British consultant cardiologist Dr Aseem Malhotra is a keynote speaker at the first international low-carb, high-fat (LCHF) conference in Cape Town in February 2015. Malhotra 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 at the conference, Malhotra gives his views on cholesterol-lowering drugs known as statins, why fat phobia is unscientific and the real heart of good medicine.
By Marika Sboros
You once wanted to become a professional cricketer. Why didn’t you?
Cricket runs in our blood in our family. My dad was actually very keen that I do cricket. He’s a big cricket fan himself. He played a lot of cricket with some of the great cricketers in his university days. Cricketers like Kapil Dev, etcetera in India. I played at a good level in cricket at school. I used to open the batting for my grammar school. It produces many good cricketers, including Mike Laverton, the former English captain. But I realised I wasn’t going to be the next (Sachin) Tendulkar. I had to make a decision in my late teens and decided to do medicine. I always wanted to study cardiology.
Medicine obviously runs in my family. Both my parents are GPs. Growing up with them, I felt like I was almost already a GP because you know all about the work. I was always interested in 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 rare heart condition called amyloidosis. He was very fit and died tragically in his early 60s. He could have lived much longer. It was heartbreaking. I also had a brother who had a small hole in his heart. He had Down’s syndrome. When he was 13, he died after he picked up a regular virus. At the time, we didn’t know it. 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 is not uncommon.
I think those things 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. There was also the romantic aspect of the heart that I liked as well.
What made you attend this conference?
I received an email from Karen Thomson saying that she’s organising this conference. She told me her background and that her grandfather was (pioneering heart surgeon) Prof Christiaan Barnard. I’ve come because there are many important messages to spread. For me, Tim Noakes is inspirational. He made a U-turn on his own advice and thinking. Very few people have the courage to say they got things wrong.
Some doctors say they’ve stayed away because they disagree with the LCHF premise, including that the diet-heart hypothesis is unproven. Is it?
Just saying “this is dangerous” and “that’s wrong” is part of the problem with modern medicine now. It’s about people’s inability to listen to differing views. We need to get this message out there that conventional dietary advice is unhelpful. It has probably been a major contributor to the obesity epidemic. We need to change it radically.
You have said that a high percentage of people who have a heart attack don’t have raised cholesterol. What are the implications ?
I wrote about it in an article in the BMJ (British Medical Journal). I came across a large US study showing that 75% of people hospitalised 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?
Overall, I don’t think the evidence that saturated causes heart disease is convincing. However, I think we need to be specific because there are many different types of saturated fats. Very few people realise this. One of the studies I spoke about (at the conference) today looked at the association between saturated fat, fat blood levels (influenced by diet) and the risk of type 2 diabetes. Type 2 diabetes is one of the major risk factors for heart disease.
The researchers found that different foods with saturated fatty acids º there are scores of different ones – had different effects. Saturated fatty acids in full-fat cheese and yoghurt, for example, were associated with a decreased risk of type 2 diabetes. Many people also don’t realise that the liver produces saturated fatty acids. And that sugar, starch and alcohol drive the association between saturated fatty acids and the increased diabetes risk.
So, we don’t need to fear fat?
Definitely not. Firstly, a diet high in total fat consumption and low or nearly absent in refined carbohydrates is the best for your health. It will also reduce your risk of heart attack, stroke, cancer and dementia. That’s proven in many good-quality studies. Most of the positive effects 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, you mentioned that a high-fat Mediterranean diet is actively healthy for hearts. Do you have a reference for that?
It’s the PREDIMED study in the New England Journal of Medicine in 2013. That was a randomised controlled trial.
That is considered the gold standard?
Nutrition studies are rare and this was on people at high risk of developing a heart attack or type 2 diabetics who had not yet had a heart attack. The trial terminated early because they found that people who were on a high-fat Mediterranean diet, 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.
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 that? Clearly, the current dietary guidelines aren’t the best evidence-based guidelines for health. The guidelines need to change and soon.
From what I’ve read, there was no scientific basis for introducing the guidelines in the first place?
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. It did not show that reducing saturated fat reduced mortality. That’s key.
What’s your view of statins?
Statins are powerful drugs for secondary prevention of heart disease. That’s in people who have had a first heart attack. There is good randomised control trial data showing 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 statins daily means a one in 83 chance that within five years, the drug 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.
Is there any good science behind statins for benefits overall?
Data suggests that statins 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 of preventing a non-fatal heart attack. However, we know also know that statins are associated with an increased risk of type 2 diabetes. You then have to make a decision. It won’t prolong your life. It may prevent a non-fatal heart attack in a small number but risk of type 2 diabetes is higher.
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.
What about the side effects?
There has been a lot of controversy about statins’ side effects. Unfortunately, part of that controversy is because most of the trial data is from industry-sponsored studies. These were clearly designed to just look at benefits. It is well-known that the industry under-reports side effects. For me, it’s about patients’ quality of life.
Most of what we do in medicine is that we don’t cure things. Or at least not many. We can cure a few things. We have antibiotics for infections and we can cure certain cancers. But most of what we do in medicine is palliation. We’re there to relieve suffering. But 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. To me, that’s the heart of good medicine.
I’m not going to get into the controversy of what percentage of people have side-effects from statins. We know the 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.
Is there any difference in statins use 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. That’s not life-threatening but I would rather not be on a pill that gives potential or 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?
Firstly, Action on Sugar is a group of experts. I have involved respected scientists who are campaigning to ensure a reduction in 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. Good evidence implicates increasing sugar consumption in development of many diseases, including type 2 diabetes and cardiovascular disease. That’s 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. Sugar is an unnecessary source of calories with no nutritional value. You don’t need any carbohydrates for added sugar.
Our main 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 consumes at least two to three times the World Health Organisation limit for sugar consumption.
That’s for adults. What about adolescents?
In adolescents, it’s higher to some degree. It may be four or five times that. Sugary drinks are one of the common sources, so we have called for a tax on sugar ydrinks. We know that a tax will reduce consumption. But we want the government to get the food industry to reduce the amount of sugar they’re adding to processed foods. People are consuming hidden sugar In the US and the UK, 50% of sugar consumption is in foods people don’t really think have sugar in them. Things like bread, ketchup, and salad dressing for example.
We’ve called for a reduction of 40% of added sugars in products 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.
Do you see progress?
Yes. The politicians are listening. But we need regulation if we’re really going to have an impact on the entire population.