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Nutrition Past and Future

The Drivers of the Herd, Part 18

The NuSI Guys, Part 8 (The “Straight Dope” or a Bending of the Truth? Dietary Trends, Part 2)

Slide 3         

Dr. Peter Attia says he is obsessed with lipidology. I can relate to that. Apparently he feels he has reached a point of sufficient expertise on this topic that he feels he should be lecturing and blogging about it. I can relate to that, too. But here is the problem: Dr. Attia is giving us bad information. His views on this topic are distorted by his low-carb ideology. I’ll demonstrate that to you in the next three videos. Attia published a series of blogs about cholesterol on his website that he called, “The Straight Dope on Cholesterol.”


Slide 4         

He also has a video on YouTube of the same name. I’ll only need to show you a few comments he has made about cholesterol from these presentations to make it clear to you that we should hold his views suspect. Here is the first one.


Slide 5         

Attia: “… so the cholesterol that we eat. And you notice I’ve have pictures of both eggs and corn here. Why am I doing that? Because remember we eat both cholesterol and phytosterol from plants. Most people don’t realize this but corn actually on a per gram basis has far more phytosterol than any other plant except one. And eggs, of course, contain cholesterol. That’s why they’re so bad for us, right?”

And you can hear a few chuckles in response to his laughing delivery. How funny to think that these silly people are worried about what eggs do to their hearts when corn is at least as bad! Haha! We laugh at their ignorance! Notice that Dr. Attia is following the Gary Taubes playbook here. He implied that corn is bad for us but he didn’t say that directly. He wants you to infer the lie without him needing to say it.


Slide 6         

In the same vein is this quotation from a blog post he wrote. Atherosclerosis is defined by sterols in the artery wall, whether those sterols are cholesterol or phytosterols. This pairing of the two implies a question: why do we worry about one and not the other?


Slide 7                   p.299. Dayspring, Thomas. “Phytosterolemia.” From Davidson, Michael, Peter P. Toth, and Kevin C. Maki. Therapeutic Lipidology. Totowa, N.J: Humana, 2007. Print.

Attia says that one of his mentors in his education about lipids and cardiovascular disease is Thomas Dayspring. Dayspring tells us in a textbook chapter he wrote about phytosterolemia that plant sterols are problematic only for individuals with specific genetic defects. He also wrote that concentrations of phytosterols in the plasma do not correlate well with dietary intake.


Slide 8                   Patel, Manoj D., and Paul D. Thompson. "Phytosterols and vascular disease."Atherosclerosis 186.1 (2006): 12-19.

How many people have these specific genetic defects? This condition is so rare that its prevalence is unknown. Dr. Dayspring estimates that only 1 in 1,000,000 is affected.


Slide 9                   Bhattacharyya, Ashim K., and William E. Connor. "β-Sitosterolemia and xanthomatosis: a newly described lipid storage disease in two sisters." Journal of Clinical Investigation 53.4 (1974): 1033.

Phytosterolemia is so rare, it was not even described in the medical literature until 1974.


Slide 10                 Nguyen, Lien B., et al. "Regulation of cholesterol biosynthesis in sitosterolemia: effects of lovastatin, cholestyramine, and dietary sterol restriction." Journal of lipid research 32.12 (1991): 1941-1948.

Notice that in this study of people with phytosterolemia that the dietary restriction of plant sterols didn’t do much of anything.


Slide 11                 Rader, Daniel J., Jonathan Cohen, and Helen H. Hobbs. "Monogenic hypercholesterolemia: new insights in pathogenesis and treatment." Journal of Clinical Investigation 111.12 (2003): 1795-1803.

If the dietary restriction of plant sterols doesn’t do much, then how else is this condition treated? There are several treatment options, but perhaps the most interesting in the present context is the restriction of dietary cholesterol. Yes, if you are that rare person with this problem you need to avoid eggs, whether Dr. Attia thinks that’s funny or not.


Slide 12                 Genser, Bernd, et al. "Plant sterols and cardiovascular disease: a systematic review and meta-analysis." European heart journal 33.4 (2012): 444-451.

Should the rest of us be concerned about plant sterols? There is some controversy over whether they should be added to the diet in the form of supplements. The FDA thinks the evidence supports their benefits very strongly. But when it comes to the foods we normally eat, the consensus view is that they are not an important factor. In fact, this recent meta-analysis on the topic found them to have no relationship at all to cardiovascular disease.


Slide 13                 Gagliardi, A. C. M., et al. "Effects of margarines and butter consumption on lipid profiles, inflammation markers and lipid transfer to HDL particles in free-living subjects with the metabolic syndrome." European journal of clinical nutrition64.10 (2010): 1141-1149.

We’ll see in the next video that Dr. Attia is convinced that apolipoprotein B is a biomarker upon which we should be very focused if we are concerned about our heart health. He should be aware that plant sterols are far better at reducing apoB than butter, which was useless for this purpose in this trial. If he were consistent in his beliefs, he would prefer corn to butter.

Do you think that Dr. Attia had a good reason as a physician to imply that we should be concerned about the effects of corn on heart disease? Or do you think he has revealed a bias with those remarks that indicates that he has trouble thinking straight about this topic? If you aren’t sure how to answer that, pause the video right now and do your own search and see if you can find anyone else implying that corn contributes to heart disease.


Slide 14       

Here’s another bizarre comment of his. He’s trying to support his statement that cholesterol is good and that’s all there is to it. He says there is a condition called Smith-Lemli-Opitz syndrome, a condition characterized by low cholesterol levels, which reveals all the terrible things that happen to people when we have too little.


Slide 15                 I have another video which more fully addresses this deceptive claim but I’ll give you a short response to this now.


Slide 16                 Porter, Forbes D. "Smith–Lemli–Opitz syndrome: pathogenesis, diagnosis and management." European Journal of Human Genetics 16.5 (2008): 535-541.

SLOS is not only characterized by low cholesterol levels. SLOS is diagnosed when one is found to have elevated levels of a precursor to cholesterol called 7-DHC, the concentration of which can be over 1000 times what is normal in these patients. That means SLOS isn’t strictly about low cholesterol levels. It’s also about an excess of 7-DHC. 7-DHC may be toxic at these concentrations.


Slide 17                 Young, S. G., et al. "Genetic analysis of a kindred with familial hypobetalipoproteinemia. Evidence for two separate gene defects: one associated with an abnormal apolipoprotein B species, apolipoprotein B-37; and a second associated with low plasma concentrations of apolipoprotein B-100."Journal of Clinical Investigation 79.6 (1987): 1842.

There are people with genetically very low cholesterol levels who do not have SLOS and so they don’t high levels of 7-DHC and they don’t any have of the symptoms Attia listed in his attempt to mislead you, assuming they have normal triglycerides. Here you see a report about people with freakishly low cholesterol levels who had no such problems. For almost anyone watching this, understand there is nothing you can do to get your cholesterol numbers this low.


Slide 18                 People with such low levels have been known to live very long and healthy lives. If Attia is really so interested in cholesterol then he knows this as well as I do, yet he apparently decided to give his readers a false impression about how much cholesterol we need. Once again, you should ask yourself what this example tells you about how much you can trust him.

I want to address one more comment of his here at greater length.


Slide 19       

This one comes from his video lecture about saturated fat, not the one about cholesterol. These remarks came about 31 minutes into it. He is explaining why he thinks it doesn’t make sense for heart disease to be dealt with preventively at the population level the way smoking has been. I assume his point is we shouldn’t ask people to eat less cholesterol and saturated fat the way we ask them to stop smoking.


Slide 20                 Attia: “The precautionary principle would be very difficult to invoke here because coronary artery disease is quite prevalent in all populations and furthermore the intervention is very complex.”

This is a doctor arguing against giving people science-based recommendations to reduce the prevalence of our number one killer. The lame reason he gives for this is that every population has the same burden of heart disease. Besides, heart-healthy diets are very complex and not well-suited to public health policy. Both of his premises are false. Recommendations on diet have been made for the last 40 years precisely because heart disease is not equally prevalent in all populations. Again, he must know this as well as I do.



Slide 21                 Lee, Kyu Taik, J. N. Davies, and R. A. Florentin. "Geographic studies of atherosclerosis." Geriatrics 21.1 (1966): 166-182.


This paragraph from a 1966 paper sums up what had been observed in cross-cultural comparisons. These researchers wrote:

“Atherosclerosis lesions have been found to exist in all populations studied. But when comparisons are made between groups of peoples from various geographic areas, the severity of the atherosclerotic lesions and the frequency with which complications of atherosclerosis occur, such as myocardial infarction, are found to vary widely. In some areas, complications of atherosclerosis are almost nonexistent while in other areas they are extremely common.”

This is not what Attia told his audience. Heart disease has not been “quite prevalent” in all populations.


Slide 22                 The researchers who wrote that decided to try to verify reports that heart attacks were hardly ever seen in Uganda. They had hearts sent to them from autopsies conducted in Uganda and concluded that infarcts were indeed almost nonexistent there.


Slide 23                 Compare the incidence rates for myocardial infarction among Ugandans as ascertained from those autopsies with comparable rates for New Orlineans. To say that heart disease was quite prevalent among Ugandans back then would be false.


Slide 24                 Shaper, A. G., and K. W. Jones. "Serum-cholesterol, diet, and coronary heart-disease in Africans and Asians in Uganda." International journal of epidemiology41.5 (2012): 1221-1225.

From Shaper, A. G., and K. W. Jones. "Serum-cholesterol, diet, and coronary heart-disease in Africans and Asians in Uganda." The Lancet 274.7102 (1959): 534-537.

The Ugandans avoided heart disease by consuming a starch-based diet with very little fat or animal protein.


Slide 25                 Snapper, Isidore. "Chinese Lessons to Western Medicine. A Contribution to Geographical Medicine from the Clinics of Peiping Union Medical College."Chinese Lessons to Western Medicine. A Contribution to Geographical Medicine from the Clinics of Peiping Union Medical College. (1941).


Likewise, it was reported in this book that in China in the 1940s heart attacks rarely occurred.


Slide 26                 Adolph, W. H. "Prewar nutrition in rural China." Journal of the American Dietetic Association 22 (1946): 867.

In those days the Chinese diet was high-carb and practically vegetarian.


Slide 27                 You can see how this researcher compared the Chinese diet with the American diet in those days. They ate lots of starches and hardly any meat or eggs.


Slide 28                 Bonhommeau, Sylvain, et al. "Eating up the world’s food web and the human trophic level." Proceedings of the National Academy of Sciences 110.51 (2013): 20617-20620.

Unfortunately, increasing prosperity in China has resulted in increasing meat and dairy consumption there, just as we saw in my previous video. The Chinese experience typifies the “nutrition transition.”


Slide 29                 Robert Saundby, DIABETES MELLITUS AMONG THE CHINESE. Br Med J. 1908 January 11; 1(2454): 116–117.

The observation was made as early as 1908 that when Chinese individuals became wealthier their dietary practices changed. This author noted the appearance of diabetes in the new wealthier classes, something rarely seen in China at the time. Notice that the people of Singapore are specifically mentioned as having European tastes and a higher incidence of diabetes.


Slide 30                 Wu, Yangfeng. "Overweight and obesity in China: the once lean giant has a weight problem that is increasing rapidly." BMJ: British Medical Journal333.7564 (2006): 362.

More recently this health professional in China lamented that this once lean nation has seen such a radical increase in obesity. This academic pointed out that rapidly increasing rates of obesity in China have been accompanied by a vast increase in the consumption of animal foods.


Slide 31                 Critchley, Julia, et al. "Explaining the increase in coronary heart disease mortality in Beijing between 1984 and 1999." Circulation 110.10 (2004): 1236-1244.

As one would predict, China isn’t so free of heart disease anymore. Look at what has happened in Beijing. These authors wrote, “much of the dramatic CHD mortality increases in Beijing can be explained by rises in total cholesterol.”


Slide 32                 Zhang, Jianjun, and Hugo Kesteloot. "Differences in all-cause, cardiovascular and cancer mortality between Hong Kong and Singapore: Role of nutrition."European journal of epidemiology 17.5 (2001): 469-477.

We just saw a mention of the diet in Singapore from 1908. Singaporeans have received more recent attention for the effects of their diets. Large differences were found in cardiovascular mortality rates between Singapore and Hong Kong in this paper. These researchers used mortality data from the WHO and nutrition data from the FAO for their analysis. More coconut oil and palm oil were consumed in Singapore. They also had a far higher ratio of animal fat to vegetable fat. Those factors may have explained why their cholesterol levels were so much higher. Singapore’s men had twice the mortality rate from cardiovascular disease as the men in Hong Kong.


Slide 33                 Steiner, P. E. "Necropsies on Okinawans; anatomic and pathologic observations." Archives of pathology 42.4 (1946): 359.

Okinawans were legendary for their longevity and health. Autopsies were performed on them in this study from 1946. The examiner wrote, “The relative freedom of these Okinawans from degenerative diseases of the cardiovascular system was amazing.” Later he commented, “The heart appeared remarkably well preserved at all ages.” Why was this? What could we learn from their exceptional cardiovascular health?


Slide 34                 The Okinawans enjoyed more physical activity and less stress than other cultures, and more important for this discussion, they consumed a “simple, predominantly vegetarian diet.”


Slide 35                 Enos Jr, William F., James C. Beyer, and Robert H. Holmes. "Pathogenesis of coronary disease in American soldiers killed in Korea." Journal of the American Medical Association 158.11 (1955): 912-914.

In the 1950s American physicians took note of this report in JAMA which contrasted the progression of atherosclerosis in young American soldiers killed in action during the Korean War with comparable Japanese men. The American subjects, who died at an average age of 22, had far more diseased arteries than the Japanese. The doctors who conducted these examinations suspected the explanation lay in the differences between Japanese and American diets.


Slide 36                 Keys, Ancel. "Coronary heart disease in seven countries." Circulation 41.1 (1970): 186-195.

Of course, the Japanese diet was famously low in fat. Their cholesterol levels were far lower than those of Americans.


Slide 37                 Burns-Cox, C. J., Y. H. Chong, and R. Gillman. "Risk factors and the absence of coronary heart disease in aborigines in West Malaysia." British Heart Journal34.9 (1972): 953.

Heart disease used to be very rare in Malaysia, too. These researchers said that “coronary heart disease has never been found among Malaysian aborigines.” It wasn’t just a coincidence that they had low cholesterol levels and consumed a starchy high-carbohydrate diet.


Slide 38                 Another important factor surely was their high rate of infestation with parasites. I explained the importance of this in my Ancestral Cholesterol videos. Many parasitic infections directly lower cholesterol levels.


Slide 39                 Diabetes was also said to be extremely rare in West Malaysia, where people depended on complex carbohydrates for the bulk of their calories.


Slide 40                 Keys, Ancel. "Coronary heart disease in seven countries." Circulation 41.1 (1970): 186-195.

I would be remiss if I didn’t remind you of the Seven Countries study of Ancel Keys and his many colleagues from around the world in which it was demonstrated beyond all doubt that the prevalence of heart disease varies widely between populations. Blood pressure and cholesterol were found to be important statistical determinants of heart disease.


Slide 41                 Law, Malcolm R., and Nicholas J. Wald. "An ecological study of serum cholesterol and ischaemic heart disease between 1950 and 1990." European journal of clinical nutrition 48.5 (1994): 305.

An article that had echoes of the Seven Countries study was written by Law and Wald in 1994. They compiled studies which recorded cholesterol concentrations from around the world and compared that data to heart disease mortality rates. They noted a tenfold range in ischemic heart disease among the 17 countries they examined. Four-fifths of the variation in deaths from ischemic heart disease could be explained by differences in serum cholesterol levels.


Slide 42                 I ask you, do you think Dr. Attia is right that a broad-based policy of preventing heart disease through diet would be “very complex”? We just saw how people used to eat. The poorest, simplest populations ate starchy foods, the only foods that they could afford to eat in bulk. Are you going to tell me that their diets were “very complex”?


Slide 43                 Arthaud, J. B. "Cause of death in 339 Alaskan natives as determined by autopsy." Archives of pathology 90.5 (1970): 433-438.

Don’t believe a low-carber who says that that the Eskimos were also free of heart disease. Autopsy studies like this one can be seen in my video called “The Eskimos Again.”

Peter Attia says our attention should be focused on apolipoprotein-B or LDL particle number if we want to understand how heart disease works. In the next two videos I’ll give you some information about apoB that he didn’t.