The following item came into my inbox and I thought people might be interested in the analysis presented. I have attached the two figures from the article as a picture above. The original article can be read at wr293.infusionsoft.com/app/... and is an InforMED article.
The words below the equals signs are those in the article, not my words.
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Butter is Back. Or Is It?
by guest contributor Sheeba Khan
In The New York Times article entitled “Butter is Back” [1] (March, 2014), food writer Mark Bittman reported that a “meta-analysis published in the Annals of Internal Medicine found that there’s just no evidence to support the notion that saturated fat increases the risk of heart disease.” Bittman’s catchy title, along with Time Magazine’s “Eat Butter” (March, 2014) and other media reports suggest to the public that eating liberal amounts of saturated fat has no impact on cardiovascular disease (CVD) risk.
The broader conclusion that some readers might reach is that dietary pattern (including total fat or animal food intake) does not influence CVD risk or that dietary research results keep changing and are meaningless (saturated fat used to be bad and now it is not). However, readers who did not look beyond the headline were misled for these reasons:
1) The New York Times article did not accurately reflect the original researchers’ conclusions: The meta-analysis’ [2] purpose was to evaluate the existing CVD guidelines to substitute saturated fats with polyunsaturated fatty acids, not to determine the relationship between total saturated fat or total fat intake and cardiovascular disease. While the analysis found no benefit in substituting saturated fats with other fats, it did not conclude that lowering animal food or fat intake had no benefit.
2) Previous research had also found no benefit in substituting types of fat to reduce CVD risk. The headlines gave the impression that new or groundbreaking results were found.
3) The original study [2] had design issues and possible conflicts of interest.
4) Most importantly, a vast body of research shows that increased fat consumption does in fact increase CVD risk and that low-fat predominantly plant-based dietary patterns reduces the risk.
1. New York Times article misinterpreted original research conclusions
The introductory paragraph of “Butter is Back” [1] advises readers to resume searching for the best pieces of pork for a stew — “the ones with the most fat”. The author references a New York Times blog, “Study Questions Fat and Heart Disease” [3] which refers to a meta-analysis published in the Annals of Internal Medicine [2].
However, in an interview with the BBC [4], Dr. Nita Forouhione, one of study’s researchers stated, “That is an oversimplification, we never said that.” Also, the meta-analysis attempted to analyze the impact of saturated fat substitution with other types of fat, and not the impact of total fat intake or of varying dietary patterns. Rather, their findings “did not yield clearly supportive evidence for current cardiovascular guidelines that encourage high consumption of polyunsaturated fatty acids and low consumption of saturated fats.”
2. Lack of benefit by substitution of saturated fat with other fats is not a new finding
Studies dating back to the 1990s have shown that fats other than saturated fat contribute to cardiovascular disease so conclusions in the Annals of Medicine article [2] are not new or surprising:
An article published in JAMA in1990 examined the influence of dietary pattern on coronary artery lesions and concluded “Each quartile of increased consumption of total fat and polyunsaturated fat was associated with a significant increase in risk of new lesions.” [5]
A study published in the Lancet in 1994 found “a direct influence of dietary polyunsaturated fatty acids on aortic plaque formation”. [6]
3. Original research article [2] had study design problem and possible conflicts of interest
Although the original research results [2] are not that relevant given the overall body of research on fat intake, dietary patterns and heart disease (section 4 below), the study had design issues and possible conflicts of interest worth noting:
3.1 Study design:
The review included 649,812 participants in total (512,420 in Prospective cohort studies of dietary fatty acid intake), 32,307 in Prospective cohort studies of fatty acid biomarkers, 105,085 in RCTs of fatty acid supplementation), of which 463,038 (71%) used self-reported questionnaires. Self-reported dietary data has been found to be inaccurate [7] and the researchers acknowledged that snacks containing saturated fat may be been under-reported. Note: Original article summary contained errors which were corrected two months later [8].
3.2 Possible conflicts of interest:
The first page of the article [2] questions the association of saturated fat and CVD: “prospective observational studies have questioned whether there really are associations between saturated fat consumption and cardiovascular disease (12)”. The meta-analysis referenced [9] was supported by the National Dairy Council (see footnote 4 in article) and may have been deliberately designed to cause confusion.
Although the original article did not promote pharmaceuticals as a method to reduce CVD risk, readers may conclude that this is the only option if diet does not play a role. Some of the researchers received grants or fees from pharmaceutical companies that sell cholesterol lowering drugs including Pfizer (listed in Potential Conflicts of Interest).
4. A large body of research shows that low-fat plant-centered dietary patterns reduce CVD risk
Unfortunately for the public, evidence on the type of dietary pattern to follow to prevent and reduce the risk of CVD recurrence is rarely reported. Examples from epidemiological, migration and clinical research demonstrate that predominantly plant-based diets that are lower in fat than the Standard American Diet (33.6% fat [10]) are associated with lower rates of CVD, and that a very low-fat plant-based diet can treat CVD:
Papua Highlanders of New Guinea eat a plant-based diet of primarily sweet potatoes and rarely develop coronary artery disease although they are heavy smokers. [11]
In the China Cornell Oxford Project (China Study), researchers analyzed the relationship between diet and cancer, and other diseases (including coronary artery disease (CAD) mortality and serum cholesterol, a marker for CVD) in rural China. Green vegetable intake was associated with reduced CAD mortality while plasma apolipoprotein B (positively associated with animal protein intake and the frequency of meat intake) increased CAD mortality. “Compared to the United States, fat intake was less than half and fiber intake was three times higher. Animal protein intake was about 10% of the US intake. Coronary artery disease mortality was 16.7-fold greater for US men and 5.6-fold greater for US women.” [12]. Unlike the meta-analysis in the Annals of Internal Medicine [2], this research captured detailed dietary records in subjects’ homes.
The Okinawans of Japan, known for longevity, have lower coronary heart disease mortality than other Japanese and much lower than people living in the U.S.:
Their traditional diet is high in vegetables and fruit and low in meat and saturated fat. Prior to 1949, 85% of their calories came from carbohydrates (primarily sweet potatoes) and 6% came from fat. [13]
Another study of Japanese people analyzed the impact of dietary pattern on CVD risk and found that the “Japanese pattern” (soybean products, fish, seaweeds, vegetables, fruits and green tea) had a lower risk of CVD mortality and the “animal food” pattern had a higher risk [14]. Even among Japanese people, risk was higher among the “animal food” group, suggesting that Japanese people do not have genetic protection.
A study comparing mortality of Japanese men in Japan to Japanese men in San Francisco found that “coronary heart disease rates are consistently and significantly lower in Japan than in American Japanese” - further evidence that Japanese men do not have a genetic advantage and that lifestyle contributes to CVD. [15]
Even in patients with advanced CVD who did not eat an optimal diet prior to developing CVD, Dr. C. Esselstyn Jr. used a very low-fat whole-foods plant-based diet (added oils, animal foods, nuts and avocados were prohibited) to stop progression over a 3.7 year period [16]. Compliance rate was 89%, demonstrating that people can change their eating patterns with the right guidance. Risk was meaningfully reduced by 61% compared to the non-compliant group (note: absolute reduction in risk of cardiovascular events after 3.3 years was only 1.1% for men using Lipitor [17]):
Conclusion
The New York Times “Butter is Back” [1] headline gave the impression that saturated fat and fatty foods have little impact on CVD. Many readers may have used this as a license to continue to eat a diet high in animal foods or fatty foods. They may have also concluded that dietary research is always changing and cannot be counted on.
However, the meta-analysis [2] referenced in the article did not conclude that animal food or total fat intake have no impact on CVD risk, but that there was no evidence of benefit in substituting saturated fats with other types of fat. Furthermore, most of the meta-analysis data was collected using self-reporting questionnaires and saturated fat intake may have been under-reported [7]. Also, the analysis questioned the recommendations to replace saturated fats with polyunsaturated fats by referencing a study supported by the National Dairy Council, suggesting possible conflict of interest.
Concluding that fat substitution does not reduce CVD is not surprising as previous studies have reached similar conclusions [5, 6].
However, research shows that dietary patterns influence CVD risk: Papua Highlanders of New Guinea [11], rural Chinese [12] and Okinawans of Japan [13] eat predominantly plant-based diets naturally lower in fat than the Standard American Diet and have lower CVD mortality than Americans. Japanese men in Japan were found to have much lower mortality than Japanese men in San Francisco, suggesting that Japanese people do not have genetic protection against CVD and that lifestyle influences risk [15]. Finally, even people with advanced CVD who were given accurate information and guidance stopped disease progression and reduced risk of recurrence by 61% using a low-fat plant-based diet [16]. Although “people want to hear good news about their bad habits” (Dr. J. McDougall) they can also change behavior and improve health outcomes!
Sheeba Khan lives in Canada, and is a long-time student of Wellness Forum Health and The Wellness Forum Institute.
References
[1] nytimes.com/2014/03/26/opin...
[2] Chowdhury R, Warnakula S, Kunutsor S et al. “Association of dietary, circulating, and supplement fatty acids with coronary risk: a systematic review and meta-analysis.” Ann Intern Med 2014 Mar 18;160(6):398-406.
[3] well.blogs.nytimes.com/2014...
[4] bbc.com/news/health-34846832
[5] Blankenhorn DH, Johnson RL, Mack WJ, el Zein HA, Vailas L., “The influence of diet on the appearance of new lesions in human coronary arteries.” JAMA. 1990 Mar 23-30;263(12):1646-52.
[6] Felton C., D. Crook, et al. “Dietary polyunsaturated fatty acids and composition of human aortic plaques.” Lancet, 1994 Oct 29;344(8931):1195-6.
[7] Poppitt SD, Swann D, et. al. “Assessment of selective under-reporting of food intake by both obese and non-obese women in a metabolic facility.” Int J Obes Relat Metab Disord. 1998;22:303-11.
[8] Correction to “Association of dietary, circulating, and supplement fatty acids with coronary risk: a systematic review and meta-analysis.” Ann Intern Med 2014 Mar 18;160(6):398-406.
[9] Siri-Tarino PW, Sun Q, Hu FB, Krauss RM. “Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease.” Am J Clin Nutr. 2010;91:535-46.
[10] Centers for Disease Control and Prevention, “Health, United States, 2016”. cdc.gov/nchs/fastats/diet.htm
[11] Luyken R, Luyken-Koning WM, Pikaar NA, Blom A. “Nutrition Studies in New Guinea.” Am J Clin Nutr 1064 Jan;14(1):13-27
[12] Campbell TC, Parpia B, Chen J. “Diet, lifestyle, and the etiology of coronary artery disease: the Cornell China study.” Am J Cardiol, 1998 Nov 26;82(10B):18T-21T.
[13] Willcox DC, Willcox BJ, Todoriki H et al. “The Okinawan Diet: Health Implications of a Low-Calorie, Nutrient-Dense, Antioxidant-Rich Dietary Pattern Low in Glycemic Load. J Am Coll Nutr 2009 Aug;28 Suppl(4):500S-516S ·
[14] Shimazu T, Kuriyama S< Hozawa A et al. “Dietary patterns and cardiovascular disease mortality in Japan: a prospective cohort study” Int J Epidemiol 2007 Jun;36(3):600-609
[15] Worth RM, Kato H, Rhoads GG, Kagan K, Syme SL. “Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii and California: mortality.” Am J Epidemiol. 1975 Dec;102(6):481-90. ncbi.nlm.nih.gov/pubmed/120....
[16] Esselstyn CB Jr et. al. "A way to reverse CAD?" J Fam Pract. 2014 Jul;63(7):356-364b.
[17] pfizer.ca/sites/g/files/g10..., p. 37
Stir fry with peanut butter sauce and baked potato. 
Gluten Free Waffles/Greek Yogurt and Chunky Peanut Butter: Lunch 8-29-2021
