The Kid’s Healthy Eating Plate was created as a fun and easy guide to encourage children to eat well and keep moving. The plate guidelines emphasize variety and quality in food choices.
The majority of the recommendations were pretty straightforward and mainstream:
The formula is simple: Fill half your plate (or lunch box) with colorful fruits or vegetables(aim for two to three different types). Fill about one-quarter with whole grains like whole grain pasta, brown rice, or quinoa, and the remaining quarter with healthy proteinslike beans, nuts, fish or chicken. Healthy fatsand a small amount of dairy (if desired) round out a tasty meal that will fuel an active, healthy lifestyle.
What caught my attention was the comment about dairy.
The dreaded words skim or low-fat did not appear in the sentence!
It would appear that a highly respect and mainstream source of nutritional advice is not making the typical (and scientifically unsupported ) recommendation to consume low fat or skim dairy products!
Indeed, if we look at their expanded comments on dairy they read:
Incorporating dairy (if desired). For example: unflavored milk, plain Greek yogurt, small amounts of cheese like cottage cheese, and string cheese.
No mention of fat content. Zip. Zero. To me, if you don’t put non fat low fat or skim next to the word diary it implies full fat.
Following their yogurt link we find no reference to preferentially consuming low fat yogurt despite the fact that the vast majority of yogurt sold in the US has been processed to remove healthy dairy fat, something the THCHSPH must be painfully aware of. (My wonderful MA Jenny’s husband, Frank, until very recently was unable to find full fat yogurt at Schnuck’s.)
As I pointed out here, a huge scam was foisted on Americans when allegedly healthy non fat yogurt filled with added sugar began to be promoted as a healthy treat.
It is almost as if the THTHCSPH has become agnostic about dairy fat and therefore is trying not to make recommendations.
Elsewhere on the THTHCSPH site however the old unwarranted advice to avoid dairy fat rears its ugly head. On a page devoted to calcium we read:
Many dairy products are high in saturated fats and a high saturated fat intake is a risk factor for heart disease”
Then this interesting (and ?ironic) observation:
And while it’s true that most dairy products are now available in fat-reduced or nonfat options, the saturated fat that’s removed from dairy products is inevitably consumed by someone, often in the form of premium ice cream, butter, or baked goods.
Strangely, it’s often the same people who purchase these higher fat products who also purchase the low-fat dairy products, so it’s not clear that they’re making great strides in cutting back on their saturated fat consumption.
The THTHCSPH seems conflicted, as well they should. They want to keep up the nutritional party line that they have been spouting for 30 years that all saturated fats are bad but they now realize that supporting non fat dairy products has likely worsened rather than improved the diet of millions of Americans.
N.B. The overall Kid’s healthy eating plate is not likely to be a favorite of kids and I disagree with some aspects of it.
Namely, I think it is fine to have red meat and processed meats in moderation and I wouldn’t push the pasta, rice, and bread.
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.
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.
When the 2015 Dietary Guidelines for Americans (DGA2015) are finally issued they will likely follow the recommendations of the DGA committee. The DGA report (available here) has made giant strides in reversing four decades of bad advice coming from the government and the American Heart Association (AHA.)
Namely, as I discussed in detail here they no longer consider cholesterol a nutrient of concern and recommend lifting any specific limit on dietary cholesterol.
In addition, as a recent article in JAMA suggested they have finally lifted any recommended limit on percent daily intake of fat and we should celebrate and encourage this.
As we have pointed out multiple times, higher fat intake is not associated with heart disease or obesity and it makes no sense, therefore to impose limits on its consumption.
In fact, replacement of fat with carbohydrates is the worst dietary change you can make (with the exception of exchanging butter for industrial processed oils containing trans-fats).
Arguably, thanks to four decades of government and AHA advice to cut fat and cholesterol we have seen the rise of sugar consumption and obesity as food manufacturers have agreeably made products that fulfill requirements for low fat but still taste good.
The new analysis and report from the DGAC 2015 will hopefully reverse this as they seem to have gotten most of the science right.
Non fat or Low-Fat Dairy Still Recommended
However, they have, inexplicably, left in recommendations for non-fat or low fat dairy.
As I have written about here and here there is no scientific evidence that supports the concept that dairy processed to remove dairy fat is healthier than the original unadulterated product.
In fact, evidence suggests full fat dairy reduces central obesity, diabetes and atherosclerosis in general.
It is virtually impossible in most grocery stores to find full fat yogurt or milk. The vast majority of the dairy aisle is devoted to various low or non fat concoctions which have had loads of sugar and chemicals added and are arguably worse than a Snickers bar.
Flawed Reasons for Low Fat Dairy Recommendations
I believe there are three reasons for this failure of the DGA 2015 and nutritional experts to correct the flawed advice to eat non or low-fat dairy over full fat:
1. In few randomized dietary studies showing benefits of a particular diet over another, non fat or low fat dairy was recommended along with a portfolio of other healthy dietary changes.
The overall benefit of the superior diet had nothing to do with lowering the dairy fat but was due to multiple other changes.
2. The dairy industry has no motivation to promote full fat dairy. In fact, they do better financially when they can take the fat out of milk and sell it for other purposes such as butter, cheese, and cream.
3. Saturated fat is still mistakenly being treated as a monolithic nutritional element. Although dairy fat is mostly saturated, the individual saturated fats vary widely in their effects on atherogenic lipids and atherosclerosis. In addition, the nature of the saturated fat changes depending on the diet of the cow.
If the DGA 2015 doesn’t get this issue right we risk another decade of the public consuming high sugar, low fat yogurt in the mistaken belief that they are engaging in healthy behavior.
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)
This container of Yoplait comes from the refrigerator in the Doctor’s Lounge at my hospital. It is often the go-to snack for busy doctors and health conscious consumers.
I used to consider Yoplait about as healthy a snack as I could get. After all, it was low in fat, owned by French farmers and it had pictures of fruit on it. How could I go wrong?
“Ultimately, we’re focused on making so good yogurt, and here’s how we see it: you can eat something that tastes amazing but isn’t that good for you. You can eat stuff that’s really good for you, but doesn’t always leave you yummed up. So good yogurt does both. All of you is happy, not just your tongue. And while so goodness will never be perfect, we’ll keep working on ways to make our yogurt more so good than it is today.”
The significant other of the skeptical cardiologist (SOSC) made the claim recently that women who felt they were having a healthy lunch by consuming fat free yogurt and salad with sugary, fat-free salad dressing might as well be eating a candy bar. At least they would enjoy it more! Could this be true?
Yoplait made the bold step in 2012 of taking out the high fructose corn syrup they had been adding to their yogurt (or yoghurt as they like to spell it), but it’s still chock full of added sugar (which is probably why it leaves you “yummed up”)
What is now in “original” Yoplait?
Original Yoplait has 12 ingredients. They are Cultured pasteurized Grade A Low Fat Milk, Sugar, Blueberries, Modified Corn Starch, nonfat milk, kosher gelatin, citric acid, tricalcium phosphate, pectin, natural flavor colored with beet juice concentrate, Vitamin A and Vitamin D3.
Indeed, the fat has been taken out but in its place – added sugar, 26 grams of sugar to be precise.
Of the 170 calories you are consuming, 104 of them are coming from sugar.
How healthy is a Snickers Bar?
A regular-sized Snickers candy bar has a total of 280 calories with 13.6 grams of fat (5 grams saturated fat), 35 grams of carbohydrates (29 grams of sugar) and 4.3 grams of protein. It is made with peanuts, milk chocolate, egg whites and hydrogenated soybean oil. If we ate 2/3 of the bar to make the calories the same as the Yoplait, there would be 19 grams of sugar (compared to 26 for Yoplait) and 8 grams of fat.
A recent review of the cardiovascular effects of tree nuts and peanuts concluded:
there is impressive evidence from epidemiological and clinical trials and in vitro studies of beneficial effects of nut consumption and their constituents on the risk of CVD (cardiovascular disease), including sudden death, as well as on major and emerging CVD risk factors.
This is because in addition to a favorable fatty acid profile, nuts and peanuts contain other bioactive compounds that provide cardiovascular benefits. Other macronutrients include plant protein and fiber; micronutrients including potassium, calcium, magnesium, and tocopherols; and phytochemicals such as phytosterols, phenolic compounds, resveratrol, and arginine.
So, consuming 2/3 of a Snickers bar is arguably healthier than Yoplait. It contains peanuts, which have demonstrable benefits in lowering cardiovascular disease despite a high fat content. Yoplait has had the heart healthy dairy fat removed and replaced with added sugars. As I mentioned in a previous post, added sugar is clearly related to increased cardiovascular risk. The higher fat and fibre content of the peanuts in the Snickers bar will increase satiety and arguably be less likely to cause obesity due to rebound overeating later in the day.
A much healthier choice than low fat, added sugar products like Yoplait (and candy bars) is full fat, plain yogurt (preferably from grass-fed cows) as I’ve discussed in previous posts. It can be combined with real fruit or even with nuts. Full fat yogurt is surprisingly hard to find on a grocery shelf. Even at Whole Foods, the vast majority of yogurt and dairy products are low fat. I’ve only been able to find two brands, Supernatural and Trader’s Point Creamery, which consistently offer full fat yogurt.
Disclaimer and clarifications
I do not receive any payments from Snickers nor from Mars, Inc., one of the most known and beloved brands of chocolate. I do not plan on seeing Godzilla, May 16. Although Snickers loves you, you do not need to like Snickers.
I recommend the Mediterranean diet (MED) to my patients. Every unbiased, systematic review of the research on diet and heart disease in the last 8 years has concluded that it is the most likely dietary model to provide protection against coronary heart disease. One review concludes
Among the dietary exposures with strong evidence of causation from cohort studies, only a Mediterranean dietary pattern is related to CHD (coronary heart disease) in randomized trials.
The MED is the only comprehensive dietary approach that has been proven to reduce total death and heart attacks in comparison to standard diets. There are two major randomized controlled trials (the only kind of study that proves the value of a dietary intervention) with this diet.
The first, called the Lyon heart Study, was in patients who had had heart attacks (secondary prevention) . As this graph demonstrates, those patients randomized to receive instruction on following the Mediterranean diet had a 60% lower death rate and a 70% lower heart attack rate. The second was published last year in the New England Journal of Medicine and was a primary prevention study: that is, participants had not had heart attacks. Participants were randomized to one of three diets: a MED supplemented with extra-virgin olive oil, MED supplemented with mixed nuts or a control diet (advice to reduce dietary fat). Participants received quarterly individual and group educational sessions and either free provision of olive oil, mixed nuts or small nonfood gifts. The high extra virgin olive oil group ingested an average of 3.6 tablespoons/day (51 grams/day equal to 459 calories/day) of olive oil with 98% of it being extra virgin olive oil. The high nut group ate 8.2% of their total daily calories in the form of nuts, including an additional approximately one ounce packet of nuts (15g of walnuts, 7.5 g of almonds, and 7.5g of hazelnuts) provided by the study coordinators. 7447 persons were enrolled (ages 55 to 80 years) for an average 4.8 years. Those persons following the MED diet (either supplemented with olive oil or nuts) were 30% less likely to have a major cardiovascular event (heart attack, stroke or death from cardiovascular causes.) There was a statistically significant reduction in stroke rate (≈39%) when considered as an isolated endpoint. We don’t know exactly what components of the MED are the most beneficial. This trial suggests that olive oil and nuts are at least two of the key ingredient so it makes sense to increase your consumption of these foods. Other studies strongly support fish consumption and alcohol consumption as key components. As I’ve discussed (?ad nauseam) in other posts, full fat dairy and eggs, although banned by most “heart healthy diets”, have not been shown to increase heart disease risk. Fermented dairy consumption, in particular, in the form of plain full-fat yogurt (not adulterated with sugar) and full-fat cheese is consistently associated with a lower risk of coronary heart disease. Plain full-fat yogurt and full-fat cheese (from goat milk) were consumed by the inhabitants of Crete, the Greek Island on which the original MED was based.
It has to be emphasized that within this pattern of eating you want to be consuming real foods, not processed products of the industrial food industry which have been manipulated to appear healthy due to being “low-fat” or “low cholesterol.”
This is a pattern of eating which is varied, interesting and sustainable.
When 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.
Another 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