American College of Physicians: Internal Medicine — Doctors for Adults ®

Thursday, July 10, 2014

Study says saturated fat as bad as sugar

A recent meta-analysis by an accomplished international team of researchers, published in a prestigious medical journal, shows that high intake of saturated fat is exactly as bad for health as a high intake of sugar and refined starch. The study also suggests there is something far worse.

The study, which pooled data from prior research and in the process aggregated findings for over 500,000 people, compared the rates of coronary artery disease—the particular bad health outcome on which the researchers chose to focus for fairly obvious, epidemiologic reasons—between those with the highest intake of saturated fat as a percent of calories, and the correspondingly lowest intake of refined starch and added sugar; to those with the highest intake of sugar and refined carbohydrate, and correspondingly lowest intake of saturated fat. The rate of cardiovascular disease was virtually identical in both groups. This indicates that a high intake of saturated fat is as bad as a high intake of sugar, as well as vice versa.

OK, now that I presumably have your attention, I’ll tell you my real agenda, which has nothing to do with saturated fat, or sugar, and everything to do with stupidity. Because, folks, when it comes to food, and food for thought alike, it is mostly stupidity that is killing us. Stupidity is worse for us than either sugar or saturated fat.

The recent meta-analysis to which I am referring is the very one you already know (although I very much doubt many of you actually read it). The meta-analysis in question is the very one published in the Annals of Internal Medicine in March. The paper itself is entitled: Association of Dietary, Circulating, and Supplement Fatty Acids with Coronary Risk: A Systematic Review and Meta-analysis. The corresponding pop culture headlines were along the lines of, “Don’t Fear the Fat” and “Butter is Back.”

I did, of course, read the study in detail, reviewing all of the data before opining, which I did back in March. I won’t reiterate that analysis now—it remains available to you. For today, there is just one point to make: What we are looking for seems to matter much more than what we find.

The study was designed to look at variation in fatty acid intake, admittedly. But the metric applied was: AS A PERCENT OF CALORIES. Obviously, the calories we take in are always 100% of the calories we take in, so if our percent intake from one thing goes down, our percent intake from another must go up correspondingly. This, I trust, does not invite argument.

The study itself pretty much ignored this consideration—a fundamental limitation. But we certainly know from population trends what we ate more as we ate saturated fat less: sugar and refined starch. We certainly didn’t eat more vegetables—our intake of those has in fact trended down.

Because this paper came out at a time when we are disgusted that decades of (allegedly) cutting fat have left us all fatter and sicker, we were looking for something else to throw under the bus. After all, we have decided to end the war on fat. One of our favorite scapegoats these days, although by no means the only one, is sugar. So this study was interpreted not based on what was found, but based on what we were seeking. The thus entirely predictable, pop culture response was advice to bring back the butter.

But let’s try a thought experiment. Imagine if we had been cutting sugar for decades, and eating more butter, cheese, and deli meats instead—and were just as fat and sick and coronary disease-prone as ever. Then, we would be disgusted with the “just cut sugar” hypothesis and would be looking for something else to blame for our woes. This study would have provided it just as readily. Because, as noted, it showed that the highest intake of saturated fat produced THE EXACT SAME BAD OUTCOMES as the alternative, which we may confidently infer to be a high intake of sugar and refined carbs.

We should all be pretty worried if we can use the exact same study to reach such opposing conclusions. We should all be pretty worried if our convictions about diet and health derive more from what we are seeking, based on the frustrations and disgust du jour, than on what we are finding based on an unbiased assessment of the epidemiologic evidence. And folks, they clearly are. And so pretty worried, I am.

The study in question said nothing good about butter, meat, or cheese. It simply showed that the typical American diet has been identically bad for decades in more ways than one, with typically high rates of heart disease to show for it every step of the way. We had a whole lot of preventable heart disease both before and after we swapped out saturated fat for sugar. Conversely, we had a whole lot of preventable heart disease both after and before we swapped in sugar for saturated fat.

I invite those of you inclined to roll your eyes at me to read the meta-analysis in its hoary detail, scrutinize the data tables, and come back with a data-driven rebuttal. I promise to listen—then. Until and unless you can do that—and I am confident you can’t—we are done here.

And folks, we are done for if we let this brand of stupidity persist. Stupidity is what’s killing us, far more surely than sugar or saturated fat. It really has to stop—because literal lives are at stake.

We do, in fact, know what dietary patterns are associated with optimal health outcomes. We know it based on vast, diverse, robust, and astonishingly consistent evidence. As evidence of the consistency of the evidence, I reached a particular set of conclusions based on my commissioned review of the literature with one set of analytical objectives. Dr. Frank Hu at Harvard and his colleagues reached a virtually identical set of conclusions based on an entirely independent review of the literature born of a different set of analytical objectives.

We are not clueless about the basic care and feeding of Homo sapiens. We really are not.

But eating well cannot be achieved by shifting from one scapegoat to the next; that merely invites new ways to eat badly. It can’t be done one nutrient at a time. If ever there was a case of fixating on a tree while the forest burns down, modern trends in nutrition exemplify it.

When we approach the interface of science and pop culture representations of it with an agenda, we are going to find what we are seeking. That won’t make it true. But since we were seeking it, we will be prone to embrace it as truth. Worse, we are increasingly prone to do so with religious zeal. I am routinely a victim of that failure to separate church and plate myself, being called names that make my wife and mother wince. All this, despite having no dietary pattern to sell anyone, and simply trying to advance this platform: wholesome foods in sensible combinations.

Yes, I argue that should be “mostly plants,” because the evidence argues that way—not because I own stock in Brussels sprouts. A Paleo style diet that derives 50% of its calories from game is still “mostly plants” by volume, and a legitimate variation on the theme for those inclined to go that way. But the popular mantra of more “meat, butter, and cheese” is off the theme altogether. I don’t say that because I win a prize every time someone declines pastrami. I say that because it’s what the weight of evidence indicates.

Honestly, I am a bit tempted to surrender, because the name-calling does get tedious. But this is my job—it’s what I do. My training in preventive medicine and my role in lifestyle medicine define and obligate me. I simply have to keep trying to add years to life and life to years, because it is what I do, and who I am. The success of that mission is highly dependent on the quality of our food.

And that, in turn, is highly dependent on the quality of our food for thought. And that has been an appalling load of mostly junk for far too long already.

No, saturated fat is NOT our nutritional nemesis, and never was. But neither is sugar, nor wheat, nor all grains. No one thing is THE thing wrong with our diets, and no one food, nutrient, or ingredient will be our salvation either. Wholesome foods, mostly plants, in sensible combinations could be—assuming an 80% reduction in all chronic disease qualifies as salvation. It’s about as close as we can come in the context of epidemiology, and pretty darn good.

What stands in the way is not our admittedly imperfect knowledge of nutrition, because frankly, we know enough. What stands in the way is hyperbolic headlines, fixed agendas, reactionism, religious zeal, profiteering, finding only what we’re seeking, and failure to learn from the follies of history.

In other words, what is far more perilous to our health than saturated fat or sugar is the prevailing standard of stupidity in the food for thought we swallow routinely. If there is a war to be waged against anything ingestible, I humbly suggest it be that.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

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Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

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William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

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Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

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Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

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Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

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Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

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Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

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PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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