Tag Archives: butter

The Bad Food Bible: A Well-Written, Sensible and Science-Based Approach To Diet

The skeptical cardiologist has been searching for some time for a book on diet that he can recommend to his patients. While I can find books which have a lot of useful content, usually the books mix in some totally unsubstantiated advice with which I disagree.

I recently discovered a food/diet/nutrition book which with I almost completely agree. The author is Aaron Carroll,  a pediatrician, blogger on health care research (The incidental Economist) and a Professor of Pediatrics and Associate Dean for Research Mentoring at Indiana University School of Medicine.

He writes a regular column for the New York Times and covers various topics in health care. His articles are interesting,  very well written and researched and he often challenges accepted dogma.

Like the skeptical cardiologist, he approaches his topics from an unbiased perspective and utilizes a good understanding of the scientific technique along with a research background to bring fresh perspective to health-related topics.

Last last year he wrote a column, within which I found the following:

Studies of diets show that many of them succeed at first. But results slow, and often reverse over time. No one diet substantially outperforms another. The evidence does not favor any one greatly over any other.

That has not slowed experts from declaring otherwise. Doctors, weight-loss gurus, personal trainers and bloggers all push radically different opinions about what we should be eating, and why. We should eat the way cave men did. We should avoid gluten completely. We should eat only organic. No dairy. No fats. No meat. These different waves of advice push us in one direction, then another. More often than not, we end up right where we started, but with thinner wallets and thicker waistlines.

I couldn’t agree more with this assessment and as I surveyed the top diet books on Amazon recently, I saw one gimmicky, pseudoscientific  diet after another. From the Whole30 approach (which illogically  completely eliminates any beans and legumes, dairy products,  alcohol, all grains, and starchy vegetables like potatoes (see how absurd this diet is here)) to Dr. Gundry’s Plant Paradox (aka lectin is the new gluten (see here for James Hambling’s wonderful Atlantic article on the huckster’s latest attempt to scare you into buying his useless supplements).

It turns out Carroll published a useful book recently, The Bad Food Bible which critically examines diet and I agree with the vast majority of what is in it.

The first three chapters are on butter, meat, eggs and salt. His conclusions on how we should approach these 4 are similar to ones I have reached and written about on this site (see here for dairy, here for meat, here for eggs and here for salt).  Essentially, the message is that the dangers of these four foods have been exaggerated or nonexistent, and that consuming them in moderation is fine.

The remaining chapters cover topics I have pondered extensively,  but have not written about: including gluten, GMOs, alcohol, coffee, diet-soda and non-organic foods.

I agree with his assessments on these topics. Below, I’ll present his viewpoint along with some of my own thoughts in these areas.

Gluten

Carroll does a good job of providing a scientific, but lay-person friendly background to understanding the infrequent (1 of 141 Americans), but quite serious gluten-related disorder, celiac disease.

However, surveys show that up to one-third of Americans, the vast majority of whom don’t have celiac disease, are seeking “gluten-free” foods, convinced that this is a healthier way of eating. Carroll points out that there is little scientific support for this; there are some individuals who are sensitive to wheat/gluten, but these are rare.

He concludes:

“If you have celiac disease, you need to be on a gluten-free diet. If you have a proven wheat allergy, you need to avoid wheat. But if you think you have gluten sensitivity? You’d probably be better off putting your energy and your dollars toward a different diet. Simply put, most people who think they have gluten sensitivity just don’t.

I do agree with him that the “gluten-free” explosion of foods (gluten-free sales have doubled from 2010 to 2014) is not justified.

However, I must point out that my 92 year old father has recently discovered that he has something that resembles gluten sensitivity. About a year ago, he noted that about one hour after eating a sandwich he would feel very weak and develop abdominal discomfort/bloating. He began suspecting these symptoms were due to the bread and experimented with different bread types without any symptom relief.

Finally, he tried gluten-free bread and the symptoms resolved.

If you have engaged in this type of observation and experimentation on your self, and noted improved symptoms when not consuming gluten, then I think you’re justified in diagnosing gluten sensitivity, and by all means consider minimizing/avoiding wheat.

GMOS

Carroll begins his chapter on genetically modified organisms (GMOs) with a description of the droughts that plagued India in the 1960s and the efforts of Norman Borlaug to breed strains of wheat that were resistant to fungus and yielded more grain. By crossbreeding various strains of wheat he was able to develop a “semi-dwarf” strain that increased what was produced in Mexico by six-fold.

Despite the fact that numerous scientific and health organizations around the world have examined the evidence regarding the safety of genetically modified organisms (GMOs) and found them to be completely safe, there remains a public controversy on this topic. In fact a Pew Poll found that while 88% of AAAS scientists believe that GMOs are safe for human consumption, only 37% of the public do – a 51% gap, the largest in the survey.

This gap is largely due to an aggressive anti-GMO propaganda campaign by certain environmental groups and the organic food industry, a competitor which stands to profit from anti-GMO sentiments. There is also a certain amount of generic discomfort with a new and complex technology involving our food.

The National Academy of Sciences analyzed in detail the health effects of GMOs in 2016. Their report concludes:

While recognizing the inherent difficulty of detecting subtle or long-term effects in health or the environment, the study committee found no substantiated evidence of a difference in risks to human health between currently commercialized genetically engi-neered (GE) crops and conventionally bred crops, nor did it find conclusive cause-and-effect evidence of environmental problems from the GE crops. GE crops have generally had favorable economic outcomes for producers in early years of adoption, but enduring and widespread gains will depend on institutional support and access to profitable local and global markets, especially for resource-poor farmers

Carroll does a good job of looking at the GMO issue from all sides. He touches on environmental downsides related to herbicide-resistant GMO crops and the problems created by patenting GMO seeds, but asserts that “these are the result of imperfect farming and the laws that regular agribusiness, not of GMOS themselves.”

Ultimately, despite these concerns, I agree with Carroll’s conclusion that:

“Foods that contain GMOs aren’t inherently unhealthy, any more are  than foods that don’t contain them. The companies that are trying to see you foods by declaring them ‘GMO-free” are using the absence of GMOs to their advantage–not yours.”

Alcohol, Coffee, and Diet-Soda

Carroll does a good job of summarizing and analyzing the research for these three topics and reaches the same conclusions I have reached in regard to coffee, alcohol and diet-soda:

-alcohol in moderation lowers your risk of  dying, primarily by reducing cardiovascular death

-coffee, although widely perceived as unhealthy, is actually good for the vast majority of people

For those seeking more details a few quotes


on alcohol:

“Taken together, all of this evidence points to a few conclusions. First, the majority of the research suggests that moderate alcohol consumption is associated with decreased rates of cardiovascular disease, diabetes, and death. Second, it also seems to be associated with increased rates of some cancers (especially breast cancer), cirrhosis, chronic pancreatitis, and accidents, although this negative impact from alcohol seems to be smaller than its positive impact on cardiovascular health. Indeed, the gains in cardiovascular disease seem to outweigh the losses in all the other diseases combined. The most recent report of the USDA Scientific Advisory Panel agrees that “moderate alcohol consumption can be incorporated into the calorie limits of most healthy eating patterns.”

Keep in mind that moderate consumption is up to one drink per day for women, and two drinks for men (my apologies to women in general and the Eternal Fiancee’ of the Skeptical Cardiologist in particular) and be aware of what constitutes “one drink.”

Also keep in mind that any alcohol consumption raises the risk of atrial fibrillation (see here) and that if you have a cardiomyopathy caused by alcohol you should avoid it altogether.


on coffee:

“It’s time people stopped viewing coffee as something to be limited or avoided. It’s a completely reasonable part of a healthy diet, and it appears to have more potential benefits than almost any other beverage we consume.
Coffee is more than my favorite breakfast drink; it’s usually my breakfast, period. And I feel better about that now than ever before. It’s time we started treating coffee as the wonderful elixir it is, not the witch’s brew that C. W. Post made it out to be.”

Strangely enough, coffee is usually my breakfast as well (although I recommend against adding titanium oxide to your morning java).  Why am I not compelled to consume food in the morning?  Because breakfast is not the most important meal of the day and I don’t eat until I’m hungry.


on diet-soda:

Carroll notes that many Americans are convinced that artificial sweeteners are highly toxic:

“no article I’ve written has been met with as much anger and vitriol as the first piece I wrote on this subject for the New York Times, in July 2015, in which I admitted, “My wife and I limit our children’s consumption of soda to around four to five times a week. When we let them have soda, it’s . . . almost always sugar-free.”

He notes, as I have done, that added sugar is the real public enemy number one in our diets. He reviews the scientific studies that look at toxicity of the various artificial sweeteners and finds that they don’t convincingly prove any significant health effects in humans.

Some believe that artificial sweeteners contribute to obesity, but the only evidence supporting this idea comes from observational studies. For many reasons, we should not highly value observational studies but one factor, “reverse causation,” is highly likely to be present in studies of diet sodas. If diet soda consumption is associated with obesity, is it the cause, or do those who are obese tend to drink diet soda. Observational studies cannot answer this question but randomized studies can.

Carroll points out that:

the randomized controlled trials (which are almost always better and can show causality) showed that diet drinks significantly reduced weight, BMI, fat, and waist circumference.”

Simple Rules For Healthy Eating

Carroll concludes with some overall advice for healthy eating:

-Get as much of your nutrition as possible from a variety of completely unprocessed foods

-Eat lightly processed foods less often

-Eat heavily processed foods even less often

-Eat as much home-cooked food as possible, preparing it according to rules 1, 2, and 3

-Use salt and fats, including butter and oil, as needed in food preparation

-When you do eat out, try to eat at restaurants that follow the same rules

-Drink mostly water, but some alcohol, coffee, and other beverages are fine

-Treat all calorie-containing beverages as you would alcohol

-Eat with other people, especially people you care about, as often as possible

These are solid, albeit not shocking or book-selling, rules that  correspond closely to what I have adopted in my own diet.

In comparison to the bizarre advice from nutrition books which dominate the best-selling diet books, I found The Bad Food Bible to be a consistent, well-written, extensively researched, scientifically-based, unbiased guide to diet and can highly recommend it to my readers and patients.

Semibiblically Yours,

-ACP

Are Plant-Based “Milks” The Margarine of the 21st Century?

Full fat dairy doesn’t make you fat or give you heart disease. But nutritional guidelines still continue to recommend the substitution of non-fat or low-fat dairy for full fat, something that flies in the face of an overall movement to consume less processed foods.

The rise of plant-based milks resembles in many ways the rise of margarine as a substitute for butter. In both cases, industry and misguided scientists collaborated to produce an industrial product to substitute for a natural food, based on an unproven projection of health benefits. Subsequent studies have shown that this was an unmitigated health disaster, as the trans fats created in the production of margarine substantially increase the risk of heart disease.

Anti-Dairy Propaganda

Vegan/vegetarian sources of nutritional information like one green planet make unsubstantiated claims about the benefits of plant-based milks and the dangers of traditional milk:

the consumption of dairy products has been linked to everything from increased risk of ovarian and prostate cancers to ear infections and diabetes. Fortunately, plant-based milks provide a convenient and healthful alternative to cow’s milk. And if you are currently making the transition to a dairy-free diet, you will find that going dairy-free has never been easier. Soy, almond, hemp, coconut, and rice milks, among others, are taking over the dairy case—and claiming supermarket aisles all their own.

Growth of Plant-Based “Milks”

In response to consumers desire for healthier alternatives to dairy, non-dairy liquid milk-like substitutes  have been thriving. Almond milk, the current darling of plant-based milks (PMB) , sales have grown 250% in the last 5 years during which time,  the total milk market has shrunk by more  than $1 billion.

In western Europe, sales of almond, coconut, rice and oat milks doubled in the five years to 2014; in Australia they rose threefold, and in North America sales shot up ninefold, according to Euromonitor.

Big global beverage food and drinks companies have been entering the PBM market recognizing that American consumers have become aware of the unhealthiness of sugar-sweetened beverages.

Coca-Cola, for example, recently purchased Unilever’s AdeS soya brand. and believes that PBM consumption will grow faster than any other segment of the beverage industry over the next 5 to 10 years. Coca-Cola also recently purchased the China Green brand of plant-based protein drinks.

What’s in Soy Milk and Why It’s Not Real Food

The plant-based milks are a mixed bag of highly processed liquids. Let’s look at soy milk which has been widely promoted as a healthy substitute for dairy. Empowered Sustenance points out that there is reason to be concerned about all the added ingredients found in Silk, a popular soy milk.

Soymilk (Filtered Water, Whole Soybeans), Cane Sugar, Sea Salt, Carrageenan, Natural Flavor, Calcium Carbonate, Vitamin A Palmitate, Vitamin D2, Riboflavin (B2), Vitamin B12.

The long list of ingredients give you an idea of how much processing is needed to approximate the nutritional components of real dairy. Whether adding back synthetic Vitamin D2, synthetic Vitamin A and calcium carbonate simulates the nutritional benefits of the naturally occurring vitamins in a naturally fatty milieu, is anyone’s guess.

Variable Nutritional  Content of Plant-Based “Milks”

Bestfoodfacts.org asked 3 academic nutritional PhD’s how they would advise consumers on substituting nondairy “milk:”

Dr. Macrina: Plant-based milks are quite variable in what they contain while cow’s milk is pretty standard. We know where cow’s milk comes from. Plant-based milks are manufactured and can have a variety of additives. I urge consumers to read the label to determine what’s best for them.

Dr. Savaiano: Yes, consumers should read the label very carefully. Plant-based drinks certainly can be a healthy choice depending on how they’re formulated.

Dr. Weaver: The plant-based beverages all cost a good deal more than cow’s milk. So, one needs to determine how much they want to pay for the nutrients and determine which nutrients you need to get from other foods. A main nutrient expected from milk is calcium. Only soy milk has been tested for calcium bioavailability (by my lab) which was determined to be as good as from cow’s milk. But none of the other plant beverages have been tested and they should be.

Is There Scientific Evidence To Support Replacing Milk and Dairy Products with Plant-based Drinks?

A recent review paper from Danish researchers attempted to answer the question:

Milk and dairy products: good or bad for human health? An assessment of the totality of scientific evidence. 

They concluded:

The most recent evidence suggested that intake of milk and dairy products was associated with reduced risk of childhood obesity. In adults, intake of dairy products was shown to improve body composition and facilitate weight loss during energy restriction. In addition, intake of milk and dairy products was associated with a neutral or reduced risk of type 2 diabetes and a reduced risk of cardiovascular disease, particularly stroke. Furthermore, the evidence suggested a beneficial effect of milk and dairy intake on bone mineral density but no association with risk of bone fracture. Among cancers, milk and dairy intake was inversely associated with colorectal cancer, bladder cancer, gastric cancer, and breast cancer, and not associated with risk of pancreatic cancer, ovarian cancer, or lung cancer, while the evidence for prostate cancer risk was inconsistent. Finally, consumption of milk and dairy products was not associated with all-cause mortality.

They went on to examine the question: Is there scientific evidence to substantiate that replacing milk and dairy products with plant-based drinks will improve health?

They noted the marked variation in nutritional content of the plant-based milks:

the nutrient density of plant-based milk substitutes varies considerably between and within types, and their nutritional properties depend on the raw material used, the processing, the fortification with vitamins and minerals, and the addition of other ingredients such as sugar and oil. Soy drink is the only plant-based milk substitute that approximates the protein content of cow’s milk, whereas the protein contents of the drinks based on oat, rice, and almonds are extremely low,

and their similarity to sugar-sweetened beverages:

Despite the fact that most of the plant-based drinks are low in saturated fat and cholesterol, some of these products have higher energy contents than whole milk due to a high content of oil and added sugar.

Some plant-based drinks have a sugar content equal to that of sugar-sweetened beverages, which have been linked to obesity, reduced insulin sensitivity , increased liver, muscle, and visceral fat content as well as increased blood pressure, and increased concentrations of triglyceride and cholesterol in the blood

PBM and real milk also differ with respect to important electrolytes and elements:

Analyses of several commercially available plant-based drinks carried out at the Technical University of Denmark showed a generally higher energy content and lower contents of iodine, potassium, phosphorus, and selenium in the plant-based drinks compared to semi-skimmed milk

and some PBM contain potentially dangerous components:

Also, rice drinks are known to have a high content of inorganic arsenic, and soy drinks are known to contain isoflavones with oestrogen-like effects. Consequently, The Danish Veterinary and Food Administration concluded that the plant-based drinks cannot be recommended as full worthy alternatives to cow’s milk which is consistent with the conclusions drawn by the Swedish National Food Agency

Finally, the authors emphasize the importance of the health effects of whole foods rather than individual nutrients. Plant-based milks are not whole or real foods:

The importance of studying whole foods instead of single nutrients is becoming clear as potential nutrient–nutrient interactions may affect the metabolic response to the whole food compared to its isolated nutrients. As the plant-based drinks have undergone processing and fortification, any health effects of natural soy, rice, oats, and almonds cannot be directly transferred to the drinks, but need to be studied directly.

The Skeptical Cardiologist Recommendation

Consumers should be very cautious in their consumption of plant-based milks. Eerily reminiscent of the push to switch from butter to margarine in the past, these drinks cannot be considered as healthier than dairy products.

They are creations of industry, promoted and produced by large companies like Coca-Cola and Unilever, whose goal is profit, not consumer’s health.

The PBMs are not true whole or real foods and their nutritional content varies wildly. Some resemble sugar-sweetened beverages like Coca-Cola.

If one of the synthetic ingredients added to these beverages turns out to have the markedly negative health effect that trans fats had, the analogy to margarine will be complete.

My  Eternal Fiancee’ has true lactose intolerance and has baristas substitute almond or soy milk when ordering a latte’.  I understand that but I’ve been trying to convince her (with increasing success lately!)  to drink my Chemex pour-over coffee and adulterate it with nothing, butter, cream or coconut oil.

Skeptically Yours,

-ACP

Featured image courtesy of One Green Planet.

For your enjoyment I present a mind-bogglingly complicated table listing the various nutrients in a mind-bogglingly long list of different plant-based milks (including hemp milk!):

 

 

 

What Happens To Cholesterol Levels When You Switch To Low Or Non Fat Dairy

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.

IMG_6135
Yoplait Original-25% Less Sugar.(but still with 18 grams per 6 oz serving). A typical supermarket/doctor’s lounge yogurt with lots of ingredients added in (sugar, modified corn starch, Vitamin A Acetate, Vitamin D3)to replace the natural good taste and nutrients found in dairy fat.
IMG_6272 (1)
Traders Point Creamery plain yogurt. Ingredients= milk and cultures. Taste =fantastic. Grams of sugar=zero.

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)
  • Current recommendations to consume non or low fat dairy (often  accompanied by increase in added sugars) are not supported by scientific studies.

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.

 

 

 

The Skeptical Cardiologist Gives Dietary Thanks

IMG_5566
Something I’m not thankful for:Vitamin Water. It consists of water, 32 grams of sugar and lots of useless vitamins. People, stop buying this stuff. You are only helping Coca-Cola fill Americans with TOO MUCH SUGAR!

On this fourth Thursday of November, 2015 the skeptical cardiologist would like to record some Thanksgiving thanks.

  • I’m thankful I’m not a turkey today.

I hear Americans consume 45 million turkeys on Thanksgiving, one sixth of the total during the year.

Americans have embraced turkeys nutritionally because they are low in saturated fat and provide lots of protein. Most nutritional advice suggests avoiding the dark meat and the skin, but I prefer to seek those portions out because they taste better and as I pointed out here last Thanksgiving, Up To Date, the major medical reference for physicians, now says “Don’t Worry About Saturated Fat Consumption.”

  • I’m thankful that dairy fat is good for you.
IMG_6510
The Eternal Fiancee’ (For whose presence in my life I am eternally grateful) Cutting Tomatoes for Crabmeat Ravigote, a traditional cajun dish full of cholesterol from eggs and crustaceans

The eternal fiancee’ and I took a cooking class in New Orleans (New Orleans School of Cooking) recently, and butter seemed to be the basis for every dish we cooked: from dark roux in our gator sauce piquante’, to the blonde roux in the Louisiana meat pies.

When the  teacher of the class, chef Austin, asked the students to introduce themselves, I told him I was the skeptical cardiologist and I was there to evaluate New Orleans dishes for my patients.

Chef Austin didn’t think I would be recommending the dishes to my patients, but I heartily endorsed them ( See here and here).

  • I’m thankful that cholesterol is no longer considered by the Dietary Guidelines for Americans Committee (DGAC) a nutrient of concern.

All may eat eggs and crustaceans without fear now.

However, there is a backlash from the vegans on this revelation: the weirdly named Physicians Committee for Responsible Medicine (PCRM’s goal seems to be elimination of all animal testing and consumption, not responsible medicine) has erected billboards in Texas targeting the chairman of the House Agriculture Committee (K Michael Conoway (R-TX)).

The final guidelines have yet to be issued, but I’m betting on the egg industry over the vegans on this one, despite the billboards.

  • I’m thankful that studies continue to come out showing coffee is not bad for you.

This study, for example, followed 90 thousand Japanese for 19 years and found that the more coffee you drink, the lower your risk of dying-from cardiac, respiratory and cerebrovascular disease. Those consuming 3-4 cups/day were 25% less likely to die than those who never drank coffee.

-I’m thankful that correlation does not equal causation.

This means that I don’t have to stop eating bacon or beef brisket (assuming I am insensitive to global sustainability concerns). On the other hand, that association between higher coffee consumption  and lower risk of dying over 19 years doesn’t mean that drinking more coffee is actually lowering the risk; but it’s certainly not increasing it.

Screenshot 2015-11-26 11.50.04Finally, I’m thankful that moderate alcohol consumption is good for your heart and I raise a toast of gratitude to patient patients, readers and correspondents.

-ACP

 

Time to Eat Butter Without Guilt

A number of readers of The Skeptical Cardiologist have pointed out to me that Time Magazine’s latest issue has a picture of butter on the cover with the headline “IMG_2965Eat Butter. Scientists labeled fat the enemy. Why they were wrong.”

The lead  article summarizes a lot of the evidence I have been writing about which suggests that saturated fat has been inappropriately vilified (here) and that added sugar and processed food may be the real root cause of the obesity epidemic (here).

It is well-written and reasonably balanced and has some catchy graphics.  It doesn’t really specifically address issues with dairy fat or butter as the title implies. I have defended high fat dairy in numerous posts over the past two years.

Hopefully this article in a well-respected mainstream newsmagazine will help correct the misinformation about diet and nutrition that has become entrenched in the consciousness of Americans.

.

Full Fat Dairy Lowers Your Risk of Obesity

ButterWhen i tell my patients that I am fine with them consuming full fat dairy products including butter I see  a mixture of responses. For many, there is a great relief that the butter they have been avoiding for the last 20 years (or consuming guiltily) can now be used. For others, the prospect of consuming full fat milk, cheese or yogurt still seems risky. After all, they have been hearing from the American Heart Association, the USDA nutritional guidelines and pretty much every nutritional advice column for the last 30 years that these products increase their risk of heart disease and contribute to obesity. Why should they believe their local cardiologist, a lone voice promoting full fat dairy against a chorus of naysayers?
Hopefully, by continuing to present scientific research on the topic I can make this concept more acceptable and counter the misinformation that is so prevalent

Researchers in Sweden have followed a cohort of rural men for over 12 years. In a previous study they found that daily intake of fruit and vegetables in combination with a high dairy fat intake was associated with a lower risk of coronary heart disease. Recently they examined their data to answer the question : how does dairy fat intake impact on the risk of developing central obesity in this middle-aged male cohort?

What is central obesity?

Central obesity refers to fat that builds up inside the abdomen. It is often measured by measuring the waist circumference: > 102 cm for males and 88 cm for females is a  marker of central obesity. Central or abdominal obesity indicates insulin resistance and is part of the metabolic syndrome and well known to increase the risk of diabetes.  It is also associated with heart disease, various cancers, and dementia. In this Swedish study, central obesity was defined as waist hip ratio ≥ 1.
The study found that 197 men (15%) developed central obesity during follow-up. A low intake of dairy fat at baseline (no butter and low fat milk and seldom/never whipping cream) was associated with a higher risk of developing central obesity (OR 1.53, 95% CI 1.05-2.24) and a high intake of dairy fat (butter as spread and high fat milk and whipping cream) was associated with a lower risk of central obesity (OR 0.52, 95% CI 0.33-0.83) as compared with medium intake (all other combinations of spread, milk, and cream) after adjustment for intake of fruit and vegetables, smoking, alcohol consumption, physical activity, age, education, and profession

Yes, these data show that participants were three times more likely to develop central obesity if they consumed skim milk and no butter compared to those who drank high fat milk and butter.

This is not an isolated finding. There is a wealth of data supporting the concept that full fat diary is less associated with obesity and markers of the metabolic syndrome, diabetes and insulin resistance.

120px-CheeseAnother recent study in a Basque population in Spain found that  participants with low or moderate consumption of cheese (high fat) compared to high consumption of cheese (high fat) had a higher prevalence of excess weight

Why do people falsely believe that fat in general and high fat dairy in particular promotes obesity?

In the past, supporters of this concept (and there are less and less in the scientific world)  would point to the energy density of fat which contains 9 calories per gram compared to 4 calories per gram for carbohydrates or protein. Obviously, if obesity is determined by calories in versus calories out then the food with more % fat compared to carbs or protein is providing more calories. All things being equal, one could expect to grow fatter on the higher % fat diet. All things are not equal, however, because one doesn’t determine how much one consumes based on the volume or weight of the food entering the mouth.

There are far more complex factors at work. How does the mixture of food components effect satiety? What is the insulin response to the food? What are the other components of the food such as vitamins, fiber, calcium and how do they interact with food absorption and metabolism?

So, even though this contradicts what has been drummed into your head for 30 years: eat full fat yogurt , cheese and milk , not fat-free, if you want to avoid getting fat

Butter versus “Healthier” Butter-like Spreads: Choose Nature over Industry

doctor's lounge donutsThe Skeptical Cardiologist occasionally wanders into the Doctors Lounge at the hospital and surveys the food choices available to him. One morning, descried amongst the carbohydrate bonanza of donuts, pastries, bagels and muffins was a bin containing little tubs of substances that could be spread on a bagel of slice of bread.

The choice was between something called Promise Buttery Spread

and Wholesome Farms Whipped Butter..

IMG_2265Conventional Wisdom and the recommendation of almost every nutritional authority for the last 30 years tells me that I should choose the Promise Buttery Spread. I would have taken this choice 5 years ago in the belief that butter with its high content of saturated fat was to be avoided. I used to spend a considerable amount of time in the pseudo-butter portion of the grocery aisles trying to determine which, of the myriad of competing alternatives, would be better than butter.
But, as I’ve noted in previous posts, the authorities have gotten it wrong.  Let’s look carefully at the two choices.

Promise Buttery Spread

Certainly the packaging would suggest that this is a “promising” choice.  It says very clearly in the small print circling the outside of the tub: “heart healthy when substituted for butter.” If you’d like to read the arcane FDA rules on which foods can make this sort of claim, they are here. Basically, if the product has less fat, saturated fat or cholesterol than butter it can make this claim.

From the website of Unilever, the giant food processing conglomerate that makes Promise and all of its siblings, we learn that Promise contains 8 grams of fat, 1.5 grams of which are saturated fat. Uniliver is very happy to provide you with the macronutrient content of Promise and its various variations. After all, they spent a lot of time researching what combination of fats, protein and carbohydrates would satisfy consumers desire for a heart-healthy substitute. Canola oil turns out to be high in monounsaturated fats just like olive oil, the major fat consumed in the heart-healthy Mediterranean diet

But how did they come up with this fine ratio of unsaturated to saturated fats? What actually goes into it?

Here are the ingredients (not obtainable from Unilever’s web site but from another source that, presumably could read the small print that I could not read on the little tub of Promise)
Vegetable Oil Blend (Liquid Soybean Oil, Canola Oil, Palm Oil, Palm Kernel Oil), Water, Whey (Milk), Salt, Vegetable Mono and Diglycerides, Soy Lecithin, (Potassium Sorbate, Calcium Disodium EDTA) Used to Protect Quality, Vitamin E Acetate, Citric Acid, Pyridoxine Hydrochloride (Vitamin B6), Artificial Flavor, Maltodextrin (Corn), Vitamin A Palmitate, Beta Carotene (Color), Cholecalciferol (Vitamin 13), Cyanocobalamin (Vitamin B12).
That’s 21 ingredients, most of which are made in a factory and added back to the mixture of exotic vegetable oils, most of which is canola oil.

What is Canola Oil? Does it come from a canola plant or seed?

A good source of information (and presumably positive) is the Canola Council web site which gives the history of Canola Oil. It all begins with oil from the seed of the rape plant, a crop grown in Canada.

Rapeseed oil naturally contains a high percentage (30-60%) of erucic acid, a substance associated with heart lesions in laboratory animals. For this reason rapeseed oil was not used for consumption in the United States prior to 1974, although it was used in other countries. In 1974, rapeseed varieties with a low erucic content were introduced. Scientists had found a way to replace almost all of rapeseed’s erucic acid with oleic acid, a type of monounsaturated fatty acid.

The Canola council website says that this process of developing rapeseed with low levels of the toxic erucic acid was not accomplished by genetic engineering, but the nongmoproject.org indicates 90% of Canola oil qualifies as genetically modified.

More history from the Canola Council:

By 1978, all Canadian rapeseed produced for food use contained less than 2% erucic acid. The Canadian seed oil industry rechristened the product “canola oil” (Canadian oil, low acid) in 1978 in an attempt to distance the product from negative association with the word “rape.” Canola was introduced to American consumers in 1986. By 1990, erucic acid levels in canola oil ranged from 0.5% to 1.0%, in compliance with U.S. Food and Drug Administration (FDA) standards.

The term canola was trademarked by the Western Canadian Oilseed Crushers’ Association (now the Canadian Oilseed Processors Association) to differentiate the superior low-erucic acid and low-glucosinolate varieties and their products from the older rapeseed varieties.

How is Canola Oil Processed?

Again, the Canola Council provides their summary of the process here.

Unlike olive oil which is just expeller expressed from olives, canola oil goes through quite a bit of processing. After pressing, about half of the oil is left, and the remainder is extracted by a solvent called hexane (interestingly, there is a controversy in the world of veggie burgers since hexane is used in processing soy and residual levels of this “neurotoxin” have been detected). This oil then goes through processes called degumming (which often involves mixing with acid), bleaching and deodorizing. To make a more solid form it is heated to hydrogenate the oil or palm kernel oil is mixed with it.

Is Canola Oil healthier than butter?

Unilever claims

Research shows that replacing saturated and trans fat with unsaturated fats can help maintain heart health.

Unfortunately, none of this research involves canola oil so it is not really applicable. In the 1980s, at the urging of health authorities, the food industry went through a similar process and created butter substitutes that utilized oils hydrogenated in a factory. The result was the consumption by the public of large amounts of trans-fats which subsequent research has shown to be great promoter of coronary heart disease. Does it make sense to put our trust in these newer , factory produced ,butter substitutes?

There are NO STUDIES that would indicate substituting canola oil for butter is a heart-healthy choice. Personally, I have grave concerns about consuming a product that has gone through such a tortured process in order to make it appear safe and palatable.

In the Doctor’s Lounge, my butter choice lists pasteurized cream and salt as the ingredients. I like that, it’s simple and straightforward. I know that most studies that have looked at consumption of dairy fat have found that it lowers risk of heart disease. Wholesome Farms is a Sysco, Inc. label and Sysco says

Wholesome Farms farm-fresh cream, eggs and other dairy offerings are typically produced at dairies located closer to our foodservice customers, resulting in fresher, more dependable products with longer shelf lives.

I have tried to contact Sysco to get more information on where my little tub of butter came from and what the cows were fed but have gotten no information.

Choose Nature, not Industry, for good health.

The choice between a highly processed, genetically modified, industry promoted vegetable oil (or blend of oils) which has been manipulated to resemble a healthy natural vegetable oil and never shown to be safe or healthy in humans, versus butter, is clear to me. Give me butter every time. I’m not excited about the fact that I can’t be sure the milk used in this little tub of butter came from pasture-raised, grass-fed cows. However, I realize that compromises have to be made for convenience sometimes. I’d rather eat the butter from unknown cows than the vegetable oil from a known factory.

It’s Time to End the War on Fat: Dietary Fat Doesn’t Make You Fat or Give You Heart disease.

Most cardiologists don’t spend a lot of time talking about diet with their patients. When they do, they usually cite the mainstream maxim that you should cut down on saturated fat by reducing red meat consumption, choosing low-fat or skim dairy products, and lean cuts of meat. Patients are referred to standard recommendations that conform to this advice that comes from the American Heart Association.

This is certainly what I did for 30 years until I started examining the research supporting these recommendations in detail. It’s a lot easier to give advice to your patients when it conforms to what they are hearing from nutritional authorities. If it doesn’t conform, you have a lot of ‘splaining to do. If doctors spend time teaching or discussing diet with our patients, we do not get reimbursed for it.

However, a close examination of the research on dietary fat and heart disease shows that there is no good evidence supporting these recommendations.

The two major fallacies are:

Eating high fat foods will make you fat.

Eating high fat or cholesterol laden foods raises your cholesterol, thereby promoting the development of heart disease

Dietary Fat and Obesity

Although these concepts have become ingrained in the consciousness of Americans, they are not supported by scientific studies; more and more researchers, nutritional scientists, and cardiologists are sounding the warning and trying to change the public’s understanding in this area.

It seems logical that the fat that we consume goes into the body and is then converted into fat that appears on our thighs or belly and lines our arteries. This logic, and weak epidemiologic studies, led to national nutritional recommendations, beginning in 1977, that Americans cut back on fat (particularly saturated fat). The food industry seized on these recommendations and began providing consumers with “low-fat” alternatives to standard foods. To make these low-fat foods palatable, sugar had to be added. Often,  due to a surplus of industrial farm produced corn, sweetening was accomplished with high-fructose corn syrup. This graph shows what happened with weight in the US:
obesity rates

Beginning in the late 1970s, the percentage of people with BMI > 30 (considered obese) increased dramatically.
More and more evidence points to increased consumption of sugar, HFCS, and refined carbohydrates as the root cause of this obesity epidemic.
I tell my overweight patients that reducing sugar and refined starch is the most important thing that they can do to shed excess pounds.  They should avoid processed foods which the food industry have manipulated to make more palatable and less healthy. This means, among other things, avoiding or minimizing drinking sugar-sweetened beverages and avoiding “drinking your calories,” cutting way back on donuts, pastries, and potatoes and when consuming pastas or breads, try to make them whole-grain.

Dietary Fat and Heart Disease

I don’t tell my patients to cut fat consumption; this advice runs counter to everything they have heard about diet and heart disease. I encourage them to consume full fat dairy and this is considered particularly heretical.

However, as I have discussed in previous posts, there is no evidence that dairy fat increases cardiovascular risk. In fact, all studies suggest the opposite: a lower risk of heart disease associated with full fat dairy consumption.

Just as all fats are not the same (consider trans, saturated and unsaturated), all saturated fats are not the same. Some, particularly, the shorter chain fatty acids found in dairy, have beneficial effects on the lipid profile and likely lower overall cardiovascular risk.

What about red meat? All of my patients have received the dogma that they need to cut back on red meat. It hasn’t come from me (not since I began looking at the scientific evidence). When I look at my patients’ cholesterol profile before and after they institute what they perceive as the optimal “heart-healthy“ diet (cutting back on saturated fat and increasing carbohydrates by reducing meat consumption and shifting to skim or low-fat dairy products), their LDL or “bad” cholesterol has dropped a little, but proportionally their HDL or good cholesterol has dropped more and their triglycerides have gone up. What is the overall effect of this dietary change? There are no studies demonstrating that this change improves your heart health.

A recent systematic review and meta-analysis of 20 studies which included 1,218,380 individuals found no relationship between red meat consumption and coronary heart disease, CHD, (or diabetes). Conversely, processed meat intake was associated with a 42% higher rate of CHD and 19% higher risk of diabetes.

Analysis of data from the Multi-Ethnic Study of Atherosclerosis population indicates

After adjustment for demographics, lifestyle, and dietary confounders, a higher intake of dairy saturated fat was associated with lower cardiovascular disease risk [HR (95% CI) for +5 g/d and +5% of energy from dairySF: 0.79 (0.68, 0.92) and 0.62 (0.47, 0.82), respectively].

There also appears to be no association between red meat consumption and mortality in Asian countries

The Womens Health initiative was started in the early 1990s to test the hypothesis that a low fat diet would lower risk of cancer, stroke and heart attacks.Women were aged 50-79 at trial enrollment in 1993-98 and were followed for an average of 8.1 years. By the end of the first year, the low-fat diet group reduced average total fat intakes to 24 percent of calories from fat, but did not meet the study’s goal of 20 percent. At year six, the low-fat diet group was consuming 29 percent of calories from fat. The comparison group averaged 35 percent of calories from fat at year one and 37 percent at year six. Women in both groups started at 35-38 percent of calories from fat. The low fat diet group also increased their consumption of vegetables, fruits, and grains.
The study design reflected a widely believed but untested theory that reduction of total fat would reduce risks of breast or colorectal cancers. Among the 48,835 women who participated in the trial, there were no significant differences in the rates of colorectal cancer, heart disease, or stroke between the group who followed a low-fat dietary plan and the comparison group who followed their normal dietary patterns.

Yes, “widely believed but untested theory” is a great description of the current recommendation to cut saturated fat because no prospective trial has proven any benefit to this approach in reducing cardiovascular disease.

There is some evidence (but still fairly weak) to support the idea that replacing saturated fat with unsaturated fat is beneficial. Thus, the popularity of the Mediterranean diet which utilizes olive oil liberally. There is good evidence that industrially produced trans-fatty acids (from products designed to take the place of inappropriately demonized butter) increase cardiovascular risk. However, this evidence does not extend to natural trans-fatty acids such as those coming from the udders of cows.

Mounting evidence suggests that replacing fat or saturated fat in the diet with carbohydrates, however, contributes to obesity, insulin resistance, diabetes, and thereby may increase your risk of cardiovascular disease.

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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Milk Drinking and Your Risk For Heart Disease

In my previous post, I referenced USDA guidelines which recommend consuming dairy but only in a low-fat form. How did the mainstream nutritional community decide the American public should shift from full fat dairy to low or no fat dairy? Prior to the 1950s there was little concern in nutritional research about fat in the American diet. Beginning in the 1950s, it became apparent that heart disease, coronary artery disease (the cause of heart attacks) in particular, had become the major cause of mortality in western countries.

The American epidemiologist, Ancel Keys, became convinced in the mid 1950s that dietary fat and cholesterol were related to heart disease. In 1970 published his “Seven Countries Study” which found a correlation between per capita fat consumption and the prevalence of heart disease in seven cherry-picked countries. These kinds of studies can be useful for developing theories about which factors might cause disease, however, they cannot prove that a dietary factor causes the disease.

Messerli recently published a tongue-in-cheek analysis of the relationship between per capita chocolate consumption in a particular country and the number of Nobel Laureates produced by that same country that illuminates the weakness of this type of study.
This is the main figure from that study: Chocolate Consumption and Nobel Laureates

There is a very nice relationship demonstrated which suggests that the more chocolate consumed in a particular country, the more Nobel Laureates produced. However, no one would seriously believe that chocolate consumption causes the kind of brilliance needed to do achieve a Nobel prize. Clearly, there are confounding variables or factors. Sometimes, confounding factors are clear and can be accounted for, but often they are not clear and cannot be accounted for.

Early studies of this type demonstrated that there was a relatively strong association between the per capital supply of milk or some component of milk and heart disease mortality. In other studies, changes in gross milk production over time and changes in heart disease deaths were shown to correlate.

Despite the weakness of such studies in proving causation, as Gary Taubes pointed out ,

“the National institute of Health (NIH) had begun (by 1988) advising every American old enough to walk to restrict fat intake, and the president of the American Heart Association (AHA) had told Time magazine that if everyone went along, “we will have (atherosclerosis) conquered” by the year 2000. The Surgeon General’s Office itself had just published its 700-page landmark “Report on Nutrition and Health,” declaring fat the single most unwholesome component of the American diet.”

Such recommendations have resulted in a whole industry devoted to developing low-fat food-like substances which the public has perceived as healthier than the natural high fat original foods. Arguably, adoption of highly processed low-fat foods, which usually increase palatability by adding refined carbohydrates , sugar, or high-fructose corn syrup have contributed to America’s obesity epidemic. This, in turn through increasing obesity-associated diabetes, hypertension, and abnormal lipid profiles could have the unintended consequence of increasing heart disease.

The major focus of low-fat dietary recommendations has been to lower red meat consumption due to the high levels of saturated fat found in pork and beef. However, despite having a significantly different saturated fat composition, dairy products have been tarred with the same brush, so to speak. This has progressed to the point where, if one enters a frozen yogurt establishment (these businesses have proliferated at an alarming rate in the last few years) it is virtually impossible to find a full fat formulation of yogurt. Prominently featured are the words “no-fat” or “low-fat” with the implication that this is healthy for you. Instead of the natural fat of dairy , you have now been convinced to eat a form of dairy that has been highly processed, depleted of most nutrients and full of sugar and unrefined carbohydrates. To make up for the fat calories which might have left you more satiated without sharp peaks in blood glucose, you can substitute a whole panoply of sugary materials, chocolate, candies, or fruit.

It turns out that when the best epidemiological studies are examined in this area, the evidence suggests a protective effect of dairy on heart disease risk. Dr. Peter Elwood, a highly respected epidemiologist at the University of Wales, has consistently pointed this out based on his and other researchers’ studies.
To quote Elwood, the best epidemiological studies are “prospective cohort studies, based on data for individual subjects within a single community, with detailed attention given to confounding” variables. Such studies “give a much better basis for the examination of independent associations between food items and disease incidence than studies based on either ecological data or relationships with risk factors.”

In 2004, Elwood published a review of such studies which was published in the European Journal of Clinical nutrition. He found 10 studies worthy of inclusion. All but one study suggested that milk protects against heart disease. Those subjects consuming the most milk were less likely to have a heart attack or stroke than those consuming no milk. The relative risk for high volume milk drinkers versus those drinking no milk for “ischaemic heart disease” (this refers to coronary artery disease , the major cause of heart attacks) was 0.87. In other words, if you drank a lot of milk you were 13% less likely to have heart disease than if you drank none.

Elwood’s original research on this was called the Caerphilly Prospective Study. Between 1979 and 1983, 2500 men completed a food frequency questionnaire. During the following 21 years, the relative risk in men who drank more than a pint of milk per day, compared with the risk in men who drank no milk was 0.66 for ischemic heart disease and 0.84 for ischaemic stroke. In other words, high milk drinkers were 34% less likely to develop coronary heart disease, the major cause heart attacks.

All the studies reviewed were set up at times when reduced-fat milk was unavailable or scarce therefore the conclusion from the best available evidence in 2004 should have been that full fat dairy lowers your risk of heart attack and stroke.

For both the general public and for my cardiac patients I, therefore, differ strongly in my advice regarding dairy consumption from most published dietary guidelines. Keeping in mind that “all things in moderation” applies just as much in this area as any other, I advise full fat dairy consumption. This means that they can consume butter, milk, full-fat cheese and yogurt. I strongly advise utilizing dairy that comes from grass-fed , pasture-raised cows for reasons I will examine in subsequent posts. Each of these dairy products has a different fatty acid profile and therefore, likely a different effect on cholesterol profiles. Butter, in particular, may warrant separating out from the other dairy products because it is a very highly concentrated fat. However, since reviewing the published data on butter consumption and cardiovascular disease, I have personally gone back to fairly liberally applying butter (again, hopefully from grass-fed, pasture-raised cows) to a lot of my foods because there are few data suggesting that butter raises my risk of cardiovascular disease and the stuff tastes awesome.