Tag Archives: obesity

Ignore The New York Times and The American Heart Association and Feel Free to Skip Breakfast

A friend recently sent the skeptical cardiologist  a link to a very disappointing NY Times article  entitled “The Case For A Breakfast Feast”

The writer, Roni Rabin (who has a degree in journalism from Columbia University)  struggles to support her sense that there is a “growing body of research” suggesting we should all modify our current dietary habits in order to eat a  breakfast and make breakfast the largest meal of the day.

Many of us grab coffee and a quick bite in the morning and eat more as the day goes on, with a medium-size lunch and the largest meal of the day in the evening. But a growing body of research on weight and health suggests we may be doing it all backward.

Rabin’s first  discussion is of an observational study of Seventh Day Adventists published in July which adds nothing to the evidence in this area because (as she points out):

The conclusions were limited, since the study was observational and involved members of a religious group who are unusually healthy, do not smoke, tend to abstain from alcohol and eat less meat than the general population (half in the study were vegetarian)

She then discusses experiments on mice from 2012 with a Dr. Panda, a short term feeding trial in women from 2013 and studies on feeding and circadian rhythm in a transgenic rat model from 2001.

There is nothing of significance in the NY Times piece that changes my previous analysis  that it is perfectly safe to skip breakfast and that it will neither make you obese nor give you heart disease.


In what follows I’ll repost my initial post on breakfast (Breakfast is Not The Most important Meal of the Day: Feel Free to Skip it) followed by a follow up post (Feel Free To Skip Breakfast Again) I wrote in 2015.

Finally, I’ll take a close look at a statment from the American Heart Association  from earlier this year which Rabin quotes and which many news outlets somehow interpreted as supporting the necessity of eating breakfast for heart health when, in fact, it confirmed the lack of science behind the recommendation.


Feel Free To Skip Breakfast

It always irritates me when a friend tells me that I should eat breakfast because it is “the most important meal of the day”. Many in the nutritional mainstream have propagated this concept along with the idea that skipping breakfast contributes to obesity. The mechanism proposed seems to be that when you skip breakfast you end up over eating later in the day because you are hungrier.

The skeptical cardiologist is puzzled.

Why would i eat breakfast if I am not hungry in order to lose weight?

What constitutes breakfast?

Is it the first meal you eat after sleeping? If so, wouldn’t any meal eaten after sleeping qualify even it is eaten in the afternoon?

Is eating a donut first thing in the morning really healthier than eating nothing?

Why would your first meal be more important than the last?

Isn’t it the content of what we eat that is important more than the timing?

The 2010 dietary guidelines state

eat a nutrient-dense breakfast. Not eating breakfast has been associated with excess body weight, especially among children and adolescents. Consuming breakfast also has been associated with weight loss and weight loss maintenance, as well as improved nutrient intake

The US Surgeon General website advises that we encourage kids to eat only when they are hungry but also states

Eating a healthy breakfast is a good way to start the day and may be important in achieving and maintaining a healthy weight

Biased  and Weak Studies on the Proposed Effect of Breakfast on Obesity (PEBO)

A recent study anayzes the data in support of the “proposed effect of breakfast on obesity” (PEBO) and found them lacking.
This is a fascinating paper that analyzes how scientific studies which are inconclusive can be subsequently distorted or spun by biased researchers to support their positions. It has relevance to how we should view all observational studies.

Observational studies abound in the world of nutritional research. The early studies by Ancel Keys establishing a relationship between fat consumption and heart disease are a classic example. These studies cannot establish causality. For example, we know that countries that consume large amounts of chocolate per capita have large numbers of Nobel Prize winners per capitaChocolate Consumption and Nobel Laureates

Common sense tells us that it is not the chocolate consumption causing the Nobel prizes or vice versa but likely some other factor or factors that is not measured.

Most of the studies on PEBO are observational studies and the few, small prospective randomized studies don’t clearly support the hypothesis.

Could the emphasis on eating breakfast come from the “breakfast food industry”?

I’m sure General Mills and Kellogg’s would sell a lot less of their highly-processed, sugar-laden breakfast cereals if people didn’t think that breakfast was the most important meal of the day.

My advice to overweight or obese patients:

-Eat when you’re hungry. Skip breakfast if you want.
-If you want to eat breakfast, feel free to eat eggs or full-fat dairy (including butter)
-These foods are nutrient-dense and do not increase your risk of heart disease, even if you have high cholesterol.
-You will be less hungry and can eat less throughout the day than if you were eating sugar-laden, highly processed food-like substances.


Breakfast Cereal

The “must eat breakfast” dogma reminds me of a quote  from Melanie Warner’s excellent analysis of the food industry, “Pandora’s Lunchbox.”

“Walk down a cereal aisle today or go onto a brand’s Web site, and you will quickly learn that breakfast cereal is one of the healthiest ways to start the day, chock full of nutrients and containing minimal fat. “Made with wholesome grains,” says Kellogg’s on its Web site. “Kellogg’s cereals help your family start the morning with energy by delivering a number of vital, take-on-the-day nutrients—nutrients that many of us, especially children, otherwise might miss.” It sounds fantastic. But what you don’t often hear is that most of these “take-on-the-day” nutrients are synthetic versions added to the product, often sprayed on after processing. It’s nearly impossible to find a box of cereal in the supermarket that doesn’t have an alphabet soup of manufactured vitamins and minerals, unless you’re in the natural section, where about half the boxes are fortified.”

The Kellogg’s and General Mills of the world strongly promoted the concept that you shouldn’t skip breakfast because they had developed products that stayed fresh on shelves for incredibly long periods of time. They could be mixed with easily accessible (low-fat, no doubt) milk to create inexpensive,  very quickly and easily made, ostensibly healthy breakfasts.

Unfortunately, the processing required to make these cereals last forever involved removing the healthy components.

As Warner writes about W.K. Kellogg:

“In 1905, he changed the Corn Flakes recipe in a critical way, eliminating the problematic corn germ, as well as the bran. He used only the starchy center, what he referred to as “the sweetheart of the corn,” personified on boxes by a farm girl clutching a freshly picked sheaf. This served to lengthen significantly the amount of time Corn Flakes could sit in warehouses or on grocers’ shelves but compromised the vitamins housed in the germ and the fiber residing in the bran”

This is a very familiar story in the world of food processing;  Warner covers, nicely, the same processes occurring with cheese and with milk, among other things.


The AHA (Always Horribly Awry) Weighs In

I pick on the American heart Association (AHA) a lot in this blog but the AHA scientific statement on “Meal Timing and Frequency: Implications for Cardiovascular Disease Prevention” published earlier this year in Circulation is for the most part a balanced summary of research in the field.

Unfortunately, the media grossly distorted the statement and we ended up with assertive headlines such as this one from Reuters:

Eating Breakfast and Eating Mindfully May Help The Heart

Reuters went on to say (red added by me for emphasis):

“Planning meals and snacks in advance and eating breakfast every day may help lower the risk of cardiovascular disease, new guidelines from U.S. doctors say.”

however, the AHA statement says nothing close to that.

This is the summary that was actually in the AHA paper:

“In summary, the limited evidence of breakfast consumption as an important factor in combined weight and cardiometabolic risk management is suggestive of a minimal impact. There is increasing evidence that advice related to breakfast consumption does not improve weight loss, likely because of compensatory behaviors during the day. …… Additional, longer-term studies are needed in this field because most metabolic studies have been either single-day studies or of very short duration”

The lead author of the paper, Marie-Pierre St-Onge, (Ph.D., associate professor, nutritional medicine, Columbia University, New York City) apparently very clearly told Reuters in an email:

“We know from population studies that eating breakfast is related to lower weight and healthier diet, along with lower risk of cardiovascular disease,” .

“However, interventions to increase breakfast consumption in those who typically skip breakfast do not support a strong causal role of this meal for weight management, in particular,” St-Onge cautioned. “Adding breakfast, for some, leads to an additional meal and weight gain.”

“The evidence, St-Onge said, is just not clear enough to make specific recommendations on breakfast.”

Health New Review published a  nice summary of news reports on the AHA statement with a discussion on the overall problem of making broad public policy dietary recommendations from very weak evidence.

New York Times Gets It Right

The New York Times does have writers who can put together good articles on health. One of them, Aaron Carroll wrote a piece in 2016 entitled “Sorry, There’s Nothing Magical About Breakfast” which does a great job of sorting through weak evidence in the field.

Carroll is a professor of pediatrics at Indiana University School of Medicine and writes excellent articles on The New Health Care blog for the Times.

His conclusions are identical to mine from 2013:

“The bottom line is that the evidence of breakfast is something of a mess. If you’re hungry, eat it. But don’t feel bad if you’d rather skip, and don’t listen to those who lecture you. Breakfast has no mystical powers.”

Mindful and Intentional Eating

If you read the AHA statement completely you come across a lot of mumbo-jumbo on intermittent fasting, meal frequency and “mindful” eating.  The abstract’s last sentence is

Intentional eating with mindful attention to the timing and frequency of eating occasions could lead to healthier lifestyle and cardiometabolic risk factor management.

and they reference this table:

 Yikes! I have no idea what they are talking about.
For those of us who need to get to work early in the morning, breakfast is likely to be the worst time for “mindful” eating.
I have a cup of coffee first thing upon arising and only eat much later in the day when I feel very hungry.
Dinner, on the other hand we can plan for, prepare with loved ones and consume  in  a very mindful and leisurely fashion with a glass of heart healthy wine or beer while enjoying good conversation.
So, ignore what apparently authoritative sources like the New York Times, Reuters, and  the AHA tell you about eating breakfast like a king, lunch like a prince, and dinner like a pauper, mindfully or otherwise.
After all, in the Middle Ages, kings likely didn’t eat breakfast as the Catholic church frowned on it. Per Wikipedia:
Breakfast was under Catholic theological criticism. The influential 13th-century Dominican priest Thomas Aquinas wrote in his Summa Theologica (1265–1274) that breakfast committed “praepropere,” or the sin of eating too soon, which was associated with gluttony.[2]Overindulgences and gluttony were frowned upon and were considered boorish by the Catholic Church, as they presumed that if one ate breakfast, it was because one had other lusty appetites as well, such as ale or wine.
Gluttonously Yours,
-ACP
 Image of king and pauper eating from the New York Times article created by Natalya Balnova.

 

The Skim Milk Scam: Words of Wisdom From a Doctor Dairy Farmer

The skeptical cardiologist only consumes full fat dairy and recommends this to his patients.

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.
quart_whole_milk_yogurt-293x300I’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 supporting full fat dairy are:

Circulating Biomarkers of Dairy Fat and Risk of Incident Diabetes Mellitus Among US Men and Women in Two Large Prospective Cohorts

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

and from Brazilian researchers

Total and Full-Fat, but Not Low-Fat, Dairy Product Intakes are Inversely Associated with Metabolic Syndrome in Adults1

 

Is Green Tea Better For Your Heart Than Black Tea?

Coffee is the  caffeinated beverage most consumed by Americans and the skeptical cardiologist. It is good for the heart (unless adulterated by titanium dioxide or lots of sugar, a horror that Starbucks likes to promote).

coffee_teaWorldwide, however, as this cool graphic demonstrates (interactive at the Economist)  tea dominates over coffee in lots of places.

Tea in general and particularly green tea is perceived by many to be incredibly healthy: fighting cancer, dementia, obesity and heart disease. But is this perception justified?

The Green Tea Superfood Hype

If you Google search the health benefits of green tea you might conclude that it is a panacea for all that ails modern civilization. However, bad nutritional advice is the norm on the internet and even  websites like Web MD, which you might consider to be reliable, spread inaccurate, misleading and poorly researched information regularly.

WebMD has an article on green tea that starts off

“Green tea is so good for you that it’s even got some researchers raving.“It’s the healthiest thing I can think of to drink,” says Christopher Ochner, PhD. He’s a research scientist in nutrition at the Icahn School of Medicine at Mount Sinai Hospital.”

Who is Chris Ochner and why is he “raving” about the health benefits of green tea you might ask? That’s certainly what I wanted to know, particularly since this same quote or variations on it are all over the internet on sites like “Herbal Republic” which ups the green tea ante with the title “”Green Tea is Beyond a Superfood”-Dr. Christopher Ochner”  (by the way, any source of nutritional information that uses the term superfood should be considered bogus.)

ochnerAlthough no source is provided for this quote from Dr. Ochner, there is a Christopher Ochner, Ph.D listed on the Icahn Medical School Staff. His Ph. D. is in psychology and he works in the areas of adolescent obesity (perhaps he pushes green tea on his obese adolescents).  I can find no publications by him on the topic of green tea and no evidence that he made these comments. I have sent him an email asking for clarification and edification.

The website,  juicing for health.com lists “5 scientifically proven reasons to drink green tea” (by the way, I consider articles with headlines that start with a number, i.e.  “3 health foods that are actually killing you from the inside”,  “5 veggies that kill stomach fat”, and “35 celebs who’ve aged horribly” are worthless and should be ignored and avoided at all costs)

Green Tea and Catechins: Magical Weight Loss elixir?

It’s hard to find good studies on green tea that aren’t somehow funded by the tea, nutraceutical or food industry.  For example, one “S Wolfram” has written extensively on the benefits of green tea in marginal scientific journals. He works for DSM Nutritional Products, LTd., a Swiss food conglomerate.(“DSM Nutritional Products is the world’s largest nutritional ingredient supplier to producers of foods, beverages, dietary supplements, feed and personal care products” says one DSM PR release”).

DSM developed a highly concentrated extract of  a catechin called Epigallocatechin Gallate (EGCG) in green tea that had been identified as having potential health benefits for humans.

In one recent “review” Wolfram wrote  in somewhat vague but highly optimistic terms

“Dose-response relationships observed in several epidemiological studies have indicated that pronounced cardiovascular and metabolic health benefits can be obtained by regular consumption of 5-6 or more cups of green tea per day. Furthermore, intervention studies using similar amounts of green tea, containing 200-300 mg of EGCG, have demonstrated its usefulness for maintaining cardiovascular and metabolic health. Additionally, there are numerous in vivo studies demonstrating that green tea and EGCG exert cardiovascular and metabolic benefits in these model systems.”

I’m not sure what “model systems” he is referring to but it is certainly not humans. He may be talking about rodents, because in 2005  Wolfram published  a paper entitled:

“TEAVIGO (epigallocatechin gallate) supplementation prevents obesity in rodents by reducing adipose tissue mass”

In the conclusions of this “landmark” study performed in mice and rats he wrote

“Thus, dietary supplementation with EGCG should be considered as a valuable natural treatment option for obesity.”

Voila! From a few experiments in rodents and a few short-term, small studies in humans performed by heavily biased scientists, DSM’s version of EGCG emerged as a leading nutraceutical (I prefer the term, snakeoil) and now you can buy this online from a host of bogus supplement/nutraceutical sites as Teavigo.

The production and marketing of TeaVigo is a classic example of how the cynical food/supplement/nutraceutical industry creates a product that has a thin veneer of scientific credibility for health promotion but is considered “natural” (despite being manufactured)

teavigo
It’s Really Pure…. and Really Useless!

and therefore appeals to Americans who are seeking “natural” ways to prevent or treat the common  chronic  diseases of Western civilization.

Because there is no good scientific evidence supporting a role for green tea extracts or ECGC in preventing any specific disease, there is no FDA scrutiny of

Screen Shot 2015-12-27 at 7.51.35 AM
Teavigo: Good for everything that ails you plus can be put in anything you would like to consume and spread on your face! The perfect nutraceutical!

the drug for efficacy and safety. This is fine for nutraceutical manufacturers as they have been granted the ability to  sell their useless products without any regulatory or FDA approval.

Companies like DSM avoid making any specific health claims for their supplements (such as this drug reduces your chances of having a heart attack or stroke) because the FDA can then go after them.
Instead, the Teavigo website makes vague but optimistic statements such as
“Green tea has long been used for health benefits and Teavigo® is the purest and most natural form of the most active substance in green tea – Epigallocatechin Gallate (EGCG). EGCG contains potent natural antioxidants and efficient free-radical scavengers (free radicals being the highly reactive compounds that cause cellular damage).
Notice the key marketing buzzwords in this statement
-Purest
-Natural
-Active
-Antioxidants
-Efficient
-Free-Radical Scavengers
-Cellular Damage
Who wouldn’t want to take a pill that is pure and natural and full of those wonderful antioxidants that stop those nasty free-radicals  from causing cellular damage?
Unfortunately, any time a proposed powerful “anti-oxidant” ( b-carotene, vitamin E, vitamin C, selenium, retinol, zinc, riboflavin, and molybdenum ) has been studied in a well done scientific trial for prevention of cancer or cardiovascular disease it has failed.
We don’ know if this is because the wrong anti-oxidants have  been chosen (for example in green tea  there are hundreds of potential beneficial chemicals)  or because extracting a single chemical from its milieu in a complex food/beverage makes it inactive or if the whole idea of stopping free-radical damage is misguided.
Why take the time to actually brew and drink green tea the website points out after all:
“To get the optimal benefits from ordinary green tea would take an intake of four to eight cups of green tea a day. With Teavigo® you get the same pure, natural and healthy effects, with more convenience and without the caffeine.”
Finally, consumers of Teavigo can be reassured because it is produced using
“A patented and unique production process with constant product quality”
Let me see here, Teavigo is natural but it is made by a “production process” with “constant product quality”.  Isn’t natural production process an oxymoron?
I have asked the Teavigo people to tell me their “production process” but so far I’ve gotten no response. Your guess is as good as mine as to what chemicals or other potentially damaging processes tea undergoes to reach the colorless and tasteless powder that is Teavigo.
 Green Tea Reality

The evidence supporting tea and green tea health benefits  is weak, coming from observational studies.  A recent review of all these observational studies (supported in part by the tea industry) concluded that

Although the evidence appears to be stronger for green tea than for black tea, which differ greatly in their flavonoid profiles, it is difficult to compare this evidence because the populations and their baseline risks of cardiovascular disease differ greatly between the individual studies on these 2 types of tea, and few studies of green tea provide evidence in non-Asian populations.

Whereas there is reasonable observational evidence that high tea consumption is associated with lower cardiovascular risk, the evidence for green tea being healthier is mostly marketing hype.

If you like green tea by all means drink it in whatever quantity you desire. It’s not bad for you. Weak observational data suggests it may reduce your stroke risk, especially if you are Asian.
On the other hand, if you like black tea or oolong tea you can feel very comfortable that it is not bad for you.  It might also reduce your risk of stroke.
There is nothing to suggest tea is healthier than coffee.
Don’t add sugar or titanium dioxide to your tea but feel free to add cream or full fat milk.
Don’t worry about caffeine unless it makes you jittery or brings on palpitations. Common sense should tell you what amount you can tolerate.
Please don’t buy or consume green tea extracts or Teavigo or any other nutraceutical.
The makers of these products are cynically preying on consumer desire for “natural” treatments, selling chemicals which have not been proven either safe or effective, and employing  misleading marketing and promotional material that implies “scientific” support that is either nonexistent or comes from very weak studies, often run by researchers employed by the industry.
 I guarantea this post was unbiased
-ACP

 

Added Sugar | Why and How to Avoid Added Sugar

The Holiday Season is upon us so it may seem cruel for the skeptical cardiologist to resume harping on the toxicity  and ubiquity of added sugar as is he is wont to do.

Instead, I’m reposting an excellent summary of the topic by Axel Sigurdsson, a cardiologist/blogger from Iceland. Axel writes an excellent blog called Doc’s Opinion which touches on many of the themes I have covered here.

Added Sugar – Why and How to Avoid It

(reposted  from Axel F. Sigurdsson, MD at Doc’s Opinion)

3506628_m-150x150When it comes to the science of nutrition, everyone seems to have an opinion. Consequently, there is huge disagreement, even among the experts. If we ask for advice, there are likely to be dozen different answers. So, in the era of information overflow, the general population has become severely confused.

Apart from having to choose between various food products, we are urged to choose between different paths, almost like finding a favorite football team or choosing a political party. Your cardiologist will likely recommend the DASH diet or a Mediterranean-type diet. Low carb and Paleo have become very popular but are often condemned by the traditional university academic. Then there is low-fat, vegan, gluten free, raw foodism and much more.

In their search for better health, people spend billions every year on books, DVD’s, meal plans, diet products, and food supplements. Simple plans that promise big results are most popular, but usually don’t work. Nonetheless, we are continuously hoaxed by marketing and empty promises.

However, in the midst of all the confusion and disagreement there is a simple measure that if taken seriously may improve our health and lessen the risk of disease more than we might ever realize. And, in fact, the academics, the vegans and the low carb, low fat and Paleo enthusiasts might all agree on this one.

Yes, I am talking about avoiding added sugar.

What Is Added Sugar?

The sugar in our diet is either naturally occurring or added. For example, fruit and milk contain naturally occurring sugars (fructose in fruit and lactose in milk).

Added sugar is the sugar that is added to food or drink during preparation or processing. Added sugar may be natural (such as fructose ) or processed (such as high-fructose corn syrup).

Added sugar provides no nutritional value. However, it boosts flavor, texture and color, and extends the shelf-life of foods like bread, breakfast cereals, tinned fruit, and vegetables. No wonder food manufacturers love sugar.

Why We Should Avoid Added Sugar

Because of the lack of nutritional value, foods that are rich in sugar are often described as empty calories. If sugary foods and beverages are a large part of our diet we are likely to miss out on important nutrients, vitamins and minerals.

Added sugar is believed to contribute to obesity.

Sugar promotes tooth decay by optimizing growth conditions for bacteria.

Recent evidence from epidemiological studies suggests that high intake of sugar-sweetened beverages increases the risk for metabolic syndrome, type 2 diabetes, coronary heart disease, and stroke (1).

Studies show that sugar-sweetened beverages increase accumulation of fat in the liver, muscle, and the visceral fat depot. Most of the studies support the fact that fructose is the main driver of these metabolic aberrations because it drives fat production and fat release from the liver (2).

A large survey published 2014 showed a significant relationship between added sugar consumption and risk of death from cardiovascular disease (3). Individuals who reported more of their total calorie intake as added sugar had a significantly increased risk of dying from cardiovascular disease.

A recently published paper addressed the link between sugar intake and risk factors for heart disease (4). The study tested the effects of consuming beverages sweetened with different doses of high fructose corn syrup on blood lipids (fats). The results showed that blood levels of LDL-cholesterolnon-HDL cholesterol, and apolipoprotein B, and triglycerides increased in a dose-dependent manner within two weeks following consumption of different doses of high-fructose corn syrup. The authors believe their findings provide a possible link to the increased risk of death from heart disease associated with increased intake of added sugar.

Sugar intake may have negative effects on blood pressure. A meta-analysis of randomized controlled trials showed high intake of sugar to be associated with elevated blood pressure (5).

What Are The Main Sources of Added Sugar?

To avoid added sugar, we have to know where to find it.

The figure below is based on data from NHANES showing the sources of added sugars in the diet of the US population 2005-2006.

Added Sugar - Why and How to Avoid It

Sources of added sugars in the diets of the U.S. population ages 2 years and older. National Health and Nutrition Examination Survey, 2005-2006

The figure shows that soda drinks, energy drinks, and sports drinks provide more than a third of added sugars consumed by Americans. If we add fruit drinks to this number, it becomes evident that more than 46.1 percent of added sugar consumed comes from sugar-sweetened beverages.

Other important sources of added sugar are grain-based desserts, dairy desserts, candy, ready-to-eat cereals, sugars and honey, tea and yeast bread.

Why It’s So Hard to Avoid Sugar

Because sugar is such a popular food additive, we can expect to find it where we least expect it. Food we think of as healthy may contain high amounts of added sugar, such as low-fat yogurt, fruit juice and sauces (e.g. tomato ketchup and sweet and sour sauce).

Added Sugar - Why and How to Avoid it

The Nutrition Facts label contains information about the amount of sugar per serving. The size of the serving (53 g in this case) has to be taken into account. Here the amount of total sugar is 24.5g per 100g (100/53 x 13g) which is very high.

Finding out how much added sugar is in our food may be confusing. The Nutrition Facts label may be misleading because it contains information about the amount of sugar per serving. So, to interpret this information, the size of the serving has to be taken into account.

The only reliable way is to look at the ingredient list. However, food manufacturers are not required to separate added sugars from naturally occurring sugars. Nonetheless, if you find sugar is listed among the first few ingredients, the product is likely to contain a high amount of added sugar.

A rule of thumb is that more than 15g of total sugars per 100g means that sugar content is high, and 5g of total sugars means that sugar content is low.

Another problem is that sugar goes by many different names. The chemical name for sugar has the ending “ose” like fructose, sucrose, glucose, and maltose. So, watch out for the “ose” ending.

The biggest obstacle, however, is that humans seem to love sugar and for most of us the love affair lasts a lifetime. Love is not easily conquered by practical reasoning and level-headed common sense.

Furthermore, there is evidence that sugar consumption can induce behavior and neurochemical changes that resemble the effects of a substance of abuse. In other words, similar to drugs such as opiates, sugar may be addictive (6).

The Bottom-Line

A worldwide study published earlier this year suggests that sugary soft drinks kill 184,000 adults every year (7). The study shows that 133,000 deaths from diabetes, 45,000 deaths from cardiovascular disease and 6,450 deaths from cancer were caused by fizzy drinks, fruit drinks, energy drinks, and sweetened iced teas in the year 2010.

Furthermore, the same study suggests that sugar-sweetened beverages significantly increase disability from diabetes, heart disease, and cancers.

The authors of the paper pin-point sugar-sweetened beverages as a single, modifiable component of diet that can impact preventable death and disability in adults in high-, middle-, and low-income countries, indicating an urgent need for strong global prevention programs.

Thus, taking actions to reduce the intake of added sugar is one of the major challenges facing public health authorities worldwide. Due to their potential commercial significance, effective measures will undoubtedly be followed by severe repercussion from parts of the food industry. But, if better health is our aim, confrontations are inevitable.

However, for us, individuals and mortal human beings the message is simple; few lifestyle measures are likely to be more effective than avoiding added sugar whenever possible.

So, what are you waiting for?

 

Doc’s Opinion is written and edited by Axel F. Sigurdsson MD, PhD, FACC.

Dr. Sigurdsson is a cardiologist at the Department of Cardiology at The Landspitali University Hospital in Reykjavik Iceland. He also practices cardiology at Hjartamidstodin (The Heart Center) which is a private heart clinic in the Reykjavik area. He is a Fellow of the American College of Cardiology (ACC), The Icelandic Society of Cardiology and the Swedish Society of Cardiology.

Dr. Sigurdsson is a specialist in internal medicine and cardiology. He did his cardiology training at the Sahlgrenska/Östra University Hospital in Gothenburg, Sweden and at the Royal Jubilee Hospital in Victoria BC, Canada between 1988 – 1996. He is past president of the Icelandic Cardiac Society.

Dr. Sigurdsson main interest has been in the field of coronary heart disease and heart failure. He has published more than 100 scientific abstracts, articles and book chapters in international journals and text books.

-ACP

 

Saturated Fat: Traditionalists versus Progressives

Why is death from coronary heart disease declining in the US at the same time that obesity and diabetes rates are climbing?

Two editorials recently published in The Lancet show the widely varying opinions on the optimal diet for controlling obesity , diabetes and coronary heart disease that experts on nutrition, diabetes and heart disease hold.

fats
Typical innocent and usual suspects rounded up in the war on fat: Cheese-data show it lower heart disease risk Full fat yogurt (Trader’s Point Creamery)-data show it is associated with lower heart disease risk Butter-Delicious. Used in moderation not a culprit.

The first paper contains what I would  consider the saturated fat “traditionalist” viewpoint. This is a modification of the misguided concept that was foisted on the American public in the 1980s and resulted in the widespread consumption of industrially produced trans-fats and high sugar junk food that was considered heart healthy.

The traditionalists have shifted from condemning all fats to vilifying only saturated and trans fats. They would like to explain at least part of the reduction in coronary heart mortality as due to lower saturated fat consumption and the accompanying lowering of LDL (“bad”) cholesterol.

The SFA traditionalists fortunately are in decline and more and more in the last five years, prominent thinkers, researchers and scientists working on the connection between diet and the heart believe saturated fats are neutral but sugar and refined carbohydrates are harmful in the diet.

Darius Mozzafarian, a highly respected cardiologist and epidemiologist, who is dean of the School of Nutrition Science and Policy at Tufts, wrote the second editorial and is what I would term a saturated fatty acid (SFA) progressive.

He makes the following points which are extremely important to understand and which I have covered in previous posts. I’ve included his supporting references which can be accessed here.

Fat Doesn’t Make You Fat, Refined Starches And Sugar Do

"Foods rich in refined starches and sugars—not fats—seem to be the primary culprits for weight gain and, in turn, risk of type 2 diabetes. To blame dietary fats, or even all   calories, is incorrect
Although any calorie is energetically equivalent for short-term weight loss, a food's long-term obesogenicity is modified by its complex effects on satiety, glucose–insulin responses, hepatic fat synthesis, adipocyte function, brain craving, the microbiome, and even metabolic expenditure Thus, foods rich in rapidly digestible, low-fibre carbohydrates promote long-term weight gain, whereas fruits, non-starchy vegetables, nuts, yoghurt, fish, and whole grains reduce       long-term weight gain.123
Overall, increases in refined starches, sugars, and other ultraprocessed foods; advances in food industry marketing; decreasing physical activity and increasing urbanisation in developing nations; and possibly maternal–fetal influences and reduced sleep may be the main drivers of obesity and diabetes worldwide".

There Are Many Different Kinds of Saturated Fats With Markedly Different Health Effects: It Makes No Sense to Lump Them All Together 

"SFAs are heterogeneous, ranging from six to 24 carbon atoms and having dissimilar biology. For example, palmitic acid (16:0) exhibits in vitro adverse metabolic effects, whereas medium-chain (6:0–12:0), odd-chain (15:0, 17:0), and very-long-chain (20:0–24:0) SFAs might have metabolic benefits.4 This biological and metabolic diversity belies the wisdom of grouping of SFAs based on a single common chemical characteristic—the absence of double bonds. Even for any single SFA, physiological effects are complex: eg, compared with carbohydrate, 16:0 raises blood LDL cholesterol, while simultaneously raising HDL cholesterol, reducing triglyceride-rich lipoproteins and remnants, and having no appreciable effect on apolipoprotein B,  5 the most salient LDL-related characteristic. Based on triglyceride-lowering effects, 16:0 could also reduce apolipoprotein CIII, an important modifier of cardiovascular effects of LDL and HDL cholesterol. SFAs also reduce concentrations of lipoprotein(a) ,6 an independent risk factor for coronary heart disease."

The Effects of Dietary Saturated Fats Depend on Complex Interactions With The Other Ingredients in Food

"Dietary SFAs are also obtained from diverse foods, including cheese, grain-based desserts, dairy desserts, chicken, processed meats, unprocessed red meat, milk, yoghurt, butter, vegetable oils, and nuts. Each food has, in addition to SFAs, many other ingredients and characteristics that modify the health effects of that food and perhaps even its fats. Judging the long-term health effects of foods or diets based on macronutrient composition is unsound, often creating paradoxical food choices and product formulations. Endogenous metabolism of SFAs provide further caution against oversimplified inference: for example, 14:0 and 16:0 in blood and tissues, where they are most relevant, are often synthesised endogenously from dietary carbohydrate and correlate more with intake of dietary starches and sugars than with intake of meats and dairy.4"

Dietary Saturated Fat Should Not Be a Target for Health Promotion

"These complexities clarify why total dietary SFA intake has little health effect or relevance as a target. Judging a food or an individual's diet as harmful because it contains more SFAs, or beneficial because it contains less, is intrinsically flawed. A wealth of high-quality cohort data show largely neutral cardiovascular and metabolic effects of overall SFA intake.7 Among meats, those highest in processing and sodium, rather than SFAs, are most strongly linked to coronary heart disease.7Conversely, higher intake of all red meats, irrespective of SFA content, increases risk of weight gain and type 2 diabetes; the risk of the latter may be linked to the iron content of meats.28 Cheese, a leading source of SFAs, is actually linked to no difference in or reduced risk of coronary heart disease and type 2 diabetes.910 Notably, based on correlations of SFA-rich food with other unhealthy lifestyle factors, residual confounding in these cohorts would lead to upward bias, causing overestimation of harms, not neutral effects or benefits. To summarise, these lines of evidence—no influence on apolipoprotein B, reductions in triglyceride-rich lipoproteins and lipoprotein(a), no relation of overall intake with coronary heart disease, and no observed cardiovascular harm for most major food sources—provide powerful and consistent evidence for absence of appreciable harms of SFAs."

Dietary Saturated Fats May Raise LDL cholesterol But This Is Not Important: Overall Effects On Obesity and Atherosclerosis Are What Matters

"a common mistake made by SFA traditionalists is to consider only slices of data—for example, effects of SFAs on LDL cholesterol but not their other complex effects on lipids and lipoproteins; selected ecological trends; and expedient nutrient contrasts. Reductions in blood cholesterol concentrations in Western countries are invoked, yet without systematic quantification of whether such declines are explained by changes in dietary SFAs. For example, whereas blood total cholesterol fell similarly in the USA and France between 1980 and 2000, changes in dietary fats explain only about 20% of the decline in the US and virtually none of that which occurred in France.11Changes in dietary fats11 simply cannot explain most of the reductions in blood cholesterol in Western countries—even less so in view of the increasing prevalence of obesity. Medication use also can explain only a small part of the observed global trends in blood cholesterol and blood pressure. Whether decreases in these parameters are caused by changes in fetal nutrition, the microbiome, or other unknown pathways remains unclear, thus highlighting a crucial and greatly underappreciated area for further investigation."

Dietary Saturated Fats Are Neutral For Coronary heart Disease Risk

Finally, SFA traditionalists often compare the effects of SFAs only with those of vegetable polyunsaturated fats, one of the healthiest macronutrients. Total SFAs, carbohydrate, protein, and monounsaturated fat each seem to be relatively neutral for coronary heart disease risk, likely due to the biological heterogeneity of nutrients and foods within these macronutrient categories.7Comparisons of any of these broad macronutrient categories with healthy vegetable fats would show harm,12 so why isolate SFAs? Indeed, compared with refined carbohydrates, SFAs seem to be beneficial.7

The overall evidence suggests that total SFAs are mostly neutral for health—neither a major nutrient of concern, nor a health-promoting priority for increased intake. 

Focusing On Reducing Saturated Fats Leads To Unhealthy Dietary Choices

I’ve written about this a lot. The most baffling aspect of this is the promotion of low or non-fat dairy.

There is no evidence that low fat dairy products are  healthier than full fat dairy products.

Non-fat yogurt filled with sugar should be considered a dessert, not a healthy food.

"Continued focus on modifying intake of SFAs as a single group is misleading—for instance, US schools ban whole milk but allow sugar-sweetened skim milk; industry promotes low-fat foods filled with refined grains and sugars; and policy makers censure healthy nut-rich snacks because of SFA content.13 "

It is extremely hard to change most people’s opinions on dietary fat.

My patients have been hearing the SFA traditionalist dogma for decades and thus it has become entrenched in their minds.

When I present to them the new progressive and science-based approach to fat and saturated fat some find it so mind boggling that they become skeptical of the skeptical cardiologist!

Hopefully, in the next few years, the progressive SFA recommendations will become the norm and maybe , some day in the not too distant future, the inexplicable recommendations for low-fat or non fat dairy will disappear.

As more data accumulates we may become SFA enthusiasts!

Saturatingly Yours,

-ACP

For another viewpoint (?from an SFA enthusiast) and  a detailed description of both editorials see Axel Sigurdsson’s excellent post here.

Can Ovine Obesity (Fat Sheep) Teach Us About Atrial Fibrillation?

Until the last year or so when patients asked me what they could do to help their atrial fibrillation (AF) I would tell them to avoid excessive alcohol consumption and take their medications as prescribed.

My response has changed because new data suggest that losing weight and exercising can significantly reduce the recurrent rate of atrial fibrillation. Now, in addition to my standard reasons for staying at ideal body weight and exercising regularly I can toss in the fact that atrial fibrillation will be less frequent and troublesome.

I had noted previously that the majority of my patient’s with AF were obese and sedentary (although there are definitely many AF patients who exercise regularly, eat a great diet and stay at their ideal body weight0 but data was lacking to suggest cause and effect.

LAAfat
View of the left atrial appendage (LAA) and posterior aspect of left atrium obtained in a 400 pound woman about to undergo  electrical cardioversion for her atrial fibrillation. The orange arrow points to extensive collection of fat in the walls of the atrium.

In addition, I had noted that when I looked at the left atrium of the vast majority of patients with AF using an imaging tool called trans-esophageal echocardiography they had evidence for fatty infiltration into the area between the atria (atrial septum)  and the wall of the left atrium.

I strongly suspected based on these observations that somehow the fat infiltrating into the walls of the left atrium was triggering AF but I had no way of proving it.  Isolated observations like these can only generate hypotheses on causality.

Science has many different approaches to solidifying or proving hypotheses and one such approach is to induce a disease in an animal similar to humans and make detailed analyses of the cause and consequences.

Australian researchers writing in JACC in July present their observations on the electrical, physiologic and structural changes that result when sheep get fat.

How Do You Make Sheep Fat?

Apparently you just let them eat as many pellets made of energy-dense soybean oil (2.2%) and molasses–fortified grain as they want.

After 36 weeks the 10 sheep given ad libitum pellets weighed twice as much as the sheep who were restricted and kept lean

After 36 more weeks of obesity the sheep were studied extensively. All sheep underwent “electrophysiological and electroanatomic mapping; hemodynamic and imaging assessment (echocardiography and dual-energy x-ray absorptiometry); and histology and molecular evaluation”.

The investigators found

“Sustained obesity results in global biatrial endocardial remodeling characterized by LA enlargement, conduction abnormalities, fractionated electrograms, increased profibrotic TGF-β1 expression, interstitial atrial fibrosis, and increased propensity for AF. Obesity was associated with reduced posterior LA endocardial voltage and infiltration of contiguous posterior LA muscle by epicardial fat, representing a unique substrate for AF”

The fat sheep developed AF and had multiple abnormalities in the left atrium, the source of AF, that made them more likely to develop atrial fibrillation.
Screen Shot 2015-09-01 at 4.32.32 PM In fact, the investigators believe it was fat collecting around the heart and specifically around the posterior left atrium that was triggering all these changes.

The pictures to the left show a heart from one of the fat sheep. The arrow points to the extensive amount of fat collecting posterior to the left atrium.

When the posterior left atrial wall was viewed microscopically, fat cells could be seen infiltrating between the muscle cells in the fat sheep (right, blue arrow) but not in the lean sheep. Screen Shot 2015-09-01 at 4.33.06 PM

In the fat sheep, fat cells (adipocytes)  were enlarged and infiltrated between the muscle cells of the left atrium, presumably disrupting the normal electrical activity and contributing to the development of atrial fibrillation.

More Reasons To Stay At Your Ideal Body Weight!

If you were previously unmotivated to avoid obesity perhaps this will motivate you.

Think about fat cells gathering around your heart and pouring their evil humours into the tissues of your left atrium and making it more likely that you will develop AF. With AF comes increase risk of stroke, heart failure and death.

-unadipocytically yours

-ACP

Are Sweet Potatoes Healthier Than Potatoes?

In recent years, sweet potatoes have become a favored alternative to potatoes for health-conscious eaters for some reason. I’ve been noticing sweet potatoes more and more on the menus of trendy/healthy/locavore oriented restaurants as an alternative to potatoes.

A typical appraisal comes from Time’s Health magazine website:

“It’s no surprise that sweet potatoes are at the top of nearly everyone’s healthiest foods list.”

EatingWell. com proclaims,

“The sweet potato is a nutritional powerhouse. Deemed a ‘superfood’ by many nutritionists, sweet potatoes are loaded with vitamin A, vitamin C, fiber and potassium, plus phytochemicals like lutein and zeaxanthin, which promote eye health. ” (Appropriately, if you click on the nutritionists link on this quote it takes you to an Amazon.com listing of pull-up diapers!)

Please note that any article that takes the term superfood seriously should be dismissed as frivolous. Stop reading immediately and never revisit the source.

Screen Shot 2015-08-06 at 10.40.32 AMThe Cleveland Clinic website provides a comparison of the two vegetables and determines that sweet potatoes win the nutritional battle by “knock-out”. (This site also claims that sweet potatoes are far better than yams, a claim I have not had time to research)

Somehow, the idea that a sweeter, tastier vegetable is better for me than its not-so-sweet relative made no sense to me.

Call me skeptical.

Are they a healthier choice than regular potatoes or is this all driven by marketing hype?

Nutritional Differences

There are some minor differences in the nutrient content of SP and P:

Screen Shot 2015-08-06 at 8.36.39 AM
A 180 gram sweet potato has 12 grams of sugar, 6 grams of fiber and 37 grams of carbohydrate
Screen Shot 2015-08-06 at 8.35.45 AM
A 173 gram potato has 2 grams of sugar, 4 grams of fiber and 37 grams of carbohydrate

 

 

 

 

 

 

Sweet potatoes have  six times more sugar and 50% more fiber than regular potatoes. Sources that proclaim SP healthier like to focus on the large amount of Vitamin A. However, we don’t necessarily need more Vitamin A in our diet and nothing suggests these minor differences are of any importance in our overall health.

Potatoes have their own PR machine which will regale you with the wonders of spuds:

“It’s a surprise for many to discover one medium potato (5.3 oz) with the skin contains:

  • 10 percent of the daily value of B6;

  • Trace amounts of thiamine, riboflavin, folate, magnesium, phosphorous, iron, and zinc…and all this for just 110 calories and  no fat, sodium or cholesterol.

  • More potassium (620 mg) than even bananas, spinach, or broccoli;

  • 45 percent of the daily value for vitamin C

The potato people would also like you to know that:

Potatoes are a vegetable.  The popular tuber counts toward the total recommended servings of vegetables. One medium-sized potato (5.3 oz.) counts as 1 cup of starchy vegetables.

On the other hand, the Harvard School of Public health has decided potatoes are not a vegetable:

“However, potatoes don’t count as a vegetable on Harvard’s Healthy Eating Plate because they are high in carbohydrate – and in particular, the kind of carbohydrate that the body digests rapidly, causing blood sugar and insulin to surge and then dip (in scientific terms, they have a high glycemic load).”

There isn’t much good evidence that the glycemic load is something we should be focusing on with diet (see here) but the Harvard people like to point to observational studies that show that people who increased their consumption of  french fries and baked or mashed potatoes  gained more weight over time.

All observational studies try to control for confounding factors in their analysis, but in the case of food consumption it is particularly difficult because it is highly likely that those individuals who are eating french fries are also engaging in other lifestyle choices that are perceived as unhealthy.

The large observational study, which found that increased consumption of potato chips and potatoes was associated with the biggest weight gain, classifies yams or sweet potatoes as a vegetable (along with tomato juice (which is mostly sugar)and tomato sauce).  Vegetables were associated with a small loss of weight over time.

The sweet potato gets to hide amongst all the arguably really healthy vegetables (like chard and brussel sprouts and kale) that  those who are truly dedicated to a healthy lifestyle have embraced with enthusiasm.  This group also exercises optimally, avoids eating junk food and processed food, and engages in other subtle behaviors that the observational study did not measure.

Why Might Potatoes Be Associated with Obesity?

I view potatoes as a ubiquitous, cheap and quickly prepared food  that allows the rapid and easy accumulation of excess calories. The average American consumes 120 pounds of potatoes per year compared to only about 5 pounds of sweet potatoes.

French fries, a staple of fast food throughout the world, when consumed hot, combine many of the sensory elements that lead to overeating. When done properly, the frying process adds a wonderful crispness to the outside, and when combined with the warm, perfectly cooked potato on the inside, the result is irresistible.

A large order of McDonald’s french fries contains 510 calories, suddenly triple the number in a medium potato, but it only costs $2.19 and is available virtually instantaneously.

Chances are those who are consuming the McDonald’s french fries are saving further money and preparation time by combining it with a Big Mac (590 calories) and a medium Coke (210 calories). This Value Meal #1 only costs $5.69 but contains 1300 calories.

Even if you are avoiding fast food, french fries and potato chips are ubiqitous. For some reason, most restaurant breakfasts which are not pancake or waffle oriented are presented with a side of potatoes. Sandwiches always seem to come with an order of potato chips. Hamburgers are served with fries. Steaks with mashed potatoes.

For most meals that contain a potato side, up to  half of the total calories are coming from the spuds.

You have to make a concerted effort to not consume some form of potato when you are eating out, and when you do that, you are now importantly paying attention more to total calories than to macronutrient content of meals.

Your other choice is to not consume all of the french fries, potato chips, grilled potatoes or mashed potatoes that are presented as a side, but many individuals feel compelled to finish everything on their plate.

Dietary Recommendations

If sweet potatoes were as ubiquitous as potatoes and became a staple of fast food restaurants and a side for any and all dishes (and if they were separated out from the rest of vegetable world), I suspect they would also be associated with weight gain.

If, on the other hand, potatoes were not markers of fast, tasty, and easily prepared and consumed food and were only eaten at trendy locavore restaurants or prepared at home, I think they would no longer be associated with obesity.

Looking at the two on strictly nutritional or scientific grounds, it is not possible to choose one over the other.

If you are overweight and ready to lose weight, cutting out the potatoes when eating out will eliminate a lot of the carbohydrates and calories you consume. But don’t think that substituting sweet potato fries is a magical solution.

I yam what I yam,

-ACP

For a Michael Pollan video on the evil of McDonald’s french fries for other reasons take a look at:

 

 

 

 

 

 

Is Exercise Impotent In Preventing Obesity?

What if all that exercise that authorities have been recommending  is not helping to stem the rising tide of obesity?

What if all calories don’t have the same ability to add fat?

These twin heresies fly in the face of the usual dogma on the cause of obesity: more calories in (gluttony) than calories out (sloth). The skeptical cardiologist has been pondering these possibilities for some time, since reading Gary Taubes book Good Calories, Bad Calories.

I have been advising my patients through this blog and during office visits that added sugar and  refined  carbohydrates are much more of a culprit in their  weight gain than fat, thus embracing the concept that there are good calories and bad calories

Exercise and Obesity

5Boro Bike Riders crossing the summit of the Queensboro aka 59th Street aka "Feelin Groovy" Bridge

But I also spend a lot of time during my office visits discussing activity levels and encouraging my patients to engage in moderate aerobic physical activity for at least 150 minutes per week.

I do this because there is good evidence that regular physical activity is associated with lower cardiovascular risk, cancer risk, mortality, and improved brain, muscle, and bone function. Exactly  what level and type of exercise is needed to reap these benefits is still up for debate.

I, personally, engage in regular moderate exercise and I think it helps maintain my weight where I want it.

Throwing Down the Gauntlet

A recent editorial in the British Journal of Sport Medicine stridently  makes the claim that exercise is not useful for weight loss as conventional wisdom teaches and that the food industry has been promoting exercise while simultaneously promoting junk food and sugar-sweetened beverages (The link I provided is no longer active because the journal has removed the editorial -“This paper has been temporarily removed following an expression of concern.”)

The authors wrote:

“members of the public are drowned by an unhelpful message about maintaining a healthy weight through calorie counting, and many still wrongly believe that obesity is entirely due to lack of exercise. This false perception is rooted in the Food Industry’s Public Relations machinery, which uses tactics chillingly similar to those of big tobacco. “

Root Causes of Obesity

It would appear that science cannot tell us with total certainty what the cause of our current obesity epidemic is.

After publishing a paper in 2014 that suggested Americans had become less active over the last 20 years, Ladabaum, et al admitted this:

“Although there is no clear answer at this time regarding the relative contribution of energy intake or physical activity (or other variables including dietary components, patterns of activity, and environmental factors, including the gut micro biome) to the public health problem of obesity, we believe that public health messages should continue to emphasize the importance of both a healthy diet and remaining physically active throughout life.”

Is Exercise Amount  A Cause or Effect?

In my own practice, I have observed a tendency for  those patients who regularly exercise or have very physically active jobs to stay thin whereas those who don’t exercise, especially if they have sedentary jobs or are retired, tend to be obese and gain weight.

But, I also note that those patients who take my recommendations on exercise to heart  are also listening to my advice in other areas, including diet and medications and are, in general, much more proactive about their health.

Therefore, I can’t say for sure whether it is the exercise  or the other aspects of a healthy lifestyle (including diet)  being followed in any individual patient that is keeping the pounds off. How much my patients move during the day when they are not specifically exercising may also be playing a role and is hard for me to assess.

There is also the mind-boggling possibility, as Gary Taubes has written about (here and in his book Why We Get Fat) that our genetics are driving both our activity levels and our food consumption:

Ultimately, the relationship between physical activity and fatness comes down to the question of cause and effect. Is Lance Armstrong excessively lean because he burns off a few thousand calories a day cycling, or is he driven to expend that energy because his body is constitutionally set against storing calories as fat? If his fat tissue is resistant to accumulating calories, his body has little choice but to burn them as quickly as possible: what Rony and his contemporaries called the “activity impulse”—a physiological drive, not a conscious one. His body is telling him to get on his bike and ride, not his mind. Those of us who run to fat would have the opposite problem. Our fat tissue wants to store calories, leaving our muscles with a relative dearth of energy to burn. It’s not willpower we lack, but fuel. “

I’m not ready to accept the heresy that exercise and activity have nothing to do with weight gain or loss. I, like most cardiologists, walk the walk and talk the talk of regular vigorous exercise for health benefits, extended longevity, cardiovascular fitness and for helping in weight control.

Exercise is not the be all and end all of weight control because increased consumption of bad or good calories can overcome the most prolonged and intense workouts but it is a useful adjunct.

Still exercising regularly,

-ACP

Fructose and the Ubiquity of Added Sugar

Since realizing that sugar, and not fat, was the major problem in the modern Western diet, The Skeptical Cardiologist has been ratcheting down how much sugar he consumes to the smallest possible amount.

This has lowered what I like to call my “sugarstat,” and has made me exquisitely sensitive to the presence of added sugar in foods.

With this sensitivity comes the heightened realization that added sugar is everywhere.

The obvious sources are soft drinks and other sweetened beverages, candy, cakes, pies, cookies, donuts and fruit juices. Once you mostly eliminate such things from your diet you become aware of the “background” levels of added sugar in other foods.

For example, when I consume what many Americans probably perceive as a “healthy” granola bar (from even the most natural or organic of manufacturers), all I can taste is a sickly sugar taste overwhelming all the other ingredients.

Low-fat yogurt (which I have compared unfavorably to a Snickers Bar here) tastes like pure sugar mixed with odd chemicals and a vague dairy flavor.

Seemingly healthy sushi tastes too sweet to me as it turns out to have lots of sugar mixed in  the rice and the popular eel sauce is mostly made up of sugar.

Most annoying  is the current trend for restaurants to put a “balsamic glaze” loaded with sugar on perfectly good vegetables like brussel sprouts, ruining them for me.

Fructose and Processed Foods

A review article in the Mayo Clinic Proceedings (1) this month presents the case for fructose (from glucose and high-fructose corn syrup) being the major cause of our obesity and diabetes epidemics and thus, the major contributor to cardiovascular disease in the US.

Fructose is a monosaccharide that combines with the monosaccharide glucose to form sucrose, which is what most people recognize as sugar.

Processed foods commonly contain a lot of added fructose-containing sugar but also, increasingly they contain high fructose corn syrup (HFCS) which contains up to 65% fructose.

Large intake of fructose goes hand in hand with consumption of processed foods. Approximately 75% of all foods and beverages in the US contain added sugars. Consumption of added sugar by Americans increased from 4 lbs per person per year to 120 lbs per person per year between 1776 and 1994.

Thanks to a dramatic increase in sugar-sweetened beverages, American teenagers consume about 72 grams of fructose daily.

There are a substantial amount of observational, short-term basic science, and clinical trial data suggesting that all this added sugar, especially fructose, are posing a serious public health problem.

The article presents these data in detail and I’ll summarize the major points as follows:

  1. Fructose is the likely component of sucrose and HFCS that promotes insulin resistance.
  2. In animals and humans, replacement of starch (chains of glucose) with sucrose or fructose causes increase glucose and insulin levels and reduced insulin sensitivity.
  3. Fructose stimulates epigenetic changes and metabolic alterations that shunt calories into storage depots in abdominal fat cells.

In simpler language, fructose promotes abdominal fat build-up and makes you more likely to develop type 2 diabetes.

Fruits and Fructose

I’m sure many of you are thinking, “but fructose is the major sugar in fruit, should I stop eating fruit?”

The answer is NO! The fructose in fruit is not highly concentrated. Fructose makes up 1% of the weight of a pear for example. It is combined with all of the good things, including fiber and phytonutrients and vitamins, that make fruit good for you.

Eliminating added fructose (sugar and HFCS) is by far the simplest thing you can do diet wise to improve your health. If you avoid added fructose, you will be cutting out a lot of the processed foods and sugar-sweetened beverages which have no nutritional value but contribute to obesity and diabetes.

Fructose as Toxin

preserves
Real fruit (right) and “Just Fruit Spread” (left). Note the attempts to make the spread appear healthy by announcing that it is “non-GMO”, glutan-free, “organic” and “perfectly sweetened with fair trade cane sugar”. Cane juice is added sugar .

Robert Lustig, a pediatric endocrinologist has talked and written extensively about fructose as a “toxin.” You can watch him here. He’s also published a lot of books on the topic including one which identifies the 56 names under which sugar masquerades.

It’s probably not worth buying that book, but keep in mind that agave and evaporated cane juice are just different forms of sugar. Makers of organic and “natural” foods are   as guilty as food industry giants at adding sugar, but they try to pretend that “natural” sources of sugar are somehow better for you.

I don’t think the science on fructose is totally settled, however, and another recent review (from scientists not funded by the food industry) concluded:

“current evidence on the metabolic effects of fructose, as consumed by the majority of populations, is insufficient to demonstrate such a role in metabolic diseases and the global obesity epidemic”

Skeptically Yours,

Anthony C. Pearson, MD, FACC

1. Added Fructose: A Principal Driver of Type 2 Diabetes Mellitus and Its Consequences. Mayo Clin Proc. 2015:90(3);372-381. DiNicolantonio, JJ, O’Keefe, JH and Lucan SC

Trends in Fat and Yogurt Consumption: We Eat Less Fat yet Get Fatter

A recent paper in JAMA and a Seinfeld episode shed some light on the change in diet and fat consumption in Americans initiated by national nutritional recommendations beginning in the 1970s.

Based on weak to nonexistent scientific evidence Americans were told to consume less total fat and cut saturated fat consumption to less than 10% of calories.

The paper shows that women in the St. Paul-Minneapolis area  followed this advice and cut fat consumption as a % of total calories from 38.4% in 1980-1982 to 30.6% in 1995-1997. Saturated fatty acids dropped from 13.5 to 10.5%. (Since then, total fat % and SFA % has drifted slightly upward and calories downward )(for the full table see fat consumption table (PDF))

Media summaries and reports on this paper have emphasized that Americans have failed to cut their saturated fat consumption to meet recommendations of the USDA (<10%) and the American Heart Association (<6%) with a call for more promotion of these (mis)guidelines.

The skeptical cardiologist has a different take.

Interestingly total calories during these time intervals went up from 1645 to 1851. Thus, in replacement of the fat calories, the women were consuming the carbohydrates and sugars the food industry had obligingly added to food to make it more palatable,  “heart healthy” and comply with guidelines.

The authors discuss the fact that during these time intervals, despite slashing fat consumption,  overall rates of obesity substantially rose. Their explanation was that the women were “underreporting” fat consumption.

A simpler and more compelling explanation is that replacement of fat with carbohydrates along with overall increase in calorie consumption was the culprit.

The Non-Fat Yogurt Scam and Seinfeld

One ongoing contributor to the phenemon of replacing healthy real food fats with engineered, highly processed and highly sugared foods is the yogurt industry.

I wrote about the non fat yogurt scam about a year ago in this post.

I happened to see the fantastic Seinfeld episode “The Non-Fat Yogurt” last night . In this episode Jerry, Elaine and George eat at a non-fat frozen yogurt shop. Everyone concurs that the yogurt is surprisingly delicious given that it is “non-fat” and begin eating it regularly.  Jerry and Elaine gain weight  and begin suspecting that the yogurt is not truly “non-fat”.

This episode aired in 1993 during the height of the shift toward unhealthy low fat, processed substitutes.  An analysis of the yogurt revealed that it was not non-fat and this is why they were gaining weight. In reality,  people get fat on truly non-fat yogurt (even Greek Yogurt) and non-fat cookies and non-fat smoothies and  anything with added sugar.

Fat consumption doesn’t make you fat.

Enjoy this snippet from the episode (and please excuse the bad language)