An Interview with Eric C. Westman, M.D., MHS Part 3: Cholesterol Clarity
Let’s complete our discussion of the health benefits and safety of low-carb, high-fat “ketogenic” diets with Eric Westman, M.D., MHS. In January, we discussed the clinical benefits obtained with real people in the real world of low-carb, high-fat diets. In February, we examined how ketogenic diets work to improve health. However, many people have been misled about dietary fat and cholesterol who needlessly fear that ketogenic diets may be a health risk. Clinical studies and real-world experience have shown the opposite to be true. Ketogenic diets can improve a person’s health—heart health, diabetes, metabolic and total long-term health.
As we have stressed in this series, people are different and so are their responses to diets. Many people have been told that to avoid becoming fat, simply eat less fat. How’s that working out? Well, the obesity and diabetes epidemics are worsening and heart disease is still the number one killer. The problem lies in the fact that “low-fat” usually means that fats have been replaced with sugar and similar refined carbohydrates and/or new-to-mankind artificial sweeteners. The so-called “low-fat foods” are actually highly processed and fractionated pseudo-foods that cause metabolic imbalances that can lead to type-2 diabetes and more body fat. Thanks to the “experts” who unscientifically manipulated the data to convince people to stop eating the whole foods that humans have safely consumed for thousands of years, many Americans switched to a dangerous experimental diet loaded with trans-fats, sugars and artificial sweeteners creating additive-loaded, empty-calorie, partial foods.
If unwanted body fat and/or a state of low-energy are not a problem for you, then congratulations, you have learned what works well for you.
If you or your friends have not been satisfied with the responses to trying the same old strategies over and over again, only to be losing headway, then a new strategy is needed. Fortunately, there are a few good choices for healthy diets. For some, it may be a vegetarian diet, for others, it may be a low-carb, high-fat diet. If your genes are showing you that what you are eating now is not giving you the health results you want, then you may wish to look at the health advantages of a low-carb, high-fat diet.
It’s a shame that many people are still repulsed at just the thought of a high-fat diet because they have been told many thousands of times over decades that high-fat diets are harmful and the way to lose weight is simply to just not eat fat. Well, how did that work out for the American public over the last 50 years as the obesity epidemic grew into a pandemic?
As Dr. Eric Westman puts it in Keto Clarity (Victory Belt Publishing, 2014), which he co-authored with Jimmy Moore, “(T)he question to ask is ‘what are the health consequences of eating a certain way? What is my health now, and what will my health likely be in the future?’” (1).
|Eric C. Westman, M.D., M.H.S.|
Let’s look at facts instead of dogma by continuing our chat with Dr. Westman. Dr. Westman is an associate professor of medicine at Duke University Health System in Durham, NC, and director of the Duke Lifestyle Medicine Clinic. At Duke, he specializes in disease prevention, as well as the treatment of obesity, diabetes and tobacco dependence.
Dr. Westman received his M.D. from the University of Wisconsin/Madison, completed an internal medicine residency and chief residency at the University of Kentucky/Lexington, and completed a general internal medicine fellowship, which included a master’s degree in clinical research. Since 1990, he carried out clinical research and clinical care at Duke regarding lifestyle treatments for obesity, diabetes and tobacco dependence, and published over 90 peer-reviewed articles.
He is currently the chairman of the board (past-president) of the Obesity Medicine Association (the largest group of Obesity Medicine Specialists in the world) and a fellow of the Obesity Society. He is an internationally known expert on low-carbohydrate nutrition and ketogenic diets.
He is the co-editor of the medical textbook, Obesity: Evaluation and Treatment Essentials, author of A Low Carbohydrate, Ketogenic Diet Manual and co-author of The New York Times best-sellers The New Atkins for a New You, Cholesterol Clarity and Keto Clarity.
In order to increase availability of low-carb information, products and clinics, Dr. Westman co-founded two new companies: HEAL Diabetes & Medical Weight Loss Clinics (www.healclinics.com) and Adapt Your Life (www.adaptyourlife.com).
More and more physicians are now recognizing that low-carbohydrate, high-fat (LCHF) diets can be the most effective long-term solutions to reducing body fat. In October, two major meta-analyses verified that LCHF diets were more effective than low-fat or low-calorie diets. In the first of the two studies, researchers at Harvard Medical School confirmed that “low-carbohydrate weight-loss interventions led to a greater average long-term weight loss than low-fat weight loss interventions” (2). This meta-analysis examined 53 studies having 68,128 participants. In the second study involving 17 randomized, controlled clinical trials involving 1,797 participants, the LCHF diets were found to result in significantly greater weight reduction than low-fat diets and had a significantly lower predicted risk of atherosclerotic cardiovascular disease (3). There’s more to the health benefits of LCHF diets than reducing body fat.
Passwater: Dr. Westman, some readers may not have read the first two parts of our discussion about how LCHF diets can improve health, but I’ll bet they have received thousands of messages incorrectly warning them that high-fat diets cause heart disease. Let’s get right to the point. Does a LCHF ketogenic diet promote heart disease?
Westman: No. A LCHF ketogenic diet does not promote heart disease. In fact, a LCHF lifestyle lowers cardiometabolic risk by lowering unhealthy blood triglycerides, and increasing healthy HDL cholesterol. We taught a generation of doctors, dietitians and the general public based on the prediction that high-fat diets promoted heart disease, but when the prospective studies were conducted, the improvement in triglyceride and HDL was unexpected.
Passwater: Can a LCHF ketogenic diet improve health in other ways?
Westman: While not all experts agree that a LCHF diet is a healthy way of eating (like I do), most experts agree that the LCHF diet is a therapy for many of the chronic medical conditions that we see today: type-2 diabetes, obesity, high blood pressure, heartburn, polycystic ovarian syndrome and fatty liver disease, to name a few. I have been using the LCHF diet as a first-line treatment for obesity and type-2 diabetes for eight years.
Passwater: I have always found the positive effects on the brain from LCHF diets interesting. People who go on fasts have often reported that it clears and sharpens their minds. A 2004 study of the long-term effects of ketogenic diets strongly reinforces the benefits of ketosis (4). It not only confirms that a LCHF diet is the most effective long-term reducing diet, but also that ketosis is desirable.
The discussion section of the study notes, “Until recently, ketosis was viewed with apprehension in the medical world; however, current advances in nutritional research have discounted this apprehension and increased public awareness of its favorable effects” (4).
In addition to the conditions you mentioned, this article reports that LCHF diets are effective in antiepileptic treatments, infantile spasms and mood stabilization in bipolar illness. Ketosis has several positive actions in the brain including positive brain energy profiles and signal transduction in neurons.
A 2013 review of the therapeutic uses of LCHF diets notes that they have been used since the 1920s as a therapy for epilepsy and can, in some cases, completely remove the need for medication. The review questions whether there are still some preconceived ideas about ketogenic diets, which may be presenting unnecessary barriers to their use as therapeutic tools (5).
That’s real verifiable evidence from real people in the real world. This is not theory, but actual results. It is consistent with the findings of Robert C. Atkins, M.D., with his patients in the 1970s and with other physicians over the decades. Yet many physicians and members of the public believe the opposite.
If a ketogenic diet can reduce heart disease risk and improve health in several ways, then one has to wonder how the public was led to believe the opposite and why they won’t look at the science. In Cholesterol Clarity, you and your co-author Jimmy Moore review the theory scientifically known as “The Lipid Hypothesis” (6).
Most of the public has been led to incorrectly believe it was not a theory (hypothesis), but proven fact. How did this theory become gospel?
Westman: Experts have naively assumed that cholesterol and fat buildup in the arteries are reduced by lowering dietary cholesterol and fat. This logic is like watching the sun go across the sky and assuming that the sun goes around the Earth. Most people believed that for a long, long time, before the ingenuity and telescopes of the astronomers discovered otherwise. When they looked at the sun, it appeared to go around the Earth. It was easy for them to conclude that the Earth was the center and the sun revolved around it. Very simple indeed. After more detailed study by astronomers, it became clear the opposite is true, the earth and other planets revolve around the sun.
The history of the Lipid Hypothesis has similarities. When you look at the arteries that are diseased with atherosclerosis (i.e., hardening of the arteries), there is fat and cholesterol in them along with other material. So, it could make sense to assume that the fat in the diet could lead to fat and cholesterol accumulation in the arteries. However, we can now examine in greater detail the particles that are carrying fat into the arteries—the small LDL-cholesterol particles that come from the VLDL (very low-density lipoprotein) cholesterol particles, which come from the liver. And where does the fat from the liver come from? From dietary carbohydrates! So, there is a paradigm shift occurring from the “dietary fat hypothesis” to the “dietary carbohydrate hypothesis” of heart disease.
The Lipid Hypothesis was published in the American Journal of Medicine in 1951 by George Duff, M.D., Ph.D., and Gardner McMillan, M.D., Ph.D. (7). Fortunately, there is a paradigm shift in the fundamental thinking well underway.
So, you asked how the dietary fat (lipid) theory became gospel. The theory gained momentum in 1984 when Ancel Keys, Ph.D., published data that seemed to support the Lipid Hypothesis in what is called the “Seven Countries Study” (8).
Passwater: Excuse me for interrupting, but I want to clarify for our readers that Dr. Keys also had an earlier study that was solely based on correlating dietary fat intake with heart disease in six highly selected countries. This was published in 1953 and is not the Seven Countries Study that you mentioned (9). The earlier study was called the “Six Countries Analysis” and was not taken too seriously because it was merely a population (epidemiological) study. Such studies cannot establish cause and effect. It was also obvious that this study was highly selective as to which countries were or were not included. The Seven Countries Study led by Dr. Keys that you mentioned was more than merely an epidemiological study, but an experimental study that actually involved intervention with dietary changes and on-going observation. Still, it did not show dietary fat or dietary cholesterol as a cause of heart disease.
Dr. Keys was an interventionist who advanced his beliefs more by political means than by scientific evidence. He rapidly rose to leadership positions including serving on the board of the American Heart Association. His claim that reducing dietary saturated fat will reduce cardiovascular disease is now considered a fallacy (10, 11).
There have been many studies examining the question of whether or not there is an association or correlation between dietary saturated fat and heart disease. Even if an association were to be found, it would not establish a cause and effect. Other factors that are associated could be the cause. However, no relationship is found in each of the studies and when the studies are all lumped together to give them greater statistical power, still no relationship is found. Now, I point out that while correlation (association) epidemiological studies cannot prove causation, a lack of association does disprove causation. If there is no correlation between two factors, then one can’t be the cause of the other. Let me give you an example of association not being causation. People having yellow fingers are associated with a high rate of lung cancer. However, scrubbing the yellow stain of nicotine off of the fingers will not improve one’s chances of avoiding lung cancer. Lung cancer is caused by smoking tobacco, not the stain left on fingers.
Association studies are properly used to see if there is a possibility of a relationship and if there is, then a study can be designed to test causation or not. Merely conducting additional correlation studies is a waste of time and money because no matter how many there are, they can’t prove a thing.
What is often overlooked, however, is that a lack of association does prove that it is not a cause. A 2010 meta-analysis of 21 prospective epidemiological studies of saturated fats with cardiovascular disease found, “there is no significant evidence for concluding that dietary saturated fat is associated with an increased risk of coronary heart disease or cardiovascular disease” (12).
A 2014 meta-analysis concluded, “Current evidence does not clearly support cardiovascular guidelines that encourage high consumption of polyunsaturated fatty acids and low consumption of total saturated fats” (13).
A 2015 meta-analysis of 41 observational studies found, “Saturated fats are not associated with all-cause mortality, cardiovascular disease, coronary heart disease, ischemic stroke or type-2 diabetes, but trans-fats are associated with all-cause mortality, total coronary heart disease incidence, and coronary heart disease mortality” (14).
For those still impressed with the purported correlation between the dietary fat available to persons in the seven countries selected by Dr. Keys and the death from a particular type of heart disease (which depended on appropriate classification), let me show you a chart prepared by Denise Minger, author of Death By Food Pyramid (15). Please see Figure 1.
This graph plots the fat intake for each of 21 countries having data available for Dr. Key’s examination at the time he selected seven countries to report on. No, no one is claiming that this chart proves anything. As Minger explains, “Although the dots are pretty scattered when fat intake is below 25% of calories, the trend becomes unmistakable once that number passes 30%: countries with higher average fat intake had the longest life expectancies. But, correlation is not to be confused with cause. That is, it may be that the amount of fat and protein available for consumption is an index of a country’s development, industrially, nutritionally, medically, and no doubt in other respects as well” (15).
The World Health Organization updated this association for several European Countries in the Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA Project) in the mid-1980s. Again, it was found that countries in which the residents consumed the most calories (energy) from fat had the lowest number of deaths from heart disease (16). Please see Figure 2.
Dr. Westman, I’m sorry I interrupted you for so long, but there is much confusion about Key’s studies that I just wanted to review some of the background for our readers. Please continue. How did things change after the first publication from the Seven Countries Study was printed?
Westman: The American Heart Association endorsed the Seven Countries Study and in 1984, the flawed LRC-Coronary Primary Prevention Trial (CPPT) was published (17). The behind-the-scenes shenanigans involved were utterly unscrupulous.
The LRC-CPPT was used by the National Institutes of Health to proclaim that no more studies were needed: “(W)e have proved that it is worthwhile to lower blood cholesterol…Now is the time for treatment” (18). The American Heart Association echoed that sentiment. As we say in our book, “Calling this the single biggest blunder in the history of medicine is not overstating the case.” And we’re still reaping what was sown three decades later.”
Passwater: Yes, the interpretation and implication of the Lipid Research Clinics (LRC) CPPT generated considerable controversy. The absolute degree of risk reduction was minimal and total mortality was not improved (19).
The CPPT was designed to determine whether reduction of blood cholesterol by drug therapy significantly lowered the atherosclerotic coronary heart disease rate in a group of hypercholesterolemic but otherwise healthy men (20–22).
The LRC-CPPT did not study dietary saturated fat or dietary cholesterol. Note that the LRC-CPPT involved only men with primary hypercholesterolemia, a rare disorder of lipid metabolism that affects at most one in 500 of the population and a very small fraction of the total number of people dying of heart attacks. The results, insignificant as they were, were then extrapolated to the entire population without primary hypercholesterolemia (23). The study did not show the desired reduction in death rate in spite of spending $142,250,000 between 1973 and 1989.
The CPPT studied 3,806 men over an average of 7.4 years. The drug plus diet changes only lowered the total blood cholesterol levels by an average of 13.4%, much less than expected. During the CPPT, 71 men died in the control group and 68 died in the treatment group. The drug had improved the chance that any of the men who took it would live through the next decade by less than 0.2%.
The difference in nonfatal heart attacks was not statistically significant. In the treatment group, 130 men (6.8%) had a heart attack versus 158 men in the control group (8.3%). After seven years, the fraction of the treatment group that had benefited was less than 2%. It is interesting to note that the difference was 1.5% in absolute reduction but was reported only as a 19% relative reduction in the abstract.
The difference in fatal heart attacks was not statistically significant either. In the treatment group, 30 men (1.6%) had a fatal heart attack compared to 38 men in the control group (2.0 percent) Thus after seven years of taking a drug and adhering to a low-fat diet), less than 1% of the men in the treatment group benefited and this amount was not statistically significant. As Paul Meier, Ph.D., a University of Chicago biostatistician stated, “to call these results conclusive would constitute a substantial misuse of the term” (24).
Pete Ahrens, Ph.D., M.D., the recognized “father” of the Journal of Lipid Research, called this extrapolation from a drug study to a diet “unwarranted, unscientific and wishful thinking.” Dr. Thomas Chambers, an expert on clinical trials, described it to Science as an “unconscionable exaggeration of all the data.” In fact, the LRC investigators acknowledged in their JAMA article that their attempt to ascertain a benefit from diet alone had failed (23). A discussion of some of the flaws in the CPPT is given in references 25 and 26.
In March 2015, we chatted with Aseem Malhotra, M.D., about his editorial in the British Medical Journal, “Saturated Fat Is Not the Major Issue.” After shooting down the widely popular, but incorrect, beliefs about dietary fat with solid scientific evidence, Dr. Malhotra pointed out that common fractured foods and sugars used to replace saturated fats are indeed major factors in heart disease. In his call for action, Dr. Malhotra stated, “The dogma of low-fat diet is damaging public health and contributing to the obesity epidemic, and this has to stop” (27).
To make matters worse, the politicians and those scientists who were being rewarded for their false information about dietary fats created a propaganda machine to scare people away from good foods that contained cholesterol. The National Cholesterol Education Program (NCEP) was created. I know that this propaganda was used to wrongly criticize Dr. Atkins for his successful diet, and I have a feeling that the NCEP continues to cause problems to physicians including yourself who, in spite of your clinical evidence to the contrary, find patients who would benefit from the diet unwilling to try it to see how it helps them because of this old and incorrect advice. There’s too much vested interest behind the cholesterol theory for it to quietly go away. Malcolm Kendrick, M.D., who you refer to in your book, put it this way: “The great ship ‘cholesterol-lowering’ has ripped its guts out on the harsh rocks of evidence, but still it does not sink” (28). Why don’t more physicians realize that it has been disproven?
Westman: Because this cholesterol hypothesis has been taught for so long, as if it were the correct explanation for cardiovascular disease, even most health professionals believe that it is true. There is a saying that most doctors practice medicine the way they were taught in medical school. Even though they are also often told that half of what they are being taught now will be proven to be wrong. The problem is that we don’t know which half it is. It is time to add “cholesterol is bad” to the half that was proven to be wrong.
Passwater: My first scientific article dispelling the link between dietary cholesterol and heart disease was printed in 1972 (29). It was appalling to me then that there was no evidence supporting the theory and so much evidence disproving it. I also discussed this in several chapters in my 1975 book,“Supernutrition: Megavitamin Revolution” (30). In 1977, I put the following on the cover of my book, Supernutrition For Healthy Hearts, “If anyone can step forward and prove that eating cholesterol causes heart disease, I will donate all of the proceeds from my book to the American Heart Association (AHA)” (31).
Westman: Even Dr. Keys, who is often called “the father of the cholesterol theory,” understood and widely published that dietary cholesterol was not a factor in heart disease. In “Human Atherosclerosis and the Diet,“ Dr. Keys concluded, “the cholesterol content of human diets is unimportant in human atherosclerosis” (32).
Furthermore, in “The Relationship of the Diet to the Development of Atherosclerosis in Man,” he stated, “The evidence indicates that the cholesterol content, per se, of all natural diets has no significant effect on either the serum cholesterol level or the development of atherosclerosis in man” (33).
In “Diet and Serum Cholesterol in Man: Lack of Effect of Dietary Cholesterol,” Dr. Keys and his colleagues published the following, which should have ended the mess: “It is concluded that in adult men, the serum cholesterol level is essentially independent of the cholesterol intake over the whole range of natural human diets. It is probable that infants, children and women are similar” (34).
Passwater: Since it has been known since the 1950s that dietary cholesterol is not related to heart disease, why, oh why, then, do those warning us about dietary cholesterol keep doing so, and to boot, they erroneously cite Dr. Keys as “proving” it? The first tenet of medicine is “first do no harm.” The NCEP has caused more harm than good.
As Colin Rose, M.D., Ph.D., cardiologist and professor of Medicine at McGill University sums it up, “There is no evidence that the life expectancy of the general population (primary prevention) has been increased by the National Cholesterol Education Program, but there is strong circumstantial evidence that the NCEP has also been very successful in encouraging the pandemic of obesity and type-2 diabetes, which will eventually kill many more people than could ever have been saved by lowering blood cholesterol with drugs” (23).
Perhaps, the paradigm shift is coming as the newly published federal government’s Official 2015 Dietary Guidelines dropped the key recommendation of earlier editions to limit consumption of dietary cholesterol to 300 mg per day (35). There are no cholesterol limits included in the 2015 edition.
Dr. Westman, with all the confusion out there, what do you recommend to your patients?
Westman: It is important to see how whatever diet and lifestyle you choose affects your health, and not just take someone’s word for it. Some people can be healthy eating a low-fat diet, but the health of others can be worsened. It is definitely not the one-size-fits all solution to preventing heart disease and diabetes that it has been touted to be. I hardly ever use a prescription pad since I changed from a typical internal medicine practice to one that addresses nutrition. I use my knowledge about medicine now to help my patients get off their medications safely. I sought out my own training by conducting clinical research and by attending meetings of the Obesity Medicine Association.
Passwater: Results always count more than theory. Dr. Westman, thank you for an informative discussion on the effectiveness and safety of ketogenic diets and for sharing your clinical experience with our readers. WF
Dr. Richard Passwater is the author of more than 45 books and 500 articles on nutrition. Dr. Passwater has been WholeFoods Magazine’s science editor and author of this column since 1984. More information is available on his website, www.drpasswater.com.
Published in WholeFoods Magazine March 2016
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