The skeptical cardiologist and his Eternal Fiancee’ have escaped dreary and oceanopenic St. Louis and are spending a week in allegedly sunny and definitely beachy San Diego.
Upon arrival we took in a Farmer’s Market in Little Italy and stumbled into Ironside Fish and Oyster.
Always in search of heart-healthy, unique and local fish dishes, I spotted on the menu a luncheon special of sheepshead fish.
California sheepshead (Semicossyphuspulcher), the existence of which I was previously unaware, turned out to be a fascinating and most delicious fish.
Before I could order it, I had to verify that I wasn’t contributing to the extinction of a species. The IUCN Red List of Threatened species lists the CS as “vulnerable” because:
“The natural history of this species, including its limited geographic range along inshore habitat, the likely increasing interest in the fishery and the currently unsustainable fishing levels (according to the models of Alonzo et al. 2004), together with the difficulties in enforcing existing regulations strongly suggest that this species will continue to decline if stronger protective action is not put into place. “
After learning the CS was vulnerable, I had to make a critical decision: should I eat it before it disappeared, robbing me of a chance to ever taste it, or should I order something that wasn’t vulnerable, thus contributing to the preservation of the continuing biodiversity of the planet. I elected to taste it.
Gender Fluid Fish
Further research revealed that the CS transitions from a reproductively functional female at birth, to a functional male during the course of a lifespan in response to social factors (?reverse Bruce Jenner).
In some sequentially hermaphroditic fish species, animals develop first as male and then switch to female (a condition called protandry), and in others, the individuals develop first as female and then switch to male (protogyny).
Clownfish (as in Finding Nemo) do the opposite of the sheepshead and are protandrous:
This species lives within sea anemones in groups of two large fish and many small fish. The two large fish are the only sexually mature fish and are a male and female breeding pair. All of the smaller fish are male. If the large breeding female is removed, her male mate changes sex to female and the next largest fish in the group rapidly increases in size and takes over the role as the sexually mature male.
While waiting for the vulnerable and sequentially hermaphroditic sheepshead to arrive, I sampled an equally
stupendous and heart-healthy side of cannelloni bean cassoulet. Chock full of Mediterranean diet essentials including kale, beans and mustard seeds, it worked really well as an appetizer.
Do not make the mistake of looking at this youtube video while waiting for your sheepshead entree’ as I did. The disturbing human-like teeth will not be part of your meal.
Finally, the 4 ounces of CS arrived, perfectly prepared a la plancha,
with an accompanying lemon butter sauce that was divine. Although butter is not officially a big part of the Mediterranean diet, frequent readers of the skepcard know that dairy fat does not make you fat or promote heart disease, and is fine (in moderation of course) as part of a heart-healthy diet.
Speaking of lingering bad dietary advice, if you investigate the nutritional content of sheepshead at a site like SELF Nutrition, the old canard that we should be limiting our dietary cholesterol raises its ugly head. Because sheepshead contain significant amounts of cholesterol (presumably from carnivorously munching on shellfish with its scary human-like choppers), the misguided nutritionists at SELF Nutrition and other would-be nutritionistas pronounce it as not optimally healthy.
PS. If you’d really like to get your nerd on about sequential hermaphroditism check out this graphic showing the independent evolution of this feature across different phylogenetic lineages!
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: Theliterature 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.
The two recent articles supporting full fat dairy are:
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
When individuals discover that they have abnormal cholesterol readings they are often told to initiate lifestyle changes to try to correct them.
Based on what physicians and patients have been taught over the last twenty years, the likely dietary change recommended and the easy , first step is likely to be to cut back on dairy fat.
After all, it’s a pretty easy transition to start using skim milk and non fat yogurt because these line the supermarket shelves and have been filled with chocolate or added sugar to taste more palatable.
You might miss the great taste that butter adds to bread or cooking but for your health you would be willing to switch to non butter spreads and cut down on the cheese in your diet because based on what you have heard from numerous media sources this is a giant step toward reducing your cholesterol numbers.
Unfortunately, it is a horribly misguided step.
Although, the switch to low or non fat dairy lowers your cholesterol numbers, it is not lower cholesterol numbers that you want: what you want is a lower risk of developing stroke or heart attack or the other complications of atherosclerosis.
Let me repeat: Don’t worry about your cholesterol numbers, worry about your overall risk of developing heart attack or stroke.
Due to 30 years of misinformation, the concept that lowering your cholesterol means lower risk of heart disease has become firmly entrenched in the public’s consciousness-but in the case of dietary intervention this has never been documented.
I take care of a 69 year old woman who has an abnormal heart rhythm and chest pain. As part of her evaluation for chest pain we performed a coronary CT angiogram (CCTA) which showed advanced but not obstructive atherosclerotic plaque in her right and left anterior descending coronary arteries.
This lady was not overweight, followed a healthy diet and exercised regularly. Her mother, a sedentary, heavy smoker, suffered a heart attack at age 54.
Her PCP had obtained lipid values on her 6 months before I saw her which were abnormal but the patient had been reluctant to start the recommended statin drug because of concerns about side effects.
After seeing her CCTA I advised that she begin atorvastastin 10 mg daily and aspirin to help reduce her long term risk of heart attack, stroke.
She decided without telling me not to take the statin, again due to side effect concerns, but started the aspirin, and began to pursue what she felt were healthy dietary changes.
When I saw her back in the office she told me “I don’t eat butter or cheese anymore and I’ve switched to skim milk.” She had substituted olive oil for butter.
Here are her lipid values before and after her dietary changes (TC=total cholesterol, LDL= bad cholesterol, HDL=good cholesterol, trigs=triglycerides)
Date TC LDL HDL trigs ASCVd 10 year risk
3/2015 275 173 72 149 7.9%
10/2015 220 122 43 274 8.3%
At first glance, and especially if we focus only on the total and bad cholesterol, this appears to be a successful response to dietary changes: a 29% reduction in the bad cholesterol and a 25% drop in the total cholesterol.
However, although the LDL or bad cholesterol has dropped a lot, the HDL or good cholesterol has dropped by more: 40%!
This is the typical change when patients cut out dairy fat-the overall ratio of bad to good cholesterol actually rises.
In addition, the pattern she has now, with a low HDL and high triglycerides is typical of the metabolic syndrome which is recognized as likely to contribute to early atherosclerosis: so-called “atherogenic dyslipidemia.”
When I plugged both sets of numbers into the ASCVD 10 year risk calculator app (see here) her estimated 10 year risk of heart attack and stroke had actually increased from 7.9% to 8.3%.
Hopefully, this anecdote will reinforce what population studies show:
There is NO evidence that dairy fat consumption increases risk of cardiovascular disease (see here)
Finally, my patient is another example of an inherited tendency to development of premature atherosclerosis: her diet, exercise, body weight were all optimal and could not be tweaked to lower her risk.
Such patients must deal with the cardiovascular cards they have been dealt. If they have advanced atherosclerosis, as much as they may dislike taking medications, statins are by far the most effective means of reducing their long term risk of heart attack and stroke.
Although most nutritional authorities are now admitting that reducing saturated fat consumption by substituting carbohydrates was really bad advice, they, for the most part, are still sticking to the overall concept of limiting all saturated fats to <10% of daily calories and substituting “healthy” polyunsaturated fats for “unhealthy” saturated fats whenever possible.
The recommendation to limit intake of calories from saturated fats to less than 10 percent per day is a target based on evidence that replacing saturated fats with unsaturated fats is associated with reduced risk of cardiovascular disease. The limit on calories from saturated fats is not a UL set by the IOM. For most calorie levels, there are not enough calories available after meeting food group needs to consume 10 percent of calories from added sugars and 10 percent of calories from saturated fats and still stay within calorie limits.
Recommendations to limit saturated fatty acids (SFAs) to <10% of calories persist, despite a spate of recent meta-analyses showing no relationship between saturated fat consumption and coronary heart disease (CHD, also known as ischemic heart disease (IHD)).
In addition, it should be abundantly clear by now that not all SFAs behave the same with respect to our lipids or our IHD risk.
Wide Variety Of Saturated Fats
Most SFAs come from animal origins, including meat and dairy products. The types of SFAs differ markedly between meat and dairy products; the associated nutrients and their interaction with SFAs also differs widely and all of this is likely to affect the risk of IHD.
For example, in the MESA (Multi-Ethnic Study of Atherosclerosis) study, each 5-g/d intake of dairy SFAs was associated with a 16% lower risk of IHD, whereas each 5-g/d intake of meat SFAs was related to a 29% higher risk of IHD.
Despite this, current guidelines continue to repeat the unsubstantiated recommendation to consume low fat dairy over full fat dairy.
Lower Risk Of Heart Disease With Dairy Saturated Fats
This study found that higher intakes of SFA in 35,597 Dutch men and women were associated with lower risks of ischemic heart disease (IHD).
In other words, the more SFA the Dutch eat, the less their chance of having a heart attack.
And, the association “did not depend on the substituting macronutrient.” Those who ate less saturated fats and more “healthy” polyunsaturated fats did no better than those who substituted carbohydrates.
The association was dependent “on the chain length and food source of SFAs.”
The authors noted that the lower risk of IHD was driven by consumption of:
short-to-medium chain SFAs (myristic acid, the sum of pentadeclyic and margaric acids, and SFAs from dairy sources including butter, cheese, and milk and milk products.
Skeptics amongst my readers might think that this study was funded by the dairy industry, but as Marion Nestle pointed out on her Food Politics blog, support came from Unilever, who would have a vested interest in promoting their low saturated fat/high polyunsaturated fat margarines as substitutes for butter fat. This is only one of 11 industry-funded studies with findings different from what the sponsors would have liked, versus 105 studies with findings supporting products of the sponsors (since Marion has been tracking such studies).
It’s likely that some saturated fats, especially when eaten immoderately, without an otherwise balanced and diverse diet, can increase your risk of heart disease.
However, the saturated fats that come from dairy products are clearly not contributing to heart disease risk or obesity and our nutritional guidelines should recommend full fat dairy, not low fat or non fat products that require addition of added sugar to maintain palatability.
The 2015-2020 Dietary Guidelines for Americans (DGA) have finally been released and I’m sure that most of you could care less what they say. You may think that they can’t be trusted because you believe the original science-based recommendations have been altered by political, food and agribusiness forces. Perhaps you don’t trust science to guide us in food choices. Perhaps, like the skeptical cardiologist, you realize that the DGA has created, in the past, more problems than they have corrected.
This time, the skeptical cardiologist believes they have made a few strides forward, but suffer from an ongoing need to continue to vilify all saturated fats.
As such, the DGA no longer lists a recommended limit on daily cholesterol consumption (step forward) but persists in a recommendation to switch from full fat to non fat or low fat dairy products, which is totally unsubstantiated by science, (see my multiple posts on this topic here).
By now you should have gotten the message that a healthy diet consists of lots of fruits, vegetables, nuts, legumes, fish, olive oil and whole grains. The DGA emphasizes this.
There is general consensus that processed foods and added sugar should be limited.
Most of the controversy is about what to limit and how much to limit foods that are considered unhealthy.
Red meat and processed meat remain in the crosshairs of the DGA (although not stated explicitly), but eggs and cholesterol have gotten a pass, something which represents a significant change for the DGA and which I have strongly advocated (here and here).
But hold on, my professional organization, the American College of Cardiology says otherwise.
Misleading Information From the American College of Cardiology
The American College of Cardiology sent me an email and posted on their website the following horribly misleading title:
The first paragraph of the ACC post reads as follows:
“Physiological and structural functions of the body do not require additional intake of dietary cholesterol according to the 2015 Dietary Guidelines released on Jan. 7 by the U.S. Departments of Health and Human Services (HHS) and of Agriculture (USDA). As such, people should practice healthy eating patterns consuming as little dietary cholesterol as possible. – ”
While technically these statements can be found in the document (by digging way down) the executive summary (infographic below) says nothing about limiting cholesterol.
The “Key Recommendations” list eggs as included under a “healthy eating pattern” along with other protein foods.
In addition, there is no mention of cholesterol under what a healthy pattern limits.
In the same section on cholesterol that the ACC inexplicably has chosen to emphasize, is this sentence:
“More research is needed regarding the dose-response relationship between dietary cholesterol and blood cholesterol levels. Adequate evidence is not available for a quantitative limit for dietary cholesterol specific to the Dietary Guidelines.”
So the DGA recommends no specific limit on dietary cholesterol.
This is consistent with what the DG advisory committee recommended when they wrote “dietary cholesterol is no longer a nutrient of concern.”
The DGA goes on to state:
“A few foods, notably egg yolks and some shellfish, are higher in dietary cholesterol but not saturated fats. Eggs and shellfish can be consumed along with a variety of other choices within and across the subgroup recommendations of the protein foods group.”
The Vegan Agenda
I have a theory on why the ACC went so wildly astray in reporting this information: they are led by a vegan.
The current president of the ACC, Kim Williams, is an evangelical vegan, unrepentant, as this NY times article points out. Apparently, he tries to convert all his patients to the “plant-based diet.”
He is quoted extensively in the ACC blurb on the DGA and is clearly attempting to put a bizarre vegan spin on the new guidelines, ignoring the evidence and the progressive shift from the 2010 guidelines.
Can any information from the ACC be trusted if such basic and important science reporting was so heavily distorted by its President?
No wonder Americans tune out dietary advice: it can so easily be manipulated by those with an agenda.
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.
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.1, 2, 3
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.2, 8 Cheese, a leading source of SFAs, is actually linked to no difference in or reduced risk of coronary heart disease and type 2 diabetes.9, 10 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
"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!
For another viewpoint (?from an SFA enthusiast) and a detailed description of both editorials see Axel Sigurdsson’s excellent post here.
The Paleo diet (primal/evolutionary) has become very popular in the last few years. Followers believe they are eating the way our stone age, or paleolithic, ancestors ate. Since our genes have not had time to evolve to match the drastic change in diet that occurred with the agricultural revolution, they argue, modern diets are making us sick and contributing to most of our chronic Western disease like atherosclerosis, diabetes and dementia.
True experts in evolutionary science have questioned most of the theoretical underpinnings of the Paleo movement. Marlene Zuk, an evolutionary biologist, has written an excellent critique in her recently published book “Paleofantasies: What Evolution Really Tells Us About Sex, Diet and How We Live.”
Dr. Zuk points out that there likely was no one single hunter-gatherer diet and that we have a very limited understanding of exactly what that diet consisted of. She also makes the point that this concept that at some point in the past, humans were perfectly adapted to their environment, is not true.
The Milk Paleofantasy
Although the Paleo movement is not monolithic on the topic, some of its leading figures are vehemently opposed to milk consumption.
For example, Loren Cordain (whose web site states that he is “widely acknowledged as one of the world’s leading experts on the natural human diet of our Stone Age ancestors”), has nothing but bad things to say about dairy and milk consumption. Cordain has a Ph.D in “health” and is quite a prolific author, having written “The Paleo Cure For Acne” (spoiler alert: the cure involves not drinking milk).
One major problem with the paleo concept of diet is the assumption that our genetic makeup has not changed or evolved over the last 10000 years.
It turns out that we are not stuck with the same genome of our caveman ancestors and that our ability to tolerate milk confirms this.
The Evolution of Lactose Tolerance
The main sugar in milk from all mammals is lactose. The ability to digest lactose depends on having the enzyme lactase present in the lining of the intestinal tract. All mammals at birth have lactase, but as they age, lactase production is reduced by around 90%. This loss of lactase leads to lactose intolerance.
Lactose that is not digested ends up being fermented by bacteria in the large intestines. This fermentation produces methane, hydrogen gases and other by-products, resulting in bloating, abdominal pain, and diarrhea.
Around 10-20,000 years ago, a mutation in the gene that controls production of lactase resulted in lactase persistence. Some of our paleolithic ancestors began noticing that they were lactose tolerant and could drink the milk of cattle that they had domesticated.
As Zuk writes:
Beginning about 7000 years ago, DNA studies of ancient bones reveal that there was a progressive increase in the frequency of lactase persistence. Increase in a genes frequency tends to correspond with a survival advantage suggesting that the ability to consume dairy prolonged lives.
Lactase persistence is present only in about 35% of the world’s population. It is common in Scandinavia and parts of Africa and the Middle East and about 90% of Americans have it.
The rapid increase in the dominant gene for lactase persistence in humans suggests that the Paleo concept of a genome stuck in the stone age is incorrect.
Stumbling onto a heart-healthy diet using Paleofantasies
Despite the lack of scientific support for the basic theories underpinning the movement, I do think the Paleo diet has some good points. For the most part, this is going to be a low-carb diet. Other areas I can agree with them on are:
Since I’ve been utilizing coronary calcium CT scans to detect early atherosclerotic plaque (see here) in my patients, I have frequently been asked about the relationship between calcium supplements and heart attack risk.
For example, Mrs. Jones has just found out that she has a very high calcium score and that it reflects the amount of atherosclerotic plaque lining and potentially clogging the coronary arteries to her heart. She has also been taking calcium and Vitamin D supplements recommended to her to prevent bone thinning and fractures in the future.
Did all that extra calcium she was consuming end up depositing in her coronary arteries, thus increasing her risk of heart disease?
This is a complex and not fully settled issue, however, there is enough evidence to suggest that we be cautious about calcium supplements.
A recent meta-analysis (Bolland MJ, Avenell A, Baron JA, Grey A, MacLennan GS, Gamble GD, et al. Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis. BMJ 2010;341:c3691) of cardiovascular events in randomized, placebo controlled trials of calcium supplements (without vitamin D co-administration) showed that calcium supplements significantly increased the risk of myocardial infarction by 31% in five trials involving 8151 participants.
A recent meta-analysis of trials involving calcium and Vitamin D supplements found a similar increased risk of cardiovascular disease in the subjects randomized to taking calcium and Vitamin D.
These authors concluded
“in our analysis, treating 1000 patients with calcium or calcium and vitamin D for five years would cause an additional six myocardial infarctions or strokes (number needed to harm of 178) and prevent only three fractures (number needed to treat of 302”
How Might Calcium Supplements Increase Cardiovascular Risks?
Calcium supplements acutely and chronically increase serum calcium concentration. Higher calcium levels are associated with more carotid artery plaque, aortic calcification, and a higher incidence of heart attack and death.
Just like atherosclerosis, the process of calcium deposition into the arteries is very complex. Higher calcium levels could alter certain regulators of the process, such as fetuin A, pyrophosphate and bone morphogenic protein-7 or bind to calcium receptors on vascular smooth muscle cells lining the arteries
Higher calcium levels may also promote clot formation.
Bone Fracture versus Heart Attack
The informed doctor would have to tell Mrs. Jones that her calcium supplements may have contributed to her advanced coronary calcium and raised her risk of heart attack and stroke.
As with all medications, she and her doctor are going to have to discuss the relative risks and benefits.
If she has great concerns about fractures and has very low bone mineral bone density (osteoporosis) along with no family history of premature heart disease then the calcium supplementation may be appropriate.
Conversely, if she has high risk factors for coronary heart disease and/or a strong family history of premature coronary heart disease and only slightly low bone mineral density, avoiding the calcium supplements would be appropriate.
Preventing Fractures and Heart Attacks
It’s best to get calcium from the foods we eat rather than a sudden concentrated load of a supplement. Full fat dairy products like yogurt and cheese are heart healthy (see here and here) and they are an excellent source of calcium.
Weight-bearing exercise (such as running/jogging/hiking) and strength-building exercise (lifting weights, resistance machines, etc.) are also important for strengthening bones.
Thus, eating full fat dairy and aerobic exercise will help prevent both a fracture and a heart attack.
Greek Yogurt sales have skyrocketed in the last five years by 2500%, driven by a perception that it is a “natural” food, healthier than regular yogurt. Plastic bins of Oikos, Fage or Chobani Greek Yogurt are dominating supermarket dairy section shelves.
The doctor’s lounge refrigerator still has excluisvely Yoplait non fat yogurt which I have written about here and compared to a Snickers bar here.
Greek Yogurt typically costs twice as much as regular yogurt but affluent women are choosing it because when the natural dairy fat is removed from the milk it is high in protein, very low in fat, convenient and (apparently) tastes good.
What makes a yogurt Greek?
Traditionally Greek yogurt is made by straining regular yogurt through a t-shirt or cheese cloth for a few hours thus separating out the liquid whey component. The whey contains the milk sugar, lactose, and the whey protein and is acidic. The resulting yogurt is thicker, has less lactose and a higher protein content.
There are no regulations requiring that yogurt labeled Greek yogurt be created in this way and some yogurt makers have utilized the wonders of food processing and technology to add certain thickeners (powdered protein or starch) to regular yogurt , mimicking Greek yogurt and labeling it as such.
You can make Greek yogurt yourself by straining it in a refrigerator for a few hours. You’ll find the liquid whey in the bowl below the strainer. The large manufacturers of Greek Yogurt, Fage and Chobani in their large factories in upstate New York are creating so much Greek yogurt they have a problem disposing of the acidic whey . Ultimately, Chobani has begun paying farmers to take the whey and it is fed to livestock.
Chobani Greek Yogurt: How Matters.
Chobani has become the #1 American Greek yogurt by convincing Americans it is the most natural and healthiest. Chobani’s marketing campaign for its 100 calorie products featured messages on the bottom of the aluminum tops one of which stated “Nature got us to 100 calories, not scientists. #howmatters.” When Piper Klemm, a food scientist read this and tweeted a picture of the lid there was a backlash from scientists which ultimately resulted in Chobani apologizing.
One science writer pointed out in detail the contributions of science to all of the ingredients in the Chobani Cherry product including chicory root fiber which is “largely inulin, a polysaccharide that is only partially digested in the human body. It behaves as a soluble fiber and allows the “5 g of fiber” claim on the label”. Other components which owe their origin to science more than nature are “natural flavors” (various compounds extracted from a plant and blended by a flavorist to resemble cherry flavor), and locust bean gum, a “polysaccharide thickener extracted from the seeds of the carob tree”.
It turns out there is a lot of food processing and technology going into Chobani all natural Greek yogurt. In fact, Chobani’s plant in New York was chosen as Food Engineering’s 2013 Plant of the Year. One of the components of that plant is a “separator” manufactured by Westfalia which uses a centrifuge to separate the whey from the yogurt, thus the process of creating Chobani greek yogurt does not involve “straining” the whey from the yogurt in the traditional manner.
Chobani is also disingenuous in its labeling, attempting to hide added sugar by calling it evaporated cane juice. The New York Post reported in June that two separate class action lawsuits were filed against Chobani and Fage for “Defendants purposefully misrepresented and continue to misrepresent to consumers that their products contain ‘evaporated cane juice’ even though ‘evaporated cane juice’ is not ‘juice’ at all – it is nothing more than sugar dressed up to sound like a healthier sweetener,”
Whole Foods Market, Inc. earlier this year said it will stop selling Chobani Inc. yogurt by early next year to make more room for smaller, exclusive brands, especially those that are organic, or don’t contain genetically modified ingredients.
Greek Yogurt: Extensively Processed To Appear Healthy and Natural
If you can find a Greek Yogurt on your supermarket shelves that hasn’t gone through extensive engineering manipulation to remove the healthy dairy fat and has not had a lot of sugar added back then it should make a fine addition to your diet.
Unfortunately the vast majority of Greek Yogurt sold in the U.S. is non or low fat and is made palatable by adding lots of sugar.
I agree with Chobani that how matters when it comes to yogurt. The less processing, the better when it comes to how food is produced and I choose yogurt made very simply from organic, grass-fed cow milk plus live cultures like that from Trader’s Point Creamery (which is, by the way, on the shelves of Whole Foods in both St. Louis and Atlanta)!
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)