The True Cause of Heart Disease: A Conversation with Dr. Aseem Malhotra

Hey everybody, this is Dr. Mark Hyman. Welcome to the Fat Summit, your chance to separate fat from fiction. And I'm here with my new friend and colleague, Dr. Aseem Malhotra from London. And he's really one of the leading thinkers in cardiology, challenging the status quo around fat, around calories, around around the conventional wisdom, around statin use, and it's sort of shaking up the scene a bit. And it's very impressive. He's doing a whole campaign against sugar and consumption in the UK, and he's an award-winning cardiologist, he's an honorary national health service consultant, and he's really pushed doctors and the media and academics to rethink sugar, rethink fat through his articles in British Medical Journal and Open Heart and many others. And I've followed his work very closely and I've been very impressed with His conclusions, which I have to say are pretty much the same as mine, so I kind of like it. But welcome, Dr. Valhotra, and welcome from London.

Thank you, Mark. I'm delighted to be able to speak to you today.

So I want to start off by asking you, how did you change from being a conventional cardiologist who was trained that low-fat diets are the right way to go for preventing heart disease and that statins are God's gift to mankind, and that all calories the same to flipping all those ideas upside down and having a totally unconventional view about the world of fat, heart disease, calories, statins, and the whole thing.

Yeah, Mark, it's a very good question. I think the first thing to say is I've had a bit of a journey in the last few years and there's been an evolution in my own thinking as I've read more and more around the science. But where it started for me, Mark, is I'm traditionally trained as an interventional cardiologist. what I was trained to do, what my passion is, is treating people with acute heart attacks, with emergency angioplasty stenting. And one thing I was very aware of during my career in the last sort of 10 years or so is I noticed there was certainly a big issue around obesity. In the UK, as you probably know, we are now officially the fattest nation in Europe. We're just slightly behind, well, yeah, slightly behind the United States. And nothing seemed to be We didn't seem to be finding any solutions. The problem seems to be getting worse. And I was seeing a lot of patients as well with a lot of increasing burden of chronic disease, multiple comorbidities. And I thought, you know, I started to look into it myself and thought, well, I want to do something about this because, you know, I'd rather, you know, someone didn't jump into the river in the first place rather than me having to save them from drowning. Right. So for me, I kind of Got an interest in this whole area initially through looking into obesity. But as I looked into it more and more and realizing obviously this is a food environment problem, I then went to more detail and looked at the science. And I was, you know, surprised initially, but then my view became more and more sort of cemented really that this low fat message actually has caused harm. It's not even a question of it not being linked to heart disease. It's actually caused harm because at the very least the food industry have utilized this low fat is good for you by adding a lot of sugar to a lot of processed foods that are marketed as healthy. And we know that sugar now, there are more and more studies coming out implicating sugar as an independent dietary risk factor for many chronic diseases. And so that's where it kind of went for me to start off with.

So you sort of had an insight when you were treating patients because Did you see metabolic changes that didn't add up for you around sugar and their diets and metabolic syndrome?

Yeah, exactly. Right, well, you know, so we've had this obsession with cholesterol. Everything's been about low cholesterol. And I used to see a lot of people that were overweight or obese whose cholesterol levels were completely normal and they were somehow reassured that their diet was fine even though they were overweight. And then I started to look into that and realized actually, you know, that it actually the cholesterol profile, we should have a more nuanced approach. You know, people should be looking more at the triglycerides and the HDL. rather than just concentrating on LDL or bad cholesterol. But also the fact that data started coming out showing that actually 75% of people admitted with myocardial infarction had normal cholesterol levels. Now the other aspect of it is-.

Well that was just to pause for a minute there. That was an impressive study of 500,000 patients. It was like 60 or 70% of all the patients who had a heart attack in the United States when they went in the hospital, 75% of them had normal cholesterol, quote, normal LDL cholesterol. But what was also interesting in that group was that most of them had low HDLs and high triglycerides, right? Sure, absolutely.

Absolutely. And, you're absolutely right. I think the figure was about 66% of those patients had metabolic syndrome, essentially markers of metabolic syndrome. And, if you had metabolic syndrome, you're admitted with a myocardial infarction, you're 50% more likely to either be readmitted or die within one year. So that obviously clearly was a marker of an adverse health outcome.

And by the way, don't statins actually make that worse? Don't they cause diabetes in men?

Well, it's very good point, Mark. So now we know, it varies in terms of what study you look at, but approximately 1% minimum, I would say, of people who take statins over a period of only two or three years will develop type 2 diabetes because of the statin. And I think that's crucial because then you start looking into, okay, well what are the benefits? And when you look at the data independently, independently analyzed, if you're at low risk of heart disease, as in you have a less than 20% risk of developing cardiovascular disease in the next 10 years, there is no mortality benefit. You're not gonna live one day longer. At the 10% level, we know that you have to treat 140 people for one person to prevent a non-fatal heart attack or stroke. So then we're now saying, well, you're more likely to get type 2 diabetes. And that's even before we get into the whole issue about side effects that interfere with the quality of life, which we know vary from, depending on various reports, but vary from at least what we'd say 10 to 20%. And that really changes the whole perception about the use of these drugs and the benefits patients are getting. And then, to add more fuel to the fire mark, how many patients are actually told that in the conversation when they're having discussion about taking statins? Every single patient thinks they're gonna benefit.

Yeah.

And therefore, in my view, we have an epidemic of misinformation around fat, around sugar, around statins.

Yeah, absolutely. So let's dig in a little bit. So with the fat and the metabolic syndrome, 'cause that's really the key here. What you're basically saying is that When you're a cardiologist and when you look at the data, most of the people coming in with heart attacks have pre-diabetes or type 2 diabetes. That's the driver of heart disease for most people. Sure, absolutely.

It's not necessarily LDL cholesterol. No, absolutely. And I think we had a publication recently in the postgraduate medical journals, a very good paper in one of the diabetes journals from a few years ago. And they actually give a hierarchy in terms of what are the most important risk factors behind heart attacks. And actually, insulin resistance comes up number one, followed by hypertension, high blood pressure, then BMI, and actually LDL cholesterol comes lower down. So even then, if you take the published data at face value, and there is certainly some question marks around publication bias, as you know. Even best case scenario, LDL is a risk factor for coronary artery disease, in my view. At best, it's really a much weaker risk factor than people believe it is.

Yeah, I mean, it doesn't seem to be as strong, for example, as the total cholesterol to the HDL ratio, right?

Sure, absolutely. And that, in fact, when people do their cardiovascular risk assessment, when you plug in all the different variables from your body mass index, your family history, to your blood pressure, to your sex, to whether you've had a history of angina, when you plug it all into in terms of your risk calculator, Actually, it's a total cholesterol to HDL ratio that's actually key.

And what determines that is the HDL is determined by your metabolic syndrome. In other words, if you were pre-diabetic or you have a high sugar refined.

Carb diet, that drives HDL down.

Absolutely. And what causes it to go up.

Is... Well, interestingly, saturated fats.

Exactly.

I mean, there are other factors, exercise is one, but certainly saturated fat tends to drive the HDL up. you've hit on a very important point there, Mark, is that one of the explanations for why when we look at the high quality observational data now, where that link between saturated fat consumption and heart disease is being questioned, one of the mechanisms is that the HDL goes up as much as the LDL, and therefore the ratio doesn't change that much in terms of your overall risk. So therefore that may be another mechanism to explain why saturated fat isn't truly the cause of heart disease. But to further that argument, Mark, what many people don't realize is that actually there are many different types of saturated fats and they have different chain lengths depending on which food they're found in. And to try and simplify it, a very good Cambridge Medical Research Council study that was done two studies in fact in 2014, very good high quality observational studies show that actually it's suggesting now that if you have full fat dairy in particular, so we're talking about full fat yogurt and cheese, the saturated fatty acids that are found in those foods are actually linked to reduce, reducing the risk of type two diabetes and heart disease, which may actually explain what we call the French paradox. So we know that in Europe, the French have the highest consumption of saturated fat. And I can tell you as a cardiologist for, you know, several years that whenever we used to have meetings and conferences, there would always be like France was the gold standard that we need to get our cardiovascular mortality rates down. as low as France. And they're having butter. Which is interesting. Yeah, well, it may well be. It's certainly one of the factors in.

My view, there's no doubt. Yeah, I remember seeing some of the analysis where they looked at plasma levels, blood levels of fatty acids, and when they stratified the types, which you could tell from what you're eating, you could tell the type of fat, margaric acid, for example, is a saturated fat from dairy. People who had high levels of that had lower risk of heart disease, which I thought was pretty interesting in the data. Yeah, it's such a mind bender because most of us have grown up thinking that saturated fat is bad and still even though total fat levels are being questioned as being useful, even in America and the new Dietary Guidelines Committee, they're still saying we should stop eating as much saturated fat and that we really we shouldn't be eating so much of it. How do you explain that? How do they kind of... and you know, they say it's inflammatory, they say.

It actually I think they're still sticking to the hypothesis mark that saturated fat increases cholesterol total and LDL and that's a risk factor for heart disease. So for them, they feel it's a no-brainer. Sorry. For them, they feel it's a no-brainer and they probably still think, okay, well, we'll err on the side of caution here until we have more and more data. To be honest, I think we have the data already. And in fact, one of the things I would suggest is that we should probably move towards more food-based guidelines rather than concentrating on macronutrients. But certainly there shouldn't be a restriction on total fat. And in my view, I think the saturated fat message, I think it's been grossly overblown. And I certainly think there is good nutritional value and very likely protective effects from full fat dairy.

Yeah, so that's interesting. So as a cardiologist, when would you recommend someone address their cholesterol, their LDL cholesterol. Because as you start taking more saturated fat in your diet, your LDL cholesterol goes up, your total cholesterol goes up, and people start freaking out and they go to their doctor and they go, your cholesterol's up, this side's hurting you, stop it. Meanwhile, they're feeling better, they're losing more.

Weight, everything's working, but how do you deal with that? Dr. Yeah, very good question, Mark. I think what I, again, coming back to what we look at is let's look at the total cholesterol to HDL ratio. I'll be very honest, I myself, you know, I haven't calculated the amount, but, and I will do that soon, but I probably have quite a high consumption of saturated fat, in my diet. And I've checked my own cholesterol levels and I can't remember the absolute numbers, but there's been a slight increase in my LDL, but my HDL rocketed. And in fact, what's interesting is, and it varies from individual to individual, you know, I think one thing we need to, I think, appreciate more and more is that one size doesn't fit all, and there may be individual variations. and sometimes an over simplistic message that one size fits all in fact as we know has caused damage. But what I would say is that my actual HDL rocketed, my triglycerides went down, my total cholesterol actually went down and my ratio got better even though I know I'm eating more saturated fat. But what I did do is I reduced my refined carbohydrates and sugar consumption. And I think that in combination actually was beneficial as well. I wouldn't-- and again, in terms of my weight, and as you know this, a diet that's higher in fat, certainly much higher in fat than what we currently recommend, the government guidelines are recommending, and lower in sugar and refined carbohydrates is in fact going to be better for your metabolic health, for your weight. And the other aspect of all of this, Mark, is if you look at the randomized controlled trial data we have-- and of course there is a paucity of data, but we still have some good data. Certainly, the beneficial effects of diet on risk of cardiovascular, not risk, just in fact outcomes of cardiovascular endpoints, whether it's heart attacks or mortality, is certainly one which is much higher in fat than current guidelines. So for me, it's a mess. It's a complete mess. The current guidelines in the United States and the UK, in my view, are a root cause of the obesity epidemic.

So our government's killing people.

Well, you can look at it that way. Certainly contributing to a lot of misery, you know, fortunately, and I'm sure, and completely unintentioned, but I think we need to correct it.

Yeah, it's an unintentional and inadvertent consequence of our dietary guidelines, both in the United States and the UK, absolutely. You know, I want to sort of tip off now to a really compelling article that you wrote in Open Heart with Dr. Nicolantonio, looking at calories as a myth. in terms of both weight and heart disease. You brought up some very compelling evidence from the DASH trial, from the Predimed trial, from the GISSI trial. You looked at different studies that were very well done studies challenging our beliefs that all calories are the same and even brought up studies that show that you could reverse heart failure by a very high fat diet and reverse diabetes by a high fat diet. They actually led to more weight loss, which was kind of interesting. Could you take us through that article and the thinking behind it and some of the studies? It's really compelling. We can dig into it.

Absolutely, Mark. That's a really good point. The title of the article was, It's Time to Stop Counting Calories. Dietary changes can rapidly and substantially reduce cardiovascular morbidity and mortality. There's a few different messages there. If we start with the calories aspect, you know, one of the issues that people forget is that different calories have different metabolic effects on the body. So one example is if you were to have 500 calories, four tablespoons of extra virgin olive oil per day on top of a relatively healthy diet. 500 calories of olive oil.

500 calories.

And you know, Mark, to be honest, I probably have much more than that in olive oil. I probably have six, seven, maybe eight teaspoons a day somehow, either in my cooking or whatever else. If you have at least four tablespoons, that's significantly associated with reducing from randomized controlled trial data, the risk of heart attack and stroke. Whereas if you have 150 calories from a sugary drink typical of a can of cola, we now know that's strongly associated with increasing the risk of type 2 diabetes. So clearly the calories have different effects on your body even in terms of health outcomes. But then you add in the other aspect of it, as you well know, is that fat calories are also the food foods that have high fat have the least impact on glucose and least impact on insulin. And insulin is a fat storing hormone.

So when you eat fat, it doesn't increase insulin or blood sugar, right?

Yeah, very minimally, you know, in comparison to protein and carbohydrate, carbohydrate being the worst. So that's another aspect. And then you've got to add in the fact about feeling full. So it's not just about the actual so-called. So, you know, I think this calorie in calorie out, you know, I think this benefited the food industry and actually the focus has been wrong. I mean, one of the other aspects is this so-called idea of maintaining a healthy weight. I don't think there's any such thing as a healthy weight. There's a healthy person.

Right. That was interesting in your articles that even without changes in weight, there were dramatic changes in risk and heart attacks if they actually ate more fat, like olive oil, nuts and so forth.

Absolutely.

And even without dramatic changes in their lipid numbers. So in other words, Your heart attack went down, your risk went down, even if you didn't lose weight or your numbers didn't get better because something else was going on.

Absolutely, and you've touched a really important point there, Mark. So that was subgroup analysis from the PREDIMED study. And actually, we know now that the benefits of the dietary changes are independent of total cholesterol, independent of body weight. These are kind of the anti-inflammatory, if you like, properties of these foods. And basically it's reducing your risk of, in layman's terms, thrombosis, plot rupture, coronary artery, occlusion. And that's probably the most likely mechanism for this.

And- those were not lay terms. Those were medical terms.

No, no, sure. So narrowing within the arteries that develops before people have heart attacks, when they have a certain blockage, as you know. Yeah, yeah. Basically reduce the clotability of blood, I think is a way of- Because not.

Everybody listening, this is gonna be a doctor, so- yeah, no, sure, sure.

No, absolutely. So what I would say is those foods are medicinal, literally medicinal. And so that's where the outcome benefit is there. And that's the other aspect is, you.

Know, there was something called the look.

Ahead trial, which was looking at people who were overweight, you know, and trying to reduce the focus was either lowering weight through just calories, lowering calories overall.

And then, you know, what was it.

A low fat intervention? It was a low fat intervention. And actually over, you know, over 10 years, there was no benefit in hard outcomes. They had no reduction in angina, no reduction in cardiovascular event rates. weight, they lost weight, but there was no outcome benefit. So the question then is, okay, fine. Of course, you know and I know, if you people overall, these were people.

Who were pre-diabetic, right? This was the study. I mean, this is just to kind of give people a background on this. This was like a $500 million study, big intervention, was going to be the holy grail of lowering calories, lowering fat, and pre-diabetics to look at outcomes. And what you're saying is there was no difference in their risk of heart attacks or strokes or death With intensive.

Lifestyle, despite doing more exercise as well.

And they lost weight. So it depends actually how you lose weight, right?

Exactly.

It depends how you lose weight and what the metabolic effects of what you're eating are. And that study was based on the kind of diet that we all believed was true because it was designed many, many years ago and it sort of outdated in its design. So that was fascinating to me that you didn't see that change. Yeah.

So what I would say is focus on good health. and the weight loss will be a side effect. Don't focus on the weight loss and focus on the good health and all these different things that you can do, especially dietary changes. So, I want to dig in a.

Little more into that article because a couple of things you said really struck me. One was that, you know, it takes decades to develop heart disease, but it takes months to reverse the changes you see. And then you can get really rapid things like with the DASH trial or the GISSI trial, other trials you saw. It wasn't like you had to do this for 10 years to see a benefit.

You talked about three months. Yeah, absolutely. When you look at the interventions and you look at the data, the lines of separation between the control and the intervention in some of these studies where people had a heart attack and they were advised to eat fatty fish versus ones that weren't, you see the actual, the benefits start to happen very quickly. I mean, they probably start within weeks and you can see those benefit within months in terms of people's event rates reducing. And I think that's really extraordinary because the perception mark, as you know, out there is, okay, I've developed, you know, heart disease takes decades to progress or develop in terms of the buildup of these fatty deposits, if you like, and in the arteries that leads to narrowing.

Yeah.

But people then think, well, that reversal of that process of reducing the risk of events from the development of the coronary artery disease will also take years. And the answer is actually no, it's much quicker than people think. And I think that's a really important message to get out there. And it comes back again to that thing about food being like a medicine. The father of modern medicine, hypocrisy said, as you know, let food be thy medicine and medicine be thy food. And he was absolutely right.

Yeah, right. It can be a poison or it can be a medicine, as you sort of ended your article with. I mean, that's really the sort of power here, is that eating badly can quickly screw you up, but eating well can quickly fix you up.

Yeah, absolutely.

And that's really compelling.

Go ahead.

No, no, I was just saying, so.

The other side of it, you're saying eating badly. So there was a good study in the Lancet showing that people who ate fast food more than twice a week, you know, had significantly increase in insulin resistance and inflammatory markers and that happened within weeks. So high sensitivity CRP went up, you know, and it's probably from the, you know, the trans fats, probably the refined carbs, the sugar, all of that combined, you know, that has actually a pro-inflammatory effect as well. so conversely, the kind of, as you say, the poisonous aspect onto the body on foods is certainly there as well. And that happens quite quickly, too. Yeah.

In functional medicine, we talk about food as information, right? So it can be exactly the same calories but have different instructions for your body. So like you said, if you eat trans fats in the studies you quoted, the calorie for calorie would increase inflammation, increase heart attacks, increase risk, whereas if you eat Omega-3 fats or olive oil, the opposite happened, calorie for calorie. So it's really fascinating to think about that. And all the sort of evidence together seems to point in this direction, but you've still got large groups of people saying that saturated fats are bad, that we should be using high dose statins, that we should get LDL down as far as possible. What do you say to those people? I'm sure they're your colleagues, sort of.

No, sure. Well, I just say let's just be transparent with that information. If that's the case, then let's actually look at the evidence as it is, show me the evidence that suggests that what you're saying is gonna cause a hard outcome, negative hard outcome, or gonna cause a heart attack. And in the case in point of Statin's Mark as well, one of the things that I wrote about separately is about us being shared decision making with patients. Rather than it being binary, you must take this pill, I think we need to evolve Mark to a position where we could say to patients, and this gives them that freedom of choice, and to say, okay, if they come to you and say, Doctor, should I be taking the statin? You look at their risk profile, you say, well, the evidence we have, as I said earlier, if you're low risk, otherwise healthy, you're not gonna live one day longer.

You mean low risk if you don't have high blood pressure, if you're not overweight, if you don't have diabetes.

Yeah, well, even some people that might have some of these risk factors still.

May be overall less than 20% risk of cardiovascular disease. Is there a questionnaire that you fill.

Out or a risk calculator that you recommend to help people assess that risk? The Q risk 2 calculator, which people can go on online, you can find it for free, doctors use it, and that can give you a risk of heart disease, cardiovascular disease, and what's it.

Called so people can look it up?

Yeah, so if you just Google Q risk 2, Q risk 2, just Google it, and it will bring you up, you know, you can put in variables, and it gives you calculation quite easily, and it looks at things like your height, your body mass index, blood pressure, your recent cholesterol profile, whether you're a smoker, your age, that kind of thing. And it gives you a risk profile. But it's quite clear and a very good way for people to remember if it's less than 20% risk of developing heart disease in the next 25 to 10 years, then in terms of mortality, because a lot of people will have different questions they want to ask, like, okay, well, how much longer will I live from taking this pill? And the answer is you won't live one day longer according to the published data. Now, there is a small chance it will reduce the risk of you having a heart attack or stroke. There's no doubt. but you're actually more likely to get type 2 diabetes.

Okay?

Yeah. And then if you go into the higher risk groups, Mark, and just to simplify it, people with established heart disease where the benefits of statins haven't really been questioned and I'm not questioning them, but even then, the absolute benefit in terms of mortality in terms of death is 1 in 83 over five years. So, it's 82 out of the 83 people who have had a established heart disease who take a statin are not going to benefit in terms of mortality.

Yeah.

So, you know, I think we, and, you know, this is really important empowering information. So, to overprescribe and underdeliver with that drug. Well, exactly. Well, people get side effects, so then they're worried about stopping the pill because they have this perception or they're told, don't stop your statin, otherwise you could die. You know, it's complete nonsense. Yeah. You know, I mean, in terms of, you know, it's, the risk is so small. And then you get into the question of, well, how much longer will I live, doctor? Well, you know, another analysis in BMJ Open recently, which I'm sure you've seen, So that if you don't have established heart disease, over five years, taking a statin will prolong your life by three days on average. And if you do, it's going to prolong your life by six days. So I think people deserve to know that. I would want to know that. I would want to know that if I was going to take this pill.

There's a father, one of the fathers of biochemical individuality, Roger Williams says there's liars, there's damn liars, and there's statisticians, right?

Absolutely.

And there's a book I saw from years ago. called How to Lie with Statistics, right? It's interesting how we spin it. And the drug companies are very good at spinning that. So they say, oh, you have a risk reduction if you have had a heart attack from 30%. Well, that means you've reduced your risk from 3% to 2%, which sounds not as good. That's an absolute risk reduction of 1%.

Absolutely.

So it sounds good when you say 30%. It doesn't sound so good when you say 1%.

Yeah, Mark. You raise a really important point here even around medical ethics because the director of risk literacy in health and risk literacy in Germany, a guy called Gerd Gigerenzer, and he's a spokesperson even for the World Health Organization, and you can look this, people can look this up if they like. He basically said it's an ethical responsibility for both doctors and patients to understand the difference between relative risk and absolute risk. to protect patients from unnecessary anxiety and manipulation in quotes.

Yeah, that's pretty fair.

How many doctors have a conversation with their patients in absolute risk terms?

You know what? I would say that, you know, when we graduate from medical school, I don't know about your medical school, but there wasn't a lot of education about how to read research. There wasn't a lot of statistical analysis or understanding relative or absolute risk or statistical power or study design or observational versus RCTs versus case control studies. I mean, they're just, we didn't get that education and it took me a long time to begin to understand how to look at the research intelligently and even if you are educated, which, and most doctors are just so busy practicing, they don't have time to really think about all this. They just hear the headlines like everybody else. And it's kind of frightening to see how, how doctor, most doctors don't really understand how to look at the literature, look at the funding, how the study was designed, what the intent was. I mean, there's so many issues around it and it's challenging. I think, you know, I was talking to Walter Willett as part of the fat summit and they have a lot of respect for him. He's really uncovered a lot of things from his observational research. But he said, you know, that saturated fat study that was done by Chowdhury, which was this big meta-analysis of randomized trials, observational data, he said, well, you know, it didn't show any link between saturated fat and heart disease, but also it was in the background of a diet that high in carbohydrates. So he said, well, we don't know what happens if you take out the carbs and you take out the saturated fat and switch it for polyunsaturated fat like omega-6 oils. Is that better? He was sort of implying it was. And he really, I want to talk to you about this because I think this omega-6 issue is really quite interesting. And there's omega-6 naturally found in nuts and seeds. I mean, most foods are complex combinations of fats. Olive oil is 20% saturated fat. So it's not like it's all oils. Some olives do have that, yeah. So, but when you take out the refined oils from seeds and vegetables and you get these high, super high levels of refined omega-6 fats and the quantities we're having are so much greater than we used to, is that a concern for you?

Because that's what I'm saying.

By the way, but the reason I'm asking is that most of the cardiology associations and recommendations are to increase those fats. And I'm wondering what you think about that. Well, the first thing to say, Mark.

Is that actually there is a danger. It's again, how you lower your cholesterol. Again, lowering cholesterol shouldn't be the end in itself. It should be your health, your health ultimately. And if the cholesterol happens to be lowered, fine. But the first should be your health outcome. Now, there was a study published in the BMJ in 2013, which actually uncovered unpublished data from the Sydney Heart Study, which was done several decades ago. And what they found was that cardiac patients who replaced butter with safflower oil containing margarine, which is high in omega-6, despite having a 13% and despite having a significant reduction in total cholesterol, had increased mortality.

And let me stop you there. So what you're saying is they reduce cholesterol by having more omega-6s, but their heart attack risk went up.

Absolutely. The actual event, the actual heart attacks went up, the actual event rate went up, the mortality in fact, not just heart attacks, their death rates went up. When you can't get more heart attacks.

There'S no bias there.

30% increase, right? It was serious. Absolutely. Significant increase there, absolutely right. And the mechanism, the postulated mechanism is that omega-6, too much omega-6 actually could be pro-inflammatory on LDL subparticles. And that's interesting. And James DiNicolantonio, you mentioned earlier, has written a paper on that as well. And the evidence is quite compelling on that as well. So it's how you lower your cholesterol really, It shouldn't be, I don't think that should be the primary focus. It should be just the fact that you should be concentrating on the evidence base for foods that are good. And I suspect Walter Willett, when he's talked about the polyunsaturated, they've focused on.

Cholesterol, because we know that if you.

Take high polyunsaturated-- It lowers your LDL. It lowers your LDL. But what does it actually mean? And as far as I'm aware, there are no hard outcome data showing that lowering LDL through polyunsaturated actually improves stops you having a heart attack. So yes, this is a whole issue around risk factorology and this is how the drug companies have also marketed so many drugs very successfully. You focus on one thing. Now, just because if you lower it by that mechanism doesn't mean that it's going to be beneficial for you. Even if that's a risk factor.

Right, like right when, for example, it's.

Like drugs for HDL. We know that drugs increase HDL have never shown any outcome benefit. But we know having high HDL which happens as a consequence of having whatever, you know, certain foods probably is going to be, you know, it's just more of a biological, natural way of raising HDL as opposed to using a drug. So we have to really think very differently about this, all of this in health.

Yeah, so what you're saying is in the studies where they found if you cut sugar and increase fats, your HDL goes up, you do better. But if you actually reduce it by taking a drug, You die.

Well, you know, that's the really good point.

And Mark, on that note, other than.

Statins, there are lots of drugs that have been produced over the years that have lowered LDL cholesterol but have never shown an outcome benefit. So it's only statins that have done that. Then the same with randomized controlled trials where there's been, I think, a half a dozen of those. And again, I think James E. Newton and Zoe Harkam were involved in a paper on this, showing there was no evidence to suggest that randomized controlled trial from randomized controlled trial data before the change in dietary guidelines reducing saturated fat actually improved benefit. And I think that the LDL cholesterol was lowered with people reducing saturated fat, but there was no outcome benefit. Now the same thing applies to the drugs other than statins, which then goes on to, which I wrote about in my BMJ article at the end of 2013 called Saturated Fat is Not the Major Issue.

Everybody should read that. It's great.

Yeah, actually, the the benefits of statins are probably independent of cholesterol lowering. They're probably some inflammatory effect, not through lowering cholesterol in my view. Yeah, well I think that brings up a good point.

I mean, the statins have, quote, an unintended side effect of being an anti-inflammatory drug. They inhibit something called nitric oxide synthase and it actually reduces inflammation, also has antioxidant properties. And we know antioxidants and anti-inflammatories help reduce the drivers of heart disease. But what's interesting is, and then someone asked about this, Dr. Ridker's data from Harvard, he looked at big studies where they found people who had high LDL, but no inflammation, they didn't seem to have a risk reduction by taking a statin. But those people who had high inflammation and high LDL, they seem to benefit taking a statin. Do you know those data?

Yes, absolutely.

I think Jupiter also showed that, didn't it? That's right. That's the trial I'm talking about, the Jupiter trial with Dr. Ridker. And, you know, that was striking to me is if you have a high LDL but you don't have inflammation with a high CRP, then that's a C-reactive protein, a marker of inflammation, then you don't really have risk. So the question is, well, how else can you lower inflammation besides taking a statin? Are there better ways? And, you know, I was impressed with your articles because you've talked about other ways that of having an anti-inflammatory diet, lower sugar, refined flours, more omega-3 fats.

Absolutely. Absolutely, Mark. No, you're absolutely spot on. I think this is very interesting, this whole area and debate. And, you know, this has been the most lucrative marketed drug in probably the history of medicine. Yeah. A lot of vested interest behind it. It's a multi-billion dollar industry from statins. So I think, you know, understandably, there are very powerful vested interests that aren't necessarily going to like what we're telling them.

So true. It's so true. It's pretty frightening. And, I think even with all the reading I've done and all the research I've done, I still have this question in my mind about LDL. My LDL has gone up from 80 to 120 because I'm eating more coconut oil. Should I be worried? And, I'm like, there's family history of heart disease. Even though I try to intellectually sort of frame it, we've all been sort of brainwashed in this way, right?

Yeah, absolutely. You're right. It's very difficult and yeah, it's ingrained within us. So there is that extra fear and you just wonder, there is that bit of doubt. And obviously, people would worry. But again, I think I would look at the whole profile really. And if your HDL has gone up, your triglycerides have gone down, your overall profile is either the same or better. And again, the other thing Mark to mention is I think that, you know, it's quite clear that LDL as a risk factor is much weaker than what.

People think it is.

Yeah, right. And certainly as you get older, you know, there's an inverse association. So over the age of 60, the higher your LDL, the lower your risk.

Of death and cardiovascular death. Yeah, that brings up another point, which is in older patients, should we be using statins?

Does it make sense for them? Yeah. In my view, I think we have to be very cautious with older patients because I think, as you know, older patients are also more vulnerable to side effects as well. Polypharmacy and the risks of polypharmacy.

Some of the data that I saw was sort of fascinating on statins is that even independent of elevations in muscle enzymes, which is what you typically see as a side effect if it's causing muscle damage, when they do muscle biopsies, the muscle cells are swollen, the mitochondria are damaged because cholesterol drugs block an enzyme that also produces CoQ10, which is necessary for proper energy production in the cell. So that's kind of concerning to me, independent of actually any symptoms or independent of elevations in muscle enzymes. It seems like almost everybody who takes a statin has some level of mitochondrial injury.

Yeah, no, it's interesting. So Beatrice Golomb, she's an American physician based in, I think, San Diego, if I'm not wrong. And she's done some work on looking statins effects in women in particular, because there is an understanding and belief, first of all, in a lot of the statin trials, there are very few women involved. They were predominantly men. And the question is, do women benefit? And she's certainly done some research suggesting that women don't have the same benefits, even those small benefits that men do, from taking statins. But what's interesting, she did a double blinded randomized placebo controlled trial looking at low to moderate dose statin intake versus people who are taking a placebo. And once you find up to 40% of those people, the females taking it within a few months, reported reduced energy and fatigue on the statin. Which is fascinating. It's a high number of people. And that's probably the commonest side effect you see is people just feeling a little bit listless, having reduced energy. Obviously, the muscle pain is more common. But yeah, that certainly concerning, especially when we have a lifestyle related disease, is you want people to be kind of being motivated to do more exercise, not less, right? Right.

So the other thing I want to jump into before we close is this idea of exercise. And with the Statin Connection, I remember reading a study that they took two groups of overweight people, gave one of them a statin, the other one didn't, they put them on a 12-week intensive exercise program. The ones without the statin actually improved their fitness with exercise, but the ones on the statins did not. Actually, they weren't able to get fit because their muscles weren't able to respond to the exercise. Do you remember that study? Yeah, absolutely.

I know that it was cited by John Abramson in the BMJ. Yeah. Public Health Interest. That makes me worried.

So let's talk about exercise. You've written about how exercise isn't the be-all and end-all that we think it is. You know, when you hear the message, eat less, exercise more, and the food companies say, well, it's all about exercise, just exercise more and you're going to solve this obesity epidemic.

Do you think that's true? Well, I think there's two things to say. On the broad perspective, so looking at the broader picture, when you look at the Lancet Global Burden of Disease reports in terms of the 10 leading risk factors for disease and disability and death worldwide, poor diet now contributes to more more disease and death than physical inactivity, smoking and alcohol combined. Okay, so in terms of hierarchy, diet is the key. Now, when we look at obesity, you know, it's very clear to me, Mark, that actually when you look at exercise and obesity, there's very little link, if anything. I'm not saying exercise isn't good. We know exercise has many benefits. There's no doubt whether it's reducing the risk of type 2 diabetes or high blood pressure or cardiovascular disease. Or dementia. But when it comes to weight loss, weight loss is not one of those benefits. The obesity epidemic is 100% driven by the types of food, stroke calories, types of calories people are consuming, not to do with exercise. Therefore, if the focus is to improve the statistics on obesity, then it's going to be through reducing the consumption of the foods we talked about earlier and having more fat certainly in the diet. But exercise is not going to be the be all and end all. And in fact, in some ways it can be harmful. So, you know, even anecdotally, I can tell you and there are studies to show this, that exercise, as you know, can for a lot of people be very powerful appetite stimulant. So the worst case scenario, which is actually a reality of what happens, partly because of the messaging and the branding and the advertising, is people think, okay, I'm gonna go to the gym, I'm gonna go on the treadmill and work out for 20 or 30 minutes, go for a run, and then I'm gonna go, and then I'm gonna go to McDonald's. Absolutely. And actually, that's harmful because not only because of the, even if you take the calorie theory, you know, at face value and you're so-called keeping a healthy weight, we know that about 40% of people with a normal body mass index will harbor metabolic abnormalities that people with obesity have, whether it's high blood pressure, insulin resistance. And there is now more and more data to suggest that even if you exercise and you're a normal body weight, if you eat, you know, pardon my language, crap, yeah. you're going to still increase your risk of getting these adverse health consequences. So, by all means, exercise, but you use- Dr. Diet, diet, diet, and then exercise.

Get the right fuel in, yeah, absolutely. It's okay. All right, we have a few minutes left. I want to get into another aspect of what you're doing because you're not just a cardiologist, you're not just reviewing the research, you're not just talking about the role of diet and health. You're actually doing things as a political activist, which I think most doctors don't really own. I don't think that their domain includes public policy, our food policy, our media, and the way the industry drives disease. So you're working at the earlier continuum of disease rather than waiting for people to get in your office, you're trying to solve the problem upstream. And you have something called Action on Sugar, which is a lobby group. You're involved in a documentary on this. Tell us more about that.

Yeah. So for me, I've had an interesting journey the last few years around trying to get messages out into the mainstream media through the BMJ and through articles in the Guardian and the Daily Mail, et cetera, about the harms of sugar and why we need to address it. And Afiya wrote an article in the BMJ in May 2013, which is called the Dietary and Advice on Added Sugar is in Need of Emergency Surgery, basically saying that the current food labeling, the messaging was actually encouraging excess sugar consumption. We need to do something about it. I got contacted by a guy called Graham McGregor, Professor of Cardiovascular Prevention in London. And he had done a lot of work over the last decade plus or so in reducing salt consumption in the UK across the population. And he wanted to do the same thing about sugar. So we basically set up a group of international experts. Robert Lustig was on there, Yoni Freedhoff, you may know, a guy called Richard Johnson. So we got a group of experts together and basically formed a kind of lobby group to try and pressurize the government and the food industry almost simultaneously to ensure across the population we get a reduction in sugar consumption. So one of the recommendations we said is that we need the food industry to be regulated so they gradually over the pace of time, timescale of about four years in all foods basically reduce the amount of sugar they add by about 40%. And from the calorie theory, that's being calculated to be enough to stop and probably reverse the obesity epidemic. If you just stick to the calorie theory. But you and I know the benefits are going to go beyond that. So that's one of the things that we're doing. We're also called for a sugar tax, sugary drinks tax.

So we're really pressurizing the government.

And, you know, we've got lots of experts and people listening. Is the government listening? Are they interested too? Well, they're under a lot of pressure actually, Mark, over here. And I don't know if you're following it, but, you know, the media is all over this and there's almost competition between newspapers now to put pressure on the government on sugar, which is amazing. And people are having it's making people angry, especially when people are realizing how they feel they've been misled on the labeling. When they know now the World Health Organization recommends a maximum upper limit for adults of six teaspoons of sugar a day or about 24-25 grams of sugar. Yet we know the average UK citizen mark is consuming at least two to three times that amount and children much more. So I think once people have realized that and how they've been misled, people are getting angry in the public now. Surveys are now showing that more than half of the British public are supporting attacks, calls for attacks on sugary drinks.

Amazing.

Which is extraordinary. So I think things are moving certainly. So I'd finish in saying that there are things that have worked with tobacco and reducing tobacco consumption over the last two or three decades. In public health we call them the three A's, looking at the availability, the affordability, the acceptability. And certainly we're definitely winning the battle on the acceptability. Now what we need to do is target the availability of these sugary drinks and sugar. And the affordability would be increasing the price, like with tobacco, the price of cigarettes, consumption went down. And Mark, as you know, the most important factor in driving reduced cardiovascular mortality death rates in the United States and the UK has been through reduction in smoking, not through medications. Reduction in smoking has had the biggest impact. So we need to see the same thing happen to get across the board people's diets improving. And I'll leave you with another interesting statistic, which I look at all the time.

Sugar is the new fat, right?

Absolutely. And the other interesting thing, statistic for the American population, which we mentioned in our paper, is based upon high quality observational studies and the randomized controlled trials. And, you know, we know it's not perfect science, but as good as we've got, if the whole of the American population were to increase their consumption of nuts by one to two portions a week, it's been calculated within one year.

That would prevent 90,000 deaths from cardiovascular disease. That's unbelievable.

Just a couple of hands of almonds and then you do 90,000 deaths.

That's impressive. Yeah, absolutely. So, you know, these are the messages we need to get out there. Wow, well I wish we could talk for a few more hours. This has been an amazing conversation and I encourage people to look up Dr. Malhotra's work and read his articles and keep in touch with what he's doing because he's making big inroads. And I'm coming to London in a few months. I'd love to get together with you.

Hang out and brainstorm about how we can disrupt the system a little more. Mark, I very much look forward to that.

It's been an absolute pleasure speaking to you.

Thank you for having me on. Okay, thank you.