Saturated Fat, Cholesterol & Carbohydrates all over the World & Updates

Hello again! It’s been a long 5 months since TheFatNurse’s last post! I’ve been finishing up the last semester of my Family Nurse Practitioner Program and getting ready for the Boards. This means I’ve been spending less time focusing on fat related issues and more time diving into other areas of health. As result, I’ve had less time to focus on the blog. I do plan to get back into updating more regularly once the year is over.

However, the past couple of weeks has had several developments that are too note worthy to not mention! Starting in Australia:

ABC has an investigative show called Catalyst in Australia. Last week they aired a controversial report on saturated fat and cholesterol’s weak association with heart disease. This generated the obvious controversy…but the show followed it up with an episode about statins that generated even more controversy!

The basic premise of this episode was the overprescription of statins based off faulty guidelines and research on primary prevention groups (this is important to keep in mind). In addition to the literature on statins and heart disease, the show also covers some of the research process/designs when drug trials are conducted that can lead to flawed conclusions.

The expected controversy even lead the Australian Advisory Committee to urge ABC to pull the episode from airing since they believed it could have lead people to stop taking their medications – leading to death. Today Dr. Kerryn Phelps, a former Australian Medical Association president, added to the controversy by writing:

Screen Shot 2013-11-01 at 12.33.06 PM

Both episodes are worth a look to understand what the discussion is all about as many people are probably going to be confused with all this conflicting advice.

Moving onto Italy:

Apparently Pasta consumption has dropped 23% in the past decade. Why is this?

Worried about its fattening effects, she and her husband eat it no more than a few times a week, favoring couscous, meat and vegetables instead. “Metabolism changes when you approach 40,” she says, “and pasta is out of the question.”

The share of women between 26 and 30 years old who believe pasta is fattening increased 26% from 2008 to 2012, according to a Nielsen survey. And among 26- to 30-year-old men, the number who think pasta makes people fat increased 16%.

Reminds me of this episode of Portlandia:

Now to Britain:

Looks like the amount of saturated fat that will be in Britain will be decreased and taken out of the food supply:

Almost half of the food manufacturing and retail industry has signed up to the Responsibility Deal Saturated Fat Reduction Pledge by agreeing to reduce the amount of saturated fat in our food and change their products to make them healthier.

Cutting the amount of saturated fat we eat by just fifteen per cent could prevent around 2,600 premature deaths every year from conditions such as cardiovascular disease, heart diseaseand stroke.

Check out the link to the story which details what companies are planning to do. Such as:

Nestlé – which will remove 3,800 tonnes of saturated fat from over a billion Kit Kat bars per year by reformulating the recipe

And whatever they end up replacing the saturated fat will make kit kats “healthier?” Sigh…

And in Sweden:

Apparently, “Sweden has become the first Western nation to develop national dietary guidelines that reject the popular low-fat diet dogma in favor of  low-carb high-fat nutrition advice.”

I’ve heard in the past that a huge portion of the population in Sweden follows a Low Carb High Fat diet so this is not too surprising.

We’ll end with China

I’ve covered in the past how asians are often used in popular press to demonstrate how carbohydrates cannot be fattening since Asians are so skinny…despite being healthy and skinny not being the same thing.

Apparently a new study was released last month showing increased carbohydrate consumption being tied to coronary heart disease in the Chinese.

I won’t get into too much about this particular study since it’s observational and relies on questionnaires – which have faults in generating conclusive evidence. However, these study designs were used in the past to demonize dietary fat. So even if this study is not conclusive, it’s worth noting since it produced different results using similar methods in the past. Some notable observations:

These associations were robust and independent of several known CHD risk factors, including socio economic status, centralobesity, smokingstatus, hypertension, and saturated fat intake.

In a Japanese cohort, the average intakes of raw white rice were 170 g/day in women and 180 g/day in men. In that study, white rice intake was found to be inversely associated with death from cardiovascular disease in men but not in women (49). The reasons for the apparent conflicting results between that study and ours are not clear.

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Salt not as bad as previously thought? Sounds familiar…

Last week an Op-Ed piece appeared in the New York Times discussing how we may have misjudged the impact of sodium on health. Reading through it, TheFatNurse couldn’t help but notice some similarities to the war on fat. Its all related to how experiments are conducted and how data is interpreted. Definitely worth a read whether or not you agree with its conclusions.

Picture from NYT Op-ED link above

HBO Documentary The Weight of the Nation: A Critique

So the world is abuzz about this weeks documentary from HBO The Weight of the Nation. No matter its views, TheFatNurse was eagerly anticipating it due to the public influence it would have since it’s sponsored partly by the institute of medicine and other important medical establishments. It also featured prominent figures such as Dr. Lustig encouraging parents that fruit juice is just as bad if not worse than soda. However, there were some glaring things that didn’t strike TheFatNurse as productive in the battle against obesity:

*Quotes are mostly paraphrased and descriptions are based off what TheFatNurse remembers while watching the movie.

1) So right off the bat they show how the weight of the nation is increasing due to BMI without even touching on the controversy of using BMI. 

They used one portly looking fellow! However, you can have a BMI of 25-29.9 and be perfectly healthy and fit looking especially if you are an athlete. Shouldn’t they at least acknowledge this?

2) TheFatNurse already covered this in a previous post but here you can see them combining the percentages of “overweight” and “obese” to the audience.

 

Over two thirds of Americans are over weight or obese (according to controversial BMI)! Combining both categories here into one percentage just makes it seem overly dramatic.

3) An obese individual makes the statement:

“Because of my high blood pressure and risk of diabetes my doctor told me to go brown. No white bread, just wheat.”

There is a lot of controversy with this since some wheat and whole grain products can actually increase an individuals blood sugar faster than processed or refined white carbs can. Additionally, there has been a lot of studies coming out where diabetics have responded very well on Low Carb High Fat diets in decreasing their blood sugars.

4) They had an interesting experiment that looked at the metabolic effects of a 5% weight gain in already obese people. They showed an individual who was already fat and informed her to add 1000 more calories from five different fast food joints over the course of the experiment. She pointed out the fat and calories of the fast foods she ate:

However, this individual kept a food journal of what she ate before she started so they would know what her normal diet was like before the 1000 calorie intervention. Granted, this is only a one day sample, but this was the only data flashed on the screen. Look at some of these foods:

Kellog’s Special K – Hey isn’t this a “low fat heart healthy cereal?”
Banana – Heathy fruit!
Fat Free Milk – healthy milk that is fat free!
Baby carrots – nice!
Apple – More fruit!
Roasted Chicken Breast – low fat white meat!
Broccoli – OoOo healthy vegetable!
Olive Oil – healthy fat right?
Brown rice – No white rice! Yay!
French Bread – Eh…well it has no fat on it at least I suppose!
Berries – More healthy fruit!

So those foods on her daily meal log are typically portrayed as the “healthy” foods one should eat. However, for the exact same day it also includes these foods which are generally regarded as bad:

Pizza Hut Pepperoni Pizza – Blah…TheFatNurse says go round table if you gonna order junk pizza!
Rice Crispy Treat – refined processed sugary junk!
Pepsi can – More sugar!
Ketchup – more Sugar!
Angel Food Cake – TheFatNurse has actually never had angel food cake interestingly enough

So this was the amount of food in her normal diet; isn’t it also the diet that is keeping her at her baseline obesity before the 1000 calories added experiment? Notice something?  It’s an extremely high carb diet! The only foods here with high fat content is the pizza!!! And even then, the pizza has about the same amount of calories in fat as carbs! So why the need to point out how much fat you’re eating!? By the way, just looking at the amount of calories and calories from fat from the entire day…one might even be able to say this is a low fat diet based off the % of fat from calories (TheFatNurse is just estimating this)!

So now she is going around adding 1000 more calories from fast food places eating things like Fried Chicken with biscuits or classic burger fries and sodas. Yes they are high fat, but they can actually be higher in carbs than fat!

The subject then informs the audience that she now has the liver of a french goose along with her cholesterol and triglycerides off the charts. Should this really be that surprising with the amount of calories and carbs she consumed? The doctor involved with the study then shows how an obese person’s liver cells become very fat but with weight reduction (while pointing at a picture that says after gastric bypass surgery) the liver cells can return to normal.

Hmm…speaking of gastric bypass and shrinking livers…before you go in for a gastric bypass guess what you are put on in an effort to shrink your liver…a low carb diet. And after? A low carb diet (this is a low carb high protein diet instead of a low carb high fat diet).

5) Okay, enough about that experiment (Interpretation was based on the way they portrayed it in the show. TheFatNurse hasn’t read the actual study to check out the methodology). Continuing on…A loving wife who’s husband has severe diabetes says:

“You don’t have to have roast beef and steak.”
Is she implying that these foods lead to her husband’s diabetes? TheFatNurse doesn’t remember, maybe she was just giving the anti-saturated fat message in hopes to avoid heart disease since diabetics are prone to heart disease (of course the link between saturated fat and heart disease is controversial itself).

6) A scientist says:

“Obesity is the driving force behind insulin resistance…”

Oh yay! But what is the driving force behind Obesity?

7) While addressing an obese individual a doctor says:

Patient: “I’ll work on exercise for my blood pressure.”
Doctors response: “I don’t care you need to be on medication.”

Granted, who knows what this individual’s pathologies are (he may indeed have needed more than just exercise), but the doctor’s response struck TheFatNurse as non patient centered and unnecessarily dramatized things for the audience.

8) Statement from some public health government person:

“How many people are able to maintain a healthy weight in this soceity?” “A third or less”

Healthy weight based off what? BMI’s 68% mentioned earlier? Is that really a good way to define “health?” It’s the cheapest way for sure since you can just use height and weight but TheFatNurse recalls studies showing skinnier people to not always having the healthier outcome than people who may be a bit fatter.

9) Another statement made:

“Being wealthy is no longer the protective factor against obesity as it use to be.”

Well duh! The notion that wealthyness can protect against obesity like some sort of prophylaxis is nonsense! It may use to be associated with lower obesity, which means it deserves exploration but to call it a protective factor?

10) A pediatrician says:

“We as pediatricians never had to worry about learning a lot about hypertension, that was a specialist disease we sent to the cardiologist…”

I’m guessing what the doctor was trying to say was she rarely dealt with hypertension in kids. However, her statements just sound very dramatized.

11) A statement made during the film:
“The diet industry has no reason to solve the problem. It puts them out of business.”
Technically…solving the obesity dilemma would put a lot of medical establishments out of business as well. The FatNurse doesn’t mean that the medical industry wants us to be obese, but just pointing out a potential flaw in that statement.

12) Extreme emphasis on the failure of Atkins diet

TheFatNurse is not trying to say that the Atkins diet is correct or failure free, but Atkins is associated with lower carb intake which flies against traditional low fat advice (TheFatNurse is not trying to say that Low Carb is the end all be all solution either; just that it’s worked for some and might be worth looking into for some people). During a segment of obese people talking about the different diets that failed them, Atkins was emphasized with the most failure through the documentaries presentation than any other diet.

13) They show two ladies who are able to lose 100+ pounds and maintain that weight loss. They show them replacing rice with a salad instead, but no mention of carb reduction?

At this point, TheFatNurse decided to stop taking notes since it required constant stopping and made watching the documentary too long! Therefore this critique really only extends to part 1 and the beginnings of part 2. 

The Good: However there are many good things about the film as well such as Dr. Lustig’s part about sugar and they briefly touched on insulin resistance. TheFatNurse liked the advice on stopping sugar sweetened drinks for instance. Additionally, they also covered processed foods a lot and over eating which was good as well. The documentary also emphasized eating real foods instead of the processed junk that is out there. Additionally they also cover how corn subsidies from the government lead to increased processed foods.

The Bottom Line: Even with all the critiques, TheFatNurse thought the documentary was well produced and highlighted a growing problem. TheFatNurse only wishes that documentaries like this would interview and touch upon different schools of thought on what causes obesity in the first place and to critique current conventional wisdom on treatment. Lots of the information conveyed to the audience is implied to be uncontroversial “facts” when there are many controversies and competing hypotheses out there on what causes obesity and what is the best treatment.

To be clear, based off the critique, TheFatNurse feels people may think TheFatNurse is pushing a low carb high fat diet, but this is not the case. Since LCHF is often neglected in the media, TheFatNurse just chooses to bring it up often as a competing theory. There are also other great theories out there like the food reward theory (future post!). Hell, there is even controversy to the mechanism behind LCHF! Does it work for some people because of the insulin carbohydrate response? Does it work because low carbohydrate diets reduce appetite throughout the day leading to calorie deficit? Of course this doesn’t mean the traditional low fat diet doesn’t work – plenty of people lose weight with it! But for those who don’t, it may be worth exploring other avenues and documentaries such as this one would have been perfect for introducing different ideas for people to go over with their doctors.

Fat Research During the MadMen Era

My friends keep obsessing over the new season of MadMen, so lets take a look at some of the landmarks of obesity related topics in this era. This era is well known for establishing Ancel Key’s Lipid hypothesis which states saturated fat increases cholesterol and increased cholesterol is a risk for heart disease therefore reduction of cholesterol and saturated fat reduced heart disease. This hypothesis is still widely accepted today. However, contradictory evidence was emerging around the same time. Two notable scientists providing an alternate hypothesis to heart disease at this time were Peter Ahrens and John Gofman.

John Gofman is famous for pioneering cholesterol research. While everyone was focusing on cholesterol as the circulating fat during the 50s, Gofman pointed out that the body circulated more lipid like substances than just cholesterol such as triglycerides. Additionally, there was also the lipoproteins that were involved in these lipids. This discovery naturally lead to the question: is there more to this story than just cholesterol? However, due to the technology at the time, it was only feasible to measure cholesterol (total).

With time, scientists eventually discovered three important Lipoproteins involved with cholesterol: HDL (the so called good one), LDL (what we commonly think of as the bad one) and VLDL (which carries most of the triglycerides). While everyone else was concerned about total cholesterol, Gofman realized that LDL seemed to be in larger amounts in patients with atherosclerosis independent of their total cholesterol. Therefore, Gofman pointed out that measuring total cholesterol was useless. However, even more compelling, was Gofman’s research on VLDL.

Gofman discovered that eating saturated fats could raise LDL which would fall in line with our current way of thinking. However, he also discovered that eating more carbohydrates would raise VLDL levels! The implications of this finding showed the potential dangers of using a low fat – high carbohydrate diet. For example, Gofman pointed out that the substitution of saturated fats for carbohydrates (the “carbohydrate factor” as he put it) could potentially cause more harm for individuals if it elevated their VLDL levels too high. This was of particular concern since cholesterol levels during this era was measured as total cholesterol and not into more specific subsets.

John W. Gofman

“If LDL was abnormally elevated, then this low-fat diet might help, but what Gofman called the ‘carbohydrate factor’ in these low-fat diets might raise VLDL so much that the diet would do more harm than good.”

– Gary Taubes, Good Calories Bad Calories

Another prominent scientist at this time was Peter Ahrens who is associated with terming the phenomenon of carbohydrate-induced lipemia. Simply put, this is circulation of fatty triglycerides in the blood (carried by VLDLs as shown from Gofman’s research) which is a risk for heart disease. The question is: was a person more likely to have this circulating systemically on a high carb or a high fat diet?

Since VLDLs were more likely to increase under carbohydrates consumption, you would be right if you said a diet focused more on carbohydrates. Ahrens demonstrated this by showing blood serum from the same patient following a high fat or high carbohydrate meal. The test tube was cloudy with triglycerides if they had eaten the carbohydrate diet but clear if they had eaten the high fat diet. However, during this period, having a high triglyceride level was still being questioned whether or not to play a role in heart disease. Ahrens warned the lipid hypothesis needed more questioning before low-fat diets (which would mean an increase of calories from carbohydrates) should be recommended since they did not know whether carbohydrates, fats or some other factor played a role in heart disease.
***Of note, Ahrens showed that a high carbohydrate diet would have less triglyceride levels if the total caloric intake was very low. A point he used to argue certain Asian countries having lower heart disease despite having a high carbohydrate diet at the time.

Margaret Albrink, at the metabolic division of Yale Medical School would provide some observations on the importance of triglycerides. Her findings showed high triglycerides were more common than elevation of cholesterol in patients with cerebral, coronary and aortic atherosclerosis. And that potential accumulation of triglycerides may be the most common lipid derangement in coronary artery disease.

Albrink presented her results to the association of the American Physicians but was met with anger and disbelief. This occurred only recently after the American Heart Association decided to accept and endorse Ancel Key’s idea of saturated fat and cholesterol (Lipid hypothesis) being the culprit. Albrink would continually be attacked by proponent’s of the lipid hypothesis. However, she would receive more support from other scientists later such as Nobel laureate Joseph Goldstein who found elevated triglyerides just as common if not more so than cholesterol in over 500 patients with heart disease. Even more interesting was a study done by Peter Kuo which showed:

More than 90% of the 286 patients were found to have hyperglyceridemia derived from increased endogenous lipogenesis from carbohydrate. This abnormal carbohydrate sensitivity was revealed with an ad libitum carbohydrate (35% to 40%) diet. Since lipoproteins synthesized from carbohydrates were shown to be rich in both triglyceride and cholesterol, carbohydrate-sensitive hyperglyceridemia was frequently found in association with hypercholesteremia. The abnormal metabolism was controlled by a sugar-free diet, with a carbohydrate allowance of 125 to 150 gm supplied as starches.

So 90% of the subjects had elevated triglycerides related to carbohydrate consumption. Additionally, since VLDLs carry triglycerides and cholesterol (majority triglycerides), that could potentially mean increases in cholesterol levels could be related to carbohydrate consumption as well. Interestingly enough, the elevated triglycerides and cholesterol were controlled when patients were put on limited carbohydrates…

Even more interesting was an editorial put out by the Journal of the American Medical Association about these new discoveries:

“Research,like therapeutics, experiences cyclic fads. These are characterized by a rush of investigators towards an avenue of research initiated by publication of a few promising studies. For nearly fifteen years, an almost embarrassingly high number of researchers boarded the “cholesterol bandwagon” in pursuit of understanding of atherosclerosis. This fervent embrace of cholesterol to the exclusion of other biochemical alterations resulted in a narrow scope of study of a disease which is probably multifaceted in causation. Fortunately, other fruitful approaches have been made possible in the past few years by identification of the fundamental role of such factors as triglycerides and carbohydrate metabolism in atherogenesis.”

Somehow tho, saturated fats and cholesterol being the culprit behind heart disease has still become unquestionable medical facts to many practitioners and thus society. Just how sure are we of this?

Peter Ahrens

“Some thought him to be obtuse or stubborn, as he refused to endorse claims that changing our diets by lowering cholesterol intake would be the sole and most effective weapon to win the battle against heart disease. He was indefatigable in pointing out the necessity of additional clinical research in human subjects to delineate individual differences in response to diet. Unpopular as these views may have been, time has revealed the correctness of his views.
http://www.jlr.org/content/42/6/891.full

Serum Lipids and Cerebral Vascular Disease
ROBERT G. FELDMAN, MD; NEW HAVEN; MARGARET J. ALBRINK, MD
Arch Neurol. 1964;10(1):91-100.

Hyperlipidemia in Coronary Heart Disease I. Lipid levels in 500 survivors of  Myocardial InfarctionJOSEPHL.GOLDSTEIN,WILLIAMR.HAzzmm, HELMUTG.ScinoTT, EDWINL.BIERMAN,andARNoG.MOTULSKYwiththeassistanceof MARYJoLEVINSKIandELLEND.CAMPBELL

Hyperglyceridemia in Coronary Artery Disease and Its Management
Peter T. Kuo, MD JAMA.1967;201(2):87-94. doi: 10.1001/jama.1967.03130020033007

CORONARY HEART DISEASE AND CARBOHYDRATE METABOLISM JAMA.1967;201(13):1040-1041. doi:10.1001/jama.1967.03130130066017CORONARY HEART DISEASE AND CARBOHYDRATE METABOLISM JAMA.1967;201(13):1040-1041. doi:10.1001/jama.1967.03130130066017