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Nutrition Past and Future

The Drivers of the Herd, Part 7

Malhotra’s Major Issues, Part 1

Slide 3                   Malhotra, Aseem. "Saturated fat is not the major issue." BMJ: British Medical Journal 347 (2013).


This past October the British Medical Journal published an essay by a cardiologist named Aseem Malhotra. The title of his piece says that saturated fat is not the major issue in heart disease. I guess we can all choose our priorities but is it at least an issue? Judging by his article he thinks it isn’t. He is mistaken. His piece was a disjointed and incoherent salvo against diet-heart and it deserves a thorough rebuttal. That’s what it’ll get in these two videos. Malhotra’s article was very short. I would have liked to comment on all of it but if I were to show you every questionable passage on screen, I would end up distributing a large fraction of a work that is protected by copyright. Therefore, I have been perhaps overly selective in the topics I’ll be addressing here and in my use of quotations on screen. As I record this video the original article is available in full for free at two different sites even though the BMJ keeps it behind a pay wall. However you go about it, I encourage you to read his whole piece and consider it in light of these videos.



Slide 4                   Malhotra, Aseem. "Saturated fat is not the major issue." BMJ: British Medical Journal 347 (2013).


Let’s start with a very obvious example of his poor thinking. Here he refers to the Seven Countries study of Ancel Keys. He says it “demonized” saturated fat. He chooses that word to inject prejudicial overtones but the study was in fact conducted by many researchers all over the world, not just by Keys, and it was at its core a statistical analysis. His response to it is to simply say that “correlation is not causation.” He doesn’t even try to address its substance.



Slide 5         


This is perhaps the clearest example you will see of the reflexive and self-satisfying non-engagement this phrase – “correlation isn’t causation” – somehow permits in the minds of the apologists for saturated fat when they see disagreeable epidemiological findings. A scientist observes nature as it is and attempts to understand what she sees. She doesn’t just glibly deny what she has seen.



Slide 6                   Malhotra has chosen to deny this reality rather than engage it.



Slide 7                   Mozaffarian, Dariush, et al. "trans-Palmitoleic acid, other dairy fat biomarkers, and incident diabetes: the Multi-Ethnic Study of Atherosclerosis (MESA)." The American journal of clinical nutrition 97.4 (2013): 854-861.


Amazingly, in the very next paragraph he cites an epidemiological study that he thinks supports his views on saturated fat. But I thought he said correlation isn’t correlation! That policy changed pretty fast!



Slide 8                   The authors of this research he’s decided to embrace didn’t take for granted that the association they found was causal, but apparently Malhotra is sure that it was. But his double standards in this instance don’t end there.



Slide 9                   He started his article by saying that trans fats are terrible for cardiovascular disease. He mentions baked goods and margarines as examples of foods containing trans fats.



Slide 10                 Mozaffarian, Dariush, et al. "trans-Palmitoleic acid, other dairy fat biomarkers, and incident diabetes: the Multi-Ethnic Study of Atherosclerosis (MESA)." The American journal of clinical nutrition 97.4 (2013): 854-861.


But the authors of the study he has chosen specifically state that the biomarker for dairy consumption they are looking at is trans-palmitoleic acid, a trans fat found in margarine, cakes, cookies, and pies!



Slide 11                 The paper specifically states that this substance is a biomarker for partially hydrogenated oils.




Slide 12                 Malhotra says this study implied a benefit from dairy foods for a cluster of indicators of metabolic syndrome. Note what he says about this. “The source of the saturated fat may be important.” Why? Because of nutrients like calcium and vitamin D which are linked to it in dairy foods. But I thought his article was about saturated fat, not calcium and vitamin D! He’s all mixed up now, as if he hasn’t thought any of this through.



Slide 13                 Let’s pause to engage this paper he likes. As I said, I don’t think it is fair to simply disregard any decently executed piece of epidemiological research just because it doesn’t neatly fit our views. Epidemiology characterizes the real world. It captures the effects of factors both known and unknown. This looks to me to be a solid paper. I’m not going to just dismiss it with an empty slogan. These researchers found that this trans fat biomarker had some favorable associations, that is if we ignore its association with higher LDL cholesterol, which is a deal-breaker for me.



Slide 14                 The authors hedged their bets about whether it was in fact dairy that was responsible for those favorable effects, but let’s take this one at face value and say yes, dairy foods were responsible for all those good things. What might it be about dairy foods that explains all that? The higher LDL is no surprise to anyone so let’s just skip that part and consider the rest.




Slide 15                 Harinarayan, Chittari Venkata, et al. "Improvement in Pancreatic β Cell Function with Vitamin D and Calcium Supplementation in Vitamin D Deficient Non-Diabetic Subjects." Endocrine Practice (2013): 1-33.


Well, we know that millions of Americans are vitamin-D-deficient. Corrected vitamin D deficiency by itself would give a plausible explanation for their finding of protection from metabolic syndrome since milk is fortified with vitamin D.



Slide 16                 von Hurst, Pamela R., Welma Stonehouse, and Jane Coad. "Vitamin D supplementation reduces insulin resistance in South Asian women living in New Zealand who are insulin resistant and vitamin D deficient–a randomised, placebo-controlled trial." British Journal of Nutrition 103.4 (2010): 549.


Here’s a study that is often cited to make this same point. Milk has been fortified with vitamin D in the United States since World War II. This policy was undertaken to prevent rickets. Today non-dairy milks made from soy, almonds, and hemp are usually fortified with vitamin D just like dairy milk so this factor does not constitute a strong reason to consume dairy.



Slide 17                 Pittas, Anastassios G., et al. "The effects of calcium and vitamin D supplementation on blood glucose and markers of inflammation in nondiabetic adults." Diabetes care 30.4 (2007): 980-986.


Dairy certainly supplies calcium to the diet, and calcium and vitamin D together seem to improve insulin sensitivity. Non-dairy milks are also usually fortified with calcium.



Slide 18                 Malekinejad, Hassan, Peter Scherpenisse, and Aldert A. Bergwerff. "Naturally occurring estrogens in processed milk and in raw milk (from gestated cows)."Journal of agricultural and food chemistry 54.26 (2006): 9785-9791.


There may be other factors at work here, too. I can only speculate. Dairy from pregnant cows is a major source of exposure to exogenous estrogens.



Slide 19                 Salpeter, S. R., et al. "Meta‐analysis: effect of hormone‐replacement therapy on components of the metabolic syndrome in postmenopausal women." Diabetes, Obesity and Metabolism 8.5 (2006): 538-554.


Post-menopausal women are at increased risk of metabolic syndrome, especially if they are overweight. The women in the study that Malhotra cites were older and quite overweight. It has been observed that hormone replacement therapy reduces the markers of metabolic syndrome. Perhaps the biologically active estrogens in dairy had a salutary effect in these women in this regard. Of course, this is just my speculation.



Slide 20                 Maruyama, Kazumi, Tomoe Oshima, and Kenji Ohyama. "Exposure to exogenous estrogen through intake of commercial milk produced from pregnant cows." Pediatrics International 52.1 (2010): 33-38.


From my perspective, it seems wiser to choose almond milk over dairy milk. Almond milk makes a significant contribution of vitamin D and calcium to the diet without all the hormones in dairy milk. And make no mistake, those hormones in milk can affect us. This fact was established in this study. After drinking cow’s milk, men were observed to have increased levels of estrone and progesterone and decreased levels of testosterone. I don’t feel I would benefit from these effects but maybe Dr. Malhotra is OK with all that.



Slide 21                 Moving on, Malhotra makes the once common but now passé claim that saturated fat promotes a type of LDL particle that is not atherogenic. He provides a reference to try to support this false claim.



Slide 22                 Musunuru, Kiran. "Atherogenic dyslipidemia: cardiovascular risk and dietary intervention." Lipids 45.10 (2010): 907-914.


The reference he chose acknowledges that all LDL particles may be similarly atherogenic and that the belief that large LDLs are less atherogenic may have arisen from misinterpreted epidemiological studies. Bingo!



Slide 23                 His reference acknowledges that there are no studies demonstrating improved outcomes based on LDL particle diameter. Therefore, his chosen reference cannot validate his claim on this point.



Slide 24                 Mozaffarian, Dariush, et al. "trans-Palmitoleic acid, other dairy fat biomarkers, and incident diabetes: the Multi-Ethnic Study of Atherosclerosis (MESA)." The American journal of clinical nutrition 97.4 (2013): 854-861.


Do you remember that study he chose about the trans fats in dairy? It was conducted on a cohort from the MESA study.



Slide 25                 Mora, Samia, et al. "LDL particle subclasses, LDL particle size, and carotid atherosclerosis in the Multi-Ethnic Study of Atherosclerosis (MESA)."Atherosclerosis 192.1 (2007): 211-217.


It was this paper also based upon MESA that is most often cited as undermining his wrong beliefs about LDL particle size. All LDLs – large or small – are potentially atherogenic. Malhotra is selective about the research he considers.



Slide 26       


I’ve made a video on LDL phenotype that Malhotra should watch so he can be a bit better informed on this topic.



Slide 27                 Malhotra oddly chooses to argue in defense of saturated fat by bringing up a recent high-profile trial which was said to demonstrate the benefits of a Mediterranean diet. He calls the control diet in that trial a “low fat” diet. The fact that he used quotation marks around the words “low fat” suggests he knows he isn’t dealing straight with us.



Slide 28                 Estruch, Ramón, et al. "Primary prevention of cardiovascular disease with a Mediterranean diet." New England Journal of Medicine 368.14 (2013): 1279-1290.


The control diet wasn’t really a diet, much less a low-fat diet. The researchers simply gave some people advice on eating a lower-fat diet.



Slide 29                 In reality, they dropped their fat consumption by only 2% to 37%. Malhotra probably knows this, just as he knows that under no reasonable definition of “low fat” is such a fatty diet really “low fat.” Why would Malhotra play games with us like this?



Slide 30                 By the way, notice that in that trial the control dieters increased their carbs a little while they decreased their fiber intake. Junky carbs make their way into a so-called “low-fat” diet trial yet again. Such a trial can tell us nothing about a proper low-fat diet. Wasn’t this obvious to Malhotra?



Slide 31                 Romeu, Marta, et al. "Diet, iron biomarkers and oxidative stress in a representative sample of Mediterranean population." Nutrition journal 12.1 (2013): 102.


A better lesson about the Mediterranean diet would come from this study of a Mediterranean population. Saturated fat joined red meat and fish as associating with increased oxidative stress. Those experiencing less oxidative stress consumed more vitamin C, vegetables, and non-heme iron, which is the iron associated with plant foods. Those results suggest we should skip the saturated fat and meat and emphasize plant foods instead.



Slide 32                 Malhotra’s thinking was especially problematic when he argued that there is something about saturated fat that makes it a great choice for keeping off excess pounds. I’ll talk about the wacky references he used to argue that in the next video.