5 Steps to prevent Heart Disease

Monday, September 28, 2015

-Response to BMJ article by Nina Teichholz looks like a Witch Hunt

After studying Bonnie Liebman's article and Arielle Duhaime-Ross's article 
the response to Nina Teicholz's article on DGAC guideline seems less like a scientific review and more like a witch hunt. 

Please see my review of The Verge Article link

Defending Nina Teicholz

I try to look more closely at the arguments 
made against BMJ article (link above)

I looked up the first critical part, Bonnie Liebman made about Nina Teicholz article. 

 I copied the actual conclusion of the Cochrane author in my link above.  Here is an excerpt: 

"The findings of this updated review(2015) are suggestive of a small but potentially important reduction in cardiovascular risk on reduction of saturated fat intake."

Liebman writes:"The meta-analysis and second review, whose senior author has been heavily funded by the dairy industry, had serious flaws."

It is suggested Dr. RM Krauss is influenced by the dairy industry and that  "the lack of a significant association between saturated fat intake and CHD may well reflect the consequences of regression dilution bias."
"About half of the studies used 1-d dietary assessments or some other unvalidated method. Food intake varies from day to day, and there is a substantial literature showing that a single 24-h recall provides a poor estimation of the usual dietary intake of an individual"

NLA Part 2 advises less than 200 mg cholesterol a day for cardioprotection

NLA Part 2 cited this meta-analysis on eating eggs

This was the NLA's spin on the trial?
"A more recent systematic review and meta-analysis of 40 studies (17 cohort studies with 19 publications and 19 trials with 21 publications) was published by Berger et al.67
In the review of17 of the 19 trials, dietary cholesterol (intervention cholesterol intake was 501 to 1415 mg/dayand 0 to 415 mg/day in the control conditions) significantly increased both serum total-C (11.2mg/dL) and LDL-C (6.7 mg/dL). When the intervention intake levels were greater than 900mg/day, there were no longer statistically significant increases in LDL-C. In this review, dietary
cholesterol also increased HDL-C (3.2 mg/dL). Similar to the Hopkins results,61the increases intotal-C and LDL-C were greatest when the baseline dietary cholesterol intake was the lowest."
This is the trial author's conclusion:


Reviewed studies were heterogeneous and lacked the methodologic rigor to draw any conclusions regarding the effects of dietary cholesterol on CVD risk. Carefully adjusted and well-conducted cohort studies would be useful to identify the relative effects of dietary cholesterol on CVD risk.

67. Berger S, Raman G, Vishwanathan R, Jacques PF, Johnson EJ.
Dietary cholesterol and cardiovascular disease: a systematic review and meta-analysis.
Am J Clin Nutr. 2015 Jun 24

"Results from well-controlled RCTs indicate that dietary cholesterol has modest effects to raise levels of total-C, LDL-C, and HDL-C. 
 The increase in HDL-C associated with increased dietary
cholesterol is of uncertain clinical importance.
 Hyper- and hypo-responders to dietary cholesterol exist, with some individuals showing little or no increases in atherogenic cholesterol levels in response to greater intake of dietary cholesterol and others showing responses wellabove the average. The biological determinants of inter-individual variability are understudied, and presently no inexpensive and widely available methods are available for identifying thosewho are likely to be hyper- or hypo-responders. 
 In controlled feeding RCTs, each 100 mg/day of dietary cholesterol raises LDL-C by an average of ~1.9 mg/dL.  
Observational data have consistently reported no association between dietary cholesterol or egg consumption (a large
contributor to dietary cholesterol intake) and ASCVD risk in the general population, but suggest that there may be increased ASCVD risk associated with greater cholesterol and egg
consumption in those with diabetes mellitus. 
 The NLA Expert Panel recommendations are,
therefore, based mainly on results from controlled-feeding RCTs showing modest effects of dietary cholesterol to raise total-C and LDL-C, while recognizing that other dietary factors(saturated fatty acids, trans fatty acids, MUFA and PUFA) more reliably and predictably influence levels of atherogenic cholesterol."
NLA Part 2 advises:
The cardioprotective eating pattern should limit cholesterol intake to  less than 200 mg day 
to lower levels of atherogenic
cholesterol (LDL-C and non-HDL-C).

DGA to remove upper limit of dietary fat?

 NLA Part 2 Lifestyle advice 2015
"Recommended macronutrient ranges for adults are 45-65% of energy from carbohydrate, 10-35% from protein, and 20-35% of energy from fat. 
As of this writing, the 2015 DGA had not yet been released, but the 2015 Dietary Guidelines Advisory Committee’s (DGAC) Scientific Report recommended removal of the upper limit for dietary fat to allow greater flexibility, particularly
with regard to reducing intakes of cholesterol-raising (12-16 carbon saturated and trans-unsaturated) fatty acids and refined grains and sugars.
In place of these dietary components,
greater emphasis is placed on increasing consumption of foods containing unsaturated fatty
acids, such as nuts and liquid vegetable oils."

22. Mozaffarian D, Ludwig DS. The 2015 US Dietary Guidelines:
Lifting the ban on total dietary fat.
JAMA. 2015;313:2421-2.

"In fact, the amount of meat, poultry, and eggs that the committee recommends — 
26 ounces per week for a 2,000-calorie diet — remains unchanged from 2010."  As of Sept 28 th from THE VERGE.  

From BMJ Nina Teicholz
"the 2015 committee(DGA) recommended extending the current cap on saturated fats, at 10% of calories, based on
1- a review by the AHA and ACC,8 
2-a 2010 NEL review, and 
3-the 2015 committee’s ad hoc selection of seven review papers (see table A on thebmj.com).9

  1. Nina Teicholz, wrote in BMJ 2015;link

"Three meta-analyses concluded that saturated fats did not increase cardiovascular mortality,14 15 16 but the committee(Dietary Guidelines Advisory Committee (DGAC) downplays these findings"

Sunday, September 27, 2015

Mozaffarian on saturated fats

          Mozaffarian on saturated fats link

Here are some important excerpts which show the futility of advising less than 7 per cent sat fats in your diet.

"The reality is much more complex.

SFAs are heterogeneous, ranging from six to 24 carbon atoms and having dissimilar biology.

For example,
palmitic acid (16:0) exhibits in vitro adverse metabolic effects,

whereas medium-chain (6:0–12:0), odd-chain (15:0, 17:0), and very-long-chain (20:0–24:0) SFAs might have metabolic benefits.4

This biological and metabolic diversity belies the wisdom of grouping of SFAs based on a single common chemical characteristic—the absence of double bonds.

Even for any single SFA, physiological effects are complex:
eg, compared with carbohydrate, 16:0 raises blood LDL cholesterol, while simultaneously raising HDL cholesterol, reducing triglyceride-rich lipoproteins and remnants, and having no appreciable effect on apolipoprotein B,5 the most salient LDL-related characteristic.

Based on triglyceride-lowering effects, 16:0 could also reduce apolipoprotein CIII, an important modifier of cardiovascular effects of LDL and HDL cholesterol.

SFAs also reduce concentrations of lipoprotein(a),6 an independent risk factor for coronary heart disease.

Dietary SFAs are also obtained from diverse foods, including cheese, grain-based desserts, dairy desserts, chicken, processed meats, unprocessed red meat, milk, yoghurt, butter, vegetable oils, and nuts.

Each food has, in addition to SFAs, many other ingredients and characteristics that modify the health effects of that food and perhaps even its fats.
Judging the long-term health effects of foods or diets based on macronutrient composition is unsound, often creating paradoxical food choices and product formulations.

Endogenous metabolism of SFAs provide further caution against oversimplified inference: for example, 14:0 and 16:0 in blood and tissues, where they are most relevant, are often synthesised endogenously from dietary carbohydrate and correlate more with intake of dietary starches and sugars than with intake of meats and dairy.4

These complexities clarify why total dietary SFA intake has little health effect or relevance as a target. Judging a food or an individual's diet as harmful because it contains more SFAs, or beneficial because it contains less, is intrinsically flawed.
A wealth of high-quality cohort data show largely neutral cardiovascular and metabolic effects of overall SFA intake.7
Among meats, those highest in processing and sodium, rather than SFAs, are most strongly linked to coronary heart disease.7
Conversely, higher intake of all red meats, irrespective of SFA content, increases risk of weight gain and type 2 diabetes; the risk of the latter may be linked to the iron content of meats.2, 8 Cheese, a leading source of SFAs, is actually linked to no difference in or reduced risk of coronary heart disease and type 2 diabetes.9, 10 Notably, based on correlations of SFA-rich food with other unhealthy lifestyle factors, residual confounding in these cohorts would lead to upward bias, causing overestimation of harms, not neutral effects or benefits.

To summarise, these lines of evidence—
1-no influence on apolipoprotein B,
2- reductions in triglyceride-rich lipoproteins and lipoprotein(a),
3- no relation of overall intake with coronary heart disease, and
4-no observed cardiovascular harm for most major food sources—
provide powerful and consistent evidence for absence of appreciable harms of SFAs.

Yet, whereas some SFA-containing foods such as yoghurt, nuts, vegetable oils, and perhaps cheese promote health,7 these findings do not support benefits for other SFA-rich foods.

Although unprocessed red meats and butter might be neutral for coronary heart disease,
no studies demonstrate appreciable benefits;
all meats seem to increase risk of weight gain and type 2 diabetes;
and processed meats clearly do harm.2, 7, 8
This is a common mistake made by SFA enthusiasts—conflating the complexities of health effects and benefits of some SFA-containing foods, and possibly some specific SFAs, with the unsupported idea that eating a lot of butter and bacon is a route to good health.

Similarly, a common mistake made by SFA traditionalists is to consider only slices of data—for example,
1- effects of SFAs on LDL cholesterol but not their other complex effects on lipids and lipoproteins;
2- selected ecological trends; and
3-expedient nutrient contrasts."

Saturday, September 26, 2015

In search of the perfect, NLA Part 2 sacrifices the good

My comments in purple.

NLA Part 2 guidelines: 
In hope of the IMPOSSIBLE perfect, 
sacrifices the REACHABLE good  

"As of this writing, the 2015 DGA had not yet been released, but the 2015 Dietary Guidelines Advisory Committee’s (DGAC) Scientific Report recommended removal of the upper limit for dietary fat to allow greater flexibility, particularly with regard to reducing intakes of cholesterol-raising (12-16 carbon saturated and trans unsaturated) fatty acids and refined grains and sugars.22 In place of these dietary components, greater emphasis is placed on increasing consumption of foods containing unsaturated fatty acids, such as nuts and liquid vegetable oils.22"

Update : (DHHS) and Agriculture (USDA) have released the eighth edition (2015-2020) of the Dietary Guidelines for Americans.

As an advocate of allowing physicians to prescribe Atkins or LCHF diet for weight loss,  I believe this opens the way for such a practice. 

I thought NLA had already reached consensus on this in 2009 when Sach's Comparative Diet Trial was published in NEJM.

Gardner's ATOZ trial in 2007 was  a head to head study of  Atkins vs. 3 other diets.  It compared well if not favorably. 
Thus to not see Atkins or South Beach Diet listed as acceptable weight loss diets in Part 2 is a disappointment to me. 

page 22:
"The NLA Expert Panel acknowledges that additional research is needed to more clearly define effective dietary strategies for enhancing adherence to hypocaloric diets, and preventing weight regain after weight loss interventions.80,86 
However, based on the evidence discussed herein, the NLA Expert Panel consensus view is that eating patterns that contain a moderate quantity of carbohydrate, lower glycemic index and load, and higher protein, have been associated with modest benefits regarding weight loss and maintenance.82,84,85 Furthermore, the Expert Panel also strongly believes that additional research is needed to more clearly define effective dietary strategies for enhancing adherence to hypocaloric diets and preventing weight regain after weight loss interventions.80,86"
80=Sachs reference
86=Gardner reference

It is curious that the blue paragraph is just a repeat of the first paragraph.  Reads like an on-going argument on the panel. 

The Impossible Perfect Goal by Lifestyle changes: 
"In RCTs, each reduction of 1% in
LDL-C or non-HDL-C is associated with a 1% reduction in coronary heart disease (CHD) event risk over a period of ~5 years.12,13 "

Page 27
"Diet Low in saturated and trans fat and cholesterol  5-10% decrease LDLc
Loss of 5% body weight                                              3-5% decrease LDCc
2 g /day PS or 7.5 g/day viscous fiber                    4 to 10% decrease LDLc
Total:                                                                    12 to 25%  decrease LDLc

"Combining any 2 of the interventions recommended would be expected to reduce LDL-C by 6 to 19%. The portfolio diet approach, which combines PS, viscous fibers, soy, and almonds has been shown to reduce LDL-C by ~30% with controlled feeding, but the reduction was less (~15%) when subjects were free-living.121,122 If maintained over an extended period, each 1% reduction in LDL-C is expected to reduce CHD risk by 2-3%, based on results from genetic variants that alter atherogenic cholesterol levels.7,11
Thus, a modest reduction of as little at 6% in LDL-C, maintained over an extended period, could reduce CHD risk by 12-18%, whereas a reduction of 15% by combining dietary interventions could potentially reduce CHD risk by 30- 45%. "

At the NLA Pittsburgh meeting, a fellow lipidologist told me he had a couple of patients who maintained a Portfolio diet for a couple of years now with a 20% reduction in LDLc. 
The NWCR has 10,000 patients who have maintained a 50 lb. weight loss over 5 years and half of them did it on their own.  Those stories are out there.  Remarkable people. 

That is the impossible perfect for 95% of the rest of the population.
Lets not sacrifice a good safe diet that is sustainable for the rest of a chronically obese persons life.  The Atkins or LCHF. 

I am amazed the Look Ahead Trial is not sited in Part 2 references. See my comment on Look Ahead below.

Yes, with 10 year LEARN diet, net 3% weight loss, the LDLc was significantly improved,  however the primary outcome of cardiac events was not improved. 

Perfection achieved with failure of outcome. 

To prevent CV events use statins and Zetia.  Outcome data.

To maintain weight loss high protein, low carb, high fat with diet medicines maybe?? 

page 22
"In the largest trial completed to date on the effects of diet composition on weight loss maintenance, Larsen et al.85 randomly assigned a group of 773 adults who had lost at least 8% of body weight to 5 diet groups to assess effects of protein intake and glycemic index on weight loss maintenance.
The groups included a control diet with intermediate levels of protein and glycemic index with the remaining subjects assigned to lower and higher protein and lower or higher glycemic index in a 2 x 2 factorial manner.
Targeted differences were 12% of energy between the lower and higher protein groups, and 15 glycemic index units for the lower and higher glycemic index groups.
In an intention-to-treat analysis, the weight regain over 26 weeks was 0.93 kg less in the groups assigned to a high-protein diet than in those assigned to a low protein diet, and 0.95 kg less in the groups assigned to a low-glycemic-index diet than in those assigned to a high-glycemic-index diet.
The group that received the combination of a higher protein and lower glycemic index diet had the least weight regain (showing a small mean additional weight loss) of the 5 treatment arms, and also had the highest rate of study completion. The authors concluded that a diet with a moderately higher protein content (average intake 22- 23% of energy during the intervention) and reduced glycemic index (56-57 units) improved the maintenance of weight loss, and may thus have advantages for weight regain prevention."

1-Gardner ATOZ and this 
Three minute Vasselli video from Columbia 
are two excellent trials of LCHF data. 
 Sachs was not a true LCHF diet. 

2-Link to Shai trial and Evidence Analysis Library slides from 2015 

3-Link to ADA guidelines of diets choices 

4-Below is a quote from my blog: 

The Modern Way to treat the Chronic Disease of Obesity 

Finally, the biggest, longest,  best  diet trial: Look Ahead.
However, then you look at the control results (DSE).
24% of the control group lost more than 10% of weight after 8 years.  WOW! No lifestyle changes, no meetings, no orlistat, no replacement meals.  They did it on their own as half of the people in NWCR do.
Take note:  This shows typical WATERFALL results of all diet trials

Quote from the NEJM paper:
"Weight loss was greater in the intervention group than the control group throughout
(8.6% vs. 0.7% at 1 year; 6.0% vs. 3.5% at study end)."

Below is a quote from the NEJM study supplement:

“ILI participants were given a calorie goal
of 1200-1500 kcal/day for those who weighed less than 114 kg (250 lbs) and
1500 to 1800 kcal/day for those over 114 kg.
They were encouraged to consume
30% of total calories from fat and at least 15% of calories from protein.”

“Meal replacement products were provided at no cost to help participants adhere to their dietary goals.
During weeks 3 to 19 of the program, individuals were encouraged to replace two meals each day with a liquid shake and one snack with a bar.
The other meal (typically dinner) consisted of conventional foods;
fruits and vegetables were added to reach the calorie goal.
From week 20 on, meal replacements were typically used for one meal per day with conventional foods consumed at the other times.”
“To maximize weight loss, a tool box of additional strategies was available for use with participants after month 6 if the individual had not achieved the 10% weight loss. The tool box included orlistat, a weight loss medication. However, since minimal weight loss benefit was observed with orlistat, the use of this medication was discontinued in 2008.”

All the big guns were used here except surgery and or Qsymia, Contrave, Belqiv or Saxenda.
Look Ahead was the death knell of diet and exercise as the treatment of the Chronic Disease of Obesity.  
All the King’s men and all the King’s Horses could not put Humpty Dumpty back together again.  
In the four courses I took from April to Dec. 2015 while preparing for the ABOM exam,  there was a guideline answer that exercise could help maintain weight loss but in my studies I learned the exercise must be matched with a very low calorie count of 1200 to 1500 calories.  For most people this sub-starvation diet is not sustainable when leptin is low and ghrelin is high.
I finally maintained my weight loss of 20 pounds with ad libitum LCHF for 4 years with less exercise.
Despite claims of nutritional ketosis and exercise causing weight loss with Atkins it did not work for me.
I added Qsymia decreased my exercise and found I ate less and lost weight.
I noticed I was on five medications that contribute to weight loss: metformin, Victoza, Invokana, phentermine and topiramate.  
I have been able to stay off Insulin and Actos.
I believe if I stay on these drugs I will maintain my weight loss.
This is the modern way to treat the Chronic disease of Obesity.

 5-CardioBrief: Second Opinion on BMJ Dietary Guideline Takedown What do other experts say on critique of the proposed U.S. dietary guidelines? link

6-Guidelines and Supporting Key Recommendations of the 2015-2020 Dietary Guidelines for Americans
Guidelines (Abbreviated)
  • Follow a healthy eating pattern across the life span.
  • Focus on variety, nutrient density, and amount.
  • Limit calories from added sugars and saturated fats and reduce sodium intake.
  • Shift to healthier food and beverage choices.
  • Support healthy eating patterns for all.
Key Recommendations
  • Follow a healthy eating pattern that accounts for all foods and beverages within an appropriate calorie level. A healthy eating pattern includes
    • A variety of vegetables from all of the subgroups—dark green, red and orange, legumes (beans and peas), starchy, and other
    • Fruits, especially whole fruits
    • Grains, at least half of which are whole grains
    • Fat-free or low-fat dairy, including milk, yogurt, cheese, and fortified soy beverages
    • A variety of protein foods, including seafood, lean meats and poultry, eggs, legumes (beans and peas), and nuts, seeds, and soy products
    • Oils
  • A healthy eating pattern limits saturated fats and trans fats, added sugars, and sodium.
  • Key recommendations that are quantitative are provided for several components of the diet of particular public health concern that should be limited.
    • Consume less than 10% of calories per day from added sugars.
    • Consume less than 10% of calories per day from saturated fats.
    • Consume less than 2300 mg/d of sodium.
    • If alcohol is consumed, it should be consumed in moderation—up to 1 drink per day for women and up to 2 drinks per day for men—and only by adults of legal drinking age.
  • The Dietary Guidelines also include a key recommendation to meet the Physical Activity Guidelines for Americans.4

Friday, September 25, 2015

I wish to correct a bias of NLA Part 2 guidelines

NLA guidelines fails to represent Low carbohydrate High Fat data.

Data that NLA Part 2 guidelines is missing link

Thursday, September 24, 2015

Head to Head Comparative Diet Study over 2 years Feb 2009

Comparison of Weight-Loss Diets with Different Compositions of Fat, Protein, and Carbohydrates


We randomly assigned 811 overweight adults to one of four diets; the targeted percentages of energy derived from
fat,     protein, and carbohydrates in the four diets were
20,        15,     and       65%;
20,        25,     and       55%;
40,        15,     and       45%;
40,        25,     and       35%.

 The diets consisted of similar foods and met guidelines for cardiovascular health.

Reduced-calorie diets result in clinically meaningful weight loss regardless of which macronutrients they emphasize.





This is composition of low fat average protein diet

This is composition of high fat high protein diet