Tag Archives: sugar

Heart Healthy Breakfast Choices?: Cheerios, Honey-Nut Cheerios and Soluble Fiber Revisited

A reader commenting on my Plant Paradox post questioned nutritional  recommendations to consume fiber. This has prompted me to revisit a post I wrote in 2014 on Cheerios and Soluble Fiber.

I mentioned at that time that Honey-Nut Cheerios was the #1 selling ready-to-eat breakfast cereal and Cheerios #4. This update Screen Shot 2018-07-15 at 7.22.55 AMindicates little has changed in the rankings or consumption of breakfast cereal since then despite a more widespread recognition that added sugar is the major toxin in our diet and that these food items are basically a vehicle for sugar.

Apparently, Americans believe honey is not sugar. But Honey Nut Cheerios contain 9 times as much sugar as cheerios. Here are the top ingredients:

Whole Grain Oats, Sugar, Oat Bran, Corn Starch, Honey, Brown Sugar Syrup, Salt, Tripotassium Phosphate, Rice Bran Oil and/or Canola Oil,

General Mills tries to emphasize the healthiness of Honey Nut Cheerios, focusing on their close relationship with bees and the natural goodness of honey in its advertising along with other factors that we now know are not important (low fat, 12 vitamins and minerals, source of iron).Screen Shot 2018-07-15 at 7.56.32 AM

Little has changed with respect to the science supporting fiber consumption to reduce cardiovascular disease since 2014.  It is still weak and based on observational studies and surrogate biomarkers.

Between the lines below is my original post with current annotations in red.


The skeptical cardiologist usually eschews the breakfast offerings in the Doctor’s lounge. I’m not really interested in consuming donuts, muffins, or bagels with their high carbohydrate load. As I’ve ranted out about previously, the only yogurt available is Yoplait low fat , highly sugared-up yogurt which is arguably worse than starting the day with a candy bar.

A selection of breakfast cereals is available including Cheerios, Raisin Bran, and Frosted Flakes. Occasionally, when I have neglected to bring in my own full-faty yogurt, granola and/or fruit I will open up one of the Cheerios containers and consume a bowl mixed with 2% milk (full-fat, organic milk which I passionately advocate here and here is not available) (2018 update, I have said “cheerio” to all breakfast cereals and no longer eat Cheerios in the doctor’s lounge). 

Pondering the Cheerios packaging and the cute little O’s made me wonder whether this highly processed and packaged food with a seemingly endless shelf life was truly a healthy choice.

The “Ready-To-Eat”  And Allegedly Heart-Healthy Cereal

Cheerios and Honey-nut cheerios were  the #4 and #1 breakfast cereals in the US in 2013, generating almost a billion dollars in sales. Both of these General Mills blockbusters undoubtedly have reached their popularity by heavily promoting the concept that they are heart healthy.

The Cheerios label is all about the heart. The little O’s sit in a heart-shaped bowl. A prominent red heart with a check inside it attests to the AHA having certified Cheerios as part of its checkmark.heart.org program. Additional text states “low  in Saturated fat and cholesterol” and “diets low in saturated fat and cholesterol may reduce the risk of heart disease.”

Is The Fiber In Cheerios “Heart-Healthy” ?

Beta-glucan is a soluble fiber primarily located in the endosperm cell wall of oats. Early studies showed that oats and beta-glucan soluble fiber could reduce total and LDL (bad cholesterol) levels. The mechanism isn’t really known. (see the end of post for possible mechanisms). The Quaker oats web site oversimplifies the mechanism thusly :

“In your digestive tract, it acts as a sponge, soaking up cholesterol and carrying it out of the body”

This narrative fits with the oversimplified and now discredited descriptions of atherosclerosis which attribute it directly to consumption of cholesterol and fatty acids. See here if you’d like to appreciate how complex the process truly is.

The FDA Sanctions Oats As Heart Healthy

In 1997, the FDA reviewed 33 studies (21 showing benefit and 12 not) and decided to allow a health claim for foods that contain oats and soluble fiber. A minimum dose of 3 grams/day of oat beta-glucan was suggested for a beneficial reduction in blood cholesterol and (presumably, although never documented) a subsequent decline in coronary heart disease.

In 1998 Johnson, et al, published the results of a study funded by a grant from General Mills that showed that  inclusion of whole grain oat ready to eat cereal providing 3 grams of beta-glucan as part of a low fat diet reduced  LDL cholesterol by 4% after 6 weeks. HDL was unchanged. Patients in this study consumed 45 grams (1.5 oz) of cheerios at breakfast and then again in the evening. There was a total of 3 grams of soluble fibre in this amount of Cheerios. A control group consumed corn flakes in a similar fashion without change in LDL.

General Mills took this weak data and ran with it and began posting on Cheerios the following statements

 “Did you know that in just 6 weeks Cheerios can reduce bad cholesterol by an average of 4 percent? Cheerios is … clinically proven to lower cholesterol. A clinical study showed that eating two 1 1/2 cup servings daily of Cheerios cereal reduced bad cholesterol when eaten as part of a diet low in saturated fat and cholesterol.”

Although the FDA had approved verbiage indicating oats may reduce heart disease “when eaten as part of a diet low in saturated fat and cholesterol” the agency objected to General Mills claiming that Cheerios lowers cholesterol “when eaten as part of a diet low in saturated fat and cholesterol”.

The FDA  issued a warning letter to General Mills in 2009 in which the agency alleged “serious violations” of the FDC Act in the label and labeling of Cheerios cereal.

Based on claims made on your product’s label, we have determined that your Cheerios® Toasted Whole Grain Oat Cereal is promoted for conditions that cause it to be a drug because the product is intended for use in the prevention, mitigation, and treatment of disease.

Lowering Cholesterol Is Not The Same As Preventing Heart Disease

The FDA was telling General Mills that it was OK to say that Cheerios may reduce heart disease but not that it can reduce cholesterol because that made it a drug. It makes no sense.

The only thing that had been demonstrated for oat soluble fiber and Cheerios in particular was a reduction in cholesterol. There has never been a study with oats showing a reduction in heart disease..

It’s the heart disease, the atherosclerosis clogging our arteries and causing heart attacks and strokes that we want to prevent. We could care less about lowering cholesterol if it doesn’t prevent atherosclerosis.

A recent review of studies since the FDA ruling shows that 70% of studies show some reduction in LDL with beta-glucan. Interstingly, the studies which added beta-glucan to liquids were generally positive whereas addition to solids such as muffins usually did not show benefit.

I’m going to accept as evidence-based the claim that whole oats can lower your LDL about 7% if you consume a very large amount of them on a daily basis.

However, the critical question for any drug or dietary intervention is does it prevent atherosclerosis, the root cause of heart attacks and strokes. There has been in the past an assumption that lowering cholesterol by any means would result in lowering of atherosclerosis.

This theory has been disproven by recent studies showing that ezetimibe and niacin which significantly lower LDL do not reduce surrogate markers of atherosclerosis or cardiovascular events any more than placebo when added on to statin drugs. (There is now weak evidence that ezetimibe does lower cardiovascular events ). The recently revised cholesterol guidelines endorse the concept of treating risk of atherosclerosis rather than cholesterol levels.


 

I do like the food writer Michael Pollan’s simple rules to “Eat Food. Mostly Plants. Not Too Much.” and this NY Times piece summarizes much of what is in his short, funny and helpful Food Rules book:

you’re much better off eating whole fresh foods than processed food products. That’s what I mean by the recommendation to eat “food.” Once, food was all you could eat, but today there are lots of other edible foodlike substances in the supermarket. These novel products of food science often come in packages festooned with health claims, which brings me to a related rule of thumb: if you’re concerned about your health, you should probably avoid food products that make health claims. Why? Because a health claim on a food product is a good indication that it’s not really food, and food is what you want to eat.

If you follow Pollan’s dictum you will get plenty of fiber, soluble or otherwise and you will avoid the necessity to obsess over the macronutrients in your diet, fiber or otherwise. Throw in some Cheerios and oatmeal every once in a while if you like them;  in their unadulterated state they are a heart-healthy food choice.

Cheerio,

-ACP

Sugar in the Morning, Evening and Supper Time

IMG_2885Added sugar is everywhere you turn in America. The skeptical cardiologist visited Home Depot recently to buy a rake and was confronted by row upon row of candy and processed  treats at the check-out counter.

I’m pretty sure I could have raked leaves for an hour and not burned off the useless calories from one of those Kit Kat bars.

Whole Foods, self-proclaimed “America’s healthiest grocery store”  always has vast rows of useless “function drinks” full of added sugar (and useless chemicals) prominently displayed at strategic spots throughout their stores.

The easy target in the battle against obesity and cardiovascular disease would seem to be added sugar. Sugar-sweetened beverages, which have no nutritional value and just contribute empty calories, are easiest target of all.

How can we convince our patients to reduce added sugar consumption? One approach that has been suggested is to tax added sugar in some way.

Voters in San Francisco and Berkeley today are deciding whether their communities will impose a tax on sugary beverages.

In San Francisco this would be a 2 cent tax per ounce on  any beverage that contains added sugar and 25 or more calories per 12 oz.  Prop. E would levy tax on some juices, coffees and flavored waters and  would raise more than $31 million a year. The money would go to children’s nutrition and physical education programs.

The soda industry has spent 7.7 million dollars in San Francisco fighting this with a heavy marketing campaign. The feeling is that if such a measure passes in one city, it could spread across America.

Readers of this blog know that I consider sugar not fat as the major toxin in our diet, contributing to obesity, diabetes and ultimately heart attack and stroke. I’ve also pointed out that huge amounts of added sugar that are hidden in smoothies, coffee drinks, and non fat yogurt.

I’m a huge advocate of not consuming these types of beverages but I’m not convinced  that this tax is the right approach.

We certainly have a precedence for taxing products which individuals consume that science and society agrees are harmful such as alcohol and tobacco. Added sugar is different in that there are so many different vehicles for its delivery.  Will taxing soda result in more candy and donut consumption?

I’d like to see one or both of these measures pass and hopefully we can monitor closely the results in these northern California cities, gathering data on overall sugar consumption as well as sugar-sweetened beverage consumption. Hopefully, measures like these will lead to greater consumer awareness of the problem of added sugar and reduction in its consumption.

Smoothies: Kings of Sugar Masquerading As Healthy Food Choice

I have had a vague interaction with smoothies in the past, but after a recent jam session with my bassist daughter and drummer son, my daughter enthusiastically recommended we get a smoothie. “Smoothie” was entered into the Apple map app and a remarkable number of establishments serving this concoction popped up.

Smoothie sales have taken off in the last decade as consumers are apparently seeking healthier alternatives to carbonated beverages.

This was my first experience with Smoothie King which is the biggest and oldest chain of smoothie purveyors. According to their web site:

Since Steve Kuhnau created the first Smoothie Bar in 1973, Smoothie King has grown to over 650 locations across three continents. From the US to the Republic of Korea, Singapore and the Cayman Islands, our purpose continues to impact millions of lives around the globe.

Our quest is simple: Make living a healthier more active lifestyle delicious and nutritious. Whether you’re trying to lose a few pounds, have a little more energy at the end of the day or simply feel better about your diet, each and every Smoothie we make is blended for a specific purpose. Which is why we call them “Smoothies With A Purpose.”

This sounds spectacularly good: who wouldn’t want to lose a few pounds, have more energy at the end of the day and feel better about their diet.

Smoothie-King-New-Store-Design-interiorThe Smoothie King store was disturbingly sterile with an intense corporate feeling and had a bewildering array of choices. I could choose from Fitness Blends, Energy Blends, Slim Blends, Wellness Blends or Take a Break Blends.

 

There are 17 “Slim Blends” to choose from. The Angel Food  (“treat your body like an angel”(I have no idea what that means)) Slim Blend contains 350 calories, 84 grams of carbohydrates, 75 grams of sugar, 4 grams of protein, and 6 grams of fiber. This comes from strawberries (I saw no real strawberries behind the counter),bananas, non-fat milk (when I asked about getting whole milk the girl behind the counter told me that they didn’t even use real non-fat milk just a powder), vanilla, turbinado (fancy and deceptive word for brown sugar) and soy protein.

What’s wrong with this? A smoothie from SmoothieKing marketed as a Slim Blend contains 75 grams of sugar, the equivalent of 19 cubes of sugar. There only 39 grams of sugar in a 12 ounce coca-cola thus the small 20 oz “Slim Blend” contains the equivalent of two cans of coca-cola in sugar. There may be some useful nutrients in this monstrosity but predominantly you are getting loads of sugar in a highly concentrated form.

As I’ve pointed out here and here, there is reason to believe that sugar contributes more to obesity and heart disease than fat. Its hard to understand how this Slim Blend would contribute to weight loss in any way. It is just another stealth dessert similar to what Starbucks promotes as I’ve discussed here. What the food industry has done to smoothies is eerily similar to what happened to yogurt which I call the no fat  yogurt scam.

Most people have figured out for good weight control and health they should avoid sodas and sugar-sweetened beverages (even my 19 year old daughter has) but smoothies are masquerading as healthy choices for slimming, for fitness or wellness when they are (in the case of ones from SmoothieKing and presumably most similar chains) an absolutely horrible dietary choice.

What we have here is the classic food industry approach to marketing: Take real food ingredients like fruits, which are healthy choices when consumed in their original state, process  them, industrialize them, add sugar and promote them as healthier dietary choices.

Add in the veneer of promoting fitness or weight loss or wellness by adding magically powerful elixirs or powders and  the duped public will line up and sales will skyrocket. Unfortunately, despite claims of health benefits, consumers will end up less healthy.

 

 

 

 

 

Are You Fed Up With Sugar?

A new documentary  movie, Fed UP, released May 9 and a   New York Times Editorial published  today are helping to focus the country’s attention on a new paradigm for what makes us fat and the importance of added sugar in causing obesity and chronic diseases. I highly recommend both viewing the movie and reading the editorial.

As I’ve pointed out here and here and as eloquently summarized by Gary Taubes in “Good Calories, Bad Calories” and “Why We Get Fat”, the concept of replacing fat with carbohydrates is not making America healthier.

The NY Times editorial and an article published by the same authors in JAMA focus on an alternative view of why people get fat. The generally accepted view is based on the (seemingly immutable)  first law of thermodynamics, that you gain weight because you have consumed more calories than you have burned with exercise. People get fat due to lack of willpower in either consuming too many calories or not exercising enough. In this paradigm, all calories are equal in their effects. To lose weight you merely need to cut back on how many calories you consume. Unfortunately, calorie restriction for weight loss fails almost all the time.

 

The alternative view of obesity posits that underlying genetic factors exacerbated by lifestyle factors such as inadequate sleep, stress and by poor quality of diet are the major reasons for obesity. These factors lead to increase in fat storage which , in turn, means less metabolic fuels available for activity. This causes an increase in hunger and a reduction in metabolic activity, muscular efficiency and physical activity.  The combination of increased energy intake and reduced energy expenditure causes obesity.

Insulin is the major hormone involved in fat metabolism and of all the things we eat highly refined and rapidly digestible carbohydrates cause the greatest insulin response. Thus, the authors write 

By this way of thinking, the increasing amount and processing of carbohydrates in the American diet has increased insulin levels, put fat cells into storage overdrive and elicited obesity-promoting biological responses in a large number of people. Like an infection that raises the body temperature set point, high consumption of refined carbohydrates — chips, crackers, cakes, soft drinks, sugary breakfast cereals and even white rice and bread — has increased body weights throughout the population.

Fed Up, the movie, focuses on how American diets became awash in added sugar and what the consequences of that has been. Dr. Robert Lustig a pediatric endocrinologist at the University of California, San Francisco is an advisor to the film and has spoken and written eloquently on this new paradigm for obesity and the dangers of processed food, fructose and sugar as in this video.

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Here’s the trailer for Fed Up.

The film has a limited release and may not be showing in your town,  but you can check out some actions the film’s web site proposes  (supporting a proposed tax on soda and  sugary beverages, investigating your school’s nutrition policy, taking a 10 day no-sugar challenge) here.

 

 

 

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

 

 

 

 

 

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.

Breakfast is Not The Most important Meal of the Day: Feel Free to Skip it

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

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.

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Yogurt and Your Heart: Part I. The No Fat Frozen Yogurt Scam

tpyogurtYogurt: Heart healthy in its natural state

The Skeptical Cardiologist is a big fan of yogurt. I prefer yogurt in its unadulterated state, 3.5 to 5% milk fat, no sugars added at the factory. Preferably sourced from a local dairy where the cows range freely and eat grass. In this form, yogurt is a very healthy, nutrition-dense, vitamin- enriched food that supplies calcium, essential vitamins, protein and fats.

Yogurt, like all full fat dairy products (with the possible exception of butter) does not increase the risk of heart disease. In fact, some epidemiologic studies show that yogurt consumption is associated with lower risk of heart attacks. It is also associated with less weight gain over time .Because these observational studies can never prove causation we cannot conclude that eating yogurt will reduce our risk of cardiovascular disease or help us lose weight, but certainly there is nothing to suggest that it contributes to heart disease or obesity.

Small prospective, randomized studies (the best kind) show that yogurt consumption may lower blood pressure and raises the good or HDL cholesterol. Again, these studies donʼt prove eating yogurt is healthier but they should make everyone comfortable eating the full fat yogurt.

The Frozen Yogurt Scam: Substitute Sugar and Chemicals for Dairy Fat

Yogurt has a reputation as being a “healthy snack.” Sales of yogurt are increasing rapidly with Greek and frozen yogurt, in particular, showing spectacular growth.

Unfortunately, a great hoax has been perpetrated on the American public. Following advice generated from organizations like the American Heart Association and the USDA government nutritional guidelines, with the idea that they are making healthier choices, Americans are choosing yogurt that is nonfat or low-fat.

When the fat is taken out of yogurt, almost invariably sugar in one form or another is added in by the food industry to enhance flavor and make it palatable.

Shape magazine (Iʼm choosing this magazine as representative of the kind of health information available online and in print on this topic) ran an article with the following headline:

The Healthiest Froyo Orders at Pinkberry, Baskin Robbins, and More Get your frozen yogurt fix without downing an entire mealʼs worth of calories

The teaser line read as follows:

Frozen yogurt may offer a healthier alternative to ice cream, but it can be easy to fall into a calorie trap when you load up on rich flavors and toppings. Check out our cheat sheet to see which froyo combos to order at popular chains. Each one is low in fat and calories—so you can enjoy a guilt-free summer treat!

The number one recommendation was for a sugar and carbohydrate bonanza with the title: “Pinkberry’s Strawberry Classic,” which contains the following nutritional ingredients:

pinkberryNonfat milk, sugar, strawberry flavor (strawberries, sugar, water, natural flavors, fruit and vegetable juice [for color], guar gum, sodium citrate), nonfat yogurt (pasteurized nonfat milk, live and active cultures), nonfat yogurt powder (nonfat milk, culture), fructose, dextrose, natural flavors, citric acid, guar gum, maltodex- trin, mono- and diglycerides, rice starch

Sugar is listed twice and overall there are 23 ingredients that have been added to make this pale imitation of real yogurt palatable. Ironically, Pinkberry claims to have “real” yogurt but the only thing I could tell from their website is the following:

Pinkberry is made with REAL nonfat milk, not from cows treated with rBST hormones, and REAL nonfat yogurt, among many other natural ingredients.

The Shape magazine article recommends you add real strawberries plus a “balsamic glaze” and estimates the total calories as 165 with 144 of which are provided by sugar (36g).

Pinkberry lists the nutritional content for a small cup (5 oz) of pink berry strawberry classic as 110 calories, 22 grams of sugar and 4 grams of protein.

The Skeptical Cardiologist does not recommend this as a “healthy snack” because of the massive amount of sugar, unrefined carbohydrates, and added chemicals. Michael Pollan’s Food Rules are violated multiple times with this ultraprocessed concoction including “Avoid foods with more than 5 ingredients” and” avoid foods which have some form of sugar (or sweetener) listed among the top 3 ingredients”.

Eat Real Food Not Ultraprocessed Industrial Concoctions

photoIn contrast to the typical nonfat frozen yogurt  sugar nightmare, a 5 oz serving of whole milk yogurt from Traders Point Creamery has 90 calories total, 5 grams of fat, 7 total grams of carbohydrate and 5 grams of protein.

There are four ingredients listed on the glass bottle for Traders Point Creamery whole milk yogurt: organic whole milk, organic skim milk, live cultures, and probiotic cultures. The cows are also pastured raised and grass-fed.

This is a yogurt I can recommend.

The food industry routinely presents us with ultra-processed, “food-like” substances that are promoted as more healthy but contain added sugar and refined carbohydrates to enhance taste and promote excess consumption. When we consume sugar added by food processing, we are consuming calories without any nutritional value.

There is no science that tells us that substituting sugar for dairy fat is better for you or for your heart. Several lines of evidence suggest excess consumption of sugar and refined carbohydrates contribute to obesity, inflammation and may increase cardiovascular and chronic disease risk. The high glycemic index and resulting spike in blood sugar may trigger hormonal responses that increase inflammation and fat storage.

America’s obesity epidemic seems to have developed as Americans, following dietary guidelines not based in science, began seeking out low-fat substitutes for real foods. Thus, we have witnessed the explosion of fat-free or low-fat frozen yogurt as food marketers and the obliging “health” media trumpeted the health benefits of these products with no evidence to support the claims.

Being the skeptical cardiologist I have to point out that there has been a shameless, unsubstantiated over-hype of the benefits of yogurt in all sorts of areas including immunity, “digestive health,” bladder cancer, and eczema. I’ll review the health benefits (if any) of the “probiotic” or “prebiotic” features of yogurt and the growth of Greek yogurt in future posts.

Full Disclosure: I have no connections with and receive no support from any food industry sponsored organization. I’m not selling anything. I’m just an unbiased cardiologist seeking the truth so I can make evidence-based recommendations on diet to my patients.  I do eat Traders Point Creamery yogurt and drink their milk but have no other connection to the whole organic yogurt I featured in the pictures.  I have, however, visited their farm and can attest to the fact that the cows are grazing in a pasture and are well treated.