Busting the cholesterol and saturated fat myths
This review article has been written because my peers and I believe that you have been completely misled and misinformed about the dangers of consuming saturated fat in the diet and the risks of developing heart disease.
It is by a combination of misinformation, poor scientific studies, corporate greed and deceptive marketing that has conspired to create one of the most damaging myths in medical history: that by consuming saturated fat in the diet and its effects on cholesterol you increase your risk of developing coronary heart disease (CHD). Sadly by following the mainstream advice for the last 30 years and eating a high carbohydrate low fat diet we now have an epidemic of obesity and type 2 diabetes in addition to high levels of heart disease.
As you will learn in this article, your total cholesterol levels are a poor predictor of heart disease; over 75% of patients admitted to hospital with a heart attack have perfectly normal total and LDL cholesterol levels and conversely at least 60 % of the people with high cholesterol numbers have perfectly healthy hearts (Malhotra 2017).
However around 66 % of patients admitted to hospital having a heart attack will have a condition known as “Metabolic Syndrome” – which is a cluster of CVD risk factors including elevated blood pressure, raised blood sugar, excess abdominal fat (enlarged waist girth), and low levels of HDL cholesterol and elevated Triglycerides (Malhotra 2017).
Since the 1980’s many of the ‘official’ dietary guidelines accepted and promoted by government and other health organisations warn us of the dangers of saturated fat “clogging up our arteries” – an analogy that has become ingrained in our subconscious, yet there is no convincing evidence that directly links dietary saturated with heart disease. We have been encouraged to remove fat from the diet and consume more carbohydrates despite the fact that there is plenty of evidence demonstrating an increased risk of heart disease from carbohydrate and sugar consumption resulting in hyperinsulinemia, insulin resistance, hypertension, weight gain, ‘pre’ & type 2 diabetes culminating in metabolic syndrome (Reaven et al, 2012).
Cholesterol has been wrongly demonised as a deadly substance that should be reduced by all means possible, conveniently enabling the pharmaceutical industry to make billions of pounds each year from ever increasing prescriptions of statins, despite their benefits being hugely over inflated through deceptive use of statistics and clever marketing. If the Pharmaceutical Industry succeeds in its mission, the majority of the population will be taking statins to prevent cardiovascular disease despite the fact that there isn’t any reliable, unbiased and non-industry funded research available to support such a plan. Sadly however modern western medicine has embraced a drug-based approach to combating all chronic disease prevention rather than encouraging patients to change their lifestyles such as adopting a High Fat Mediterranean diet and taking up regular exercise – both of which are far more powerful medicines in themselves without the unwanted side effects.
Why cholesterol is important:
- Cholesterol is one of the most vital molecules in the body; without it we would die
- Brain synapses – the vital connections between nerve cells in the brain are made almost entirely from
- Cholesterol forms an important constituent of all cell membranes
- Cholesterol is the basic raw material required to create Vitamin D. This highly important vitamin is not
only required to create healthy bones, protect against certain cancers, but has recently been identified as a having a protective effect on heart health – specifically coronary heart disease and heart failure. A recent study by Professor James Chong demonstrated that Vitamin D was able to reduce the amount of scar tissue (via its action on cardiac colony-forming unit fibroblasts) forming in the heart following a myocardial infarction (heart attack) and thus reducing the chances of impaired ‘pumping capacity’ as a result. Vitamin D deficiency is relatively common and under diagnosed especially during the winter months.
- Sex hormones are created from Cholesterol such as Testosterone, Oestrogen and Progesterone
- Cholesterol is a key component of Bile which is released from the gall bladder to help with food digestion
At this point I think it’s important to point out that under normal circumstances LDL cholesterol – aka the “Bad Cholesterol” is not harmful until it becomes damaged through a process called oxidation which may result from toxins such as cigarette smoke, chronic stress or indeed when too much sugar is present in the bloodstream and creates damaged toxic molecules called advanced glycation end products (AGEs). Both of these processes contribute to chronic inflammation within the artery walls (endothelium) and ultimately coronary heart disease. Coronary heart disease is actually a chronic inflammatory disease that responds well to a high fat low carb Mediterranean diet.
The other important point to take note of is that a diet rich in sugar and refined carbohydrates will cause insulin resistance and will raise triglyceride levels – an important and independent risk factor for heart disease. So when you next have blood lipid profile test ask the doctor or nurse for a copy of your results. The two most important items you want to look at are your Triglycerides and HDL-c aka “Good” Cholesterol. According to leading preventative cardiologists your Triglyceride to HDL ratio is a much better predictor of heart attack risk than total cholesterol or LDL cholesterol. So your ideal would be fasting levels of HDL > 1.03 mmol/L for men and > 1.29 mmol/L for women and low levels of Triglycerides < 1.7 mmol/L both of which respond to dietary changes. Interestingly HDL-c levels increase rapidly when you add more healthy fats in the diet such as Extra Virgin Olive Oil and Virgin Coconut Oil – the latter being 90% saturated fat! Triglycerides can be lowered by both reducing refined carbohydrates and eating more Omega 3 Fatty Acids from oily fish (Malhotra 2017).
NB: Important Point on LDL Cholesterol
Conventional mainstream medical wisdom will tell you that eating a diet high in saturated fat will raise your LDL cholesterol (aka bad cholesterol) and increase your risk of developing coronary heart disease and Statins are prescribed primarily to lower your LDL cholesterol down to those ‘magic’ levels that NICE Guidance have set for us and the pharmaceutical industry strive to continuously lower. We all know this to be true right? – Well not exactly. You see when we first started hearing about the ‘evils’ of LDL – it was named “bad cholesterol” because doctors and researchers thought that is was the cholesterol that caused a build up of plaque in our arteries. However LDL itself isn’t actually cholesterol; it’s a ‘PARTICLE’ – The Low Density Lipoprotein (LDL) particle that is the ‘transport vehicle’ that contains the cholesterol and triglycerides within it and shuttles them around the bloodstream. So the concept of bad cholesterol is misleading as it’s actually the carrier particle (LDL) and the size of this particle that’s important – cholesterol itself appears to be an innocent bystander. To complicate matters – not all LDL particles are equally harmful or “atherogenic” which is a term used by doctors to describe something that drives the development of artery plaque or “atherosclerosis”. (Stick with me, we’re almost there on the technical stuff!) So basically some of our circulating LDL are large, buoyant particles (Type a) and some are small and dense (Type b)The small dense particles appear to be the atherogenic ones which we want to avoid. Because they are so small and dense they are able to penetrate the artery walls (endothelium) and begin the process of forming plaques. The large buoyant particles on the other hand appear to be harmless. So you may ask: Why am I telling you all of this? Ok, its important to understand because low fat carbohydrate rich diets not only lower HDL (good stuff) and raise triglycerides (bad stuff), they also create small dense LDL particles that are hazardous to our coronary arteries. All of these 3 factors increase our risk of heart disease.
NB: When however we eat a HIGH FAT LOW CARBOHYDRATE DIET the reverse is true: HDL increases, triglycerides decrease, and the circulating LDL becomes a large ‘fluffy’ harmless particle. Collectively these changes in response to diet decrease our risk of having a heart attack. To summarise: Consuming dietary saturated fat may raise cholesterol, but importantly it raises HDL cholesterol and the good part of LDL cholesterol (LDL- type A) far more than it raises the bad part of LDL cholesterol (LDL type B). There is no evidence that supports a direct relationship between saturated fat and heart disease (Sinatra 2017).
Also important to note that if you haven’t had a heart attack and don’t suffer from coronary heart disease taking a cholesterol lowering Statin drug will not prolong your life by a single day! FACT. However if you have suffered a heart attack taking a statin may benefit you whilst you remain high risk, and these benefits are most likely due to one its “pleiotropic effects” which are independent of cholesterol lowering. Statins do “other things” as cardiologists so eloquently say, although when you look at the absolute risk reductions over 5 years the benefits don’t look quite so impressive: 96% of patients saw no benefit at all, 1.2% of patients are prevented from death, 2.6% were helped by preventing another heart attack, and only 0.8% were prevented from having a stroke (NNT.com 2018). These figures are not what big pharma wants you to see, neither do they want you to know the potential side effects or harms caused: 2% of patients develop diabetes and 10% (reported) are harmed by muscle damage. Of course these common side effects are conveniently ‘swept under the carpet’.
So you may be wondering how and why have we been following this inaccurate nutritional advice for so long and where did this “fake news” come from in the first place?
Back in 1953 an American scientist named Ancel Keys published his now ‘infamous six countries study’ where he plotted on a graph the dietary fat intake of six countries against the numbers of deaths from heart disease. His graph showed a straight line relationship between higher fat intake and increased mortality (Figure 1).However, at the time of the study, there were data also available for another 16 countries. Keys chose to omit these 16 countries from his study because they did not fit his suggested linear relationship. Keys is responsible for the diet-heart hypothesis, which for many years has been the focus of heart attack prevention strategies around the world. It is important to note the word “hypothesis”. The fact is that these ideas have never actually been proven (only an association and not causality) and yet Keys’ research findings informed and were adopted by health organisations such as the American Heart Association (AHA), the British Heart Foundation (BHF) and government public health agencies in the UK despite the caveats of a British Doctor named John Yudkin who completely refuted Keys data. Yudkin’s much more comprehensive data showed that the single dietary factor that had the strongest association with coronary heart disease was indeed Sugar and not fat at all. Unfortunately Yudkin’s research was ridiculed at the time by the medical establishment (who had already made their minds up) and subsequently his ideas were ignored. Ironically his book “Pure White and Deadly – How Sugar is Killing us and what we can do about it” has recently been reprinted and become popular again today for good reason.
Figure 1. Graphic showing the six data points chosen by Keys in grey and the data Keys omitted as red points.
So let’s take a look at some of the recent evidence. The following passage has been taken from an editorial published in The British Journal of Sports Medicine (BJSM) last year (Aug 2017), and co- authored by Dr Aseem Malhotra – an outspoken Cardiologist, Anti – Sugar Campaigner and author of The Pioppi Diet who challenges conventional views on saturated fats and is a pioneer in the fight against sugar and its deleterious effects on health;
“Despite popular belief among doctors and the public, the conceptual model of dietary saturated fat clogging a pipe is just plain wrong.
A landmark systematic review and meta-analysis of observational studies showed no association between saturated fat consumption and ( 1) all-cause mortality, (2) coronary heart disease (CHD), (3) CHD mortality, (4) ischaemic stroke or ( 5) type 2 diabetes in healthy adults.(1) Similarly in the secondary prevention of CHD there is no benefit from reduced fat, including saturated fat, on myocardial infarction,
Cardiovascular or all-cause mortality. (2) I t is instructive to note that in an angiographic study of postmenopausal women with CHD, greater intake of saturated fat was associated with less progression of atherosclerosis whereas carbohydrate and polyunsaturated fat intake were associated with greater progression.( 3)
Shortly after this review findings were published from The PURE Study (6) which followed the dietary habits of 135,000 participants from 18 countries for 7 years and found that a high carbohydrate intake was associated with a higher risk of mortality (death), whereas total fat – including saturated fat were associated with lower risk of mortality. In addition all types of fat were not associated with cardiovascular disease, myocardial infarction (heart attack), or cardiovascular disease mortality. Stroke risk was inversely associated with saturated fat consumption – in other words eating saturated fat actually reduced risk of stroke. The paper concludes by saying “Global dietary guidelines should be reconsidered in light of these findings”.
In January this year (2018) David Chappell and I attended an Exercise Medicine Symposium in Cardiff – primarily as we wanted to hear the two keynote speakers – Dr Aseem Malhota and Professor Peter Brukner deliver their presentations on “You Can’t Outrun a Bad Diet” & “Why We Are Getting Fatter and Sicker”. Both experts explained how public health dietary messages have caused more harm than good and what we can do about it. More recently we both attended a conference in London for which the keynote speaker was Gary Taubes – an investigative journalist specializing in diet and nutrition and author of several books including “Why We Get Fat” and “The Case Against Sugar”. Gary’s history of the Diet-Heart Hypothesis left none of the audience (including many doctors) in any doubt that the dietary guidelines that are still current are based on fundamentally flawed research. He also presented the evidence for the benefits of switching to a High Fat Low Carb Diet.
Fortunately thanks to pioneering work of Dr Aseem Malhotra and many other supporting healthcare professionals – the tide is beginning to change. The Public Health Collaboration (PHC) is a charity that’s been set up by Samuel Feltham as an ‘antidote’ to Public Health England’s Eatwell Guide – that still promotes low fat foods and refined carbohydrates to the public. Overwhelming evidence has helped inform the creation of new healthy eating guidelines from the PHC Expert Panel and I am proud to have recently been appointed an ‘Ambassador for Brighton and Hove’ to help spread the word to the public, patients and healthcare professionals. These new healthy eating guidelines and weight loss advice handouts are now available from all Take Heart Classes as we want to give our members the best evidence based advice available so that they can achieve optimal health and fitness through our community cardiac rehab programmes in Sussex.
Meanwhile the government needs to accept responsibility that its recommendations for healthy eating and weight loss clearly haven’t worked. The UK has one of the highest prevalence of obesity in Europe at 25% and the number of people living with type 2 diabetes has more than doubled since 1996. Both cost the NHS £16 billion a year, and the UK economy at large £47 billion a year. These worrying statistics suggest that there is something wrong with the lifestyles of the UK population.
However, according to the latest National Diet and Nutrition Survey published in 2014 by PHE and the FSA adults in the UK have been generally following healthy eating guidelines. In fact on average adults in the UK have been eating 383 calories below the recommended daily amount as well as eating just below the recommended 35% for total fat consumption . This paradox of the public following the “healthy eating” guidelines yet alarming health statistics showing otherwise brings into question the very guidelines that the UK population is being asked to follow. Many GP’s, nurses, pharmacists and sadly dieticians are still following these guidelines that frankly would be thrown out of court once the evidence had been heard against them.
The following Information is from thePublic Health Collaborations (PHC) Official Guidelines
Concern No 1: The Avoidance of Foods because of its Saturated Fat Content
The NHS Choices website recommends that people should “Go for lower-fat milk and dairy foods.” This is based on the fact that full fat dairy foods contain higher amounts of saturated fat and under the Healthy dairy choices for adults section it says “A diet high in saturated fat can also lead to raised levels of cholesterol in the blood, and this can put you at increased risk of a heart attack or stroke.” The NHS Choices website also states under the Meat in your diet section that “Some meats are high in fat, especially saturated fat. Eating a lot of saturated fat can raise cholesterol levels in the blood, and having high cholesterol raises your risk of heart disease.”  Both recommendations were last updated in 2015 with review dates in 2017. However, well before then many analyses had been published finding that saturated fat is not an issue of concern. In March 2010 an analysis published in The American Journal of Clinical Nutrition by the Harvard School of Public Health followed 347,747 people over 5-23 years and concluded that ”Intake of saturated fat was not associated with an increased risk of coronary heart disease, stroke, or cardiovascular disease.” [ 17]
Following that in July 2012 a review published in the European Journal of Nutrition concluded that
“observational evidence does not support the hypothesis that dairy fat or high-fat dairy foods contribute to obesity or cardiometabolic risk, and suggests that high-fat dairy consumption within typical dietary patterns is inversely associated with obesity risk.”
Finally, in March 2014 the University of Cambridge published an analysis in the Annals of Internal Medicine looking at a total of 643,226 people concluding that ”Current evidence does not clearly support cardiovascular guidelines that encourage high consumption of polyunsaturated fatty acids and low consumption of total saturated fats.” 
In fact a month after the advice from NHS Choices on meat was last reviewed in August 2015 an analysis of up to 339,090 people was published in the BMJ concluding that “Saturated fats are not associated with all-cause mortality, cardiovascular disease, coronary heart disease, ischemic stroke, or type 2 diabetes” . Over a decade previously an analysis published in the BMJ by the Harvard School of Public Health in July 2003 followed 43,732 men over 14 years and concluded that “These findings do not support associations between intake of total fat, cholesterol, or specific types of fat and risk of stroke in men.” 
One of the most worrying aspects of the advice to lower fat consumption, and specifically saturated fat, was an analysis published in OpenHeart in February 2015 which looked at the evidence available in 1983 when the UK were first told to restrict fat concluded that “Dietary recommendations were introduced for 220 million US and 56 million UK citizens by 1983, in the absence of supporting evidence from randomised controlled trials.” 
In retrospect, there was never any strong evidence to recommend reducing total and saturated fat consumption and in the 30 years since the deteriorating health of the UK population suggests such advice may have been a dire mistake, however well intentioned. Quite possibly if the UK had been advised to go for foods in their natural form instead of unnaturally man-made low-fat foods for the past 30 years then there would not be such high rates of obesity, type 2 diabetes and cardiovascular disease, nor the associated social and financial costs they incur.
In light of this scientific evidence the Public Health Collaboration suggests that the UK stops recommending the avoidance of foods because of saturated fat content in order to focus on the consumption of food in its natural form, however much saturated fat it contains.
So if saturated fat isn’t bad for us but we know that sugar and refined carbs are – what should be eating? Enter the High FaMediterranean Diet…
The Lyon Heart study showed that adopting a Mediterranean diet in secondary prevention improved hard outcomes for both recurrent myocardial infarction (heart attack) and all-cause mortality (death) despite there being no significant difference in plasma low-density lipoprotein (LDL) cholesterol between the two groups. It is the alpha linoleic acid, polyphenols and omega-3 fatty acids present in nuts, extra virgin olive oil, vegetables and oily fish that rapidly attenuate inflammation and coronary thrombosis (blood clot in coronary artery)(6)
Here are the foods we advise cutting down on or eliminating from your diet (depending on disease status)
Bread, Potatoes, Pasta, Rice, Cereals (including granola and instant oats), crisps, biscuits and cakes, Fruit Juice, Soda’s, and high sugar content alcoholic drinks such as Beer although Red wine, Dry White Wine and spirits as they contain less sugar and can still be enjoyed in moderation. Beware of “FAKE FOODS” such as “low fat Foods” as they often contain added sugars – avoid them where possible – they are not healthy! Aim to eat Whole Unprocessed Foods.
Pioppi Diet Top Ten Foods (From The Pioppi Diet by Dr Aseem Malhotra)
- Extra Virgin Olive Oil (2-4 Tablespoons daily)
- Nuts (a handful daily ) Walnuts, hazelnuts, almonds
- Fibrous Vegetables including: Broccoli, Cauliflower, Courgettes, Aubergines, Onions, Sweet Potatoes
- Fruits including: tomatoes, avocados, apples, berries (blueberries, blackberries and raspberries)
- Herbs and Spices including: Garlic, Ginger, Turmeric, Basil and cinnamon.
- Fatty Fish for Omega 3’s including: Salmon, mackerel, sardines and anchovies
- Dark Chocolate ( 2 squares ) Preferably 85% cocoa solids
- Coconut (Cook freely with extra virgin coconut oil)
- Eggs (minimum of 10 each week)
- Full Fat and fermented dairy such as:(Greek FULL FAT Yogurt,Cheese and grass-fed butter)
R J Stantiford MSc., Dip H.ed, ACSM C-EP, BACPR cert
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