Heart of the Matter – ABC Catalyst

The Australian Broadcasting Corporation Catalyst program series produced a 2 part program collectively titled Heart of the Matter. The programs are titled Dietary Villains and Cholesterol Drug War. These programs were aired in October 2013.

The presenter and co-producer is Dr Marianne Demasi. The medical experts interviewed include Dr Michael Eades, Dr Jonny Bowden and Dr Stephen Sinatra. Science and medical writer Gary Taubes was also interviewed.

Lyon Diet Heart Study

The Catalyst program Heart of the Matter references the Lyon Diet Heart Study as evidence that cholesterol is not implicated in heart disease.  If you actually read the Final Report of the Lyon Diet Heart Study [1] , it clearly states that cholesterol is indeed implicated in heart disease.

The Lyon Diet Heart Study is a “randomized, single-blind secondary prevention trial aimed at testing whether a Mediterranean-type diet, compared with a prudent Western- type diet, may reduce recurrence after a first myocardial infarction.”

The Final Report of the Lyon Diet Heart Study shows that “the data confirm the impressive protective effect of the Mediterranean diet.”  It also states, “major traditional risk factors, such as high blood cholesterol and blood pressure, were shown to be independent and joint predictors of recurrence.”

This report concludes, that “for each increase of 1 mmol/L of total cholesterol increased the risk of recurrence by 20% to 30%.  Epidemiological studies have consistently shown a positive correlation between plasma cholesterol levels and the incidence of (and mortality from) CHD in various populations.  Thus, our population does not appear to be different from other low-risk populations.”

This is not the conclusion that Catalyst managed to derive from the Lyon Diet Heart Study.

This report also states that an increased leukocyte count increased the risk of heart disease.

Other Risk Factors

Another important and independent risk factor for heart disease is homocysteine level greater than 9 mmol/L.  Optimal level for homocysteine is 6 mmol/L.  Homocysteine is a non-protein, sulphur containing amino acid.  High levels indicate deficiency in B12, B9 (folic acid) or B6.  It can also be raised from smoking, kidney disease and diabetes.  Average homocysteine levels are higher in vegetarians and vegans than in the general population.

Six Countries Study

Ancel Keys’ paper Atherosclerosis: A Problem in Newer Public Health paper was presented in New York in January 1953.  This paper is commonly referred to as the Six Countries Study.   He stated that the present high rate of death from degenerative heart disease is not inevitable by showing comparisons with other countries. [2]

Keys does state in this paper that “the high reliability with groups and the low reliability with individuals apply to all of the measurements so far studied: total cholesterol, cholesterol/phospholipids ratio, . . . .”.

Firstly, at this stage of his research, Keys implicated fat (% calories from fat) as an indicator of heart disease – not saturated fat.

Secondly, this paper does refer to his previous surveys and the works of others.  He was not relying on only the statistics of the 6 selected countries to make his conclusions.

J Yerushalmy and H Hillboe criticised the paper Atherosclerosis: A Problem in Newer Public Health in the publication Fat In The Diet and Mortality From Heart Disease [3] , claiming that Keys only choose 6 countries that supported his hypothesis.  They state Keys did not give reasons for his selection.  This is clearly incorrect.  If you read Keys’ paper, Keys did give the reasons for choices.

Strom and Jensen - NorwayThe Scandinavian countries were excluded because of the effects of the World War II.  The consumption of meat and eggs dropped during the war and so did the level of heart disease.  [4]  However, two areas of Finland were included later in the Seven Countries Study.

The WHO data shows France as having little heart disease even though it has a high fat consumption, giving rise to the French Paradox myth.  According to a paper in the Dialogues of Medicine – Vol 13 No 3 2008, [5], the French paradox is indeed a myth.

The clear conclusion, driven by the facts as summarized by Pierre Ducimetière, is that the rates of CHD are not so low in France, animal fat intake is not so high, and the diet-heart concept is not so unique that the existence of a “French paradox” can be sustained, except for satisfying cultural fantasy or for wine enthusiasm and marketing. Thus, the real paradox is why the French paradox continues to exist as a concept, when it should be replaced by the less mystifying view, namely, “the more Mediterranean, the better”.

The Catalyst program stated that data from 22 countries was available to Ancel Keys but he chose the data that fitted his hypothesis.  The Catalyst program does not state the source of this data from the 22 relevant countries.

Jacob Yerushalmy and Herman Hilleboe examined the data from all of the 22 countries in the WHO Epidemiological and Vital Statistics 1951-1953 publication.  The results were published in their paper Fat in the diet and mortality from heart disease.

Note that Keys’ paper was presented in January 1953.  Yerushalmy and Hilleboe used World Health Organisation data from the years 1951-1953.

The Catalyst program states that you could have chosen six other countries and drawn different conclusions.  What six countries?

Even if data from all the 22 countries are included, it still shows:

  • positive correlations between heart disease and calories consumed, fat consumption, animal fat consumption, animal protein consumption and
  • negative correlations with heart disease and carbohydrate consumption, vegetable protein consumption, vegetable fat consumption.

Hillboe later co-authored a paper Risk Factors in Ischemic Heart Disease in Vol 53 No 3 American Journal of Public Health showing that “high cholesterol was the greatest risk factor of any single variable in ischemic heart disease”.

In the conclusion of this paper, Keys states that there is sufficient evidence to “warrant a large extension of this type of epidemiological research”.  His views were refined with later studies including the Seven Countries Study.

Seven Countries Study and the Mediterranean Diet

Ancel Keys and colleagues posed the hypothesis that differences among populations in the frequency of heart attacks and stroke would occur as a result of physical characteristics and lifestyle and diet.

Surveys were carried out 1958 – 1970 in populations of men aged 40-59, in 16 areas of seven countries. Follow-up surveys were continued until the 1990s.

Most of the areas were stable and rural and had wide contrasts in habitual diet. Women were excluded because cardiac disease was less common and because of the invasiveness of physical examinations. [6]

 Seven Countries - Calories from Saturated Fats

B: Belgrade, Yugoslavia; C: Crevalcore, Italy; D: Dalmatia, Yugoslavia; E: East Finland; G: Corfu, Greece; J: Ushibuka, Japan; K: Crete, Greece; M: Montegiorgio, Italy; N: Zutphen, Netherlands; R: Rome, Italy; S: Slavonia, Yugoslavia; T: Tanushimaru, Japan; U: USA; V: Velika Krsna, Yugoslavia; W: West Finland; Z: Zrenjanin, Yugoslavia

Who coined the name and introduced the concept of Mediterranean diet?  In 1975, Ancel Keys and his wife Margaret published the book How to Eat Well and Stay Well the Mediterranean Way (New York, NY: Doubleday & Co; 1975) based on the results of his studies.

According to Keys, “The heart of what we now consider the Mediterranean diet is mainly vegetarian: pasta in many forms, leaves sprinkled with olive oil, all kinds of vegetables in season, and often cheese, all finished off with fruit, and frequently washed down with wine.”

The conclusion of the Catalyst program –  “Exercise and a Mediterranean-style diet is the best way to prevent heart disease.”  How is this different from the conclusions of Ancel Keys?

Ancel Keys and his wife Margaret lived a village in southern Italy for 28 years.  Keys lived to be 100 years old and his wife 97.

Cholesterol Recommendations

Dr Bill Roberts (previous long-time editor of the medical journal Cardiology), Dr Bill Castelli (director of the Framingham Heart Study), Dr Caldwell Esselstyn  (surgeon at the Cleveland Clinic) have stated that they have never seen a heart disease fatality when cholesterol levels are below 150 mg/dL (3.9 mmol/L). [7]

Dr John Mcdougall recommends the same guidelines and recommends oat bran, garlic, vitamin C, vitamin E and niacin if there is difficulty in reaching this level.  [8]

He also states that HDL “Good” Cholesterol is Not Worth Your Attention because HDL cholesterol will fall as total and LDL cholesterol falls. [10] [9]

The China Project

The China Project involved Colin Campbell, professor of nutritional biochemistry at Cornell, Chen Junshi, Deputy Director of Institute of Nutrition and Food Hygiene at the Chinese Academy of Preventive Medicine, Richard Peto of the University of Oxford and Li Junyao of the China Cancer Institute.  It is one of the most comprehensive studies ever of nutrition.

The study examined 360 different health, lifestyle and nutrition factors of 6,500 people in 65 different counties in China and found over 8,000 significant correlations.

According to Professor Campbell, [10]

Lower blood cholesterol levels are linked to lower rates of heart disease, cancer and other Western diseases, even at levels far below those considered “safe” in the West. At the outset of the China Study, no one could or would have predicted that there would be a relationship between cholesterol and any of the disease rates. What a surprise we got! As blood cholesterol levels decreased from 170 mg/dL to 90 mg/dL (4.4 mmol/L to 2.3 mmol/L), cancers of the liver, rectum, colon, male lung, female lung, breast, childhood leukemia, adult leukemia, childhood brain, adult brain, stomach and esophagus (throat) decreased.

The Catalyst conclusion that a low-fat high carbohydrate Mediterranean style diet is the best way to avoid heart disease is consistent with Ancel Keys’ conclusion.

It is in stark contrast with the high fat, high protein diet advocated by Gary Taubes. [11]

Even more effective than a Mediterranean-style diet is a whole-food, plant-based diet as advocated by Professor Colin Campbell, Dr Caldwell Esselstyn, Dr Dean Ornish, Dr Neal Barnard, Dr John McDougall and Dr Michael Greger.

According to Professor Campbell,

The vast majority of all cancers, cardiovascular diseases, and other forms of degenerative illness such as the auto-immune diseases, kidney disease and macular degeneration can be prevented and often reversed, simply by adopting a whole-food, plant-based diet.

Footnotes

  1. de Lorgeril, M. et al. (1999) Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study. Circulation. 99 (6), 779–785.
  2. Keys, A. (1953) Atherosclerosis: a problem in newer public health. Journal of Mt Sinai Hospital. July-Aug; 20 (2), 118–139.
  3. Yerushalmy, J. & Hilleboe, H. E. (1957) Fat in the Diet and Mortality from Heart Disease.
  4. Strom, A. & Jensen, R. A. (1951) Mortality from Circulatory Diseases in Norway 1940-1945. The Lancet. 1 (6647), 126–129.
  5. Tunstall-Pedoe, H. (2008) The French Paradox : Fact or Fiction? Dialogues in Cardiovascular Medicine. 13 (3)
  6. Steinberg, D. (2007) The Cholesterol Wars:  The Skeptics vs. the Preponderance of Evidence. San Diego, CA: Academic Press.
  7. Campbell, T. C. & Campbell, T. M. (2006) The China Study. Dallas USA: Benbella Books.
  8. McDougall, J. (2002) Cholesterol – When and How to Treat [online]. Available from: http://www.nealhendrickson.com/mcdougall/020900pucholesterol.htm.
  9. McDougall, J. (2004) HDL ‘Good’ Cholesterol is Not Worth Your Attention [online]. Available from: https://www.drmcdougall.com/misc/2004nl/apr/040400pufav5.htm.
  10. Campbell, T. C. & Campbell, T. M. (2006) The China Study. Dallas USA: Benbella Books.
  11. Greger, M. (2005) Carbophobia: The Scary Truth about America’s Low-Carb Craze. New York: Lantern Books.

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