Sailing The Atlantic

Please check out our latest piece published in The Atlantic, exclusively at:

Atlantic Article

Where’s the Beef?

For many a year I have preached the Grassroots Gourmet Gospel about eating fresh and avoiding adulterated products through following The Path of The Three“Be’s”:

• Be Aware and Avoid the call of the Junk Food/Fast Food Siren
• Be Fresh-But No Adultery!
• Be On Time and In Proportion

Yet, many people are still unaware that this goes beyond simply avoiding fast food or junk food. Simply because something is purchased at a supermarket does not mean it is free from prior manipulation. The act of altering our foodstuffs by adding or subtracting compounds and/or altering the form of the food by cooking, irradiating or freezing has some effects. Some, perhaps the vast majority, of these effects are negligible. Perhaps some only have significance with long cumulative exposure or critical combination. Perhaps others are altered, for better or worse, by a tincture of time. Other effects may only manifest in the setting of susceptible genetics or physiology. These are the great unknowns regarding the Law of Unintended Consequences. What is clear is that the variables and thus the result operate in equations much more complex than simple addition and subtraction.

And it is also an oversimplification to label groups of foods as simply good or bad. Red meat, as a group, contains the entire gamut of possibilities. There are fresh lean game cuts and grass fed free range beef steaks. AT the other end there are industrialized geometrically symmetrically processed patties with a list of additives longer than Keith Richards’ toxicology report. As chef and an interventional cardiologist I am often asked my opinion about red meat consumption. So I shall opine: as but one in long lineage of omnivores, to put it quite simply, I love my meatses. And I love my meatses fresh. Although my choices are driven by my taste buds and several million years of evolutionary hardwiring I find adjudication within the confines of medical science. As an example several recent studies, including a meta-analysis comprising over a million participants worldwide performed by Harvard, have failed to demonstrate a correlation between consumption of fresh red meat and increased cardiovascular risk[i]^{,[ii],[iii],[iv],[v]}. However, there did appear to be increased cardiovascular risk and an increased risk of developing diabetes when highly processed meat products were regularly consumed.

Why? How? Is there a difference?  Isn’t eating any red meat the cardiovascular equivalent of launching an atherosclerotic drone into your coronary artery? The answer is there appear to be major differences and it’s time we moved beyond bovine bigotry by regarding all red meat as a single class of foodstuffs. It’s like lumping a Yugo and a Ferrari together as “cars” and being confused at the quarter mile time trial results.

Consistent with the previous data examining cardiovascular risk and the consumption of fresh red meat, the largest study to date examining red meat consumption and stroke risk was recently published[vi]. Over 40,000 Swedish men aged 45-79 were followed by questionnaire for over a ten year period. The researchers found that consumption “of processed meat, but not of fresh red meat, was positively associated with risk of stroke.”  The increased risk was over twenty percent. Dr. Robert Eckel, a Professor of Medicine at The University of Colorado and a past President of The American Heart Association also noted that the group with the highest intake of processed meat in the Swedish study also had a healthier diet overall, including more fruit, vegetables, and whole grains. He commented that this “suggests that the effects of processed meat may confound the benefit of a heart-healthy diet.”

This study follows on the heels of a very large and interesting study demonstrating the increased cardiovascular risk when the dietary ratio of sodium (often referred to as “salt intake”) to potassium is greater than one. This may explain why previous studies have failed to definitively link increased absolute amounts of sodium to cardiovascular morbidity and mortality. The effect may lie in a ratio, not absolutes. The processing of a piece of fresh pork, with sodium to potassium ratio less than one, to produce a slice of ham (even low-fat ham) inverts that ratio. The causative possibilities are intriguing, but the important question remains.

Where’s the beef?

It should be back on the menu-but only if you keep it fresh!

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[i] (Micha, Wallace, & Mozaffarian, 2010)

[ii] (Siri-Tarino, Sun, Hu, & Krauss, 2010)

[iii] (Micha & Mozaffarian, Saturated fat and cardiometabolic risk factors, coronary heart disease, stroke, and diabetes: a fresh look at the evidence, 2010)

[iv] (Siri-Tarino P. , Sun, Hu, & Krauss, 2010)

[v] (Siri-Tarino P. , Sun, Hu, & Krauss, Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease, 2010)

[vi] (Larsson, Virtamo, & Wolk, 2011)

To Salt or Not To Salt; Perhaps It’s the Ratio

Recently there has been a lot of press about the role of salt, or sodium, as a risk factor for the development cardiovascular disease and subsequent events. A recent meta-analysis looked at salt intake and found that higher levels of salt intake were associated with a modest increase in blood pressure. This increase did lead to an increase in the absolute number of cardiovascular events, but this did not reach statistical significance. This follows on the heels of another study that examined normotensive (those without hypertension) individuals and found that the highest mortality risk was in the group with the lowest sodium intake, as measured by sodium excretion. These findings have reignited the debate of the role of sodium in the development of heart disease and levels of appropriate sodium intake; even as the new guidelines call for the consumption of lower amounts.

What do we know? The data seem clear that increasing levels of salt, or sodium, are associated with increases in blood pressure and contributes to or worsens hypertension. Hypertension is a risk factor for the development of cardiovascular disease and a potent risk factor for stroke risk. Treating underlying hypertension has been demonstrated to reduce both cardiovascular and stroke risk. The operative hypothesis to this point has been that the communicative property applies here: that reducing salt intake would reduce the blood pressure and thus translate into a reduction in cardiovascular risk. Unfortunately, as Dr. Yusuf, DPhil from McMaster University and a cardiovascular expert on meta-analysis notes the direct evidence linking high dietary salt consumption and cardiovascular disease is “weak and inconsistent.” We also know that in the body, sodium exists in a ratio related balance with potassium. Potassium is another element necessary for proper bodily functioning and is especially important from a cardiovascular perspective.

A recent study published in the Archives of Internal Medicine sheds some new light into the reason why we have seen these apparently contradictory results (Yang, Liu, & Kuklina, 2011). As one of the study investigators, Dr. Kuklina, notes, “This is the first large, nationwide study where we followed a pretty big cohort of people and looked at sodium and potassium at the same time.” The examined over 12,000 people for all cause and cardiovascular risk as part of the Third National Health and Nutritional Examination Survey (NHANES III). What they found over a 15 year period was that the highest risk group had a very high ratio of sodium to potassium in their diet. Previous analytic concentration focusing on only half the equation would explain the dichotomous findings over the years. As sodium increased, risk increased about 20% for every 1000mg/day. However, for every 1000mg/day increase in potassium, the risk decreased about 20%. Thus, based on these findings what is of paramount import is maintaining a sodium/potassium ratio less than 1.

What does this mean? It means even more evidence to be following our Grassroots Gourmet™ principles. Firstly, Fast/Junk food is often loaded with sodium, which is why we strive to be aware and avoid the call of the junk food fast food siren. Second we want to be fresh-but no adultery! Over 75% of our intake of sodium each day is derived from pre-packaged, processed and prepared food. When using sodium to season and create a perfectly balanced and delicious meal, we add only about 5% of what is our daily intake. Not only that, but processing adulterates and alters the composition of our food in a potentially detrimental way. As noted by the study authors, a 100g (about 3 ½ ounces) serving of natural wholesome fresh pork contains roughly 60 mg of sodium and about 340mg of potassium. But if you industrially process that into the average deli ham you end up with 920mg of sodium and only 240mg of potassium. Avoiding fast food and preprocessed adulterated food will help reduce sodium intake. Consuming foods rich in potassium such as fruit (apricots, bananas, avocados, tomatoes, cantaloupes and oranges for example), vegetables (like beets, brussel sprouts, lima beans, winter squash, potatoes and spinach) and legumes like peanuts as well as yogurt will contribute to increasing potassium intake. As with all things in Nature, it’s about the balance.

Saltier Language

Very often here we have discussed how sometimes Less can be More, but sometimes Less is simply Less. Sometimes it depends on the road Less traveled. If you haven’t read July’s article in Basil Magazine (link here: Dr. Mike’s July Basil Magazine Article) take a moment to do so, the following discussion continues the data and thoughts provided therein.

A recent review of trials looking at the effect of sodium reduction on cardiovascular endpoints looked at seven previous studies: three in normotensive individuals, two in hypertensives, one in a mixed population of those with hypertension and those with normal blood pressure and one group with heart failure (notoriously sensitive to the effects of increased salt intake).

What this analysis, published in the Cochrane Database of Systematic Reviews and the American Journal of Hypertension[i] did was look at the combined results from these studies. The cumulative examination looked at over 6000 participants attempting to reduce their dietary intake of salt (sodium). It confirmed that lowering the intake of salt did result in a blood pressure reduction of 1 to 4mmHg. Additionally, there appeared to be a risk reduction in those reducing salt consumption (verified by examining urinary excretion of sodium), although this was not statistically significant.

Part of the difficulty in examining these studies is that when the changes are small in nature, it takes a very large amount of participants (which means a lot of money to do the studies) to show a statistically significant difference. For example, for the difference in this study to have reached statistical significance it would have required about 18,000 participants; at which point the apparent benefit may not have even been realized.

What does seem to be important is the method of exposure to high levels of salt intake. Chronic exposure to high sodium intake appears to increase the risk of hypertensive effects. However the direct evidence linking high dietary salt consumption and cardiovascular disease is “weak and inconsistent,” according to Salim Yusuf, DPhil, of McMaster University. Reducing sodium exposure works to lower blood pressure and that is hypothesized to correlate with a reduction in cardiovascular morbidity and mortality. Previous studies have demonstrated that intensive sodium restriction may yield only modest levels of blood pressure reduction, on the order of 1mmHg[ii] . One reason why asking participants to reduce their dietary intake of sodium may not be effective may be a matter of degrees. Only around 5% of our intake of sodium comes from what we add, over 75% of our daily intake of sodium comes in pre-processed, prepackaged and prepared foods. Therein lays the “hidden” danger.

Enter our Grassroots Gourmet™ principles:

• Be Aware and Avoid the Call of The Junk Food/Fast Food Siren- An extraordinary amount of these items are extremely high in sodium, often used as a means of preservative. These items are often meant to be assembled-usually fried in some form-not cooked. This is about as far from freshly prepared and crafted real food as you can get.
• Be Fresh, But No Adultery- Even when shopping to prepare items yourself, be on guard. The prepared and prepackaged items are often very high in sodium, frequently used as preservatives and flavor enhancers. The less adulterated and manipulated your ingredients are when you start the more you can control what does -and what doesn’t- go into your food.

If you want to host your own party of deliciousness, watch your guest list.

 

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[i] (Taylor, Ashton, & Moxham, 2011)

[ii] (Cochrane Database Syst Rev , 2004)

Salty Language

If you have not checked out  July Issue of Basil Magazine, what the heck are you waiting for! Here’s the link to Dr. Mike’s July article to kick off your reading pleasure:

Dr. Mike’s July Basil Magazine Article

What is Good for the Goose…

We have often written and commented in this forum and other venues that what is good for one condition is not always transferable to another. Again, it seems that moderation and common sense in the end bring Science around to what we intuitively seemed to know. But then again, that is perhaps a very viable definition of common sense itself.

Case in point. People with some forms of hypertension respond very well to reductions of sodium, often referred to as “salt” in the public vernacular, with a corresponding decrease in their elevated blood pressure readings. The question then, is a sodium restricted, or “low-salt” diet a better choice for everyone? The conventional medical wisdom would say “Yes.” Common sense would say sodium is a needed essential mineral and if we watch our total consumption (as over 75% of daily sodium intake comes from the pre-packaged, prepared and processed food sources) by employing our Grassroots Gourmet philosophy of Be Fresh and Being Aware (and avoiding the junk food/fast food) we can enjoy perfectly seasoned food without resorting to salt substitutes or permanent residence in the Land of The Bland.

A recent study performed in Europe for the European Project on Genes in Hypertension (EPOGH) Investigators looked at this very question. They looked to see if a reduction in salt intake would reduce the number of cardiovascular events. They looked at over 3500 participants prospectively. They were followed for a median of almost 8 years. The investigators looked at the urinary excretion of sodium as a measure of sodium intake; the more you take in the more you pee out. The highest death rate was those with the lowest excretion of sodium and the lowest death rate in those with the highest sodium excretion. The greatest mortality rate was in those consuming the diet lowest in sodium, or “salt.” Sodium excretion did not predict cardiovascular events, although there was an association between higher sodium intake (as measured by excretion) and an increase of 1.71mm Hg per 100mmol sodium increase on the systolic (top number) of the blood pressure¹.

So follow the Path of The Grassroots Gourmet, one of common sense and moderation, and you, too, can achieve Healthy AND Delicious. What is Life, if not a little salty?

 

 

 

1.Katarzyna Stolarz-Skrzypek, MD, PhD; Tatiana Kuznetsova, MD, PhD; Lutgarde Thijs, MSc; Valérie Tikhonoff, MD, PhD;Jitka Seidlerová, MD, PhD; Tom Richart, MD; Yu Jin, MD; Agnieszka Olszanecka, MD, PhD; Sofia Malyutina, MD, PhD; Edoardo Casiglia, MD, PhD;Jan Filipovský, MD, PhD; Kalina Kawecka-Jaszcz, MD, PhD; Yuri Nikitin, MD, PhD; Jan A. Staessen, MD, PhD. Fatal and Nonfatal Outcomes, Incidence of Hypertension, and Blood Pressure Changes in Relation to Urinary Sodium Excretion.JAMA. 2011;305(17):1777-1785

 

Cut salt by half, says American Heart Association

 So says a recent newspaper headline; and we’ve been down this road before. In fact, I am still very often asked, “how do I reduce my salt intake” by patients, the health conscious and the public in general; especially as they watch me season the food as I prepare it. They wonder aloud about a cardiologist who adds salt to food as he cooks it. Doesn’t less salt mean:

• No added salt when I cook?
• No added salt to my food before I eat?
• I have to use only “salt substitutes”?

The short answer is a definitive “no,” to all of the above. As a brief refresher, what we mean when we use the term “salt” in the vernacular is the amount of sodium we consume. And we currently consume a lot, over 3,000mg per day. However, over 75% of the sodium we consume comes from prepackaged, prepared and processed foodstuffs. It is hidden in monosodium glutamate and other flavor enhancers, in sodium benzoate and other preservatives, in diet sodas and energy drinks to bacon and meals, ready to eat (MREs). So how do we combat the ubiquitous menace? If we follow our Grassroots Gourmet Threefold Path of the Be’s numbers 1 and 2 we are spot on with a winning game plan.

1. Be Aware and Avoid the Junk Food/ Fast Food Siren: This collection of heavily processed offerings waiting to be assembled is a huge source of sodium. Simply avoiding these often calorie rich, nutrient poor offerings will dramatically reduce your sodium intake.
2. Be Fresh-But Don’t Adulterate: If you’re not purchasing your meals already assembled, then obviously you have to prepare it. But to successfully avoid the temptation to grab something quick, easy and pre-done only to buy something premade you heat in a microwave is to slide from the frying pan into the fire. Shelf life is enhanced by the use of preservatives, and these are a huge source of sodium containing compounds. Fresh food tastes great because it is fresh and doesn’t require artificial flavors or boosters-both sources of unwanted sodium. When you shop for choices, don’t be lulled into falling for the promises of highly adulterous choices. Stick to just being Fresh.

If you season the food appropriately as you prepare it, it should not require any additional table salt prior to eating it. That’s about an additional 5% daily sodium reduction. The amount we ingest daily from salt used to season the food as we cook it is only around 6%. Salt added at the table and consumed in the prepared, packaged and processed choices is over 80% of our daily sodium intake. Avoid prepackaged, fast food options; season your food (so it remains delicious) as you prepare it, don’t add salt at the table and start with fresh unadulterated product and you can easily cut your sodium consumption by almost half-without suffering any loss of flavors. Now that’s something worth its weight in salt.