free (except for thousands of cyclists) roads

Unlike my previous rides in Brooklyn and Manhattan (under the guidance of legendary Park Slope flaneur, NYC biking advocate, and old high school chum David Alquist) I was not in constant peril from automobile encounters because we cyclists had the mean streets of New York all to ourselves.

Take a look at this video to understand “why cyclists come from around the world for an experience of the Big Apple unlike any other”.

Urban Cycling as Transportation

The NYC event, and the fact that this is “bike to work week,” lead me to ponder aspects of urban bike riding, specifically, cycling as transportation.  Since cycling is physical exercise and there is scientific evidence (observational studies only) linking regular physical activity to a significant cardiovascular risk reduction, we might expect that it would help us live longer. 

A reasonable physical activity goal , endorsed by most authorities,  is to engage in moderate-intensity aerobic physical activity for a minimum of 30 min on 5 days each week or vigorous-intensity aerobic activity for a minimum of 20 min on 3 days each week. This level of exercise helps with weight control, fitness and is associated with lower mortality from cardiovascular disease .

METS:calories
METs and calories consumed per hour for various physical activities

The metabolic equivalent of task (MET) is a measure of the energy cost of physical activity. The chart to the left gives METs for various activities.  Individuals should be aiming for 500–1,000 MET min/week. Leisure cycling or cycling to work (15 km/hr) has a MET value of 4 and is characterized as a moderate activity  A person shifting from car to bicycle for a daily short distance of 7.5 km would meet the minimum recommendation (7.5 km at 15 km/hr = 30 min) for physical activity in 5 days (4 MET × 30 min × 5 days = 600 MET min/week).

 

Thus, cycling to work for many individuals would provide the daiy physical activity that is recommended for cardiovascular benefits. However, cycling in general, and urban cycling in particular, carries a significant risk of trauma and death from accidents and possibly greater exposure to urban pollutants.

bikversuscardeaths
from CBS (Statistics Netherlands) Traffic and Transport, 2008

This table shows the estimated numbers of traffic deaths per age category per billion passenger kilometers traveled by bicycle and by car (driver and passenger) in the Netherlands for 2008. These data suggest that there are about 5.5 times more traffic deaths per kilometer traveled by bicycle than by car for all ages. Interestingly, there is no increase in risk for individuals aged 15-30 years. On the other hand , those of us in the “baby-boomer” generation (?slowed reflexes, poor eyesight, impaired hearing) and older are at an 8 to 17 fold increase risk.

In the Netherlands, where a very large percentage of the population regularly rides bikes, there has been considerable scientific study of the overall health consequences of biking and we have reasonably good data on the question of relative safety of biking versus driving a car for short distances. You can watch the happy people of Groningen (“the world’s cycling city”, where 57% of the journeys in the city are made by bicycle) riding their bikes below.

Health Impact of Transition from Car to Bike for Short Trips

One study quantified the impact on all-cause mortality if 500,000  people made a  transition from car to bicycle for short trips on a daily basis in the Netherlands and concluded

For individuals who shift from car to bicycle, we estimated that beneficial effects of increased physical activity are substantially larger (3–14 months gained) than the potential mortality effect of increased inhaled air pollution doses (0.8–40 days lost) and the increase in traffic accidents (5–9 days lost). Societal benefits are even larger because of a modest reduction in air pollution and greenhouse gas emissions and traffic accidents.

Apart from the highest average distance cycled per person, the Netherlands is also one of the safest countries in terms of fatal traffic accidents so it’s reasonable to ask whether these data apply to other countries. This study concluded

 When  traffic accident calculations for the United Kingdom were utilized, where the risk of dying per 100 million km for a cyclist is about 2.5 times higher, the overall benefits of cycling were still 7 times larger than the risks.

If you decide to bike to work this week, braving the elements , the possible automobile collisions and the automobile exhaust you can rest comfortably with the thought that not only are you  prolonging your own life but by reducing greenhouse gas emissions and air pollution you are contributing to the health of everyone around you.

How Starbucks is Making Heart-Healthy Coffee into A Stealth Dessert

Chemex
The Skeptical Cardiologist’s preferred method of making coffee-hand poured over freshly ground beans, filtered through a Chemex filter (yes, I know it’s laborious and the pictures aren’t as pretty as Starbucks, but it is really good!)

Many of my patients believe that coffee is bad for them. I’m not sure where this belief comes from; perhaps the general belief that anything that they really like and are potentially addicted to cannot be healthy.

It’s not uncommon for a patient to tell me after a heart attack that they have “really cleaned up their act” and have stopped drinking alcohol and cut back on coffee. They seem disappointed when I tell them that moderate alcohol consumption and coffee consumption are heart healthy behaviors.

In contrast to what the public believes, the scientific evidence very consistently suggests that drinking coffee is associated with living longer and having less heart attacks and strokes. Multiple publications in major cardiology journals in the last few  years have confirmed this.

You can read the details here and here. The bottom line is that higher levels of coffee consumption (>1 cup per day in the US and >2 cups per day in Europe) are NOT associated with:

  • Hypertension (if you are a habitual consumer)
  • Higher total or bad cholesterol  (unless you consume unfiltered coffee like Turkish, Greek or French Press types, which allow a fair amount of the cholesterol-raising diterpenes into the brew)
  • Increase in dangerous (atrial fibrillation/ventricular tachycardia) or benign (premature ventricular or supra-ventricular contractions) irregularities in heart rhythm

Higher levels of coffee consumption compared to no or lower levels IS associated with:

  • lower risk of Type 2 Diabetes
  • lower risk of dying, more specifically lower mortality from cardiovascular disease
  • Lower risk of stroke

So, if you like coffee and it makes you feel good, drink it without guilt, there is nothing to suggest it is hurting your cardiovascular health. It’s a real food. These tend to be good for you.

Making Coffee Unhealthy: Dessert as Stealth Food

People have always added things to coffee – cream, half and half, milk, skim milk, sugar, artificial sweeteners. The coffee data doesn’t reveal to us what the consequences of these additions are, but given the consistent positive health associations of coffee, they must have had a minor effect.

However, in the last 20 years, the food industry, led by the behemoth Starbucks (which controls 1/3 of the coffee served in the US and has 11,000 stores and growing) has turned coffee into a stealth dessert. Starbucks offers the consumer (by their own admission) 87,000 different choices of coffee drinks.
A basic coffee house drink is a latte’. This consists of one or more shots of espresso combined with steamed milk (skim, 2% or whole) and topped with foam. According to Starbucks, the 16 ounce, medium (I refuse to use their size terminology), cafe latte’ made with 2% milk, contains 17 grams of sugar and 7 grams of fat, yielding a reasonable 190 calories. Those who drink these should understand that they are consuming a glass of milk, plus coffee. Dairy products have consistently been associated with lower cardiovascular risk. They would arguably be better off consuming a whole milk (11 grams fat, 16 grams sugar, 220 calories) latte’ as I’ve pointed out in previous blogs here and here.

 

 

( Cinnamon Dolce Latte . Picture taken from Starbucks web site.

Most of the latte’s consumed at Starbucks aren’t plain latte’s, however; they are nightmares of added sugar. Let’s take the Cinnamon Dolce Latte’: (A complete nutritional breakdown is available from Starbucks’ website (I do congratulate Starbucks for finally capitulating and presenting nutritional data on their products at stores, allowing the public to draw back the curtain on the Starbucks Oz. Their website provides a cool way to compare your drink with whole/2%/skim/soy milk or with and without whipped cream)) It contains 38 grams of sugar, 6 grams of fat, and 11 grams of protein, yielding 260 calories, 152 of which are coming from sugar. That’s 22 grams more sugar, compared to their unadulterated latte’. (There must be an internet site devoted to promoting the health benefits of cinnamon since I hear about them so often from my patients but this claim is not evidence-based)

 

 

mochae frap
Picture of the Mocha Frappacino “Dessert” from the Starbuck website

My 17 year old daughter’s drink of choice at Starbucks is the Mocha Frappuccino® Blended Beverage, which, according to Starbucks, is “Coffee with rich mocha-flavored sauce, blended with milk and ice. Topped with sweetened whipped cream.” It contains 60 grams of sugar, 15 grams of fat and has 400 calories.

Such concoctions have no right to consider themselves coffee, they should be labeled as a sugar-laden dessert that happens to have some coffee in it. To give some perspective, the typical 20 ounce soda contains 40 grams of sugar (the equivalent of 10 packs of sugar).  Starbucks has added 44 grams of sugar to coffee and milk in order to draw children, teens and unsuspecting adults to consume more “coffee.”

There is growing evidence that sugar, not fat, is the major toxin in our diet. The misguided concept that cutting fat in the diet and replacing it with anything, including sugar, will reduce cardiovascular disease is gradually being rolled back. Nutritional advocates are now zeroing in on appropriate targets like sugary beverages.

It’s sad that Starbucks, which started out making a good, real product that was actually good for you, has morphed into an international, growth-obsessed, behemoth that is pumping billions of grams of added sugar into our stomachs.

But, as the significant other of the skeptical cardiologist (SOSC) often muses, people are always looking for new ways to con themselves into thinking they are eating/drinking something healthy, when in fact, they are just eating/drinking cleverly disguised desserts. Starbucks has made a huge success for themselves by providing people what they want: a way to kid themselves.

 

Is A Snickers Bar Healthier Than Yoplait Yogurt?

This container of Yoplait comes from the refrigerator in the Doctor’s Lounge at my hospital. It is often the go-to snack for busy doctors and health conscious consumers.
I used to consider Yoplait about as healthy a snack as I could get. After all, it was low in fat, owned by French farmers and it had pictures of fruit on it. How could I go wrong?yoplait

In addition, Yoplait is focused on making “so good yogurt” as the company (now owned by General Mills) explains

“Ultimately, we’re focused on making so good yogurt, and here’s how we see it: you can eat something that tastes amazing but isn’t that good for you. You can eat stuff that’s really good for you, but doesn’t always leave you yummed up. So good yogurt does both. All of you is happy, not just your tongue. And while so goodness will never be perfect, we’ll keep working on ways to make our yogurt more so good than it is today.”

The significant other of the skeptical cardiologist (SOSC) made the claim recently that women who felt they were having a healthy lunch by consuming fat free yogurt and salad with sugary, fat-free salad dressing might as well be eating a candy bar. At least they would enjoy it more! Could this be true?

Yoplait made the bold step in 2012 of taking out the high fructose corn syrup they had been adding to their yogurt (or yoghurt as they like to spell it), but it’s still chock full of added sugar (which is probably why it leaves you “yummed up”)

What is now in “original” Yoplait?

Original Yoplait has 12 ingredients. They are Cultured pasteurized Grade A Low Fat Milk, Sugar, Blueberries, Modified Corn Starch, nonfat milk, kosher gelatin, citric acid, tricalcium phosphate, pectin, natural flavor colored with beet juice concentrate, Vitamin A and Vitamin D3.Yoplait_Original_Mountain-Blueberry

Indeed, the fat has been taken out but in its place – added sugar, 26 grams of sugar to be precise.

Of the 170 calories you are consuming, 104 of them are coming from sugar.

How healthy is a Snickers Bar?

snickers.jpgA regular-sized Snickers candy bar has a total of 280 calories with 13.6 grams of fat (5 grams saturated fat), 35 grams of carbohydrates (29 grams of sugar) and 4.3 grams of protein. It is made with peanuts, milk chocolate, egg whites and hydrogenated soybean oil. If we ate 2/3 of the bar to make the calories the same as the Yoplait, there would be 19 grams of sugar (compared to 26 for Yoplait) and 8 grams of fat.

A recent review of the cardiovascular effects of tree nuts and peanuts concluded:

there is impressive evidence from epidemiological and clinical trials and in vitro studies of beneficial effects of nut consumption and their constituents on the risk of CVD (cardiovascular disease), including sudden death, as well as on major and emerging CVD risk factors.

This is because in addition to a favorable fatty acid profile, nuts and peanuts contain other bioactive compounds that provide cardiovascular benefits. Other macronutrients include plant protein and fiber; micronutrients including potassium, calcium, magnesium, and tocopherols; and phytochemicals such as phytosterols, phenolic compounds, resveratrol, and arginine.


 

Curb your hunger.jpgSo, consuming 2/3 of a Snickers bar is arguably healthier than Yoplait. It contains peanuts, which have demonstrable benefits in lowering cardiovascular disease despite a high fat content. Yoplait has had the heart healthy dairy fat removed and replaced with added sugars. As I mentioned in a previous post, added sugar is clearly related to increased cardiovascular risk. The higher fat and fibre content of the peanuts in the Snickers bar will increase satiety and arguably be less likely to cause obesity due to rebound overeating later in the day.

A much healthier choice than low fat, added sugar products like Yoplait (and candy bars) is full fat, plain yogurt (preferably from grass-fed cows) as I’ve discussed in previous posts. It can be combined with real fruit or even with nuts. Full fat yogurt is surprisingly hard to find on a grocery shelf. Even at Whole Foods, the vast majority of yogurt and dairy products are low fat. I’ve only been able to find two brands, Supernatural and Trader’s Point Creamery, which consistently offer full fat yogurt.

Disclaimer and clarifications

godzilla.jpgI do not receive any payments from Snickers nor from Mars, Inc., one of the most known and beloved brands of chocolate.  I do not plan on seeing Godzilla, May 16. Although Snickers loves you, you do not need to like Snickers.snickersloves you.jpg

 

 

 

 

 

Searching for Subclinical Atherosclerosis: Am I about to drop dead?

Nearly every day I see a patient in the office who has just experienced a friend or relative suddenly “dropping dead.”  Understandably, they are very concerned about this and want to know “Is this going to happen to me?”

There is very good reason to be concerned. Cardiac disease is the leading cause of death in America. Despite considerable progress, regrettably 50% of deaths occur suddenly, without any previous symptoms which would have suggested a cardiac problem. It doesn’t just hit the overweight or the smoker. It not uncommonly strikes the very fit and seemingly healthy, as in the case of the St. Louis Cardinal pitcher, Daryl Kile, who was found dead in his hotel room at the age of 34. This question of who is going to suddenly drop dead (sudden cardiac death or SCD) is one of the fundamental unsolved mysteries in current cardiology.

Atherosclerosis and Dropping Dead

Most SCD in individuals over the age of 35 is related  to the development of fatty plaques (atherosclerosis) in the arteries that supply blood to the heart (coronary arteries) and the subsequent sudden rupture of these plaques (thrombosis).hrtatk-07 The result of this rupture is the complete blockage of the artery and the total cessation of blood flow to a portion of the heart muscle. When that heart muscle portion becomes starved for oxygen, the muscle cells start dying and a myocardial infarction (MI) or heart attack occurs. You can view an animation of this process here With any MI, the dying muscle cells can become electrically irritable and initiate an abnormal heart rhythm called ventricular tachycardia (VT) or ventricular fibrillation (VF). This abnormal rhythm is what causes people to “drop dead” suddenly. Basically, the heart cannot pump blood efficiently in VT or VF; thus, there is no blood flowing to the brain and other vital organs. This is a long, complicated chain of events, but basically it begins with the development of fatty plaques or atherosclerosis. It makes sense that we can stop people dropping dead from MI by stopping the development and progression of atherosclerosis. Atherosclerosis develops long before any clinical signs or symptoms of disease. You can feel totally fine and have a huge build up of plaque in all of the arteries of your body. This is termed subclinical atherosclerosis. It makes sense, and it has been scientifically proven, that those with a huge buildup of plaque (high plaque burden) are at higher risk for MI and death than those with low or no plaque burden. It also makes sense that treating those patients with high plaque burden will be most beneficial.

How Do you know if you have atherosclerosis

I discussed the standard recommended method for determining risk of MI/SCD in my last post on statins. Basically, this is simply adding up the factors we know contribute to atherosclerosis: diabetes, cigarette smoking, hypertension, age, gender and cholesterol levels. However, most heart attacks and strokes occur in people who are classified by traditional risk factor scoring as low or intermediate risk. Conversely, others are misclassified as high risk and mistakenly advised to take drugs to reduce their risk factors for the rest of their lives.

How Can We Detect Subclinical Atherosclerosis?

In my office practice I offer patients two tests which directly detect and quantify subclinical atherosclerosis. One looks for plaque  and thickening in the larger arteries of the neck, the carotid arteries, and one looks for calcium in the coronary arteries. I’ll go into detail about both of these in subsequent posts. For now, I will just say that the carotid screening technique uses harmless ultrasound while the coronary calcium technique uses ionizing radiation from a CT scan. Neither test is covered by insurance or Medicare. Both tests have been shown to improve our ability to identify those at risk for MI and stroke.

These tests are helpful in two general areas:

*The first scenario is the patient who appears to be at low or intermediate risk for atherosclerosis based on the risk estimator, but who has a strong family history of MI, sudden death or stroke. If we identify significant subclinical atherosclerosis in this patient, statin therapy is more likely to be beneficial.

*The second scenario is the patient who has been put on statins for primary prevention based on standard risk estimator but has no family history of ASCVD and is questioning the need for treatment. In this patient if we find no subclinical atherosclerosis, a strong argument can be made to stop the statin drug.

SHAPE Guidelines II Slide_Page_38
Proposed method for utilizing carotid vascular and coronary calcium tests for better identification of subclinical atherosclerosis and more appropriate utilization of treatment in order to prevent heart attacks and sudden cardiac death

There is an organization dedicated to promoting the detection of SA by these tests and an algorithm for treatment called SHAPE  (Society for Heart Attack Prevention and Education). Interestingly, after a female Texas state representative suffered an MI, in 2009, Texas Governor Ricky Perry signed off on the Texas Heart Attack Prevention Bill mandating health-benefit plans to cover screening tests for SA. No other state to my knowledge has such a law.

How to Stop Sudden Cardiac Death

The two tests I mentioned are a good second step towards identifying the individual at risk for MI and SCD but we still don’t know who among those with advanced subclinical atherosclerosis is going to experience a sudden rupture of plaque, have an MI and drop dead.

We need a way to identify those patients with vulnerable plaque (one that is about to rupture) and aggressively treat those patients. This is an area of intense research focus. You can view a fascinating video (accompanied by weirdly cool music) created by SHAPE here and another (featuring a gun shooting a heart) here emphasizing the importance of the vulnerable plaque.

Why I Recommend the Mediterranean Diet

I recommend the Mediterranean diet (MED) to my patients. Every unbiased, systematic review of the research on diet and heart disease in the last 8 years has concluded that it is the most likely dietary model to provide protection against coronary heart disease. One review concludes

Among the dietary exposures with strong evidence of causation from cohort studies, only a Mediterranean dietary pattern is related to CHD (coronary heart disease) in randomized trials.

The MED is the only comprehensive dietary approach that has been proven to reduce total death  and heart attacks in comparison to standard diets. There are two major randomized controlled trials (the only kind of study that proves the value of a dietary intervention) with this diet.

lyon
From Eric Roehm at http://www.nutritionheart.com

  The first, called the Lyon heart Study,  was in patients who had had heart attacks (secondary prevention) . As this graph demonstrates, those patients randomized to receive instruction on following the Mediterranean diet had a 60% lower death rate and a 70% lower heart attack rate. The second was published last year in the New England Journal of Medicine and was a primary prevention study: that is, participants had not had heart attacks. Participants were randomized to one of three diets: a MED supplemented with extra-virgin olive oil,  MED supplemented with mixed nuts or a control diet (advice to reduce dietary fat). Participants received quarterly individual and group educational sessions and either free provision of olive oil, mixed nuts or small nonfood gifts. The high extra virgin olive oil group ingested an average of 3.6 tablespoons/day (51 grams/day equal to 459 calories/day) of olive oil with 98% of it being extra virgin olive oil. The high nut group ate 8.2% of their total daily calories in the form of nuts, including an additional approximately one ounce packet of nuts (15g of walnuts, 7.5 g of almonds, and 7.5g of hazelnuts) provided by the study coordinators. 7447 persons were enrolled (ages 55 to 80 years) for an average 4.8 years. Those persons following the MED diet (either supplemented with olive oil or nuts) were 30% less likely to have  a major cardiovascular event (heart attack, stroke or death from cardiovascular causes.) There was a statistically significant reduction in stroke rate (≈39%) when considered as an isolated endpoint. We don’t know exactly what components of the MED are the most beneficial.  This trial suggests that olive oil and nuts are at least two of the key ingredient so it makes sense to increase your consumption of these foods. Other studies strongly support fish consumption and alcohol consumption as key components. As I’ve discussed (?ad nauseam) in other posts, full fat dairy and eggs, although banned by most “heart healthy diets”, have not been shown to increase heart disease risk.  Fermented dairy consumption, in particular, in the form of plain full-fat yogurt (not adulterated with sugar) and full-fat cheese is consistently associated with a lower risk of coronary heart disease. Plain full-fat yogurt and full-fat cheese (from goat milk) were consumed by the inhabitants of Crete, the Greek Island on which the original MED was based.

It has to be emphasized that within this pattern of eating you want to be consuming real foods, not processed products of the industrial food industry which have been manipulated to appear healthy due to being “low-fat” or “low cholesterol.”

This is a pattern of eating which is varied, interesting and sustainable.

It’s one that can last a lifetime. ,

More Evidence That Sugar is the Major Toxin in our Diets

A can of Coke (12 fl ounces/355 ml) has 39 grams of carbohydrates (all from sugar, approximately 10 teaspoons),[47] 50 mg of sodium, 0 grams fat, 0 grams potassium, and 140 calories. Image courtesy of Gwyneth Pearson who likely consumed it
A can of Coke (12 fl ounces/355 ml) has 39 grams of carbohydrates (all from high fructose corn syrup, equivalent to approximately 10 teaspoons of sugar), 50 mg of sodium, 0 grams fat, 0 grams potassium, and 140 calories. Image courtesy of Gwyneth P, who likely consumed it (the beverage in the can, that is, not the image)
The skeptical cardiologist had to temporarily interrupt his scintillating research into Canola Oil and the Mediterranean diet in order to highlight a study published yesterday in the Journal of the American Medical Society that adds further evidence to the paradigm that sugar is not just causing obesity but is actually killing us.

In a previous post on low-fat yogurt I emphasized that a great pseudo-scientific scam had been foisted on Americans, the promotion of low fat substitutes for real food. The low-fat substitutes masquerade as more heart healthy because saturated fat has been removed but they are actually less healthy because sugar or high fructose corn syrup has been added. Substantial evidence indicates that consumption of sugar and refined carbohydrates are contributing to obesity and cardiovascular disease (CVD), not the unjustly demonized  saturated fats. Now there is evidence to suggest sugar is actually directly promoting heart disease.

In the article, the authors analyzed data from subjects who participated in the National Health and Nutrition Examination Survey (NHANES). They estimated the “usual percentage of calories from added sugar” for individuals.

Added sugar “includes all sugars used in processed or prepared foods, such as sugar-sweetened beverages, grain-based desserts, fruit drinks, dairy desserts, candy, ready-to-eat cereals and yeast breads, but not naturally occurring sugar, such as in fruits and fruit juices.”
Among the 11733 participants there were 831 CVD deaths with a median follow up of 14.6 years.

Those who consumed 25% or more of calories from added sugar were 2.75 times more likely to die than those who consumed less than 10% of calories from added sugar. The risk of CVD mortality increased exponentially with increased  percentage of calories from added sugar.

Major sources of added sugar in American adults diet included sugar-sweetened beverages (37%), grain-based desserts (14%), dairy desserts (6%) and candy (6%). One 360-ml can of regular soda contains about 35 g of sugar (140 calories) or 7% of total calories.

The authors discussed emerging evidence suggesting multiple pathways by which sugar might play a role, including promoting hypertension, increased de novo lipogenesis in the liver (resulting in high triglycerides) and promoting inflammation.

My first dietary recommendation to my patients is to cut out the added sugar. This is both for weight management and lower heart attack risk. The low-fat,  processed “food-like substances” you have been choosing are far worse for you than the unprocessed high fat food they replaces.

Egg Nog: Recipe for a Heart Attack or Heart Healthy?

It’s Christmas Eve and you are starting to make merry. Time to break out the egg nog? Or should you eschew this fascinating combination of eggs, dairy and alcohol due to concerns about heart disease?

    eggCardiac deaths increase in frequency in the days around Christmas.

    Could this be related to excessive consumption of egg nog?

    Egg nog is composed of eggs, cream, milk and booze. All of these ingredients have become associated with increased risk of heart disease in the mind of the public.
    Nutritional guidelines advise us to limit egg consumption, especially the yolk, and use low-fat dairy to reduce our risk of heart disease

    A close look at the science, however, suggests that egg nog may actually lower your risk of heart disease.

    Eggs are high in cholesterol but as I’ve discussed in a previous post, cholesterol in the diet is not a major determinant of cholesterol in the blood and eggs have not been shown to increase heart disease risk.

    Full fat dairy contains saturated fat, the fat that nutritional guidelines tell us increases bad cholesterol in the blood and increases risk of heart attacks. But some saturated fats improve your cholesterol profile and organic (grass-fed, see my previous post) milk contains significant amounts of omega-3 fatty acids which are felt to be protective from heart disease.
    Milk and dairy products are associated with a lower risk of vascular disease!

    Whether you mix rum, brandy, or whisky into your egg nog or you drink a glass of wine on the side you are probably lowering your chances of a heart attack compared to your abstemious relatives. Moderate alcohol consumption of any kind is associated with a lower risk of dying from cardiovascular disease compared to no alcohol consumption.

    So, drink your egg nog without guilt this Holiday Season!
    You’re actually engaging in heart healthy behavior.