Face the fats: what’s the science for dietary guidelines?

5 minute read

Clinical Nutrition

By

Dr Joe Kosterich

Everybody knows a low saturated-fat diet is better for health, right? So why are we getting much heavier? asks Dr Joe Kosterich

Where is a wonderful saying by Mark Twain; “It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so”.  Today, books by Twain no doubt carry trigger warnings lest some university student gets upset by an idea they don’t like.

Unfortunately, there are some in medicine who also need trigger warnings and are not interested in hearing views contrary to their own. When British consultant Clive Bates visited to talk about tobacco harm reduction (including to a parliamentary committee) various health bodies refused to meet with him. Why? Because he supports vaping for harm reduction and they do not.

You would think it makes more sense scientifically to hear the arguments of those with a different view in emerging areas (before anyone raises anti-vaxxers, vaccines are not an emerging area).

So, the rest of this article carries a trigger warning. If you don’t like your ideas on dietary guidelines and saturated fats to be challenged, then turn the page or otherwise look away now.

There is a startling graph on page 328 of Big Fat Surprise, by Nina Teicholz, which shows the percentage of obese people in the United States between 1971 and 2006. There is an inflection point where the graph changes from a flat line to an incline. This inflection point is the first introduction of low fat dietary guidelines in that nation.

One of the arguments put by those in public health for the increase in rates of obesity (and type 2 diabetes) is that the public do not follow the guidelines. Sales figures for vegetables, red meat, grain products, vegetable oils and full fat dairy show the exact opposite. The public has adopted a low saturated fat diet over the last 40 years – to its detriment.

There has been a growing view that this advice was not based on science.

A 2014 paper in JAMA stated “Reducing total fat (replacing total fat with overall carbohydrates) does not lower cardiovascular disease risk …”

In 2015 the BMJ published something even more damning: “Dietary recommendations were introduced for 220 million US and 56 million citizens in the UK in 1983, in the absence of supporting evidence from randomised control trials.”

American congressman and physician, Andy Harris MD wrote on The Hill; “… the lack of sound science has led to a number of dietary tenets that are not just mistaken, but even harmful – as a number of recent studies suggest”.

A confluence of many coinciding historical events got us to this point.

Simplified, our views on saturated fats and cholesterol have been shaped by the “settled science” promoted by American physiologist, Ancel Keyes, in the 1960s. His ability to shout down critics rather than his scientific method (based on selecting six of 22 countries) won the day.

Now, the Prospective Urban Rural Epidemiological (PURE) study of 135,000 people in 18 countries over seven years has changed the “game”. It found a high-carbohydrate, low-fat diet was associated with increased mortality and heart disease.

Total and saturated fats were associated with a decreased risk of death. Fat consumption was not associated with cardiovascular disease, stroke or mortality.

Furthermore, the study found eating fruits and vegetables beyond moderation did not have any health benefit.

It has turned conventional thinking upside down. To quote author Dr Mashid Dehghan (PhD) from Canada’s McMaster University: “Global dietary guidelines should be reconsidered in the light of these findings.”

What has been the response to this? Attempts to discredit the work while putting fingers in the ears and singing “la la la”.

The main Australian dietitians group, the Dietitians Association of Australia, continues to promote a diet high in grains (carbohydrate) and low in fat.  A glance at their website shows they receive sponsorship from manufacturers of grain-based foods.

Supporters of ketogenic, paleo and other low carbohydrate health fat (LCHF) diets are castigated for “cutting out whole food groups”. Vegetarian and vegan diets which cut out whole food groups do not attract this criticism.

You can speculate as to the reasons for this.

Ultimately, we have dietary guidelines, which were never based on rigorous science. Real-world outcomes show that the public, in following the guidelines, has become heavier and has higher rates of type 2 diabetes. Major research shows that the opposite of what we have believed is, in fact, the case.

We need to be scientists, not ideologues, and stop believing that which “just ain’t so”, despite believing it for 40 years.

Dr Joe Kosterich is a general practitioner based in Perth. You can read more at www.drjoetoday.com

References

1. https://jamanetwork.com/journals/jama/article-abstract/2338262 

2. http://openheart.bmj.com/content/2/1/e000196.full 

3. http://ajcn.nutrition.org/content/early/2010/01/13/ajcn.2009.27725.abstract 

4:doi: http://dx.doi.org/10.1016 s0140 – 673 (17) 32252-3

5. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32252-3/fulltext?elsca1=tlpr 

6. http://thehill.com/blogs/congress-blog/healthcare/353486-mandate-is-clear-flawed-dietary-guidelines-process-must-be 

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Dr Rosemary Stanton
Dr Rosemary Stanton
6 years ago

There are a number of errors in the above. Australians have never heard of the dietary guidelines and they certainly don’t follow them. Less than 7% of people eat the recommended servings of vegetables, legume consumption is tiny, wholegrain consumption is low. Average consumption of fruit is half the recommended 2 pieces a day. Yes, red meat consumption has fallen as more people eat chicken – and substitute snacks & fast foods for dinner – but consumption of sausages and fatty burgers remain high.

Judging a diet by macronutrient content is way too gross to be meaningful. As I’ve written often, the same amount of saturated fat is found in a small custard tart, 70g of potato crisps, 35g of cheese, 1 tablespoon of lard or a small steak. Equally, we can list totally dissimilar foods as sources of carbohydrate (lentils or lollies?). Just adding up sat fat or carbs tells you very little about the foods people are consuming.

The elephant in the room is that 35% of the average adult’s and 40% of children’s energy intake comes from junk foods. That’s what we should be attacking. And while we’re at it, get Health Ministers to pass a requirement for the quantity of added sugars to be declared on food labels – something you and I would at least agree on. (Note that Australia’s Dietary Guidelines have always recommended limiting added sugars and foods and drinks containing them – listed in current guidelines.)

Before praising Nina Teicholz’ book, perhaps read some criticisms of it. Seth Loder (BS in Food Science & Nutrition and MS in Nutritional Sciences, Website The Science of Nutrition) has written: The Big Fat Surprise (by Nina Teicholz): A Critical Review; Parts 1 & 2. Also Good Calories, Bad Calories (by Gary Taubes) https://thescienceofnutrition.wordpress.com

Also take a look at some of the facts about Ancel Keys ( including your oft-repeated but incorrect claim that he used 6 out of 22 countries). See True Health Initiative: an evidence-based response to revisionist histories, available from http://www.truehealthinitiative.org
or Marion Nestle. Food politics. Another ongoing saga: the legacy of Ancel Keys. https://www.foodpolitics.com/2017/08/another-ongoing-saga-the-legacy-of-ancel-keys/
or Nutrition Wonk blog by Katherine: Ancel Keys and the Seven Countries Study: A Response to “The Sugar Conspiracy“ (paper written for the Guardian by journalist Ian Leslie in 2016) http://www.thenutritionwonk.com
or Kahn J. The keys to good health were always in Dr Ancel Keys’ hands: now you can rest in peace. https://journal.thriveglobal.com/the-keys-to-your-good-health-were-always-in-dr-ancel-keys-hands-now-you-can-rest-in-peace-77b03977fc12

Perhaps actually read The 7 countries study. https://www.sevencountriesstudy.com/about-the-study/investigators/ancel-keys/

Australia’s Dietary Guidelines are based on foods and evidence about foods, not individual nutrients. Concentrating on nutrients only leads to nutrient-enriched junk foods. And they’ve always recommended limiting junk foods. Sadly no one has taken any notice.

If you want to blame anyone, try the processed food industry who introduced literally thousands of low-fat foods loaded with sugars and refined starches that were never recommended in our dietary guidelines.

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Lizzie
Lizzie
Reply to  Dr Rosemary Stanton
6 years ago

I still find it amazing that we have all abandoned our real human way of eating for a life full of junk food and processed foods. This includes wheat, rice etc. Rosemary Stanton you should sit down and be quiet. The day we went away from our real “diet” and started down the track of fervent low fat and high carb and sugar was our dooms day. Keys was an arrogant fool who was listened to because he was a bully. Most people I know try to eat by the guidelines but fail. They have no idea food groups are a made up thing or that insulin is a hormone and can have the same devastating health issues as women have with other hormone problems. The believe they are doing the right thing. And of course these burgers are cooked in seed oils along with the fries etc. and the food industry uses these seed oils in almost every concievable product on sale. Seed oils go rancid and poison us. High sugar gives us diabetes and other life problems. All added sugar, pastry, pasta and other high carb foods convert to glucose in our system and raise our blood sugar. If it is constant it becomes a problem as the body stops working properly and cannot cope the constant deluge of glucose. Then there is the fructose, too much fruit and your live can’t cope with the fructose and it stores it in itself and other parts of the body till it can process it. If it isn’t able to process it is builds up and causes NAFLS. If you don’t know this then you should not be in your job. If you are being paid or supported by the junk food industry and the sugar industry as above. I am sick and tired of so called experts, supported by dodgy food producers and big pharma telling me how I should eat and live. Get out of my space, go peddle your crap to someone who will listen. Oh sorry they are listening aren’t then and look what’s happened we have a population of obese, type 2 diabetics increasing daily to the point where the medical and hospital system is groaning with the weight of it and governments aren’t getting enough money in to support it. All for sake of the dollar. Sell them a pill or potion but don’t tell them we lied and there is cure without them having to spend money. What a wonderful world we live in. Totally orchestrated by greed

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Dr Rosemary Stanton
Dr Rosemary Stanton
Reply to  Lizzie
6 years ago

Lizzie

I don’t think you have read the Australian Dietary Guidelines (put out by the NHMRC and the Department of Health). They specifically tell people to avoid junk foods and sugar. Sadly, people do not eat too much fruit – average consumption is just one piece a day. Studies showing fructose is a problem use quantities comprising 25% of daily energy. Few people would consume that much.

Your rant is really over the top. I have been criticised by the sugar industry since I did the first school canteen survey in 1968 and we had evidence to show that kids needed to stop eating sugary foods. That criticism has continued over the years since the first dietary goals in 1979 emphasised the need to avoid eating too much sugar. Every revision has continued to include such advice and it has taken huge amounts of effort to keep it there. I have also had to endure many years of sustained criticism from the junk and processed food industries. They do not pay me – they actively try to undermine every bit of public health work that I am involved in.

If virtually no one follows the dietary guidelines (which do emphasise good fats) but are not ‘low fat – or ‘high carb, then you really can’t blame the guidelines for the current health problems. You seem to ignore the fact that 35% of people’s kilojoules (40% for kids) comes from the junk foods that the guidelines tell people to avoid. Unfortunately, advertising influences them to eat this junk. Sadly, virtually nothing is spent promoting healthy foods.

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Fifi
Fifi
Reply to  Dr Rosemary Stanton
6 years ago

In reply to Rosemary’s assertions that the Australian public don’t know the guidelines, I would argue that most do. It has been and is still taught in all schools. Parents are given a copy of the NHMRC guidelines with every child enrollment package. The children are taught it frequently. (On a recent daycare tour we were told that they discuss “healthy choices” every single morning tea time for children aged 2-5). Most patients I have come across are familiar with the food pyramid or NHMRC plate picture. They diligently recite that they should have a diet rich in whole grains and low in fat. But they are getting fatter and more diabetic.

But I do agree with the elephant in the room comment. We need to address the consumption of highly processed junk and takeaway foods. It’s not going to happen though with the DAA accepting sponsorship from Macdonalds and Nestle. They even had Macdonalds catering a lunch at a DAA conference not that long ago. Their argument was they were promoting the healthy choices range at Maccas. Anyone with any marketing know how (or common sense for that matter) knows that someone might go into Maccas with the intention of buying a salad and come out with a large Quarterpounder meal. How can you resist all those pictures of juicy burgers or ignore the smell? Basically, their salads and sliced apples are a way of increasing traffic and increasing sales across all of their products. Do the DAA honesty not get this, or do they not care? I was flabbergasted to hear another doctor was advised by an accredited dietitian to eat a spoonful of Nutella nightly to address her lack of weigh gain in the third trimester of her pregnancy. Bad enough until it became apparent she was seeing the dietitian for GDM. What the? At least Ferrero aren’t a DAA sponsor that I am aware of…..

In response to Malcolm’s post and the whole vegan vs diets low in grains argument. Let’s just all agree that a diet low in processed and manufactured foods is best and move forward. We have so much common ground, but the differences keep getting highlighted and defended (in public) which is at the detriment to our patients (and wider community) who want to eat real foods and we are confusing them. The animal welfare and sustainability aspect is upsetting for many people and that’s why many Paleo followers (which BTW, aren’t neccessarily LCHF) are more gatherers than hunters (something that might surprise you) and eat leaf to root and nose to snout (Eg. Don’t waste any food). Some social media leaders in Paleo promote the 9v9 challenge. (Nine serves of veggies a day for nine days to promote the practice of having more veggies in the diet). Indeed I teach patients to replace the excessive amounts of processed carbs in their diets with veggies that grow above the ground, as many already have plenty of animal products in their diet.

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Dr Rosemary Stanton
Dr Rosemary Stanton
Reply to  Fifi
6 years ago

Fifi

I totally agree that having the DAA accept sponsorship from food companies should stop.

Why do you think people ignore the Dietary Guidelines? Could it have something to do with the foods so readily available (at sports grounds, service stations, taking up so much of the supermarket, from school canteens) and the fact that it’s the junk foods that are mostly advertised. Advertisers of junk food spend millions of dollars – not just on TV and in magazines but in advergaming directed at kids. They do this because it works. Junk food companies sponsor kids sports and even some school programs. This ensures that teachers and parents think they are ‘good guys’ and so they don’t criticise their products – which the kids demand because they’ve seen the promotions.

Now contrast this with the promotions for carrots or broccoli or chick peas or other straight healthy products. We shouldn’t really be surprised by the resulting diet.

BTW – when people say they know about the dietary guidelines, I usually find they don’t. For example, the Australian Dietary Guidelines are not ‘low fat’ and no guidelines ever suggested people eat the hundreds of low fat products that the food industry saw as good money spinners.

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Joe Kosterich
Joe Kosterich
Reply to  Dr Rosemary Stanton
6 years ago

“A number of errors” ,meaning you don’t agree which you are free to do. That you don’t like that the advice given for the last 35 years is the problem rather than the solution does not change the fact that it is. Most “junk food” that is consumed comes from supermarket aisles and carries four stars or a tick or an elephant stamp!

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Malcolm Mackay
Malcolm Mackay
6 years ago

Misinformation presented with such confidence. All the usual assertions are there. Discredit Ancel Keys – recent ‘white paper’ published which vindicates his findings. Claim the USA went low fat – national consumption data shows that fat intake increased with each decade. Cite the PURE study – yes, it did find poverty stricken groups living on refined carbs had higher death rates. Claim it’s unfair to wave the dietary guidelines at Paleo-Atkins diet but not plant-based diets – the reality is that vegetarian /vegan diets can meet all of the dietary guidelines.
Who do we listen do? Joe Kosterich or authoritative collaborations such as the American Heart Association who recently published a ‘Presidential Advidory’ reiterating the harmful effects of dietary saturated fats.

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Brooke
Brooke
6 years ago

Thank you Joe, high time that the evidence is reviewed. As a GP I continually share in the frustration of my patients as they follow the Australian Dietary Guidelines, yes they are aware of them and as educated adults they follow them – usually as a dietician prescribed diet plan, yet they are growing larger, more depressed with aching joints. They walk or go the gym, but you just can’t exercise away a bad diet. The high amounts of grain based products and 2 serves of fruit a day leave them craving more carbs and they just can’t break the cycle. I can’t increase my T2DM pts medications high enough to cope with all the carbs they are prescribed. There is a better way, other countries are seeing the light, let’s just hope Australia doesn’t take too long to correct this wrong. For the health of the nation.

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Jaclyn Montefiore
Jaclyn Montefiore
6 years ago

The repeated statement by policy makers and nutrition experts that Australians are not following the Australian Dietary Guidelines brings two questions to mind:
1) why have Dietary Guidelines at all if no-one is following them? Why waste millions of dollars of taxpayer dollars reviewing them at defined intervals if they are so ineffective at reducing the burden of chronic disease as has been proven over the past few decades? It makes no sense to continue with the same approach which has clearly failed and a change of course is urgently needed. Possibly something similar to the Brazilian dietary guidelines could be considered which emphasise basing the diet on unprocessed foods, cooking and eating within good social structures. Simplifying the guidelines in this way would have them less amenable to interference by the food industry and minimise public confusion. A summary of these can be found here: http://www.fao.org/nutrition/education/food-based-dietary-guidelines/regions/countries/brazil/en/
2) Why aren’t the reasons and / or barriers of why people are following the dietary guidelines ever explored? The best that is offered is vague statements along the lines of ‘obesity and chronic disease are multifactorial conditions’. When the majority of the class fails a subject, it is worthwhile exploring the teaching and the curriculum rather than constantly blaming the students.

Saying that ‘no one knows about the Guidelines’ is factually incorrect on multiple fronts. As a GP I see patients on a daily basis who are showing clinical evidence of heart disease and diabetes and almost always they say, “Yes Doc, I know what to eat as part of a healthy diet” and go on to recite pretty much the dietary guidelines. The Guidelines are taught in every school. They influence the food offered at every hospital, school, daycare centre. They are mentioned in GP Guidelines for all of the common chronic conditions (Heart disease, Type 2 Diabetes). They direct cultural norms with relation to food. To imply that no one knows about them or follows them or in no way do they influence the food supply is simply not true.

The DAA and Heart Foundation state that the focus should be on ‘dietary patterns’ rather than nutrients. However, featured prominently in all guidelines from these bodies, including Guideline 3 of the ADG’s is “Limit intake of foods containing saturated fats…” which perpetuates the public’s fear of including fat in their diets from natural sources, despite the fact that these types of healthy fats have never been shown to be harmful in the context of an eating pattern that is predominant in unprocessed foods, as linked to a meta-analysis in this article.

Nutrition experts give over-emphasis to the virtue of ‘wholegrains’, despite the fact they are less nutrient dense than other foods such as vegetables, eggs and other animal products. A recent Cochrane review concluded “There is insufficient evidence from RCTs to recommend consumption of wholegrain diets to reduce the risk of cardiovascular disease”. http://www.cochrane.org/CD005051/VASC_whole-grain-cereals-cardiovascular-disease
Furthermore, food industry label highly processed and sugary foods with ‘wholegrain’ on the label, meaning the perception of these products is that the food is healthy, to the public. For example, several brands of breakfast cereal have ‘Wholegrain’ on the label but in actual fact contain 20% or more of sugar (Kellogg’s ‘Sustain’ being just one example).

It is likely that many different dietary patterns can be conducive to good human health. However, they should all have the common element of being minimal in processed, packaged and fast-foods – whether that be largely plant-based, paleo or LCHF. As difficult as it is for some to accept, the present dietary guidelines are in dire need of modification to promote better public health outcomes.

17
Dr Rosemary Stanton
Dr Rosemary Stanton
Reply to  Jaclyn Montefiore
6 years ago

Jaclyn

Those of us who worked on the Dietary guidelines would have loved to be able to do something as simple as the ones that the Brazilian government has brought out. Indeed I wrote an article for Australian Doctor on this very topic (published Sept 16, 2016). I would dearly love such guidelines and will continue to press for something similar.

The NHMRC needs particular levels of evidence for all statements and guidelines and at this stage, although the Brazilian ones are so sensible, there is no published evidence on their efficacy. Hopefully such evidence will be forthcoming as WHO and others move to establish food and whole of diet based guidelines in the future. The Australian guidelines (2013 revision) did at least take a food based approach to all evidence rather than a nutrient based approach.

The Cochrane review you referred to (best to go for the total article no just the abstract) looked specifically at primary prevention of deaths from cardiovascular disease in studies using wholegrains for at least 12 weeks. (No study went for more than 16 weeks). You can read it at http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005051.pub3/full. As they noted, most studies had some methodological limitations and only small numbers of participants. And of course, they didn’t look at the rest of the diet in the subjects. So it’s not really strange that this review was unable to show any benefits in such a short time.

I totally agree with you on claims being made on sugary cereals and a number of us are continuing to protest against this absurdity.

Your final point that many different dietary patterns can be conducive to good human health is totally in accord with the dietary guidelines. So is the recommendation to avoid fast foods and highly processed junk foods.

Thank you for not being as rude as some other comments.

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Kim Bland
Kim Bland
6 years ago

Great article Joe and lots of good discussion. Clearly with this much difference in opinion if it’s one thing we can agree on it’s that we need to go back and look at this again. If it’s one thing we’re all trained to do it’s not to accept something because it’s always been that way. Keep searching, keep learning and always have an open mind to new ideas I say. Nice work Joe.

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Susan Swanston
Susan Swanston
6 years ago

I am not a scientist or expert, I am “just a GP” who happens to have an interest in weight management and I spend a significant proportion of my working life trying to help my patients lose weight, prevent type 2 diabetes or improve their diabetes control. I do not conduct RCTs but I do observe real people with real lives and real health problems. It is my observation that there are two distinct groups of people who suffer from obesity and type 2 DM. The first group are generally educated and the initial consult usually starts with the patient saying “I know what I should be eating and I generally eat really healthily”. They then proceed to recite the guidelines – eat whole grains, unsaturated or low fat, 5 pieces of fruit a day etc. When I review their food diaries I find they eat lots of whole grain bread, wholemeal pasta, brown rice and low fat spreads and yoghurts with mountains of fruit – yet they are still overweight and often have fatty liver disease.

The second group are generally of low socioeconomic groups with a poor standard of education. They eat a very high carbohydrate diet, mostly processed foods and frequent visits to fast food outlets. They are also overweight with a multitude of health problems as a consequence.

The fundamental difference in the two groups is their acceptance of my LCHF advice. The former accept that the guidelines are flawed and understand that although they have been trying to follow a healthy lifestyle, it is not working. They are receptive to change, understand the science when it is explained to them and change their diet. Not surprisingly they lose weight and maintain their weight loss as long as they continue to engage with treatment.

The second group are very difficult to treat. They don’t understand the science and struggle to change their longstanding dietary habits. They use poverty as an excuse despite the fact that they can buy vegetables cheaply at the market stalls. Their food diaries are awful, I have even picked up a case of severe vitamin C deficiency in a patient who eats nothing but refined carbs – not a vegetable in sight. This group have no knowledge of guidelines and really no insight into the harm that their diet is doing. I try to educate them in the LCHF approach but the outcome is poor. The lure of sugar, particularly in the form of soft drinks, is too great and they very quickly disengage when they realise that I don’t have a magic wand in my drawer to solve all their problems.

So I keep going and help those who want to change, and I know that the LCHF way of life works for weight loss and control of type 2 DM, not because I read about it but because I witness it every day of my professional life. I see lives transformed, insulin dropped from 80u to zero with reductions in HbA1c from 10.6 to 6.5 in 3 months, miserably unhappy women with no self esteem become confident and happy in their own bodies, patients with PCOS fall pregnant after losing weight and so it goes on. In my opinion the guidelines are wrong and need to be changed, and whilst that will undoubtedly be a step in the right direction, it certainly won’t solve the obesity epidemic.

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