Dietary Villains
Part I: Fat Phobia
“It is now increasingly recognized that the low-fat campaign has been based on little scientific evidence
and may have caused unintended health consequences”
Frank Hu and W. WillettHarvard School of Public Health
“Types of Dietary Fat and Risk of Coronary Heart Disease: A Critical Review” AJCN Vol. 20, 1(5-19) 2001
Hormonal Obesity Theory
FatteningCarbohydrates
Increased Insulin level
Insulin Resistance
Fibre Obesity
High TGLow HDL
Hypertension
Diabetes
Metabolic Syndrome
Fatty Liver
High Protein
Cortisol
Vinegar
Fructose
WheatSuper-carbohydrate Fasting
DiseasesOf Civilization
DiabetesHeart DiseaseCancerPeriodontitis
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CholesterolHarmful alien substance?
Daily Cholesterol needs 20% dietary (animal products)
80% manufactured by bodywww.kidneylifescience.ca
Ancel Keys
Seven countries study - 1970 conclusions1. Cholesterol levels predicted heart disease risk2. Amount of saturated fat in the diet predicted cholesterol levels3. Monounsaturated fat protected against heart disease
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War on Cholesterol
1984 NIH Consensus Conference “there is no doubt that low fat diets will afford significant protection against coronary heart disease”
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Diet-Heart Hypothesis
1. Increased cholesterol associated with increased CV disease2. Dietary saturated fat increases cholesterol3. Therefore dietary fat increases cardiovascular disease
Dietary FatCholesterol
Cholesterol CardiovascularDisease
Lipid Hypothesis
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Prevention of Coronary Heart Disease, by Dr. Harumi Okuyama et al
Total serum cholesterol levels and mortality risk as a function of age. A report based on the Framingham dataArch Intern Med. 1993 May 10;153(9):1065-73 Kronmal RA
Cholesterol and Age
Decreasing mortality with higher cholesterol
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Cholesterol in Women
Framingham Heart Study
Long Term Mortality
J Womens Health. 1997 Jun;6(3):295-307, Zareba et alPrognostic value of cholesterol in women of different ages
Age <55
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Cholesterol and women
Survey of 52 087 Norwegians from 1992-1994
Is the use of cholesterol in mortality risk algorithms in clinical guidelines valid? Ten years prospective data from the Norwegian HUNT 2 study J Eval Clin Pract. 2012 February; 18(1): 159–168
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Dietary Fat and Cholesterol
Dietary Fat Increased serumcholesterol
CardiovascularDisease
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Framingham Heart Study
“There is considerable range of serum cholesterol levels within the Framingham Study Group. Something explains this inter-individual variation, but it is not diet” Tavia Gordon (NIH)
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Framingham Diet Study
“Unfortunately, these data were never incorporated into a definitive report“Tavia Gordon
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Framingham Diet Study
No discernible relationship between reported diet intake and serum cholesterol levels
Oct 30, 1970
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Framingham Diet Study 1977
Cholesterol Intake
Below Median
Above Median
Mg/ day Mmol/ L Mmol/ L
Men 704 ± 220.9 6.16 6.16
Women 492 ± 170.0 6.37 6.26
“There is no indication of a relationship between dietary cholesterol and serum cholesterol level”
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Dietary Fat and Serum Lipids
Daily nutritional intake and serum lipid levels. The Tecumseh studyAm J Clin Nutr. 1976 Dec;29(12):1384-92
No influence of fat or cholesterol on serum cholesterol
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National Cholesterol Education Program
“Dietary cholesterol causes marked hypercholesterolemia in many laboratory animals, including nonhuman primates. High intakes of cholesterol in humans, however, do not cause such a marked increase in serum cholesterol”Translation – “Non human primates should DEFINITELY avoid dietary cholesterol. Humans, though, not so much.”
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Industrialization
Increased Dietary FatIncreased Life ExpectancyIncreased Coronary Artery Disease
IncreasedIndustrialization
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Exercise in FutilityStudy Journal/ Author Conclusions
A Longitudinal Study of Coronary Heart Disease
Circulation.1963; 28: 20-31Oglesby P
1,989 patients followed over 4 years. No relationship of dietary fat to CAD
Diet and Heart: A Post Script BMJ 1977; 2(6098): 1307-14 Morris JN
No relationship of CAD to dietary fat
Dietary intake and the risk of coronary heart disease in Japanese men living in Hawaii
Am J. Clin. Nutr. 31: 1270-1279, 1978. Yano K
7,705 men over 6 years.No relationship of CAD to dietary fat
Relationship of dietary intake to subsequentcoronary heart disease incidence: The PuertoRico Heart Health Program
Am. J. Clin. Nutr. 33: 18 18-1827, 1980 Garcia-Palmieri MR
10,000 patients over 6 years. No relationship of CAD to dietary fat. Protective effect of legumes
Diet, Serum Cholesterol, and Death from Coronary Disease: The Western Electric Study
NEJM 1981: 304; 65-70 Shekelle RB
1900 patients over 20 years. No relationship of CAD and saturated fats
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Dietary Fat and Heart Disease
“Total fat intake was not significantly related to the risk of coronary disease”
Q1 Q2 Q3 Q4 Q50
0.20.40.60.8
11.2
Multivariate Adjusted for Trans fats
Risk of CAD
Dietary Fat Intake and the Risk of Coronary Heart Disease in Women N Engl J Med 1997; 337:1491-1499 Hu FB
Nurses Health Study
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Dietary Cholesterol
Q1 Q2 Q3 Q4 Q50
0.2
0.4
0.6
0.8
1
1.2
1.4
11.16 1.09 1.08 1.12
CAD
DIETARY FAT INTAKE AND THE RISK OF CORONARY HEART DISEASE IN WOMENN Engl J Med 1997;337:1491-9 Hu FB
P=0.49
Dietary Determinants
Arch Intern Med. 2009;169(7):659-669 Mente AA Systematic Review of the Evidence Supporting a Causal Link Between Dietary Factors and Coronary Heart Disease
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No correlation with total fat, saturated fat or PUFA
Dietary Determinants - Fats
A Systematic Review of the Evidence Supporting a Causal Link Between Dietary Factors and Coronary Heart DiseaseArch Intern Med 2009;169(7):659-669 Mente A
“recent prospective studies (or meta-analysis of studies) have failed to detect a causative link between (percentage of dietary fat and obesity)”Translation - despite 40 years of trying to link dietary fat and obesity there is still no evidence
National Cholesterol Education Program
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Saturated Fats
Q1 Q2 Q3 Q4 Q50.7
0.75
0.8
0.85
0.9
0.95
1
1.05
Adj
uste
d re
lativ
e ri
sk
Dietary fat and risk of coronary heart disease in men: cohort follow up study in the United States
BMJ 1996;313:84 Ascherio A
Quintiles of Saturated FatIntake
Risk of Heart Attack
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Dietary Fat and Stroke
7,895 Japanese-Hawaiian healthy men
Q1 Q2 Q3 Q4 Q50
5
10
15
20
25
30
35
40
45
FatProteinSodium
Dietary and Other Risk Factors for Stroke in Hawaiian Japanese MenStroke 1985 Vol 16; 3:390-96 Kagan A
10 year stroke incidence
Quintiles of Nutrient Intake
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Inverse association of dietary fat with development of ischemic stroke in menJAMA. 1997 Dec 24-31;278(24):2145-50 Gillman MW
Dietary Fat and Stroke
Lowest intake of fatHighest risk of stroke
Highest intake of fatLowest risk of stroke
PUFA not protectiveP=0.33
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Dietary fats, carbohydrate, and progression of coronaryatherosclerosis in postmenopausal womenAm J Clin Nutr 2004;80:1175–84 Herrington et al
Dietary Fat and CV disease
Lower Saturated fat =More progression CAD
PUFA
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Dietary Fat and Heart Disease
29,098 men and women
Dietary fat intake and early mortality patterns – data from The Malmo Diet and Cancer Study J Intern Med August 2005; 258(2): 153-65 Leosdottir M
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French Paradox
Total Fat (g/day)
Animal Fat CV Death0
50
100
150
200
250
171
108
82
157
72
216
FrenchAmerican
CV D
eath
per
100
,000
WHO 2000
Males age 35–74www.kidneylifescience.ca
Saturated Fat Phobia
Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular diseaseKrause et al AJCN 2009
Saturated fat protective for stoke!
Saturated fatCompletely irrelevant
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Saturated Fat
Dietary intake of saturated fatty acids and mortality from cardiovasculardisease in Japanese Am J Clin Nutr doi: 10.3945/ajcn.2009.29146, Yamagishi K
Cohort study of 58,453 Japanese
Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 50.6
0.650.7
0.750.8
0.850.9
0.951
1.051.1
Stroke MI Total CVD
Adj
uste
d O
dds
Ratio
Saturated Fat Intake
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Dairy Fat and Diabetes
Prospective cohort study of 3,736 pts Trans-Palmitoleic Acid, Metabolic Risk Factors, and New-Onset Diabetes in US AdultsAnn Intern Med. 2010 December 21; 153(12) Mozaffarian D
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Diabetes and Inflammation
2.22.32.42.52.62.72.82.9
33.1
CRP (mg/l)HOMA
Adj
uste
d O
dds
Ratio
Trans-Palmitoleic Acid, Metabolic Risk Factors, and New-Onset Diabetes in US AdultsAnn Intern Med. 2010 December 21; 153(12) Mozaffarian D
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Eggs
A Prospective Study of Egg Consumption and Risk of Cardiovascular Disease in Men and Women JAMA April 21, 1999
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Eggs
Egg consumption and risk of coronary heart disease and stroke BMJ 7 Jan 2013
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Eggs and Diabetes
Overal
l CVD
IHD
Stroke
IHD m
ortality
Stroke
morta
lity
Diabetes
0
0.4
0.8
1.2
1.6
0.96 0.97 0.93 0.98 0.92
1.42
Low vs. High Egg consumption
Pool
ed H
azar
d Ra
tio
Egg consumption in relation to risk of cardiovascular disease and diabetes Am J Clin Nutr July 2013, Jang Yel Shin et al
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Nuts and Heart Disease
Almost never
1-4/month
2-4/ week
>5/week
0
0.2
0.4
0.6
0.8
1
1.2
Nut Consumption
Adj
uste
d Re
lativ
e Ri
sk
Frequent nut consumption and risk of coronary heartdisease in women: prospective cohort study BMJ 1998;317:1341–5 Hu FB
86,016 women from Nurse’s Health Study
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Omega 3 supplements
18,645 hypercholesterolemic Japanese patients Effects of eicosapentaenoic acid on major coronary events in hypercholesterolemic patients (JELIS) Lancet March 31, 2007 1090-98 Yokoyama et al
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Low Fat Diets after Heart Attack not effective
Effects of changes in fat, fish, and fibre intakes on death and myocardial reinfarction: diet and reinfarction trial (DART) Lancet. 1989 Sep 30;2(8666):757-6 Burr ML
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Increased Fish intake after Heart attack
Effects of changes in fat, fish, and fibre intakes on death and myocardial reinfarction: diet and reinfarction trial (DART) Lancet. 1989 Sep 30;2(8666):757-6 Burr ML
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Trans Fats
Margarine intake and subsequent coronary heart disease in menEpidemiology. 1997 Mar;8(2):144-9 Gillman MW
20 year follow up from Framingham study 1966
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Industrial Vegetable Oils1. Seeds de-hulled, de-skinned and ground into meal and heated2. Pressing - Meal fed into a screw press, under pressures up to 20,6850 kilopascals3-. Solvent extraction - Hexane used to dissolve oil, which is then recovered by distilling4. Solvent Removal – Oil is boiled by steam, and the lighter hexane floats upward5. Refining - Heat oil to 85C and mix sodium hydroxide. Soap forms and is removed by centrifuge.6. Degumming - Treating them with 95C water, steam, or water with acid. The gums (phosphatides), precipitate out, and the dregs are removed by centrifuge.7. Bleaching - filtered through fuller's earth, activated carbon, or activated clays8. Deodorization - steam is passed over hot oil in a vacuum at 250C. Citric acid at. 01 percent is also added to oil after deodorization to inactivate trace metals9. Enjoy “all-natural, healthy” vegetable oil!
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Increased Deaths with PUFA
Sydney Diet-Heart StudyReplaced saturated fats with PUFA
Use of dietary linoleic acid for secondary prevention of coronary heart disease and deathBMJ 2013;346:e8707 doi: 10.1136
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No Cardiac Benefits to PUFA
Test of Effect of Lipid Lowering by Diet on Cardiovascular RiskArterioscler Thromb Vasc Biol. 1989;9:129-135 Frantz ID
39% fat diet – replaced saturated fats with PUFA
CV Event rate
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Increased Deaths with PUFA
Treatment
Control
All Cause Mortality
Test of Effect of Lipid Lowering by Diet on Cardiovascular RiskArterioscler Thromb Vasc Biol. 1989;9:129-135 Frantz I
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Increased deaths with PUFA
Use of dietary linoleic acid for secondary prevention of coronary heart disease and deathBMJ 2013;346:e8707 doi: 10.1136/bmj.e8707 (Published 5 February 2013) Ramsden CE
Increased deaths with Omega 6
Protection with Omega 3
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Homicide
Each point represents 1 country and 1 year
Increasing homicide rates and linoleic acid consumption among five Western countries, 1961-2000 Lipids. 2004 Dec;39(12):1207-13 Hibbeln J
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Depression
Increasing homicide rates and linoleic acid consumption among five Western countries, 1961-2000Lipids. 2004 Dec;39(12):1207-13 Hibbeln J
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Multiple Risk Factor Intervention Trial
Quit smoking, lower BP, eat a low fat dietDr. Jeremiah Stamler JAMA. 1982 Sep 24;248(12):1465-77
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No Benefit to Low Fat Diet
Dr. Jeremiah Stamler JAMA. 1982 Sep 24;248(12):1465-77
40.4/ 1000
41.2/ 1000
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Copyright restrictions may apply.
Beresford, S. A. A. et al. JAMA 2006;295:643-654.
Women’s Health Initiative
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Prentice, R. L. et al. JAMA 2006;295:629-642.
Invasive Breast Cancer
Beresford, S. A. A. et al. JAMA 2006;295:643-654.
Invasive Colorectal Cancer
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Fats are ProtectiveThe Effect of Co-ingestion of Fat on the Glucose, Insulin and gastric inhibitory polypeptide responses to carbohydrate and protein Am J Clin Nutr 1983; 37:941-4 Collier G
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Fats are Protective
AUC Glucose Response 1 hr
Eating fat reduces glucose response
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Mediterranean Diet
Primary Prevention of Cardiovascular Disease with a Mediterranean DietN Engl J Med 2013;368:1279-90 PREDIMED study
MI, Stroke, or CV Death
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Hormonal Obesity Theory
FatteningCarbohydrates
Increased Insulin level
Insulin Resistance
Fibre
Obesity
High TGLow HDL
Hypertension
Diabetes
Metabolic Syndrome
Fatty Liver
High Protein
Cortisol
Vinegar
Fructose
WheatSuper-carbohydrate Fasting
DiseasesOf Civilization
DiabetesHeart DiseaseCancerPeriodontitis
Fat
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