OCTOBER 29, 2008

The Naked Emperor and Saturated Fats, by David Diamond

A guest post

The misinformation about saturated fat, cholesterol and heart disease, the so-called "heart-diet" connection, reminds me of the story about the emperor's new, but nonexistent, clothes. An emperor hires tailors who promise to make him a set of remarkable new clothes, but they say the clothes will be invisible to anyone who is incompetent or stupid. When the emperor goes to see his new clothes, he sees nothing at all, for the tailors are swindlers and there aren't any clothes. Afraid of being judged incompetent or stupid, the emperor pretends to be delighted with the new clothes and "wears" them in a grand parade through the town. Everyone pretends to see the clothes, until a child yells out, "He hasn't got any clothes on!"

In the heart-diet story, those playing the role of the tailors who have misled people on saturated fats and cholesterol are a mixed bunch, including sincere but misguided clinician scientists, less than sincere scientists provided funding by big pharma, and other big businesses, such as cereal companies (eat Cheerios to lower your cholesterol by 4 points, as if that mattered). Other tailors include the government, which has misinformed the public with low saturated fat guidelines, and big pharma-written "NIH" guidelines about desirable LDL/HDL levels, to be achieved largely through statins.

The role of the villagers who pretend to see the clothes in the contrived heart-diet story is played by MDs and the rest of the public, which have been misled by decades of govt and drug company sponsorship of misinformation about meat, eggs, cholesterol and saturated fat. Unfortunately, in the heart-diet fable, the nakedness of the emperor is not so apparent. The MDs and the public see the king as fully clothed because decades of misinformation have tainted their view of healthy vs unhealthy foods (remarkable, isn't it, that the French with their diet high in saturated fats have such great health and low incidence of obesity compared to the US; somehow a glass of wine a day reverses the toxicity of the French diet).

The role of the child who speaks out against the crowd is played by numerous brilliant, sincere, informed MDs, PhDs and science writers who have pleaded with the public to learn about the research which has demonstrated that people need not fear saturated fats and cholesterol. These writers and scientists have scoured the research on diet and health to provide convincing evidence that we should fear polyunsaturated fats more than saturated fats (corn oil will kill you far more efficiently than butter), as well as the real villains: partially hydrogenated fats, refined sugar, obesity and a sedentary lifestyle.

I can't begin to cover the vast amount of research on this topic here, and there is no need for me to do so. There are thoroughly researched books and articles written by MDs, Ph.D.s and science writers on the topic who have eloquently described the science, business and politics behind our sad state of nutritional misinformation.

For anyone interested in truly learning about diet and health, I urge you to begin by reading articles by Ravnskov, The questionable role of saturated and polyunsaturated fatty acids in cardiovascular disease, J. Clin. Epidemiol. 1998:51 (6), 443-460, and Colpo, LDL Cholesterol: "Bad" Cholesterol or Bad Science?, J. Amer. Physicians and Surgeons, 2005:10 (3) 83-89.

And read the books below, and visit the following web site for unbiased (i.e., unsupported by industry) information.

Some of the books that I have read on the topic and recommend:

The only thing I can add which I found myself is that the NIH guidelines given to cardiologists regarding aggressive reduction of LDL levels come in part from this document, which seems impressive: however, it is only at a separate web link that you find out that 8 of the 9 authors of the paper received massive funding from big pharma: This conflict of interest should’ve been provided in the original document. Moreover, in an independent analysis of the same data, Hayward et al (Ann.Intern.Med., 145, 520-530, 2007), who were funded only by the Veterans Administration, concluded that:

current clinical evidence does not demonstrate that titrating lipid therapy to achieve proposed low LDL cholesterol levels is beneficial or safe.

Whereas the guidelines written for NIH by big pharma to lower LDL levels aggressively with statins were met with press releases to the medical community, Hayward et al's much more careful analysis has largely been ignored; the villagers aren't being told the king is naked.

To your health...

David Diamond

To comment on this blog please write to jamesdouglasbremner@yahoo.com and indicate whether comments are public or private. If you click on the comment link your comments will get truncated after a couple of sentences (sorry).

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COMMENTS

Doug Bremner wrote on October 29, 2008

Thanks, David. I have read the article from the VA researchers on the lack of correlation between LDL concentrations and heart disease outcomes and cited them in my book, although I haven't read these books on saturated fats. I always find it fascinating how some ideas seem to take on a life of their own, perpetuated by the media. In fact, Charles Hugh Smith wrote about that topic today on his blog.

Some books on related topics of nutrition that offer more evidence that food corporations are driving popular perceptions about nutrition that are not always in our best interest include Marion Nestle, Food Politics; Michael Pollan, In Defense of Food, Omnivore's Dilemma, and Botany of Desire.

Finally, a reader forwarded this interesting article by Michael Pollan entitled Farmer in Chief, an Open Letter to the Next President Elect about how politicians should pay more attention to the looming issue of food and how we produce it.

Marilyn Mann wrote on November 2, 2008

Hi Doug, here is a comment on the post by David Diamond. Thanks.

First, no one is saying that elevated LDL is the only risk factor for heart disease. It is one of many. But if Diamond is saying it is not a risk factor at all, I would have to disagree. The epidemiological evidence linking LDL levels to risk for heart disease is pretty extensive. In addition, many (although not all) interventions that lower LDL have resulted in a lower risk for heart disease, making it unlikely that statins achieve their benefits solely through pleiotropic effects (i.e., effects unrelated to lowering LDL).

I looked at Uffe Ravnskov's book and soon realized that he cherry-picks and distorts the evidence. Ravnskov is a member of The International Network of Cholesterol Skeptics (THINCS) -- you can check out their website www.thincs.org. Harriet Hall on the Science-Based Medicine blog has written about them.

http://www.sciencebasedmedicine.org/?p=219

http://www.sciencebasedmedicine.org/?p=22

Among other things, I have yet to hear people who deny any connection between LDL levels and heart disease explain the very high rate of early heart attacks in people with heterozygous or homozygous familial hypercholesterolemia. For example, my husband has FH in his family and his family history is as follows: mother: nonfatal heart attack at 58maternal uncle: fatal heart attack at 40maternal grandfather: fatal heart attack at 35

Familial hypercholesterolemia is caused by a number of genetic mutations, the most common type being defects in the gene that codes the LDL receptor. The LDL receptors are responsible for removing LDL from the body, so when they do not function well LDL builds up. People with heterozygous FH usually have LDL levels 2-3 times normal. Granted, not all people with heFH have early heart attacks, but without treatment their risk is many times normal. Fortunately, if treatment with statins is started early enough the risk is drastically reduced

Diamond's attack on the traditional low-fat diet seems a bit of a straw man now that so many people in mainstream medicine are recognizing the benefits of the Mediterranean diet. I really have no opinion on whether eating lots of saturated fat increases the risk of heart disease in humans. That kind of question is very difficult to prove or disprove.

Oh, by the way, I occasionally correspond with Rod Hayward, and I've read the article Diamond quoted. Hayward is not saying there is no evidence for lowering LDL with statins. He just is saying there is no evidence for using specific LDL targets, e.g., 100, 70, etc., to titrate statin dose. In addition, he believes in incorporating lipid levels into the initial assessment of cardiovascular risk, along with other risk factors. All he is saying is that once you have estimated someone's risk (e.g., 10% or whatever) you should not worry about what LDL levels you achieve, or at least there is no evidence that aiming for particular targets results in better outcomes, as compared to just using the particular doses that were used in clinical trials.

David Diamond wrote on November 7, 2008

Marilyn, Point #1

no one is saying that elevated LDL is the only risk factor for heart disease. It is one of many. But if Diamond is saying it is not a risk factor at all, I would have to disagree. The epidemiological evidence linking LDL levels to risk for heart disease is pretty extensive.

My response:

Marilyn didn't read my comments closely enough. I didn't say that LDL is not a risk factor for heart disease. With all due respect to our blogmaster, it was Doug, not I, who wrote that there was a lack of correlation between LDL and heart disease.

Marilyn, Point #2

many (although not all) interventions that lower LDL have resulted in a lower risk for heart disease, making it unlikely that statins achieve their benefits solely through pleiotropic effects (i.e., effects unrelated to lowering LDL).

DD:

The basis of Marilyn’s point is the widespread misconception that LDL is "bad" cholesterol, and it's levels need to be reduced through the use of statins, or any other means, to have better heart health. The simplistic idea that LDL cholesterol is "bad" and HDL is "good" for your heart is just plain wrong; but there is a twist to the LDL story that explains why there's some evidence that LDL reduction correlates with a reduced incidence of heart disease. A subset of LDL, the oxidized form of LDL (ox-LDL), is, without a doubt, a primary factor in the development of heart disease. Almost 20 years of solid research has conclusively demonstrated that ox-LDL is a critical factor in the pathogenesis of atherosclerosis.

What causes oxidation of LDL? Excessive intake of sugar, polyunsaturated (corn) vegetable oil, stress, sedentary lifestyle, diabetes, high blood pressure, smoking, obesity: all of the villains of modern society which are associated with heart disease increase ox-LDL. Back to the original topic of my commentary, I'm not aware of any evidence that eating meat increases ox-LDL.

How do you reduce ox-LDL?

Exercise, red wine, dark chocolate, nuts, garlic, foods rich in antioxidants; all of the well-known heroes of good heart health reduce ox-LDL. Other impressive work has shown that genistein, an antioxidant, reduces ox-LDL. Genistein is found in soy beans, which may be related to why people who eat soy products, e.g. tofu, have a reduced incidence of cardiovascular disease. The dark chocolate findings are very impressive, with a low incidence of heart disease in people who eat large amounts of cocoa.

The important message is that you don't need to take a drug to nonspecifically lower your LDL levels to protect your heart. The goal should be to reduce the oxidation of your LDL, whatever the total LDL levels are. I would rather reduce my intake of sugar and eat beef, chicken, nuts and exercise instead of taking drugs which muck with my cholesterol.

Why haven't you heard more about ox-LDL, and why don't doctors know about ox-LDL, despite 20 years of research on it? My guess is because big pharma hasn't come up with a drug that blocks oxidation of LDL. Until there's a drug to prescribe, doctors will be kept in the dark by big pharma, and most doctors won’t take it upon themselves to become educated on the topic.

Marilyn, Point #3

I looked at Uffe Ravnskov's book and soon realized that he cherry-picks and distorts the evidence. Ravnskov is a member of The International Network of Cholesterol Skeptics (THINCS); you can check out their website www.thincs.org. Harriet Hall on the Science-Based Medicine blog has written about them.

DD:

Once again, Marilyn isn't addressing the points I made in my commentary.

I provided the THINCS web site and books I had read on this topic because these sources of information provide scientific evidence that meat is not bad for you; that was the primary point of my commentary. To elaborate further, there is evidence that a diet high in sugar, polyunsaturated (vegetable) oil and partially hydrogenated fats, which when accompanied by a sedentary lifestyle and obesity and/or diabetes, is a prescription for a heart attack. It's the french fries, bread and ice cream on your plate that will kill you, not the cheeseburger.

The other books I mentioned are scholarly productions which deserve great respect. For example, Colpo's book is a massive work with over 1000 references and in-depth discussion of every topic related to diet and heart health. Taubes' book has a great historical perspective on how the diseases of modern civilization (such as cancer and heart disease) can be traced to the increased intake of refined sugar, not saturated fat, in the past century.

Marilyn, Point #4

Among other things, I have yet to hear people who deny any connection between LDL levels and heart disease explain the very high rate of early heart attacks in people with heterozygous or homozygous familial hypercholesterolemia. Granted, not all people with heFH have early heart attacks, but without treatment their risk is many times normal. Fortunately, if treatment with statins is started early enough the risk is drastically reduced

DD:

I'm not aware of any scientific evidence that treatment with a statin prolongs life in people with any genetic disorder which produces hypercholesterolemia. I’m also not aware of any evidence that prophylactic treatment of any group of people with a statin prolongs the lives of those treated vs placebo. That is, in a comparison of 5, 10, 20 year mortality rates in people with high cholesterol without heart disease in placebo vs statin treatment – who lives longer? If the study hasn't been done, then you're not justified in saying that a person with heFH has a lower risk of a heart attack with statin treatment.

Marilyn, Point #5

Diamond's attack on the traditional low-fat diet seems a bit of a straw man now that so many people in mainstream medicine are recognizing the benefits of the Mediterranean diet.

DD:

Once again, Marilyn is criticizing issues that I didn't raise. Let's get back to what I actually said. I didn't attack a low fat diet or the Mediterranean diet; I didn’t even mention the Mediterranean diet. If by the Med diet you mean a diet consisting of fruit, vegetables, olive oil, fish and nuts, then that certainly is a fine heart healthy diet. I'm not advocating that you have to eat meat to be healthy.

Let's explore this issue further. My original point was that there isn't good evidence that saturated fat is bad for you. Indeed, the people who live along the Mediterranean have quite a substantial amount of meat in their diet. The creator of the idea of the benefits of the Mediterranean diet, Ancel Keys, happen to visit Italy in the 1950's, when it was in an economic decline after WW II. It was only because of this transient decline in their economy that people were eating less meat. Traditionally, for people in the Mediterranean, including France, meat is a substantial part of their diet, and they enjoy good heart health. Support for this idea was provided in a study of Italian Americans, published in the Journal of the American Medical Association (JAMA) over 40 years ago. These folks ate a real Mediterranean diet, one that was heavy on saturated fat, with lots of beef, lard and butter in their diet. Despite this seemingly heart-unhealthy diet, these people had an abnormally low incidence of heart disease [1]. The lack of heart disease in this group may have been related to their close social support which reduced their stress, and perhaps their low intake of fast food and sugar. Unfortunately, the new generation of Italian Americans has a higher incidence of heart disease, perhaps because they are less socially connected and they eat more fast food and sugar.

Marilyn; Point #6

I really have no opinion on whether eating lots of saturated fat increases the risk of heart disease in humans. That kind of question is very difficult to prove or disprove.

DD:

Actually, no, it's not that difficult to prove. Population studies of people who have a diet high in saturated fat, but low in sugar, show that they have great heart health. As I mentioned above, the group of Italian Americans that ate lots of saturated fats had a low incidence of heart disease. Around the world, groups of people who eat saturated fat, without sugar have excellent heart health. Another example is the Masai of Africa, who subsist primarily on a diet composed of blood, milk and meat, and they have a very low incidence of heart disease. They are not genetically gifted to be protected from heart disease because Masai who eat a traditional Western diet develop heart disease just like everyone else.

One final example is the diet of the Eskimos (Inuit). Traditionally, Eskimos have lived on a diet that is exclusively derived from polar bear meat, sea mammals and fish, and they have had great health. Unfortunately, in recent years Eskimo health has declined as they have become smokers and have adopted a western (sugary) diet.

An interesting study based on the Eskimo diet was published in JAMA in 1929 [2]. This was a time before the great cholesterol scare, which began in the 1950's. In 1929 people were concerned about a high protein diet causing heart disease. The Eskimos, however, ate only meat in their diet – lots of protein and no vegetables, fruit, grains or any other source of carbohydrates, and yet they had no evidence of cardiovascular disease, or any other possible protein diet-related diseases, such as nephritis. The great health of the Eskimos is not explained by a genetic abnormality, as their diet also produced salutary effects on the Icelandic explorers Stefansson and Anderson. Stefansson lived with the Eskimos for 7 years, eating polar bear meat, fish and sea mammal meat.

http://www.thearctic.is/articles/topics/legacystefansson/enska/index.htm

Back in the U.S., Stefansson and Anderson agreed to be studied under controlled conditions; they were studied for 1 year under the guidance and scrutiny of Johns Hopkins University scientists. These two men, for an entire year, ate only meat. Their diet averaged about 2,660 calories/day, with 79% of the calories from fat, 19% of the calories from protein and only 2% of the calories from carbohydrates. The paper describes how their health was stable, their weight changed little, with a slight loss of weight for Stefansson. Many parameters were examined, including blood pressure, cholesterol levels, vitality, teeth, bowels, etc. The only notable finding was that Anderson's progressive hair loss had stopped shortly after his all meat diet had begun, and his hair loss remained in check for the entire year.

A related more recent paper showed that people with food allergies who were put on a long-term meat (beef) only diet developed a dramatic reduction in their cholesterol levels from 263 to 189 mg/dl, and their triglycerides dropped from 113 to 74 mg/dl. [3]

The science clearly indicates that we can dispel with the notion that beef adversely affects heart disease risk factors.

Here's a summary of the primary points I've made in my two contributions:

1: the real dietary villains of good health are intake of simple carbs (sugar, candy, muffins, white bread), partially hydrogenated fats, fried foods and polyunsaturated fats (corn oil).

2: The lifestyle features that are heart unhealthy are unrelieved stress, a lack of exercise, smoking and obesity.

3: and as Doug emphasizes so much in this blog, before you take medication, give it some thought as to whether you really need it, and if there are alternative strategies. Instead of taking drugs to globally reduce LDL, it's better to focus on reducing ox-LDL, by lifestyle changes, such as by reducing stress and exercising, and by diet: enjoy red wine, dark chocolate, nuts, garlic, and in general, eat foods rich in antioxidants.

and don't worry about eating saturated fat; enjoy a meal of steak and eggs!

To your good health

David

(by the way, I have no financial ties to the beef and related industries)

1. Stout,C., Morrow,J., Brandt,E.N., and Wolf,S., Unusually low incidence of death from myocardial infarction; study of an Italian American community in Pennsylvania, JAMA, 188 (1965) 845-847.

2. Lieb,C.W., The effects on human beings of a twelve months' exclusive meat diet, JAMA, 93 (1929) 20-22.

3. Newbold,H.L., Reducing the serum cholesterol level with a diet high in animal fat, South Med. J., 81 (1988) 61-63.

Marilyn Mann wrote on November 8, 2008

On risk reduction with statins in patients with heterozygous familial hypercholesterolemia, see this article:

http://eurheartj.oxfordjournals.org/cgi/content/full/29/21/2625

On oxidized LDL, see the following:

http://jem.rupress.org/cgi/content/abstract/203/4/813

Statins in familial hypercholesterolemia

http://www.bmj.com/cgi/content/abstract/337/nov11_1/a2423?ct

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