What’s the Optimal Cholesterol Level?

Optimal Cholesterol Level.jpg

No matter where we live, how old we are or what we look like, health researchers from the Institute of Circulatory and Respiratory Health have discovered that 90% of the chance of having a first heart attack "can be attributed to nine modifiable risk factors." The nine factors that could save our lives include: smoking, too much bad cholesterol, high blood pressure, diabetes, abdominal obesity, stress, a lack of daily fruit and veggie consumption, as well as a lack of daily exercise.

Dr. William Clifford Roberts, Executive Director of Baylor Heart and Vascular Institute and long-time Editor in Chief of the American Journal of Cardiology, is convinced, however, that atherosclerosis has a single cause--namely cholesterol--and that the other so-called atherosclerotic risk factors are only contributory at most. In other words, we could be stressed, overweight, smoking, diabetic couch potatoes, but if our cholesterol is low enough, there may just not be enough cholesterol in our blood stream to infiltrate our artery walls and trigger the disease. Thus, the only absolute prerequisite for a fatal or nonfatal atherosclerotic event like a heart attack is an elevated cholesterol level.

It was not appreciated until recently "that the average blood cholesterol level in the United States, the so-called normal level, was actually abnormal," accelerating the blockages in our arteries and putting a large fraction of the normal population at risk. That's cited as one of the reasons the cholesterol controversy lasted so long--an "unwillingness to accept the notion that a very large fraction of our population actually has an unhealthily high cholesterol level."

Normal cholesterol levels may be fatal cholesterol levels.

The optimal "bad cholesterol" (LDL) level is 50 to 70. Accumulating data from multiple lines of evidence consistently demonstrate that that's where a physiologically normal LDL level would be. That appears to be the threshold above which atherosclerosis and heart attacks develop. That's what we start out at birth with, that's what fellow primates have, and that's the level seen in populations free of the heart disease epidemic. One can also look at all the big randomized controlled cholesterol lowering trials.

In my video, Optimal Cholesterol Level, you can see graphing of the progression of atherosclerosis versus LDL cholesterol. More cholesterol means more atherosclerosis, but if we draw a line down through the points, we can estimate that the LDL level at which there is zero progression is around 70. We can do the same with the studies preventing heart attacks. Zero coronary heart disease events might be reached down around 55, and those who've already had a heart attack and are trying to prevent a second one might need to push LDL levels even lower.

Atherosclerosis is endemic in our population in part because the average person's LDL level is up around 130, approximately twice the normal physiologic level. The reason the federal government doesn't recommend everyone shoot for under 100 is that despite the lower risk accompanying more optimal cholesterol levels, the intensity of clinical intervention required to achieve such levels for everyone in the population would "financially overload the health care system. Drug usage would rise enormously." But, they're assuming drugs are the only way to get our LDL that low. Those eating really healthy plant-based diets may hit the optimal cholesterol target without even trying, naturally nailing under 70.

The reason given by the federal government for not advocating for what the science shows is best was that it might frustrate the public, "who would have difficulty maintaining a lower level," but maybe the public's greatest frustration would come from not being informed of the optimal diet for health.


It's imperative for everyone to understand Dr. Rose's sick population concept, which I introduced in When Low Risk Means High Risk.

What about large fluffy LDL cholesterol versus small and dense? See Does Cholesterol Size Matter?

More from the Framingham Heart Study can be found in Barriers to Heart Disease Prevention and Everything in Moderation? Even Heart Disease?.

In health,

Michael Greger, M.D.

PS: If you haven't yet, you can subscribe to my free videos here and watch my live, year-in-review presentations:

Image Credit: lightwise © 123RF.com. This image has been modified.

Original Link

What’s the Optimal Cholesterol Level?

Optimal Cholesterol Level.jpg

No matter where we live, how old we are or what we look like, health researchers from the Institute of Circulatory and Respiratory Health have discovered that 90% of the chance of having a first heart attack "can be attributed to nine modifiable risk factors." The nine factors that could save our lives include: smoking, too much bad cholesterol, high blood pressure, diabetes, abdominal obesity, stress, a lack of daily fruit and veggie consumption, as well as a lack of daily exercise.

Dr. William Clifford Roberts, Executive Director of Baylor Heart and Vascular Institute and long-time Editor in Chief of the American Journal of Cardiology, is convinced, however, that atherosclerosis has a single cause--namely cholesterol--and that the other so-called atherosclerotic risk factors are only contributory at most. In other words, we could be stressed, overweight, smoking, diabetic couch potatoes, but if our cholesterol is low enough, there may just not be enough cholesterol in our blood stream to infiltrate our artery walls and trigger the disease. Thus, the only absolute prerequisite for a fatal or nonfatal atherosclerotic event like a heart attack is an elevated cholesterol level.

It was not appreciated until recently "that the average blood cholesterol level in the United States, the so-called normal level, was actually abnormal," accelerating the blockages in our arteries and putting a large fraction of the normal population at risk. That's cited as one of the reasons the cholesterol controversy lasted so long--an "unwillingness to accept the notion that a very large fraction of our population actually has an unhealthily high cholesterol level."

Normal cholesterol levels may be fatal cholesterol levels.

The optimal "bad cholesterol" (LDL) level is 50 to 70. Accumulating data from multiple lines of evidence consistently demonstrate that that's where a physiologically normal LDL level would be. That appears to be the threshold above which atherosclerosis and heart attacks develop. That's what we start out at birth with, that's what fellow primates have, and that's the level seen in populations free of the heart disease epidemic. One can also look at all the big randomized controlled cholesterol lowering trials.

In my video, Optimal Cholesterol Level, you can see graphing of the progression of atherosclerosis versus LDL cholesterol. More cholesterol means more atherosclerosis, but if we draw a line down through the points, we can estimate that the LDL level at which there is zero progression is around 70. We can do the same with the studies preventing heart attacks. Zero coronary heart disease events might be reached down around 55, and those who've already had a heart attack and are trying to prevent a second one might need to push LDL levels even lower.

Atherosclerosis is endemic in our population in part because the average person's LDL level is up around 130, approximately twice the normal physiologic level. The reason the federal government doesn't recommend everyone shoot for under 100 is that despite the lower risk accompanying more optimal cholesterol levels, the intensity of clinical intervention required to achieve such levels for everyone in the population would "financially overload the health care system. Drug usage would rise enormously." But, they're assuming drugs are the only way to get our LDL that low. Those eating really healthy plant-based diets may hit the optimal cholesterol target without even trying, naturally nailing under 70.

The reason given by the federal government for not advocating for what the science shows is best was that it might frustrate the public, "who would have difficulty maintaining a lower level," but maybe the public's greatest frustration would come from not being informed of the optimal diet for health.


It's imperative for everyone to understand Dr. Rose's sick population concept, which I introduced in When Low Risk Means High Risk.

What about large fluffy LDL cholesterol versus small and dense? See Does Cholesterol Size Matter?

More from the Framingham Heart Study can be found in Barriers to Heart Disease Prevention and Everything in Moderation? Even Heart Disease?.

In health,

Michael Greger, M.D.

PS: If you haven't yet, you can subscribe to my free videos here and watch my live, year-in-review presentations:

Image Credit: lightwise © 123RF.com. This image has been modified.

Original Link

How to Design Saturated Fat Studies to Hide the Truth

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Where do the international consensus guidelines to dramatically lower saturated fat consumption come from? (I show the list in my video, The Saturated Fat Studies: Buttering Up the Public). They came from literally hundreds of metabolic ward experiments, which means you don't just ask people to change their diets, you essentially lock them in a room--for weeks if necessary--and have total control over their diet. You can then experimentally change the level of saturated fat consumed by subjects however you want to, and see the corresponding change in their cholesterol levels. And the results are so consistent that you can create an equation, the famous Hegsted Equation, where you can predict how much their cholesterol will go up based on how much saturated fat you give them. So if you want your LDL cholesterol to go up 50 points, all you have to do is eat something like 30% of your calories in saturated fat. When you plug the numbers in, the change in cholesterol shoots up as predicted. The experiments match the predictions. You can do it at home with one of those home cholesterol testing kits, eat a stick of butter every day, and watch your cholesterol climb.

These ward experiments were done in 1965; meaning we've known for 50 years that even if you keep calorie intake the same, increases in saturated fat intake are associated with highly significant increases in LDL bad cholesterol. Your good cholesterol goes up a bit too, but that increase is smaller than the increase in bad, which would translate into increased heart disease risk.

So if you feed vegetarians meat even just once a day, their cholesterol jumps nearly 20% within a month. To prevent heart disease, we need a total cholesterol under 150, which these vegetarians were, but then even just eating meat once a day, and their cholesterol shot up 19%. The good news is that within just two weeks of returning to their meat-free diet, their cholesterol dropped back down into the safe range. Note that their HDL good cholesterol hardly moved at all, so their ratio went from low risk of heart attack to high risk in a matter of weeks with just one meat-containing meal a day. And indeed randomized clinical trials show that dietary saturated fat reduction doesn't just appear to reduce cholesterol levels, but also reduces the risk of subsequent cardiovascular events like heart attacks.

So we have randomized clinical trials, controlled interventional experiments--our most robust forms of evidence--no wonder there's a scientific consensus to decrease saturated fat intake! You'll note, though, that the Y-axis in these studies seen in my video The Saturated Fat Studies: Set Up to Fail is not cholesterol, but change in cholesterol. That's because everyone's set-point is different. Two people eating the same diet with the same amount of saturated fat can have very different cholesterol levels. One person can eat ten chicken nuggets a day and have an LDL cholesterol of 90; another person eating ten a day could start out with an LDL of 120. It depends on your genes. But while our genetics may be different, our biology is the same, meaning the rise and drop in cholesterol is the same for everyone. So if both folks cut out the nuggets, the 90 might drop to 85, whereas the 120 would drop to 115. Wherever we start, we can lower our cholesterol by eating less saturated fat, but if I just know your saturated fat intake--how many nuggets you eat, I can't tell you what your starting cholesterol is. All I can say with certainty is that if you eat less, your cholesterol will likely improve.

But because of this extreme "interindividual variation"--this wide variability in baseline cholesterol levels for any given saturated fat intake--if you take a cross-section of the population, you can find no statistical correlation between saturated fat intake and cholesterol levels, because it's not like everyone who eats a certain set amount of saturated fat is going to have over a certain cholesterol. So there are three ways you could study diet and cholesterol levels: controlled feeding experiments, free-living dietary change experiments, or cross-sectional observations of large populations. As we know, there is a clear and strong relationship between change in diet and change in serum cholesterol in the interventional designs, but because of that individual variability, in cross-sectional designs, you can get zero correlation. In fact, if you do the math, that's what you'd expect you'd get. In statistical parlance, one would say that a cross-sectional study doesn't have the power for detecting such a relationship. Thus because of that variability, these kinds of observational studies would seem an inappropriate method to study this particular relationship. So since diet and serum cholesterol have a zero correlation cross-sectionally, an observational study of the relationship between diet and coronary heart disease incidence will suffer from the same difficulties. So again, if you do the math, observational studies would unavoidably show nearly no correlation between saturated fat and heart disease. These prospective studies can be valuable for other diseases, but the appropriate design demonstrating or refuting the role of diet and coronary heart disease is a dietary change experiment.

And those dietary change experiments have been done; they implicate saturated fat, hence the lower saturated guidelines from basically every major medical authority. In fact, if we lower saturated fat enough, we may be able to reverse heart disease, opening up arteries without drugs or surgery. So with this knowledge, how would the meat and dairy industry prove otherwise? They use the observational studies that mathematically would be unable to show any correlation.

All they need now is a friendly researcher, such as Ronald M. Krauss, who has been funded by the National Dairy Council since 1989, also the National Cattleman's Beef Association, as well as the Atkins Foundation. Then they just combine all the observational studies that don't have the power to provide significant evidence, and not surprisingly, as published in their 2010 meta-analysis, no significant evidence was found.

The 2010 meta-analysis was basically just repackaged for 2014, using the same and similar studies. As the Chair of Harvard's nutrition department put it, their conclusions regarding the type of fat being unimportant are seriously misleading and should be disregarded, going as far as suggesting the paper be retracted, even after the authors corrected a half dozen different errors.

It's not as though they falsified or fabricated data--they didn't have to. They knew beforehand the limitations of observational studies, they knew they'd get the "right" result and so they published it, helping to "neutralize the negative impact of milk and meat fat by regulators and medical professionals." And it's working, according to the dairy industry, as perceptions about saturated fat in the scientific community are changing. They even go so far to say this is a welcome message to consumers, who may be tired of hearing what they shouldn't eat. They don't need to convince consumers, just confuse them. Confusion can easily be misused by the food industry to promote their interests.

It's like that infamous tobacco industry memo that read, "Doubt is our product since it's the best means of competing with the body of fact that exist in the mind of the general public." They don't have to convince the public that smoking is healthy to get people to keep consuming their products. They just need to establish a controversy. Conflicting messages in nutrition cause people to become so frustrated and confused they may just throw their hands up in the air and eat whatever is put in front of them, which is exactly what saturated fat suppliers want, but at what cost to the public's health?


If that "Doubt is our product" memo sounded familiar, I also featured it in my Food Industry Funded Research Bias video. More on how industries can design deceptive studies in BOLD Indeed: Beef Lowers Cholesterol? and How the Egg Board Designs Misleading Studies.

In health,
Michael Greger, M.D.

PS: If you haven't yet, you can subscribe to my free videos here and watch my live, year-in-review presentations--2013: Uprooting the Leading Causes of Death, More Than an Apple a Day, 2014: From Table to Able: Combating Disabling Diseases with Food, 2015: Food as Medicine: Preventing and Treating the Most Dreaded Diseases with Diet, and my latest, 2016: How Not To Die: The Role of Diet in Preventing, Arresting, and Reversing Our Top 15 Killers.

Image Credit: Taryn / Flickr

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The Saturated Fat Studies: Buttering Up the Public

NF-Sept29 The Saturated Fat Studies Buttering Up the Public.jpeg

Time magazine's cover exhorting people to eat butter could be viewed as a desperate attempt to revive dwindling print sales, but they claimed to be reporting on real science--a systematic review and meta-analysis published in a prestigious journal that concluded that current evidence does not clearly support cardiovascular guidelines that encourage cutting down on saturated fat, like the kind found in meat and dairy products like butter.

No wonder it got so much press, since reducing saturated fat intake is a major focus of most dietary recommendations worldwide, aiming to prevent chronic diseases including coronary heart disease. So, to quote the Center for Science in the Public Interest, "What gives? Evidently, shaky science...and a mission by the global dairy industry to boost sales."

They interviewed an academic insider, who noted that some researchers are intent on showing saturated fat does not cause heart disease, which can be seen in my video The Saturated Fat Studies: Buttering Up the Public. In 2008, the global dairy industry held a meeting where they decided that one of their main priorities was to "neutralize the negative impact of milk fat by regulators and medical professionals." And when they want to do something, they get it done. So they set up a major, well-funded campaign to come up with proof that saturated fat does not cause heart disease. They assembled scientists who were sympathetic to the dairy industry, provided them with funding, encouraged them to put out statements on milk fat and heart disease, and arranged to have them speak at scientific meetings. And the scientific publications we've seen emerging since the Mexico meeting have done just what they set out to do.

During this meeting, the dairy industry discussed what is the key barrier to increasing worldwide demand for dairy. There's global warming issues and other milks competing out there, but number one on the list is the "Negative messages and intense pressure to reduce saturated fats by governments and non- governmental organizations." In short, the negative messages are outweighing the positive, so indeed, their number one priority is to neutralize the negative image of milk fat among regulators and health professionals as related to heart disease.

So if we are the dairy industry, how are we going to do it? Imagine we work for Big Butter. We've got quite the challenge ahead of us. If we look at recommendations from around the globe, there is a global scientific consensus to limit saturated fat intake with most authoritative bodies recommending getting saturated fat at least under 10% of calories, with the prestigious U.S. Institute of Medicine and the European Food Safety Authority recommending to push saturated fat consumption down as low as possible.

The latest guidelines from the American Heart Association and the American College of Cardiology recommend reducing trans fat intake, giving it their strongest A-grade level of evidence. And they say the same same for reducing saturated fat intake. Since saturated and trans fats are found in the same place, meat and dairy, cutting down on foods with saturated fat will have the additional benefit of lowering trans fat intake. They recommend pushing saturated fat intake down to 5 or 6%. People don't realize how small that is. One KFC chicken breast could take us over the top. Or, two pats of butter and two cubes of cheese and we're done for the day--no more dairy, meat, or eggs. That'd be about 200 calories, so they are in effect saying 90% of our diet should be free of saturated fat-containing foods. That's like the American Heart Association saying, "two meals a week can be packed with meat, dairy, and junk, but the entire rest of the week should be unprocessed plant-foods." That's how stringent the new recommendations are.

So this poses a problem for Big Cheese and Chicken. The top contributors of cholesterol-raising saturated fat is cheese, ice cream, chicken, non-ice cream desserts like cake and pie, and then pork. So what are these industries to do? See The Saturated Fat Studies: Set Up to Fail.

For those unfamiliar with Trans Fat in Meat and Dairy (and refined vegetable oils), that's why I made a video about it.

The U.S. National Academy of Sciences Institute of Medicine "as low as possible" position, echoed by the European Food Safety Authority, is described in my video: Trans Fat, Saturated Fat, and Cholesterol: Tolerable Upper Intake of Zero.

What happened when a country tried to put the lower saturated fat guidance into practice? See the remarkable results in Dietary Guidelines: From Dairies to Berries.

Don't think the dietary guidelines process could be undermined by underhanded corporate tactics? Sad but true:

In health,
Michael Greger, M.D.

PS: If you haven't yet, you can subscribe to my free videos here and watch my live, year-in-review presentations--2013: Uprooting the Leading Causes of Death, More Than an Apple a Day, 2014: From Table to Able: Combating Disabling Diseases with Food, 2015: Food as Medicine: Preventing and Treating the Most Dreaded Diseases with Diet, and my latest, 2016: How Not To Die: The Role of Diet in Preventing, Arresting, and Reversing Our Top 15 Killers.

Image Credit: Johnathan Nightingale / Flickr

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Starch-Blocking Foods for Diabetics?

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How did doctors treat diabetes before insulin? Almost a thousand medicinal plants are known antidiabetic agents, including beans, most of which have been used in traditional medicine. Of course, just because something has been used for centuries doesn't mean it's safe. Other treatments for diabetes in the past included arsenic and uranium. Thankfully many of these other remedies fell by the wayside, but scientific interest in the antidiabetic potential of beans was renewed in the past decade.

Diabetes is a global public health epidemic. Although oral hypoglycemic medications and injected insulin are the mainstay of treatment of diabetes and are effective in controlling high blood sugars, they have side effects such as weight gain, swelling, and liver disease. They also are not shown to significantly alter the progression of the disease. Thankfully, lifestyle modifications have proven to be greatly effective in the management of this disease. And if there is one thing diabetics should eat, it's legumes (beans, chickpeas, split peas, and lentils).

Increased consumption of whole grains and legumes for health-promoting diets is widely promoted by health professionals. One of the reasons is that they may decrease insulin resistance, the defining trait of type 2 diabetes. The European Association for the Study of Diabetes, the Canadian Diabetes Association and the American Diabetes Association all recommend the consumption of dietary pulses as a means of optimizing diabetes control. What are pulses? They're peas and beans that come dried, and are therefore a subset of legumes. They exclude green beans and fresh green peas, which are considered more vegetable crops, and the so-called oil seeds--soybeans and peanuts.

A review out of Canada (highlighted in my video, Diabetes Should Take Their Pulses) compiled 41 randomized controlled experimental trials, totaling more than a thousand patients, and corroborated the diabetes association nutrition guidelines recommending the consumption of pulses as a means of optimizing diabetes control. They discovered that some pulses are better than others. Some of the best results came from the studies that used chickpeas. In terms of beans, pintos and black beans may beat out kidney beans. Compared to the blood sugar spike of straight white rice, the combination of black or pinto beans with rice appeared to reduce the spike more than kidney beans and rice.

Dark red kidney beans may not be as effective because they have lower levels of indigestible starch. One of the reasons beans are so healthy is they contain compounds that partially block our starch-digesting enzyme, which allows some starch to make it down to our colon to feed our good gut bacteria. In fact, the inhibition of this starch-eating enzyme amylase, just by eating beans, approximates that of a carbohydrate-blocking drug called acarbose (sold as Precose), a popular diabetes medication. The long-term use of beans may normalize hemoglobin A1C levels (which is how you track diabetes) almost as well as the drug.

What about avoiding metabolic derangements in the first place? See my video Preventing Prediabetes By Eating More.

What else may help?

What may hurt?

-Michael Greger, M.D.

PS: If you haven't yet, you can subscribe to my free videos here and watch my live year-in-review presentations Uprooting the Leading Causes of Death, More Than an Apple a Day, From Table to Able, and Food as Medicine.

Image Credit: Emily Carlin / Flickr

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How Learning to Cook Can Save Your Life

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The eating habits of modern Americans have been described as, "eating breakfast in their cars, lunch at their desks and chicken from a bucket." Within the last few decades, Americans are eating out more and more, and cooking fewer meals at home, which are typically healthier. Home-cooled meals tend to contain less saturated fat, cholesterol, and sodium, and more fiber. Therefore, the benefits to preparing healthy food at home may include the prevention of chronic disease. Just because food is prepared at home doesn't mean it's healthy, though. Microwaving a frozen pizza isn't exactly home cooking.

One of the problems is many people no longer know how to cook. For example, one study reported that 25% of the men in the study had absolutely no cooking skills whatsoever. Another study in the UK compared the nutritional content of meals created by television chefs to TV dinners, and both were then compared to the nutritional guidelines published by the World Health Organization. The researchers looked at a hundred of each, and not a single one complied with the nutrition standards. And the TV chef recipes were even less healthy than the TV dinners!

Many people don't know how to make healthy food taste good. This is not a new problem; an editorial in the Journal of the American Medical Association bemoaned the same issue back in 1913. In the United States, "vegetables are frequently boiled in a way which deprives them of their characteristic odor and their toothsomeness. 'Villainous and idiotic' are the only adjectives that can describe our methods of cooking vegetables."

Researchers in Taiwan recently found that in a group of elderly Taiwanese people, those who cooked their own food were not only healthier, but also lived longer. In a ten year study, highlighted in my video, Cooking to Live Longer, those who cooked most frequently had only 59% of the mortality risk. This took into account the exercise people got grocery shopping, physical function, and chewing ability. So why did they live longer? Those that cooked typically ate a more nutritious diet with a higher consumption of vegetables.

The effect on mortality was much more evident in women than in men. It turns out that "men were, with doubtful justification, more positive about the nutritional value of convenience foods compared with women." Women who cooked made better food choices in general.

As one author noted in the book Something from the Oven, over the last century:

"we began the long process of turning over to the food industry many of the decisions about what we eat...Today our staggering rates of obesity and diabetes are testimony to the faith we put in corporations to feed us well. But the food industry is a business, not a parent; it doesn't care what we eat as long as we're willing to pay for it. Home cooking these days has far more than sentimental value; it's a survival skill."

With the onslaught of health information out there, access to simple, healthy recipes has never been easier. While cooking at home requires more effort, energy, and cleaning, the results, health aside, are often more rewarding. Learning to cook is a simple art, and with the right amount of patience and delicious ingredients, it can help us take back control of our own lives.

Check out your local public library for cookbooks--I've been amazed at the selection in all of the cities I've lived. Or for those for which books are just so 20th century, the online Rouxbe Cooking School holds healthy cooking classes.

More on fast food:

Some other unsavory bits about the food industry:

I think this is the only other mention of celebrity chefs I have:
Paula Deen: diabetes drug spokesperson

-Michael Greger, M.D.

PS: If you haven't yet, you can subscribe to my free videos here and watch my live year-in-review presentations Uprooting the Leading Causes of Death, More Than an Apple a Day, From Table to Able, and Food as Medicine.

Picture by Moyan Brenn on Flickr

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Why Some Dietary Cholesterol Studies Fail to Show Harm

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How else can we make decisions for ourselves and our families but by the best available balance of evidence? The latest meta-analysis, pooling data from more than a dozen studies involving more than 300,000 people, indicates that there is a dose dependent association between egg consumption and the risk of cardiovascular disease and diabetes. But that doesn't mean every individual study showed evidence of harm. Even though the totality of evidence points to harm, the egg industry can cherry-pick studies that show no apparent effects.

If eggs are harmful, why don't all of the studies on heart disease and egg consumption show significant harm? It may have to do with Geoffrey Rose's "sick population" concept. If an entire population is sick, then the range of "health" may not be sufficiently broad to establish a significant association. Rose's paper is one of the most famous papers ever written in preventive medicine and should be required reading for all medical students.

Imagine if everyone smoked 20 cigarettes a day. If everybody smoked, then clinical studies, case-control studies, and cohort studies would all lead us to conclude that lung cancer was a genetic disease; and in one sense that would be true. Some smokers get cancer; others lifelong smokers never do. But if everybody smoked, we'd never know that smoking was a risk factor. Thankfully, in the case of cigarettes and lung cancer, it so happened that the original study populations contained about equal numbers of smokers and non-smokers. In such a situation, studies are able to identify smoking as the main risk factor.

But take cholesterol. In the video, When Low Risk Means High Risk, you can see the cholesterol levels of the people with and without heart disease in the famous Framingham Heart Study. There's hardly any difference because practically everybody's cholesterol was too high; it's like everyone was a smoker. The painful truth is that even someone at "low risk" for heart disease is likely to die of heart disease. Everyone who eats the standard Western diet is, in fact, a high-risk individual when it comes to heart disease.

In a sick population like ours where nearly everyone is eating lots of saturated fat and cholesterol, adding some more saturated fat and cholesterol in the form of eggs may just take us from one sorry state--probably dying from heart disease--to another sorry state--still probably dying from heart disease.

So when the current federal guidelines say we need to particularly restrict dietary cholesterol if we're at high risk for heart disease, we need to realize that nearly all Americans that live past middle age are at high risk of dying from heart disease--it's our #1 cause of death. As stroke specialist David Spence and colleagues put it, "A 20-year old man might feel safe smoking and eating egg yolks because his heart attack is 45 years or so in the future. But why would he want to accelerate the progression of his atherosclerotic plaque and bring it on sooner? Stopping egg yolks after the heart attack would be like quitting smoking after lung cancer is diagnosed."

There may in fact be a plateau of risk for smoking, too. Whether we smoke for 25 years or 35 years, our risk for lung cancer may be the same--really high, but about the same. The tobacco industry could truthfully tell someone who's smoked for most of their lives that, don't worry, you can keep smoking and your risk of lung cancer won't go up (conveniently failing to mention that if you're already at high risk and you quit completely, your risk would drop dramatically). It's like if you took a raging drunk and had them take a shot of whiskey. In someone who's hammered, it might not make much difference, but to a teetotaler, a couple shots could have quite an effect. So it's like the alcohol industry with a group of drunks saying, see, couple shots, no big deal. But that doesn't mean it's not better to be sober.

Instead of going from high risk to high risk, better to go to low risk or no risk.

This reminds me of what the beef industry tried to pull. See BOLD Indeed: Beef Lowers Cholesterol?

Is our diet really that bad? See Nation's Diet in Crisis.

Here are a few other important egg industry videos:

-Michael Greger, M.D.

PS: If you haven't yet, you can subscribe to my free videos here and watch my live year-in-review presentations Uprooting the Leading Causes of Death, More Than an Apple a Day, From Table to Able, and Food as Medicine.

Image Credit: Keoni Cabral / Flickr

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Where Do You Get Your Fiber?

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Vegetarians and vegans are all too familiar with the question: Where do you get your protein?

Well, we can finally put to rest the question of whether vegetarians get enough protein thanks to a large study that compared the nutrient profiles of about 30,000 non-vegetarians to 20,000 vegetarians and about 5,000 vegans, 5,000 flexitarians (vegetarian most of the time), and 5,000 pescetarians (no meat except fish). The average requirement is 42 grams of protein a day. As you can see in the graph in the video, Do Vegetarians Get Enough Protein, meat eaters get way more than they need, and so does everyone else. Vegetarians and vegans average 70% more protein than the recommendation every day.

It's surprising that there's so much fuss about protein in this country when less than 3% of adults don't make the cut, presumably because they're on extreme calorie-restricted diets and aren't eating enough food period. But 97% of Americans get enough protein.

There is a nutrient, though, for which 97% of Americans are deficient. That nutrient is fiber.

Less than 3% of Americans get even the recommended minimum adequate intake of fiber. That's something we really have to work on.

On average, we get only about 15 grams a day. The minimum daily requirement is 31.5, so we get less than half the minimum. Men are particularly deficient. If we break down intake by age and gender, after studying the diets of 12,761 Americans, the percent of men between ages 14 and 50 getting the minimum adequate intake is zero. (The only nutrient Americans may be more deficient in than fiber is potassium. See 98% of American Diets Potassium Deficient.)

This deficit is stunning in that dietary fiber has been protectively associated in population studies with the risk of diabetes, metabolic syndrome, cardiovascular disease, obesity, and various cancers as well high cholesterol, blood pressure, and blood sugars. Therefore, it is not surprising that fiber is listed as a nutrient of concern reported by the Dietary Guidelines Advisory Committee. Protein is not.

One problem is that most people have no idea what's in their food; more than half of Americans think steak is a significant fiber source. By definition, fiber is only found in plants. There is no fiber in meat, dairy or eggs, and little or no fiber in junk food. Therein lies the problem. Americans should be eating more beans, vegetables, fruits, and whole grains--but how are they doing?

96% of Americans don't eat the minimum recommended daily amount of beans, 96% don't eat the measly minimum for greens, and 99% don't get enough whole grains. Nearly the entire U.S. population fails to eat enough whole plant foods.

Even semi-vegetarians make the fiber minimum, though. Those eating completely plant-based diets triple the average American intake. When closing the fiber gap, you'll want to do it gradually though, no more than about five extra grams a day each week until you can work your way up. But it's worth it. "Plant-derived diets tend to contribute significantly less fat, saturated fat, cholesterol, and food-borne pathogens, while at the same time offering more fiber, folate, vitamin C, and phytochemicals, all essential factors for disease prevention, optimal health, and well being." And the more whole plant foods the better. If we compare the nutritional quality of vegan versus vegetarian, semi-vegetarian, pesco-vegetarian and omnivorous diets, traditional healthy diet indexing systems consistently indicate that the most plant-based diet is the healthiest one.

For more on how S.A.D. the Standard American Diet is, see Nation's Diet in Crisis.

Americans eating meat-free diets average higher intakes of nearly every nutrient. See my video Nutrient-Dense Approach to Weight Management.

Isn't animal protein higher quality protein though? See my videos:

For more on protein, see: Plant Protein Preferable and Prostate Cancer Survival: The A/V Ratio.

And for a few on fiber:

In health,
Michael Greger, M.D.

PS: If you haven't yet, you can subscribe to my free videos here and watch my live year-in-review presentations Uprooting the Leading Causes of Death, More Than an Apple a Day, From Table to Able, and Food as Medicine.

Image Credit: Nathan Rupert / Flickr

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Eliminate Most of Your Chronic Disease Risk in Four Steps

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In 1903, Thomas Edison predicted that the doctor of the future will give no medicine, but instead "instruct his patient in the care of the human frame in diet and in the cause and prevention of disease." A hundred and one years later, the American College of Lifestyle Medicine was born. Lifestyle docs like myself still prescribe meds when necessary, but, based on the understanding that the leading causes of disability and death in the United States are caused mostly by lifestyle, our emphasis is particularly on what we put in our mouths: food and cigarettes. An "impressive number of studies have shown that lifestyle is the root cause of what ails us." The good news is that by changing our lifestyle we can dramatically improve our health.

You have the power.

We've known for a long time that for most of the leading causes of death our genes account for at most 10 to 20% of risk, given that rates of killers like heart disease and major cancers differ up to a 100-fold among various populations, and that when people migrate from low- to high-risk countries, their disease rates almost always change to those of the new environment. For example, at least 70% of strokes and colon cancer are avoidable, as are over 80% of coronary heart disease and over 90% of type 2 diabetes. So maybe it's "time we stop blaming our genes and focus on the 70% that is under our control." That may be the real solution to the health care crisis.

It doesn't take much. Adhering to just four simple healthy lifestyle factors can have a strong impact on the prevention of chronic diseases: not smoking, not being obese, exercising half an hour a day, and eating healthier (more fruits, veggies, whole grains, less processed foods and meat). Four simple things cut our risk of developing a chronic disease by 78%. 95% of diabetes risk out the window, 80% of heart attack risk, gone. Half of stroke risk, a third of cancer risk, simply gone. Think of what that means in terms of the numbers. As it stands now, each year a million Americans experience their first heart attack or stroke, a million get diabetes, a million get cancer.

Do we actually get to live longer, too? The CDC followed about 8,000 Americans 20 years or older for about six years. They found that three cardinal lifestyle behaviors exerted an enormous impact on mortality. People who do not smoke, consume a healthy diet, and engage in sufficient physical activity can substantially reduce their risk for early death. By "not smoking" they just meant not currently smoking; by "healthy diet" they just meant in the top 40% in terms of complying with the rather wimpy federal dietary guidelines; and by being "physically active" they just meant averaging about 21 minutes a day or more of at least moderate exercise. Those that managed at least one of the three had a 40% lower risk of dying. Those that hit two out of three cut their chances of dying by more than half. Those that scored all three threw 82% of their chances of dying in those six years out the window.

What does that mean in terms of how much longer we get to live? A similar study on health behaviors and survival, highlighted in my video, Turning the Clock Back 14 Years, didn't just take people's word for how healthfully they were eating, they measured the level of vitamin C in people's blood, a biomarker for how many plants they were eating, and the drop in mortality risk in those nailing all healthy behaviors was equivalent to being 14 years younger.

I discuss the role diet may play in preventing the 15 leading causes of death in my 2012 annual review video Uprooting the Leading Causes of Death.

How does your diet compare? Calculate Your Healthy Eating Score.

I go into depth into the exercise component in my video Longer Life Within Walking Distance.

For more on slowing the aging process, see my videos:

And more on my chosen clinical specialty, lifestyle medicine, in:

In health,
Michael Greger, M.D.

PS: If you haven't yet, you can subscribe to my videos for free by clicking here and watch my full 2012 - 2015 presentations Uprooting the Leading Causes of Death, More than an Apple a Day, From Table to Able, and Food as Medicine.

Image Credit: Marlon E / Flickr

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Don’t Forget Fiber

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The famous surgeon Denis Burkitt is better known for his discovery of a childhood cancer now known as Burkitt's lymphoma than for his 1979 international bestseller, Don't Forget the Fibre in Your Diet.

Anyone asked to list the twenty or more most important advances in health made in the last few decades would be likely to include none of what Dr. Burkitt considered to be among the most significant. What was the number one most important advance in health according to one of the most famous medical figures of the 20th century? The discovery that "Many of the major and commonest diseases in modern Western culture are universally rare in third-world communities, were uncommon even in the United States until after World War l" yet are now common in anyone following the Western lifestyle. So it's not genetics--they're lifestyle diseases (See Dr. Burkitt's F-Word Diet). This means they must potentially be preventable.

Those eating the standard American diet have very high levels of a long list of diseases--such as heart disease and colon cancer--that were similar to the rates of disease in the ruling white class in apartheid Africa. Conversely, the rates in the Bantu population were very low. These native Africans ate the same three sister diets of many Native Americans, a plant-based diet centered around corn, beans, and squash. In fact, it was reported that cancer was so seldom seen in American Indians a century ago they were considered practically immune to cancer--and heart disease. What are "very low" rates? 1300 Bantus were autopsied over five years in a Bantu hospital and maybe one case of ischemic heart disease, the West's number one killer.

The Bantu's rates of heart and intestinal disease is similar to poor Indians, whereas wealthier Indians who ate more animal and refined foods were closer to those in Japan--unless they moved to the U.S. and started living like us. You find similar trends for the other so-called Western diseases, which Burkitt thought were related to the major dietary changes that followed the lndustrial Revolution: a reduction in healthy whole plant foods--the source of starch and fiber-and a great increase in consumption of animal fats, salt, and sugar. His theory was that it was the fiber. He believed all of these major diseases may be caused by a diet deficient in whole plant foods, the only natural source of fiber.

Fiber? In a survey of 2,000 Americans, over 95% of graduate school-educated participants and health care providers weren't even aware of the daily recommended fiber intake. Doctors don't even know. How much fiber should we shoot for? The Institute of Medicine recommends 38 grams for men 50 years and younger and 30 grams for men over 50 years. Women 50 years and younger should get 25 and those older than 50 should get 21 grams. But these levels are just the minimum. I recommend we look to our evolutionary past for more clues on fiber intake. See my video Paleolithic Lessons.

One analogy Dr. Burkitt used is this: "If a floor is flooded as a result of a dripping tap, it is of little use to mop up the floor unless the tap is turned off. The water from the tap represents the cause of disease, the flooded floor the diseases filling our hospital beds. Medical students learn far more about methods of floor mopping than about turning off taps, and doctors who are specialists in mops and brushes can earn infinitely more than those dedicated to shutting off taps." And the drug companies is more than happy to sell us rolls of paper towels, so patients can buy a new roll every day for the rest of their lives. To paraphrase Ogden Nash: modern medicine is making great progress, but just headed in the wrong direction.

How do we know that diet was the critical factor? Because when we place people stricken with these diseases on plant-based diets, their disease can be reversed (Our Number One Killer Can Be Stopped). In fact it was the work of Burkitt and others in Africa that led to the disease reversal work of pioneers like Nathan Pritikin (Engineering a Cure).

More on fiber:

And for more of the scoop on poop:

-Michael Greger, M.D.

PS: If you haven't yet, you can subscribe to my free videos here and watch my live year-in-review presentations Uprooting the Leading Causes of Death, More Than an Apple a Day, and From Table to Able.

Image Credit: Rachel Hathaway / Flickr

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