Saturated fat is bad for you…….really???

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by Grant Schofield and Helen Kilding

Addendum note from Grant: This post has generated an enormous amount of debate – see the comments section.  Its interesting as the authors of this study came back into the debate early.

Another study, this time it’s my colleagues much closer to home in New Zealand, and they received quite a bit of media space from it. The authors sought to estimate the potential impact on cardiovascular health of modifying dietary intake of saturated fat across the New Zealand population, and whether this would be appropriate and feasible.

They decided that while there was no evidence that fat intake affected health, substituting saturated fats with polyunsaturated fats would be of use and is “feasible” for the health of New Zealanders.

Here’s the paper. “Review of the evidence for the potential impact and feasibility of substituting saturated fat in the New Zealand diet (Rachel H. Foster, Nick Wilson, Burden of Disease, Epidemiology, Equity and Cost-Effectiveness (BODE3) Programme, Department of Public Health, University of Otago – Wellington, New Zealand).

They concluded that “Replacing 5% of daily energy consumed as saturated fat with polyunsaturated fats would be expected to reduce cardiovascular events by about 10%.”

Here’s what the media made of it – The New Zealand Herald, and Stuff.co.nz

And I got more than a few questions from readers….for example:

Hi Grant

What’s your take on this study? (see attached)

Many of the fats they mention as bad I have been eating for the past two months and have lost weight and improved cholesterol! This is an actual result and if anything by default resulted in me consuming less of their so called good fats i.e canola oils, polyunsaturated oils etc.

No wonder it  is hard for people to make informed decisions about diet with so much conflicting information. End of the day I decided to see for myself and make myself the test subject on a LCHF diet and continue to be thankful I did.

So what do we make of all this? First, they actually found no association between fat intake and disease outcomes in their meta-analysis. So great, fat isn’t a risk. But they did conclude that because replacing saturated fat reduces risk, that saturated fat must therefore be a risk factor.

I guess they haven’t considered the latest meta analysis in the American Journal of Public Health (2013)  “Food Sources of Saturated Fat and the Association With Mortality: A Meta-Analysis “. This specifically looks at saturated fats. They show very limited evidence for most saturated fats foods having any association with CVD or cancer. Probably processed meat is the strongest association. In this sort of food product, saturated fat isn’t the only metabolic ingredient.

Nor have they considered that actual experimental evidence through randomized controlled trials (there are more than 20 now) does not show a harm for increasing saturated fat intake in LCHF diets. All the “established” cardio-metabolic risk markers show very favorable outcomes compared with all other diets. No long term outcomes, but these are well known and regarded proxies.

The recently published Sydney Heart study data shows that exactly the opposite happened back in the 1970s, when they replaced saturated fat with polyunsaturated fat and saw things get worse. Here’s the BMJ editorial on this. And here are some results:

“Participants were randomly divided into two groups. The intervention group was instructed to reduce saturated fats (from animal fats, common margarines and shortenings) to less than 10% of energy intake and to increase linoleic acid (from safflower oil and safflower oil polyunsaturated margarine) to 15% of energy intake. Safflower oil is a concentrated source of omega-6 linoleic acid and provides no omega-3 PUFAs. The control group received no specific dietary advice.

Both groups had regular assessments and completed food diaries for an average of 39 months. All non-dietary aspects of the study were designed to be equal in both groups.

The results show that the omega-6 linoleic acid group had a higher risk of death from all causes, as well as from cardiovascular disease and coronary heart disease, compared with the control group.”

Nor have they considered almost all of the growing mechanistic evidence that metabolic issues, including CVD, are inflammatory based and the evidence points strongly to a myriad of interacting pathways, from gut microbiome, to sugar, to simple carbs, to the stress axis, to VLDL and triglycerides through the liver etc etc. The direct effect of dietary saturated fat is not clear in any of these mechanisms and unlikely to be a factor.

Overall, the evidence from the association studies is weak, equivocal, or inconsistent, depending on what term you like best.  Experimentally and mechanistically it doesn’t stack up.  Come on guys, are you doing your reading? It’s not good enough when there is such a broader amount of evidence. Your study doesn’t lead to a rationale for reducing saturated fat and replacing it with polyunsaturated.

Worse still, you’re promoting the use of manufactured vegetables oils which are high in Omega 6 and likely to be inflammatory, adding further to the problem.  These oils are also quite unstable and easily oxidized further, adding to metabolic problems. Saturated fat is not.

Avoiding fat will likely mean eating more carbohydrate.  For many, this will further dysregulate their carbohydrate metabolism and make them more insulin resistant resulting in a downward cycle with all the direct and indirect effects of hyoerinsulinemia.  These guys just haven’t even thought that the active metabolic ingredient in their weak epidemiology might be something else which they haven’t or can’t control for…..insulin-raising carbs.

WHAT I THINK WE SHOULD THINK ABOUT WITH FAT:

  1. Fat contains loads of calories
  2. Fat is an essential nutrient
  3. Highly processed fats are inflammatory
  4. Good quality whole foods, including loads of vegetables, are good for you.  Their fat content appears not to harm you.
  5. Omega 3 fats are good for you. These are poly unsaturated so if that is what they are talking about then great.  But these guys go on to talk specifically about manufactured seed oils – these are not good.
  6. In high carb, insulin-provoking diets, fat seems to add to the insulin response.  This seems to be worse in people who are insulin resistant.  By itself, fat is metabolically benign, at least as far as insulin response is concerned. A good reason to avoid the standard American diet.
  7. Processed meats are likely to be bad for you.  I’m not sure if it’s the actual fat and I’m not sure what the mechanisms might be – inflammatory? We may never know if they are for sure because no one is likely to run an experimental trial where people get a long dose of processed meat.

Take home messages:

  • Don’t believe everything you see in a scientific paper.  Sometimes they go past the evidence.
  • Carry on eating fat, hopefully in the absence of processed and simple carbs as they may harm you in combination.

How did fat get such a bad name in the first place?

We’ve been brainwashed in to thinking that when we eat saturated fat it goes straight into our bloodstream, instantly bonding to the inside of our arteries, eventually clogging them up completely. This is bullshit. Atherosclerosis is caused by oxidised LDL particles penetrating our arterial walls, inciting inflammation and damaging the arterial tissue. And what increases LDL particle number?

  1. Insulin resistance and metabolic syndrome
  2. Poor thyroid function
  3. Infections
  4. Leaky gut
  5. Genetics

Let’s look at that list again…..no mention of dietary intake of saturated fat.

And when we talk about saturated fat, everyone always wants to talk about cholesterol. Dietary cholesterol does not affect total blood cholesterol. In fact, when we do eat cholesterol, our body makes less of it to keep our blood levels in balance.

So even if eating fat doesn’t result in CVD, won’t eating fat make us fat?

No again. As we’ve said before, fat doesn’t make you fat. Fat is very satisfying, especially when paired with low-carb eating. A nice steak rippled with fat is far more filling than some crusty bread spread with butter. You’ll eat a decent piece of the former and be satisfied but could easily polish off half a loaf of the bread with a good helping of butter and still be hungry. It’s difficult to overeat on a high-fat, low-carb diet.

Our bodies want to use fat for energy, but when we eat fat in the presence of large amounts of dietary carbohydrates, it makes it difficult to access fat for energy. On the flip side, dietary fat in the presence of low levels of dietary carbohydrates makes it easier to access fat for energy. It’s also easy to overeat fat and carbs together – think hot chips, buttered toast, milk chocolate.

And let’s think about farming for a second….how do you fatten cattle? You feed them lots of lots of grass (a carbohydrate). According to a recent post on Christine Cronau’s Facebook page, “70 years ago, farmers tried to fatten their livestock with saturated fat. It backfired! The pigs lost weight and became more active. Of course, the farmers weren’t silly enough to persist with something that didn’t work, yet our conventional health professionals have insisted on doing so!” I’ve tried to source more detail on this but have drawn a blank so far.

How happy are New Zealanders?

SWI

How happy are you?  How well are you doing in your life?  How happy are New Zealanders, and how do they compare with other countries?

All big questions. You can find out how you compare with the average New Zealander of your age and sex here.  You can access the Sovereign New Zealand Wellbeing Index here.  You can view TVNZ’s Sunday episode aired on the topic here.

I am very proud to announce the public release of this Sovereign New Zealand Wellbeing Index. It’s the first survey point in a six-year research partnership with Sovereign .  It’s also the first time anyone has tried to understand the epidemiology of wellbeing in a large (n=10,000) population representative sample in NZ.  We will follow some of the same cohort across the six years. The basic logic is that if you want to improve the wellbeing of the population, then first you had better measure it, and generate some hypothesis forming associations.

We also used the same measures as used in the European Social Survey wellbeing module.

So this has been several months’ work for me, and even more work for my dedicated research team, as well as a team at Sovereign working on the comms side.  Thanks everyone for the enormous amount of work.

Actually, that’s been the coolest thing about this project. The well developed comms and advocacy angle that Sovereign has been able to bring to the partnership.  They’ve got an interest in reducing stress and increasing wellbeing straight out form a claims perspective as well as the corporate social responsibility angle

Frankly, we are very used to doing high quality research which mostly gets published in journals a few people read, and a few masters and PhD theses which even fewer (maybe even only a few!) people read.

So now, we have had a great link into releasing the report, advocating government and policy makers, getting TV and media coverage of the results and so forth.

Mostly, I’ve been blogging about nutrition, exercise, weight loss and chronic disease prevention and treatment research at the Human Potential Centre at AUT University. That’s where I am a Professor (Public Health) and the Director of this research centre.  I will do a few more blogs in the wellbeing space to augment this report release.

Wellbeing is an area we are really getting into.  We are trying to bring many of the principles of positive psychology into health. We also want to bring some of the principles of health, especially nutrition and exercise into positive psychology. Each discipline has lots to offer, but combined even more so.

These sorts of national accounts or indices of wellbeing have become popular in Europe recently and other less robust world-wide measures like the Happy Planet Index. To our knowledge, we are the first to do both mainstream health measures and wellbeing measures.

Sunday on TVNZ did a great job of presenting some of the results.  Thanks TVNZ.  See here.

You can go online and either take the entire survey and see what we measured, or just the “7-item flourishing scale”   Goto www.mywellbeing.co.nz. We have the norms for your age and sex, so you can compare you results with those overall and of similar kiwis in the survey.  Have a go its fun.  Take the quiz.

Results for the Sovereign Wellbeing Index (This is the exec summary – get the full report here)

This report presents key findings from the Sovereign Wellbeing Index about the wellbeing of New Zealand adults in late 2012. The survey is the first national representation of how New Zealanders are faring on a personal and social level. The Sovereign Wellbeing Index provides a much needed look into how New Zealanders are coping within the economic conditions.

Wellbeing around New Zealand

Using flourishing as a measure of wellbeing there were small but consistent effects of gender, age and income. Older, female and wealthier New Zealanders on average showed higher flourishing scores. Similar findings were found across all other measures of wellbeing giving some confidence in the convergence of measures.

  • There were only small differences in average flourishing scores between ethnic groups (NZ European slightly higher than Asian) and regions across New Zealand.
  • Social position was a powerful indicator of wellbeing. Those higher on the social ladder reported much higher wellbeing.
  • The five Winning Ways to Wellbeing were all strongly associated with higher wellbeing. People who socially connected with others (Connect), gave time and resources to others (Give), were able to appreciate and take notice of things around them (Take notice), were learning new things in their life (Keep learning), and were physically active (Be Active) experienced higher levels of wellbeing.

Super Wellbeing

We looked at the 25% of the population with the highest wellbeing scores and examined what factors defined this group from the rest of the population. This underpins the idea that psychological wealth and resources can be identified and public policy and action, and personal resources utilised to improve these determinants.

  1. Similar findings to wellbeing in general were identified. Females were 1.4 times more likely to be in the super wellbeing group than males. More older, higher income, and higher social position New Zealanders were in the super wellbeing group.
  2. Connecting, Giving, Taking notice, Keeping learning, and Being active were all strongly associated with super wellbeing.
  3. Other health measures were also strongly associated with super wellbeing. These included better overall general health, non-smokers, exercisers and those with healthier diets and weights were all more likely to experience super wellbeing.

International comparisons

When compared with 22 European countries using the same population measures, New Zealand consistently ranks near the bottom of the ranking in both Personal and Social Wellbeing. New Zealand is well behind the Scandinavian countries that lead these measures.

New Zealand ranks 17th in Personal Wellbeing. Personal Wellbeing is made up of the measures of Emotional Wellbeing (rank 16th), Satisfying Life (rank 16th), Vitality (rank 16th), Resilience and Self- esteem (rank 19th), and Positive Functioning (rank 23rd).

New Zealanders did however rank above the mean for happiness, absence of negative feelings and enjoyment of life. However, we were still well below the top ranked countries.

New Zealand ranks 22nd in Social Wellbeing. Social Wellbeing is made up of the dimensions of Supportive Relations (rank 21st), Felt lonely (rank 20th), Meet socially (rank 21st), Trust and Belonging (rank 23rd), People in local area help one another (rank 21st), Treated with respect (rank 22nd), Feel close to people in local area (rank 23rd), and most people can be trusted (rank 11th).

Further exploration of our worst-ranked Social Wellbeing indicator ‘Feeling close to people in local area’ showed considerable variation across the country with the major cities scoring worst with Auckland at the top. Regional areas fared somewhat better. Younger people and NZ European New Zealanders scored lowest.

Future

New Zealanders make choices everyday about their wellbeing. These are both personal choices as well as democratic choices about public policy and action at local and national levels. It is our vision that this index can help frame both personal choices and public policy and action in New Zealand. If it isn’t wellbeing for ourselves and others we are ultimately striving for, then what is it?

The Sovereign Wellbeing Index will continue to monitor the wellbeing of New Zealanders over the next four years. We plan to follow-up some of the participants in this nationally representative cohort to see how their wellbeing changes with time as well as continue to run this national index and benchmark indicators against European countries.

Do diabetes specialists have learning resistance?

The healthy diabetes plate is a peer-reviewed “evidence based guidelines for healthy eating for Type 2 diabetics”.PCD41A12s01

Here’s my rant around what I consider to be a gaping hole in sensible logic.

Here’s the biological logic:

  1. You have become metabolically dysregulated. In mainstream medicine, your doctor will call you “insulin resistant”.
  2. That means your body is having difficulty getting glucose out of your blood stream into your cells.
  3. Your body still needs to get rid of this glucose, so your pancreas produces more insulin to get the glucose into the cells.
  4. Chronically high insulin makes you more insulin resistant, requiring you to produce more and more insulin. It gets worse and worse. Fat oxidation is turned off, and adipocyctes (fat cells) take up extra glucose and fat.
  5. No matter how much insulin you produce, you can’t move all the glucose into cells. Your blood glucose is high which damages the body irreparably.
  6. Sometimes, because of the stress of overproduction of insulin, the pancreas will have burnout in the beta cells which produce the insulin. Then you’ll need extra insulin, like a Type 1 diabetic.

Here’s your choice:

  1. Take mainstream diabetes treatment advice and follow their dietary guidelines (see above and below). That will be a low fat, moderate carb diet, where you should probably restrict calories. This will result in continued high blood glucose and insulin as you are eating quite a lot of carbs. Whole grains and beans are suggested as they are higher quality and absorbed more slowly. That just means high insulin the whole day for the insulin resistant person. I’ve written about the evidence for this previously.
  2. OR Here’s a novel idea…..or am I missing something here all you diabetes specialists and dieticians? RESTRICT YOUR DIETARY CARBS to very low amounts (<50g/day), eat more fat, and everything will improve. Here’s the outcomes when you do this.
    Just a thought. A glaringly obvious solution to the problem of being unable to tolerate carbs and move them into cells……don’t eat them!

    Take a look at the diabetes food pyramid below…..a low fat diet will be a high carb diet, even with high lean protein, because excess protein ends up being dealt with in exactly the same way as carbs. I contend the only way that a diet like this can work to help a diabetic is if somehow they have enough will power to semi-starve themselves into a very low calorie diet. That diet now works because it too is now a low carbohydrate diet. Why does mainstream medicine seem to be so resistant to even considering this possibility? Who’s right here? Do I have learning resistance, or do the current guidelines just make no sense in the light of the evidence? Insulin resistance or learning resistance?

    pyramid

Why some people must restrict carbs

Spot the difference
OK, I will start this by saying that this is a more academic piece about metabolic control in type 2 diabetics, and the ethics of feeding them low fat diets. It is a bit technical in places and deals directly with original research. Read on if you are interested!
The key message is that in my opinion, when you are insulin resistant, really the first option you should consider is restricting carbs. I hear a lot about “it’s the processed carbs, not the starchy veges that are the problem”, that “vegetarian and vegan approaches are good at reversing type 2 diabetes”, that “fibre solves everything” and so on.
Look, I agree that healthy humans can eat a wide variety of macro-nutrients that may contain plenty of carbs and nothing adverse will happen, but it’s likely that processed carbs will help metabolically well regulated healthy people into insulin resistance and a downward cycle of getting fatter and sicker. The mechanisms by which fructose (sucrose – table sugar is half fructose) work are being understood more clearly by modern science. The way fructose stirs up inflammation, blood lipids, liver fat deposition, addictive pathways in the mesolimbic system in the brain, and causes leptin resistance (the off switch hormone) are all important factors.
Once, or if, you become insulin resistant, I believe that macro-nutrient profiles are very important. Mainly, I am talking about restricting dietary carbs. Remember, if you are insulin resistant then you will have a problem getting dietary carbohydrate into your cells. The pancreas needs to produce more insulin to help do this. In the early stages of insulin resistance, all this means is you end up being hyperinsuliemic – having constantly high insulin – if you eat even moderate amounts of any dietary carbohydrate.
Hyperinsulinemia is known to have multiple direct and indirect effects on the body, making things significantly worse. Insulin is directly inflammatory. Insulin turns off fat oxidation and promotes fat storage and conversion of carbs into fat (de novo lipogenesis). Insulin probably blocks the hormone leptin in the brain (off switch not working again!). High insulin is directly implicated in many cancers, especially breast and prostate cancers. The list is growing all the time as we understand more about this essential hormone, which causes havoc when out of whack.
Interestingly, the treatment approach of most endocrinologists, dieticians and diabetes specialists is to advise those with insulin resistance to have a low fat, moderate protein, high fruit and vegetable diet. Taken correctly, and iso-calorically for weight maintenance, for even consistent small weight loss, this wil be a moderate or high carbohydrate diet. True, the carbs have some fibre and you could avoid all processed carbs. Nonetheless, it is overall carb load that is important here for the insulin resistant person.
Here’s the kicker – some of the “best” carbs recommended for these people by health professionals, because they are low glycemic index, don’t help. This is because these carbohydrates are absorbed slowly into the system; but because the insulin resistant person is so easily overwhelmed by even moderate carb loads, the result is day-long hyperinsulinemia. There’s plenty of evidence for this too.
The evidence comes, in the main, from feeding studies comparing normal metabolically functioning people, with type 2 diabetics.
Here are a few examples:
1. First, I have written about this before in less detail, the study with beans and glucose. The main thing about this paper is that it compares diabetics with healthy non-diabetic controls. This is very important to see the differential insulin response provoked by the same carb load. This study shows how the insulin responses to several types of beans are high and prolonged for Type 2 diabetics compared with controls.
2, This study in Diabetic Medicine in 1989 shows how rolled oat meals in diabetics result in massive hyperinsulinemia and hyperglycemia compared to the healthy controls after 3 hours. It seems to me that any of these meals are the last thing you would want to feed to a Type 2 diabetic.
Rasmussen et al (1989). Postprandial glucose and insulin responses to rolled oats ingested raw, cooked or as a mixture with raisins in normal subjects and type 2 diabetic patients.
Cooking and processing of food may account for differences in blood glucose and insulin responses to food with similar contents of carbohydrate, fat, and protein. The present study was carried out to see if short-term cooking of rolled oats caused an increase in blood glucose. Furthermore, we wanted to see if dried fruit could substitute for some of the starch without deterioration of the postprandial blood glucose response. We therefore compared the blood glucose and insulin responses to three isocaloric, carbohydrate equivalent meals in 11 normal subjects and 9 Type 2 diabetic patients. Meals composed either of raw rolled oats, oatmeal porridge or a mixture of raw rolled oats with raisins were served. In normal subjects, the three meals produced similar glucose (75 +/- 22, 51 +/- 16 and 71 +/- 23 (+/- SE) mmol l-1 180 min, respectively) and insulin response curves (3160 +/- 507, 2985 +/- 632 and 2775 +/- 398 mU l-1 180 min, respectively). Type 2 diabetic patients also showed similar postprandial blood glucose (515 +/- 95, 531 +/- 83 and 409 +/- 46 mmol l-1 180 min, respectively) and insulin (5121 +/- 850, 6434 +/- 927 and 6021 +/- 974 mU l-1 180 min, respectively) responses to the three meals. Thus, short-term cooking of rolled oats has no deleterious effect on blood glucose and insulin responses, and substitution of 25% of the starch meal with simple sugars (raisins) did not affect the blood glucose or insulin responses.
3. Here’s another paper in Diabetes Care from 1987. In this study they fed diabetics 50g of starch contained in various foods. The foods were neither isocaloric, nor matched for other marco-nutrients (see table). The insulin response was greater for many of the foods than predicted by the glucose response. There were no comparison controls though.
fig 3
The glucose and insulin areas under the curve are shown below. A few comments – while the lentils and kidney beans provoked a lower peak glucose, the rise took longer and the response was still increasing at 2 hours. Second, the results show that all foods produced hyperinsulinemia for several hours afterwards.
Untitled
fig2.1
4. And then this paper in Diabetes Care from 1998. Look at the insulin curve responses to three different meals below – a standard American meal, a low starch/high fibre meal, and a high starch meal. You’ll notice a few things. First, the subjects are hyperinsulinemic after all meals. Second, the low starch meal appears to do much better than the higher starch meal. This research is flawed because the macronutrient compositions of the two meals are different – so it’s not the carbs that define the different insulin responses. There are no healthy controls either – so who knows what the difference is between meals and insulin resistant/insulin sensitive subjects.
The “high starch” diet is 55% carbs, 15% protein, and 30% fat. The “low starch” meal is 43% carbs, 22% protein, and 34% fat. So we see here that people have better insulin responses on lower carb, higher protein, higher fat diets! Just reduce the carbs a bit more and you might have something that resembles a healthy diet for a Type 2 diabetic. Another example of poorly conducted research reaching the wrong conclusions about dietary carbs.
5. Finally, heres a paper in the Archives of Internal Medicine from 2005. The figure shows the day long insulin response of the same subjects (they are their own control) on a low carb diet. The low carb diet is ketogenic. To be fair, the diets are not isocaloric because the subject spontaneously ate less food, as is usual for a low carb diet. They were not restricted and ate to fullness though.
Boden-Insulin51
Take home message:
If you are insulin resistant, you are by definition carbohydrate intolerant. Conventional treatment is to reduce fat, eat less processed carbohydrate, but still at least a moderate carb diet. That will result in chronic hyperinsulinemia and make things worse. The best and most sustainable approach is to restrict carbs and to eat moderate protein with fat as needed to fill you up. You can achieve the same result on a vegan diet or a vegetarian diet, it doesn’t matter, although more difficult. I would hypothesize that any diet in which the symptoms of diabetes are reversed is a carb restricted diet, whether it be through carb retsriction alone or an overall very low calorie diet.
Call to action? Understanding that dietary carbs affect some people very negatively is very important but not understood at all by mainstream medicine. Start telling your doctor about this! Pass on this blog, email people, get on Facebook or Twitter – do what you can. This will be a ground up movement in changing public health nutrition.

Is exercise damaging my heart?

the-heart-300x300

Recent high profile athlete cases of heart problems, especially arrhythmias, has had many of us asking several questions about the endurance exercise we do on a regular basis. These include:

  1. What’s the risk?
  2. Is it linked to the actual exercise or something else?
  3. What might you do to mitigate the risk, but still get the benefits of being fit?

It really seems that the evidence is starting to stack up from case studies, to epidemiology, to mechanisms. Let’s explore the issues.

1. What’s the risk?

A recent study published in the European Heart Journal shows several things. Actually, there is a really great comment in a blog by cardiac specialist Dr John Mandrola.

To sum up (that is, to skip the abstract and comments below and get straight to the next point), there is strong associational evidence that hard and prolonged endurance exercise may damage the heart, which results in sometimes serious heart problems. The overall risk is doubled compared to non-athletes, but the overall risk is still only around 2%.

Here’s the abstract of the study…

Aims We aimed to investigate the association of number of completed races and finishing time with risk of arrhythmias among participants of Vasaloppet, a 90 km cross-country skiing event.

Methods and results All the participants without cardiovascular disease who completed Vasaloppet during 1989–98 were followed through national registries until December 2005. Primary outcome was hospitalization for any arrhythmia and secondary outcomes were atrial fibrillation/flutter (AF), bradyarrhythmias, other supraventricular tachycardias (SVT), and ventricular tachycardia/ventricular fibrillation/cardiac arrest (VT/VF/CA). Among 52755 participants, 919 experienced arrhythmia during follow-up. Adjusting for age, education, and occupational status, those who completed the highest number of races during the period had higher risk of any arrhythmias [hazard ratio (HR)1.30; 95% CI 1.08–1.58; for ≥5 vs. 1 completed race], AF (HR 1.29; 95% CI 1.04–1.61), and bradyarrhythmias (HR 2.10; 95% CI 1.28–3.47). Those who had the fastest relative finishing time also had higher risk of any arrhythmias (HR 1.30; 95% CI 1.04–1.62; for 100–160% vs. >240% of winning time), AF (1.20; 95% CI 0.93–1.55), and bradyarrhythmias (HR 1.85; 95% CI 0.97–3.54). SVT or VT/VF/CA was not associated with finishing time or number of completed races.

Conclusions Among male participants of a 90 km cross-country skiing event, a faster finishing time and a high number of completed races were associated with higher risk of arrhythmias. This was mainly driven by a higher incidence of AF and bradyarrhythmias. No association with SVT or VT/VF/CA was found.

Dr Mandrola says the following:

It’s pretty simple: extreme endurance exercise, done over the long term and with great intensity, increases the risk of arrhythmia. There’s no refuting this strong association. These observations are both plausible and consistent with prior studies.

There should be no surprise when an endurance athlete shows up with atrial fibrillation or some other arrhythmia. We are not surprised when masters-aged athletes suffer from other inflammation-induced maladies, like overuse injuries, heart attacks, infections, and even divorce; why are we surprised they get AF?

But context is important. Previous studies have shown Vasaloppet finishers enjoy lower overall mortality. They smoke less, carry less body fat, and report better eating habits. This bolsters the idea that the lifestyle of endurance racing confers good overall health to most participants. Exercise is good. That observation remains unchanged and unchallenged. In the US, we would do better with an epidemic of over- rather than under-exercise.

It’s also important to emphasize that association is not causation. We don’t know whether excessive exercise alone caused the arrhythmia episodes. There are too many possible confounding variables to make a causation link.

[Grant – true, but see below, there is mounting evidence that it is exercise that causes this]

And . . . just because intense and long-term endurance exercise increases the risk of arrhythmia does not mean athletes should avoid a sport they love. These studies don’t tell us to recommend against endurance exercise. They simply inform both doctor and athlete of possible consequences. There are always trade-offs.

As physicians and teachers, knowledge of the association between chronic inflammation and disease might help us give better advice to our athletic patients. My guess, and it is just a guess, I am no coach, is that the same things that help an athlete avoid AF might also make them faster. Do you think getting adequate rest and recovery improves VO2max? Do you think being content with something less extreme than an Ironman or cross-country ski marathon might be antiarrhythmic? What’s wrong with a fast 10K?

[Grant – see below – I think its more about changing nutrition and training methods, but more work needs to be done]

2. Is it linked to the actual exercise or something else?

This is an important point because the study above is only correlational. However, there is enough mechanistic evidence developing to show that the actual exercise itself might be the cause. A study in forty endurance athletes showed significant signs of right ventricular damage following an endurance event lasting between 3 and 11 hours.

The authors conclude that “intense endurance exercise causes acute dysfunction of the RV, but not the LV. Although short-term recovery appears complete, chronic structural changes and reduced RV function are evident.”

3. What might you do to mitigate the risk, but still get the benefits of being fit?

Overall, I would say that these studies and the broader developing evidence shows that excessive and extreme endurance training increase your risk of heart problems. Like anything else, that’s a population measure. What it actually comes down to is whether it affects you or not. That’s binary, not probabilistic. You will either develop a heart problem or you will not.

So what do you do? If you, like me, like the exercise; you understand the benefits are many and done well outweigh the risk, I would say reconsider how you train. I wrote about this is in a previous blog on polarised training and fat adaptation. Both are likely to reduce the oxidative stress on the body and the time you spend in the prolonged hard cardio zone.

Remember, loads of oxidative stress, glycogen burning, and reactive oxygen species has numerous effects on the body; especially the immune system, tissue damage, and DNA damage. This results in a longer recovery time, more sickness, and higher risks of longer term problems.

Take home messages:

  • Exercise is still overwhelmingly good for you. We have a population epidemic of marathon sitting, not marathon running.
  • But…exercise taken to extreme might damage your heart, and you won’t know you have done damage until it’s too late.
  • New training and nutrition techniques may reduce the stress on the heart and body because you go slower more often, and only occasionally really fast (and probably get fitter), and you burn mostly fat (with your heart using ketones as a fuel which it prefers).
  • So, stop flogging yourself at training, eat less carbs – especially sugar, and eat more healthy fat. You might even be faster! You also certainly will be helathier.

Curing Type 2 Diabetes

I’m writing this post and getting these videos out there after a conversation with a diabetes nurse who was very happy to go around telling her diabetic patients, and anyone else who would listen, that “you can’t cure type 2 diabetes”. Really? No chance of completely reversing all the symptoms?

First is an interview with Dr Jay Wortman by the Diet Doctor (one of my favorite bloggers in the LCHF field)

The second is Dr Wortman’s film about curing diabetes in Canadian first nations’ people. It’s called “My Big Fat Diet“. It comes in three parts.

Enjoy

Will sweeteners make you fat or sick?

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Now here’s a very controversial topic: aspartame and other artificial sweeteners. My conversations with (usually) men on sugar and substitutes usually go something like this:

Me: ‘Have you thought about replacing your fizzy drinks with diet drinks like Coke Zero or Diet Coke?’

‘No.’

Me: ‘Why not?’

‘I don’t drink that shit.’

Me: ‘What do you mean?’

‘It’s full of that artificial crap, like those sweeteners and other chemicals. They cause cancer. Diet Coke is a girls’ drink, as well.’

Me: ‘So you’d rather drink that 500 ml of Coke, which has 12 teaspoons of sugar in it?’

‘Yep.’

Me: ‘Even though half of that Coke will send your blood sugar through the roof, raise your insulin, and leave you hungrier than before you had it, while the other half that is fructose will go straight to your liver and screw you up in several other ways? And even though there is no evidence for negative outcomes, especially cancer, in the artificial sweeteners like aspartame, one of the most tested and long-standing additives to the human food supply?’

‘What are you talking about, [usually some profanity starting with d or f and ending with -head]?’ (Returns to drinking, laughing at me.)

Okay, my overall approach was probably fundamentally flawed and really misses the mark on the ‘how to win friends and influence people’ scale, but this is very typical of the responses I hear from men. I’m not a promoter of diet drinks for their own sake, but if you want a sweet drink I think the choice is a no-brainer. Sugary drinks – and fruit juice is in this category as it contains exactly the same amount of sugar as regular Coke – are a worse choice than a diet drink. Sugar is relatively toxic to the body. Aspartame is probably not.

What the heck does “probably not” mean? That’s a very good question. The answer is that there isn’t much evidence, especially experimental evidence with humans, showing adverse health outcomes.

Don’t you hate it when researchers sit on the fence and say that sort of stuff? There isn’t convincing evidence that sweeteners don’t harm you either. So it’s a double edged sword. The reality is that you would be better off drinking water. But that’s not the social and environmental reality of the world we live in. I’m saying that all things being equal, I’d prefer the diet drink to the full sugar version.

OK, I hear all the paleo, whole foods guys screaming – and I hear you. But how do you balance that approach with the pragmatism of public health? (clue: think about our approaches to reducing smoking which is obviously bad for you).

Here’s why I would take a more pragmatic approach to sweeteners. First, all foods are made of chemicals. Nutrients are chemicals. Too much or too little of any nutrient has adverse effects. In other words, when we exceed our biological capacity to deal with a nutrient it is almost always a problem. This is why high carb diets are a problem for some people. Aspartame, when synthesised, breaks down into phenylalanine (an amino acid), aspartic acid, and methanol – all of which are found naturally in foods. So I think it’s a matter of perspective and harm with sweeteners. We can deal with these substances in small amounts.

This isn’t everyone’s view, but I think there is now enough evidence to make this recommendation a public health one. In other words, on the continuum of water being the best and sugary drinks the worst, sweetened drinks and meals fit somewhere in between. That’s different than a personal health choice. It might be considered “harm minismisation”. Some people will say that by drinking sweet (even artificially sweetened) drinks you are giving people a taste for sweet stuff. My response is that we already like sweet stuff and no amount of abstinence from sugar will completely cure our taste for it. That being said, lower carb, sugar free diets do go a long way to curing the actual addition many people develop. Through sweeteners, food technology allows us to enjoy sweetness without the sugar.

Besides aspartame, which can have an aftertaste that some people find off-putting (and was originally developed as a fly spray which is even more off putting), there are two other popular sweeteners available in New Zealand: Splenda and Stevia.

Splenda is sucralose, which is made from sucrose (normal sugar), but with a refining process that reduces the calories. Because sucralose is inert (not metabolised) in the body it is calorie free. This product looks and feels a bit more like actual sugar and doesn’t have the same aftertaste as aspartame sweeteners, so it is much better for cooking and baking.

Stevia is a natural plant extract. In New Zealand it is sold under the name Sweete in 2 g sachets, which contain 1 calorie. Compared with sugar, the onset and duration of sweetness is slower and longer. Stevia is, however, about 16 times sweeter than sugar, the 2 g sachet providing the same sweetness as a teaspoon of sugar. So if you are worried about being natural, this plant-extract additive is pretty good.

On balance, I much prefer the Stevia sweetener.

A few comments about research on these sweeteners:

  1. None are likely to stimulate an insulin response on their own.
  2. I acknowledge that actual experimental trials with these substances on humans will never happen because that research is unethical. So we are left with only some prospective study showing no harm. That’s not that convincing.
  3. A study out last week in the journal “Diabetes Care” showed something very interesting. The paper by Pepino et al was entitled “Sucralose Affects Glycemic and Hormonal Responses to an Oral Glucose Load“. So you can see from the title that Sucralose (Splenda), although on its own doesn’t stimulate an insulin response, combined with glucose does magnify the glycemic and insulin response and area under the insulin curve. That’s interesting. I have no idea why that would happen, whether it happens with other sweeteners, how much glucose is required for this response, or whether it applies in slimmer subjects (average BMI was 42). In any case, it is a bit of a warning about Splenda in particular. Not sure about the others.
  4. Watch out for emotional claims about research in this space. Here’s a great example of one about the above paper which is titled “Splenda and Sucralose shown to contribute to the development of diabetes“. That seems to happen all the time in this field. Let’s agree that absence of evidence isn’t the same as evidence of absence. But let’s also agree that the evidence just isn’t their yet for the outright harm of these substances.

So will they make you fat and sick? They might, but sugar is more likely to do so. Are they harm free? Probably not entirely, but in an obesity epidemic let’s be pragmatic in public health.

What about kids on LCHF?

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This blog was inspired by a question/objection to LCHF from my friend Stuart: “Don’t growing kids need a rich and varied diet when they are growing?”

I couldn’t agree with you more Stuart.  Let’s cover this in two parts, the rich and the varied separately.

Rich:  Yes, kids like all humans respond well to a nutrient dense diet. I am advocating a nutrient dense diet full of fibre, and whole foods full of micronutrients.  Children, like adults, should eat until they are satisfied.  Their food should be based, like adults, on primal principles. In other words, the starting hypothesis for the diet that children thrive on should be based in evolutionary biology, not what the modern food supply is.

The reality is that we have had 100,000 generations of  humans who have successfully bred, raised off spring, and bred again on diets full of whole foods, often high in fat and low in carbohydrates. There is still no evidence that diets high in carbohydrates are essential for optimal human growth and development.

Yet, there is a widespread belief that carbs are absolutely essential for children’s growth and development.  Especially as a source of dietary fibre and other “essential nutrients” (usually not specified what these actually are). A recent article in the Guardian reported on Gwyneth Paltrow’s children being on a low carb eating pattern. It was interesting to see a variety of reactions to this approach.  At one end there were the dietitians claiming that the children would be at health risk because of the absence of the vital carbohydrates.  And that they would no longer be able to think clearly and this would affect brain functioning. Others, with a more balanced view in my opinion, note that from an evolutionary biology perspective there is no reason children shouldn’t flourish under these sorts of whole food conditions.

We certainly need more research in this field with kids.  If the adult data are anything to go by, then children should flourish under a diet that more closely resembles that of our ancestors.

Varied:  Do you mean that refined carbohydrates offer a healthy variation?  If so, no I disagree. These are not part of a rich and varied diet.  Can they eat them now and then?  Yes, like some adults, that is probably OK.  Metabolically healthy children are highly insulin sensitive.  They will spontaneously react to swiftly remove carbohydrate from their blood.  This is what a sugar high is in its extreme in children – the body reacting to remove carbohydrate from the system by all means possible.  I feed my children carbohydrates in higher quantities than I eat them. Heck I even give some of them wheat products. Sugar, yeah that too sometimes.  But my children are metabolically healthy and will deal with it.  They will need to modify this as they age into middle and older adulthood, as it is inevitable that they will become less carbohydrate tolerant.

By metabolically healthy I mean a normal weight.  It’s not normal to be a fat kid. I mean normal blood glucose, I mean normal motivation to be active, I mean normal physical skills appropriate to age. I also mean normal blood pressure, normal liver, and good lipid profiles.  Many children in our society aren’t in this state and it’s not their fault. Being obese as a child, according to some researchers, has about the same effect on quality of life as having cancer as a child. It’s no fun for the child.  They know it, we know it.  Let’s start talking about it.

As Dr Robert Lustig says, “But the kicker here is that fat kids don’t get sugar highs. They just reach for another cookie”. In other words, a high carb diet in a metabolically dysregulated child is not OK.  It’s not because they are the same as a metabolically dysregulated adult.  Children now have fatty livers, insulin resistance and diabetes because of the food, mostly sugar, they are being fed.  Is this because they are gluttonous sloths?  No, it’s not their fault.  It’s no ones individual fault.  It’s the fault of the food industry, poor government regulation, poor nutrition research, and poor public health recommendations.  For fat kids it’s not OK to keep stuffing down the carbs.  That won’t help and if sugar especially is involved, the problem will probably only get worse.

It’s worth watching Dr Lustig’s “Sugar the Bitter Truth” lecture on youtube.  Its great and the first medical endocrinology lecture to go viral.  For the technically minded geeks, his address at the ancestral health symposium is even better.

Lustig has clearly made a decision to, publicly at least, attack sugar as the demon in childhood obesity. Most would agree that is probably the best place to start, especially nutrient-poor sugary drinks.  However, the obvious next logic in his arguments must extend to processed and other rapidly absorbed carbohydrates.

Are we ready for this next step in our society? I am.

OK, I’m ranting, maybe raving now I think.  But did I make the point? Rich is good. Varied doesn’t mean refined sugar and carbs to be “balanced”, especially if you are in metabolic trouble.

So what do my kids eat?

I am the first to admit I’m not a perfect parent, even when it comes to diet. In fact, that seems to be quite a hard part of parenting. That said, we have switched things around from what I would say is conventional eating in our family and it’s going fine.

The reality is that my kids are not on a LCHF diet. They eat mostly whole foods, mostly good quality meats and fats, mostly wheat free, with a dose of the foods all kids get exposed to these days. Is sugar good for them?  I doubt that it does much good.  On the other hand they are insulin sensitive and deal with it pretty well.  So no worries.

In fact that’s a point for the whole LCHF thing.  What I am advocating in general is that high carbs affect some people adversely.  Paradoxically, these are the people who are most vulnerable to obesity and metabolic syndrome. That’s not my kids and it may not be you, now at least.  As we all get older we will probably tolerate carbs less well.  Some kids may even be in this category and you’d have to approach their eating with a little more rigor than I do.

Here’s how it goes for the kids in my house 90% of the time

Breakfast

  • out: cereal, skim milk, toast and spreads, fruit juice, sugar
  • in: eggs, bacon, all fruit, yogurt, smoothies with full fat milk and berries

Lunch:

  • out: sandwiches, processed muesli bars, chips
  • in: cooked meat, fruit, cheese, yogurt

After school:

  • Fried rice with vegetables, eggs, yogurt, cookies (yes I know but that’s the way it goes), fruit, milk

Dinner:

  • Whatever we are having, which is typically meat, fish and vegetables or salad and some sort of high fat dessert (e.g. cream and berries).

Do they buy chocolate bars, soda, and other sweets?  Yes they do.  Do I support it? Sometimes, but mostly not.  Remember, a treat is only a treat when it is not all the time. It’s an imperfect world and we’re doing what we can.

Paradise lost, paradise found. A tale of health in the South and North Pacific

The untouched (and healthy) paradise of Southern Vanuatu

Traditional village life still exists somewhere in the world – Anetytum, Vanuatu

I’ve been lucky enough to contract to the World Health Organization in the South and North Pacific to take on work in the daunting area of non-communicable disease (NCD) prevention (obesity, diabetes, heart disease, etc). It’s been a privilege, but a task which has no easy solution.  Here’s a tale of paradise and paradise lost.  The two extremes of what I’ve seen in the Pacific.

The happiest place in the world?

Aneityum is a small island in Southern Vanuatu. It has several villages, each with its own chief and leadership structure. There are no roads, no cars and no electricity. Almost all of the food is grown locally or caught in the sea. There is a growing, but very small, local tourism operation; some cruise ships stop by for a visit, but they are confined to a smaller island, which the locals have given the tourist-friendly name of Mystery Island. So their sole income is from a small amount of tourism. Money is really only needed for education purposes, i.e. for children going to high school on Tanna, the biggest nearby island. There are both English and French schools on the island. Money is also needed for a small amount of clothing. Everyone has moved on from grass skirts and the like and wears Western-style shorts and T-shirts. One of the first things I saw when I arrived was an All Blacks hat. I’m not sure the guy who was wearing it had heard of the All Blacks, though!

The staple diet on Aneityum comprises fruits, vegetables, water, fish, coconut everything and an occasional small amount of imported rice. In terms of exercise, their system of community subsistence agriculture keeps them active all day. We walked four hours to the next village and back in a single day. Here, this is normal activity.

Do they suffer from lifestyle diseases? Very, very little! They’re primarily concerned with other health care, though they are pretty well organised with this, with a dispensary led by a local who is trained in nursing and other aspects of practical health care.

This is paradise found. Real food, real people, and real happiness. These are the happiest people I have ever met. Do they have problems? Yes, of course. Are they healthy specimens? Pretty much. Do they feel they are missing out on something in life? Absolutely not. Would they eat takeaways and sugary drinks if they could get their hands on them? You bet.

Do these people get diabetes easily when exposed to the industrial food diet?  Yes, Port Villa, Vanuatu’s capital, is just starting to see the rise of the pandemic there.  I just hope and pray that these guys stay as they are.

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Happy, healthy kids. Two French speaking little boys give us the thumbs up!

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A catch of flying fish and sea salmon.  Just paddle your canoe out at night.  Put your lantern on and the fish all leap into the boat.  When it’s full, paddle in.  Simple as that!

Time bomb: Kiribati

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The sad state of Kiribati. Under-nourished kids play on the rubbish in front of a polluted lagoon. Underweight kids and obese adults with diabetes.  If it’s calories in/calories out then are the adults too greedy and eating all the food? I don’t think so.  This is why “the experts” need to travel and see this stuff for themselves.  

Tarawa is the main island in the Republic of Kiribati (formerly the Gilbert Islands). It is right on the equator, about three hours flight north of Fiji, and is famous for the Battle of Tarawa in World War II, in which the US and Japanese smacked it out with huge losses on both sides. You can still see some of the wreckage. A coral atoll, with a maximum height above sea level of 2 m, the island may well cease to exist in a few decades because of global warming. It’s hard to grow food on a coral atoll, and local food supply is a massive issue for the 42,000 people who live on Tarawa, which measures just 40 km long and 300 m wide. Fishing is good (offshore at least), although the influx of foreign aid has meant that a lot of people no longer fish. In any case, the main lagoon is polluted to the extent that there is no inshore fishing or swimming possible.

This is pretty much the opposite of Southern Vanuatu. Staple foods are cheap imported products such as soft drinks, white rice, flour, sugar, tinned fish and instant noodles. We saw diabetes running at 60 per cent, the highest I have ever heard of. Out of hundreds of people that I measured, I think only one or two were not obese. There is a road that runs the length of the island and everyone rides in a car or minibus. Habitual walking and manual work have decreased.

The net result in Tarawa is paradise lost. Rubbish everywhere, NCDs out of control, with no solutions in sight. I measured the blood-sugar levels of everyone in my local health team. They all had diabetes.  Fasting blood glucose was over 10  mmol/L for everyone.  Remember normal is under 5.

The physiotherapy department at the hospital only deals with amputees from diabetes complications. That’s running between 5 and 15 a month.

Two islands in the beautiful Pacific. One on real food and a traditional lifestyle, the other on the cheapest energy available: processed carbohydrates. If you ever wanted evidence that processed carbohydrates damage humans, you should go to Kiribati and have a look for yourself.

Here we have the perverse and real situation that  there are obese adults and undernourished kids in the same family. That’s what you get on a high simple carb diet. Its wrong and it’s not the fault of these guys. what do you think is happening here?  Are the parents eating all the food and starving the kids?  Of course not.  It’s metabolic dysfunction from the carbs running riot.

I wrote this post because it was a turning point for me in understanding that it was nothing to do with calories in and calories out. It is metabolic and hormonal control.  It’s fairly clear to me.

More pictures to give you a flavour of what we saw in the “Happiest place in the world”. The only dodgy thing in these places are the toilets, especially at night.

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Sunset on Aniwa in Southern Vanuatu

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The island’s health committee shows off their health monitoring techniques

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Sunday village lunch after church at Futuna Island.  Health checks conducted after service but before lunch. Real food is all you can get here!

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I wanted to have a caption saying “Grant Schofield picking up a chick!”

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No caption needed

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A day’s physical activity on the island

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Where else in the world can you walk up to the edge of an active volcano and breathe in poisonous gases. dodge flying lava, and all this with no health and safety regulations?! Tana Island

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This was, no kidding, someone’s carry on baggage on a local flight! You slip your fingers under the gills to hold it as you walk on.

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Lean, strong, and healthy in Vanuatu