MALHOTRA ON THE HEART OF GOOD MEDICINE

Dr Aseem Malhotra is a British consultant cardiologist and a key speaker at the first international low-carb, high-fat (LCHF) conference in Cape Town in February 2015. Malhotra is also that rare but growing breed: a cardiologist with an open mind and heart.

He is science director of Action on Sugar, a group of 23 specialists working to reduce sugar consumption in that country.

Here, in a Q&A on the conference, Malhotra tells me why he decided to attend. Malhotra also makes crystal clear his views on cholesterol-lowering drugs known as statins and why fat phobia is not scientific.  

 By Marika Sboros

You once wanted to be a professional cricketer.  Cricketing’s loss is clearly cardiology’s gain.  Why didn’t you become a cricketer?

I’ve always had a passion for sport.  I played at a good level in cricket at school I used to open the batting for my grammar school, which produces many good cricketers. Among these have been Mike Laverton, the former English captain. I had to make a decision in my late teens to pursue a career in medicine.

Did your parents guide you to medicine?

Well, my dad was actually very keen that I do cricket.  He’s a doctor but a big cricket fan himself.

What kind of doctor is your father?

He’s a general practitioner, but he played a lot of cricket with some of the great cricketers in his university days. Among these were cricketers like Kapil Dev, etcetera in India. Cricket runs in our blood and I made a decision (probably the right one) that I was also very attracted to becoming a cardiologist. For a long time, I wanted to do cardiology. I realised that I wasn’t going to be the next (Sachin) Tendulkar. Therefore, I’d probably be better off doing cardiology.

What made you decide to specialise in cardiology?

Medicine obviously runs in the family and that had an influence on me (in a positive way) although I had decided I didn’t want to do general practice.  Both my parents were GPs and growing up in a family of two GPs, I felt like I was almost already a GP because you know all about the work.  I was always interested the human body and science, but I had very up close and personal experiences of people with their hearts.

What prompted that?

When I was young, my grandfather died of a very rare heart condition, called amyloidosis.  He was a very fit man.  It was tragic, he died in his early 60s. He could have lived much longer.  That isn’t something that runs in families but it was heartbreaking.  I had a brother, who had a small hole in his heart, but he had Down’s syndrome and at the age of 13, he picked up a regular virus.  At the time, we didn’t know what happened, but he basically went into heart failure within the space of a week of being well. It’s likely that he had something called myocarditis, which can happen. He passed away.

It’s a long time ago, but I think those things definitely influenced my thinking about cardiology.  When I went to medical school, I was fascinated with the heart.  We know that heart disease is the biggest killer in the Western world.

It is in South Africa, too.

To some degree, there was the romantic aspect of the heart that I liked as well, and I just pursued that career.

Why did you decide to attend this conference? 

I received an email from Karen Thomson saying that she’s organising this conference with Tim and obviously. She told me about her background and that her grandfather was  (pioneering heart surgeon) Prof Christiaan Barnard.  I didn’t hesitate to say that I will attend.

I’ve come because there are many important messages to spread and I want to be part of that process.  For me, Tim Noakes has been inspirational.  I think he’s an amazing man and a great scientist.  One way in which Tim stands out for me is the fact that he made a U-turn on his own advice and what he was following, and very few people can do that.  I think that’s a real credit to him and a real strength.  I’ve had a lot of respect for Tim and I’ve engaged with him over the last few years on this issue.

Some doctors have said that they’re staying away because they disagree with the basic premise of LCHF – including that the diet-heart hypothesis is unprovenIs it?

It’s unfortunate that there are people who have criticised this conference.   By simply saying “this is dangerous” and “that’s wrong” is actually, part of the problem with modern medicine now – with people’s inability to listen to people who have differing views.  We need to get this message out there that the current dietary advice has been unhelpful.  It has probably been a big contributor to the obesity epidemic.  We need to change it and we need to change it radically.

I heard you saying that an incredibly high percentage of people who have a heart attack, actually, don’t have raised cholesterol.  What’s the percentage?

I wrote about this in one of my BMJ articles.  I found a references paper in America.  It was a very large study in which, it was found that 75% of people admitted with a heart attack, had normal cholesterol levels.  That suggests that cholesterol isn’t as big an issue as we think it is.

What about saturated fat?  Do you believe that saturated fat causes heart disease? 

I think there are a number of things to say here.  Overall, I don’t think the evidence that saturated causes heart disease, is convincing. However, I think we need to be even more specific because there are many different types of saturated fats.  Very few people realise this. One of the studies I spoke about today, looked at the association between saturated fat and the blood (influenced by diet) and the risk of developing type 2 diabetes. As you know, type 2 diabetes one of the major risk factors for heart disease.

What they found is that different saturated fatty acids (and there are scores of different ones) had different ones and they come from different foods.  What’s interesting is that saturated fatty acids that came from full fat cheese and yoghurt for example, were associated with a decreased risk in developing Type 2 Diabetes.  The other interesting thing, which many people don’t realise, is that the liver produces saturated fatty acids themselves and the saturated fatty acids that were associated with the increase of Type 2 Diabetes were being driven by sugar, starch, and alcohol.

 I’ve learned much at this conference. So we don’t need to fear fat?

You’re absolutely right.  Firstly, having a diet that is high in  total fat consumption and  low or nearly absent in refined carbohydrates is going to be the best diet for your health. It will also reduce your risk of heart attack, stroke, cancer, and dementia.  That has ’s been proven in many good quality studies. Most of the positive effects that we have demonstrated so far, in terms of reducing those risks, are from foods such as nuts, extra virgin olive oil, and oily fish for example.

In your talk earlier, you mentioned that a high-fat Mediterranean diet is healthy, and that there’s some research for that.  Do you have a reference for that?

It’s the PREDIMED study, which was published in the New England Journal of Medicine in 2013.  That was a randomised controlled trial.

That was the gold standard?

Nutrition studies are rare and this was about people who were at high risk of developing a heart attack, or Type 2 Diabetics who didn’t have a heart attack.  The trial was terminated early because what they found was within 4.8 years, those people who were on a high-fat Mediterranean diet, which was supplemented with olive oil or nuts, actually had a significantly reduced risk of having a heart attack, stroke, or dying.  It was a 30% (what we call relative risk) reduction, compared to a traditional Mediterranean diet that was low-fat and higher in refined starches.

What’s interesting is that the total fat consumption in the high-fat Mediterranean diet was 41%.  Now, the current dietary guidelines tell us we shouldn’t see more than 30%.  How do you square all of that?  Clearly, the current dietary guidelines aren’t the best evidence-based guidelines for your health.  I don’t believe that they are.  The guidelines need to change and soon.

Yes, and according to Zoe Harcombe and others, there was no scientific basis for introducing them in the first place.

I think there was some observational data.  Ancel Keys’s study for example.  He associated saturated fat with cholesterol and heart disease.  There were flaws in that study.  Zoe’s paper highlighted that the randomised control trial data we had up to that point did notshow that reducing saturated fat, reduced mortality. That’s key.

What’s your view of statins?

I think statins have a role.  They are very powerful drugs, used in the secondary prevention of heart disease. These are the people, who have heart attacks.  We can’t deny the fact that we have good randomised control trial data, that if you take a statin when you’ve had a heart attack, it will reduce the risk of death.  The absolute risk reduction is about one in 83.  It’s reasonable to put someone who has had a heart attack on statins. We know that taking that statins means there’s a one in 83 chance (if you take that statins daily) that within five years, the statin itself will reduce your risk of premature death.

However, that’s not the case for lower risk groups. That includes people who, for example, don’t have heart disease, are otherwise healthy, and have a less than 20% risk of having a heart attack over 10 years. Statins will not prolong your life.  There’s no mortality benefit.

Is there any good science behind statins for benefits overall?

There is data that suggests that it will prevent a non-fatal heart attack, in one in 140 that take it.  That means that for you as an individual, there’s a less than 1% chance that it’s going to prevent a non-fatal heart attack.  However, we know also know that statins are associated with increasing risk of type 2 diabetes.  You then have to make a decision.  It’s not going to prolong your life.  It’s going to prevent non-fatal heart attack in a small number, but you’re more likely to get type 2 diabetes.

On a personal level, given that information, I wouldn’t choose to take (a statin). However, if a patient wants to take it with that information, I’m fine with it. My responsibility is to communicate benefit and risk properly to them.  That’s even before you get into the discussion about side effects.

What about the side effects?

There has been a lot of controversy about statins’ side effects.  Unfortunately, part of that controversy has happened because most of the trial data is from industry-sponsored studies. These were clearly designed to just, look at benefits.  They’re known to under-report on side effects.  For me, it’s about what interferes with the patients’ quality of life.  That’s what’s most important for most of us.

Most of what we do in medicine: We don’t cure things.  Or at least not many. We can cure a few things. We have antibiotics for infections and certain cancers can be cured, but most of what we do in medicine is palliation. We’re there to relieve suffering.  That’s my job, as a doctor.  When somebody comes through the door to see me, I want to do what I can to improve their quality of life when they exit the door.

I’m not going to get into the controversy of what percentage of people have side-effects. We know that that these exist in terms of reports of muscle pains and reduced energy. But if patients are experiencing disabling side effects from statins then what’s the point? They should not have to live in misery for a  marginal benefit.  That’s my personal view and I think that I’m very happy to have that conversation with my patients, and help them make a decision.

Is there any difference in statins for men and women?

We only have one double-blinded randomised control trial on statins, independent of industry, specifically looking at in women.  Again, this is a gold standard of study.  What they found is that up to 40% of women taking a low dose of statins reported reduced energy and fatigue.  Now, that’s not life-threatening, but I would rather not be on a pill that’s going to give me some potential/marginal benefit and just feel lethargic all the time.

You are science director of Action on Sugar.  How much progress have you made in reducing sugar in food?

It’s a very good question, Marika.  Firstly, Action on Sugar is a group of experts – respected scientists whom I’ve involved in this, are campaigning to ensure that we reduce our sugar consumption.  The first part of that campaign is raising awareness about the fact that sugar has become almost unavoidable.  It’s in many processed foods.  We know that there is good evidence now, to show that increasing sugar consumption is implicated in a host of diseases, including Type 2 Diabetes and cardiovascular disease (even in people of normal weight).  It’s not just about obesity.  In fact, it’s beyond obesity.

It’s about the diseases, associated with obesity.  It’s an unnecessary source of calories with no nutritional value.  You don’t need any carbohydrates for added sugar.  We know all of that stuff but actually, the main ultimate aim is to ensure that the whole population reduces our sugar consumption.  In the UK for example, we know that the average UK/British adult is consuming at least two to three times the World Health Organisation limit for sugar consumption.

That’s for adults. What about for adolescents?

In adolescents, it’s higher to some degree.  It may be four or five times that.  Sugary drinks is one of the common sources, so we have called for sugar drinks tax.  We know that tax on sugary drinks will reduce consumption but actually, what we want the government to do is to get the food industry to reduce the amount of sugar they’re adding to processed foods.   Much of the sugar that people are consuming is hidden.  As we know, in the States and in the UK, 50 percent of sugar consumption is in foods people don’t really think have sugar in them – things like bread, ketchup, and salad dressing for example.

What we want to do is get the food industry to reduce the amount of sugar they’re spiking our food with and we’ve called for a reduction of 40% over four to five years.  According to the Department of Health in the UK, that would be enough to potentially, reverse the obesity epidemic, so it would have a big impact.

Are you getting anywhere?

Yes. We’ve gotten attention.  The politicians are listening.  They’re asking for what we think but we haven’t had the regulation yet and that’s what we need.  If we’re really going to have an impact on the entire population, it has to happen through regulation.  There’s no doubt.