Saturated fat and cardiovascular disease

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Most medical, scientific, heart-health, governmental, and professional authorities agree that saturated fat is a significant risk factor for cardiovascular disease, including the World Health Organization,[1] the Food and Nutrition Board of the National Academy of Medicine,[2] the American Dietetic Association,[3] the Dietitians of Canada,[3] the British Dietetic Association,[4] American Heart Association,[5] the British Heart Foundation,[6] the Heart and Stroke Foundation of Canada,[7] the World Heart Federation,[8] the British National Health Service,[9] the United States Food and Drug Administration,[10] and the European Food Safety Authority.[11] All of these organizations recommend restricting consumption of saturated fats to reduce that risk.

However, some meta-analyses of clinical trials and cohort studies have provided evidence against the recommendation for reduced intake of saturated fat,[12][13][14][15][16] including one critique by scientists[17] and one by a trade association.[18]

History

Cholesterol and cardiovascular disease

The initial connection between arteriosclerosis and dietary cholesterol was made by the Russian pathologist Nikolay Anichkov, prior to World War I.[19] Another significant contribution to the debate was made by the Dutch physician (internist) Cornelis de Langen, who noticed the correlation between nutritional cholesterol intake and incidence of gallstones (and soon after, arteriosclerosis and other "Western diseases") in the Javanese population in 1916.[20][21] De Langen reported on his findings at the conference of the International Society of Geographic Pathology in 1935. These observations were made on patients admitted to the municipal hospital in Jakarta. Consequently, he studied this phenomenon in defined populations outside the hospital. He showed that the traditional Javanese diet, very poor in cholesterol and other lipids, was associated with a low level of blood cholesterol as well as a low incidence of cardiovascular disease (CVD), while the prevalence of CVD in Europeans in Java, living on the Western diet, was significantly higher.[20] De Langen's colleague, Isidor Snapper, made a similar observation in North China in 1940. Since de Langen published his results only in Dutch, his work remained unknown to most of the international scientific community.[20]

Saturated fat and cardiovascular disease

The hypothesis that saturated fat has a detrimental effect on human health gained prominence in the 1950s as a result of the work of Ancel Keys, a US nutritional scientist.[22] At that time in the USA, the incidence of heart disease was rapidly increasing, for reasons that were not clear.[22] Keys postulated a correlation between circulating cholesterol levels and cardiovascular disease, and initiated a study of Minnesota businessmen (the first prospective study of CVD).[23]

Keys presented his diet-lipid-heart disease hypothesis at a 1955 expert meeting of the World Health Organization in Geneva.[24] In response to criticism at the conference, he set out to conduct the years-long Seven Countries Study.[25] Ancel Keys joined the nutrition committee of the American Heart Association and successfully promulgated his idea such that in 1961, with the result that the AHA became the first group anywhere in the world to advise cutting back on saturated fat (and dietary cholesterol) to prevent heart disease.[26] This historic recommendation was reported on the cover of Time Magazine in that same year.[27]

Systematic reviews

Summary table of data

Systematic review Relationship between cardiovascular disease and saturated fatty acids (SFA)
American Heart Association: Presidential Advisory on Dietary Fats and Cardiovascular Disease[5] "Randomized controlled trials that lowered intake of dietary saturated fat and replaced it with polyunsaturated vegetable oil reduced cardiovascular disease by about 30%, similar to the reduction achieved by statin treatment."
Hamley, 2017[13] This review found no effect of saturated fats, when replaced by vegetable oils rich in polyunsaturated fatty acids (PUFA), on total mortality or cardiovascular mortality. "Available evidence from adequately controlled randomised controlled trials suggest replacing SFA with mostly n-6 PUFA is unlikely to reduce CHD events, CHD mortality or total mortality. The suggestion of benefits reported in earlier meta-analyses is due to the inclusion of inadequately controlled trials. These findings have implications for current dietary recommendations."
Hooper, 2015[28] This review found that reducing saturated fats, particularly by replacing them with unsaturated fats, reduced the risk of cardiovascular events by 14%, but no benefit to reducing total fat. There was no effect of saturated fats on total or cardiovascular mortality. "The findings are suggestive of a small but potentially important reduction in cardiovascular risk on modification of dietary fat, but not reduction of total fat, in longer trials. Lifestyle advice to all those at risk of cardiovascular disease and to lower risk population groups, should continue to include permanent reduction of dietary saturated fat and partial replacement by unsaturates."
Ramsden, 2016[14] "Available evidence from randomized controlled trials shows that replacement of saturated fat with linoleic acid effectively lowers serum cholesterol but does not support the hypothesis that this translates to a lower risk of death from coronary heart disease or all causes."
de Souza, 2015[15] "Saturated fats are not associated with all cause mortality, CVD, CHD, ischemic stroke, or type 2 diabetes, but the evidence is heterogeneous with methodological limitations."
Schwab, 2014[29] "there was convincing evidence that partial replacement of SFA [saturated fat] with PUFA [polyunsaturated fat] decreases the risk of CVD, especially in men."
Chowdhury, 2014[16] "Current evidence does not clearly support cardiovascular guidelines that encourage high consumption of polyunsaturated fatty acids and low consumption of total saturated fats."
Farvid, 2014[30] "In prospective observational studies, dietary LA [linolenic acid] intake is inversely associated with CHD [coronary heart disease] risk in a dose-response manner. These data provide support for current recommendations to replace saturated fat with polyunsaturated fat for primary prevention of CHD."
Ramsden, 2010[31] Replacing saturated fats with mixed omega-6 and omega-3 fatty acids n-3/n-6 PUFA diets lowered the risk of non-fatal heart attack and death from cardiovascular disease by 22%, while there was a non-significant trend of a 13% increased risk when omega-6 fatty acids alone were substituted. "Advice to specifically increase n-6 PUFA intake, based on mixed n-3/n-6 RCT data, is unlikely to provide the intended benefits, and may actually increase the risks of CHD and death."
Jakobsen, 2009[32] This is the sole individual participant data meta-analysis of the observational studies. Pooled data found that for every substitution of 5% of dietary energy from SFA with PUFAs reduced the risk of coronary events by 13%, and coronary deaths was by 26%, whereas replacing 5% of energy intake from SFAs with carbohydrates increased the risk of coronary events by 7%, with a non-significant trend of an increase in coronary deaths. Monounsaturated fatty acid intake was not associated with coronary outcomes.

Review details

A 2017 systematic review focusing on adequately controlled randomized controlled trials concluded that replacing saturated fats with mostly n-6 polyunsaturated fats is unlikely to reduce coronary heart disease (CHD) events, CHD mortality or total mortality. The 2017 review showed that inadequately controlled trials (e.g., failing to control for other lifestyle factors) that were included in earlier meta-analyses explain the prior results.[33]

A 2017 systematic review by the American Heart Association recommended that decreasing saturated fat intake and increasing consumption of monounsaturated fats and polyunsaturated fats could lower risk of cardiovascular disease by about 30%.[5]

A 2015 systematic review also found no association between saturated fat consumption and risk of heart disease, stroke, diabetes, or death.[15]

A 2015 systematic review of randomized control trials by the Cochrane Library found that reducing saturated fat intake resulted in a 17% reduction in cardiovascular events, and that replacing saturated fats with cis unsaturated fats in particular is beneficial. It concluded: "Lifestyle advice to all those at risk of cardiovascular disease and to lower risk population groups should continue to include permanent reduction of dietary saturated fat and partial replacement by unsaturated fats."[28][34]

In 2014, a systematic review and meta-analysis of 72 published studies totaling 530,525 participants, looked at observational studies of dietary intake of fatty acids, observational studies of measured fatty acid levels in the blood, and intervention studies of polyunsaturated fat supplementation. The authors of the review concluded: ″Current evidence does not clearly support cardiovascular guidelines that encourage high consumption of polyunsaturated fatty acids and low consumption of total saturated fats.″[16]

A 2014 systematic review looking at observational studies of dietary intake of fatty acids, observational studies of measured fatty acid levels in the blood, and intervention studies of polyunsaturated fat supplementation concluded that the findings ″do not support cardiovascular guidelines that promote high consumption of long-chain omega-3 and omega-6 and polyunsaturated fatty acids and suggest reduced consumption of total saturated fatty acids.″[35] Researchers acknowledged that despite their results, further research is necessary, especially in people who are initially healthy. Until the picture becomes clearer, experts recommend people stick to the current guidelines on fat consumption.[36] Indeed, Nita Forouhi, one of the coauthors of the meta-analysis, stated to the BBC that headlines proclaiming that "butter is back" are "an oversimplification, we never said that" and noted that the study was not able to distinguish between the differing effects of reducing saturated fat intake depending on what foods were used in substitute. "While that research is going on I don't think we should just go changing everything. It's too premature to give the public the impression that they have a licence, based on this preliminary research, which is exciting but not yet definitive, to say butter is back."[37]

Moreover, Walter Willett warned that the conclusions of the meta-analysis are seriously misleading, contains major errors and omissions, and should be retracted.[38] In response to the Chowdhury review, Willett et al. commented:

″The meta-analysis of dietary fatty acids and risk of coronary heart disease by Chowdhury et al. contains multiple errors and omissions, and the conclusions are seriously misleading, particularly the lack of association with N-6 polyunsaturated fat. For example, two of the six studies included in the analysis of N-6 polyunsaturated fat were wrong. The relative risks for Nurses’ Health Study (NHS) and Kuopio Ischemic Heart Disease Study (KIHD) were retrieved incorrectly and said to be above 1.0. However, in the 20-year follow-up of the NHS the relative risk for highest vs lowest quintile was 0.77 (95 percent CI: 0.62, 0.95); ptrend = 0.01 (the authors seem to have used the RR for N-3 alpha-linolenic acid from a paper on sudden cardiac death), and in the KIHD the relative risk was 0.39; 95% confidence interval [CI], 0.21-0.71) (the origin of the number used in the meta-analysis is unclear). Also, relevant data from other studies were not included.
Further, the authors did not mention a pooled analysis of the primary data from prospective studies, in which a significant inverse association between intake of polyunsaturated fat (the large majority being the N-6 linoleic acid) and risk of CHD was found. Also, in this analysis, substitution of polyunsaturated fat for saturated fat was associated with lower risk of CHD. Chowdhury et al. also failed to point out that most of the monounsaturated fat consumed in their studies was from red meat and dairy sources, and the findings do not necessarily apply to consumption in the form of nuts, olive oil, and other plant sources. Thus, the conclusions of Chowdhury et al. regarding the type of fat being unimportant are seriously misleading and should be disregarded.″

Views

Mainstream opinion

Specialist/professional textbooks

The 2009 European Society of Cardiology Textbook of Cardiovascular Medicine states that, in cohort studies, the positive relationship between fat intake and CVDs was linked to their saturated fatty acid content.[39]

2007's Cardiovascular Prevention and Rehabilitation states that large epidemiological studies have shown consistent associations between the intake of saturated fatty acids and CHD mortality.[40]

According to the 2007 Critical Pathways in Cardiovascular Medicine, substituting unsaturated fat for saturated fat may lower LDL cholesterol without simultaneously lowering HDL cholesterol. This dietary principle partly underlies the Mediterranean style of diet, which has been associated with reduced cardiovascular event rates in two randomized controlled trials.[41]

The 2003 second edition of Evidence-based Cardiology in 'PartII: Prevention of cardiovascular diseases' recommends a low intake of SFA, less than 7% of daily calories, and intake of foods rich in myristic and palmitic acids should be especially reduced. The recommendation was evaluated to be supported by the best grade of available evidence.[42]

Position statements and guidelines of major health organizations

Medical establishments

In 2003 a World Health Organization (WHO) and Food and Agricultural Organization (FAO) expert consultation report concluded: "intake of saturated fatty acids is directly related to cardiovascular risk. The traditional target is to restrict the intake of saturated fatty acids to less than 10%, of daily energy intake and less than 7% for high-risk groups. If populations are consuming less than 10%, they should not increase that level of intake. Within these limits, intake of foods rich in myristic and palmitic acids should be replaced by fats with a lower content of these particular fatty acids. In developing countries, however, where energy intake for some population groups may be inadequate, energy expenditure is high and body fat stores are low (BMI <18.5 kg/m2). The amount and quality of fat supply has to be considered keeping in mind the need to meet energy requirements. Specific sources of saturated fat, such as coconut and palm oil, provide low-cost energy and may be an important source of energy for the poor."[1]

In its 2007 guidelines, the European Society of Cardiology states that there are strong, consistent, and graded relationships between saturated fat intake, blood cholesterol levels, and the mass occurrence of cardiovascular disease. The relationships are accepted as causal.[43]

The Mayo Clinic considers saturated fats potentially harmful and monounsaturated and polyunsaturated fats potentially helpful. It references the Dietary Guidelines for Americans, 2010 and recommends reducing foods rich in saturated fat and emphasizing options with more monounsaturated and polyunsaturated fats.[44]

The British Dietetic Association guidelines found good evidence in systematic reviews of randomized controlled trials that reducing saturated fat reduces morbidity in patients with CVD.[45]

The 2007 position statement of the American Dietetic Association and the Dieticians of Canada holds that epidemiological studies have shown a positive association between the intake of saturated fatty acid and the incidence of coronary heart disease.[3]

The Harvard School of Public Health holds that saturated fats should be replaced with cis monounsaturated and polyunsaturated fats, but that they should not be replaced with refined carbohydrates.[46]

Heart-health organizations

The Canadian Heart and Stroke Foundation assesses that consumption of saturated fat raises LDL levels, which are a risk factor for cardiovascular disease.[47] Similar positions are held by the American Heart Association,[5] the British Heart Foundation,[6] the National Heart Foundation of Australia,[48] the National Heart Foundation of New Zealand,[49] and the World Heart Federation.[8] The Irish Heart Foundation states that saturated fats can raise LDL cholesterol and increase the chance of developing heart disease or stroke.[50]

Governmental guidelines

The Dietary Guidelines for Americans, 2010 produced by the U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services, says the human body makes more than enough saturated fats to meet its needs and does not require more from dietary sources. It says higher levels of saturated fats are associated with higher levels of total cholesterol and low-density lipoprotein "bad" cholesterol and recommends reduced saturated fat intake.[51] The guidelines are based on the recommendations of the Dietary Guidelines Advisory Committee (DGAC) report that incorporated the results of the review of 12 studies from 2004 to 2009 conducted by the Nutrition Evidence Library (NEL), part of the Evidence Analysis Library Division of the USDA's Center for Nutrition Policy and Promotion. The NEL concluded that there was "strong" evidence that dietary saturated fats increased serum total cholesterol and LDL cholesterol and increased risk of cardiovascular disease.[52][53]

Editorial, commentary and conference findings

A 2010 debate at the Academy of Nutrition and Dietetics's 93rd conference stated: "Regarding saturated fat, the key point agreed upon by the panel and scientific community at large was that researchers agree that replacing saturated fat with healthy polyunsaturated fats is beneficial for health and cardiovascular disease." Recommendations for dieticians emphasized using mono- and polyunsaturated fats whenever possible, avoiding trans fats. Further, "The evidence against saturated fat may not be as strong as dietary guidelines have interpreted [it is clear] that PUFAs (especially) and MUFAs are healthy fats", and that while there is room for saturated fats within the diet, but "[they] should not be viewed as good for you".[54]

A 2010 review found that the risk of coronary heart disease is reduced when saturated fatty acids are replaced with polyunsaturated fatty acids, but there was no clear benefit in replacing saturated fatty acids with carbohydrates or monounsaturated fatty acids.[55]

A 2009 review found that the best evidence showed reduced intake of saturated fat decreased the risk for coronary heart disease.[56]

Another 2009 review found that epidemiological evidence suggested a negative influence on vascular function from saturated fat, but that the experimental evidence did not support this convincingly.[57]

Opinion contradictory to the mainstream

A 2009 scientific conference reported that despite the contribution of dairy products to the saturated fatty acid intake of the diet, there was no clear evidence that dairy food consumption is consistently associated with a higher risk of cardiovascular disease.[58]

The 2010 U.S. Dietary Guidelines Advisory Committee report was criticized for the "use of an incomplete body of relevant science; inaccurately representing, interpreting, or summarizing the literature; and drawing conclusions and/or making recommendations that do not reflect the limitations or controversies in the science", stating that the evidence associating dietary saturated fat with increased risk of cardiovascular disease is inconclusive.[17]

A 2010 meta-analysis concluded that no evidence exists that dietary saturated fat is associated with increased risk of cardiovascular diseases,[12] but this conclusion was disputed,[59] and the authors of the meta-analysis themselves later noted: "A critical question is what macronutrient should be used to replace saturated fat. ... Epidemiologic studies and randomized clinical trials have provided consistent evidence that replacing saturated fat with polyunsaturated fat, but not carbohydrates, is beneficial for coronary heart disease."[60]

An opinion editorial of US dietary guidelines – which recommended lower intake of saturated fat – summarized systematic reviews and meta-analyses, suggesting effects on the incidence of cardiovascular diseases by reducing dietary saturated fat were insignificant.[61] The critique itself drew demands for retraction by more than 180 scientists,[62][63] and consequently was twice corrected.[64][65]

See also

References

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    expanded in book: Nina Teicholz (2015). The Big Fat Surprise: Why Butter, Meat and Cheese Belong in a Healthy Diet. Simon & Schuster. ISBN 978-1451624434.
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