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BJSM Online First, published on April 25, 2017 as 10.1136/bjsports-2016-097285

Saturated fat does not clog the arteries: 7500 high-risk patients. Furthermore, the
Lyon Heart study showed that adopting
a Mediterranean diet in secondary
coronary heart disease is a chronic prevention improved hard outcomes
for both recurrent myocardial infarc-
inflammatory condition, the risk of tion (NNT=18) and all-cause mortality
(NNT=30), despite there being no signif-
which can be effectively reduced from icant difference in plasma low-density
lipoprotein (LDL) cholesterol between
healthy lifestyle interventions the two groups. It is the alpha linoleic
acid, polyphenols and omega-3 fatty acids
present in nuts, extra virgin olive oil, vege-
Aseem Malhotra,1 Rita F Redberg,2,3 Pascal Meier4,5 tables and oily fish that rapidly attenuate
inflammation and coronary thrombosis.6
Coronary artery disease pathogenesis and testing.4 When plaques rupture (analogous Both control diets in these studies were
treatment urgently requires a paradigm to a pimple bursting), coronary throm- relatively healthy, which make it highly
shift. Despite popular belief among bosis and myocardial infarction can occur likely that even larger benefits would
doctors and the public, the conceptual within minutes. The limitation of the be observed if the Mediterranean diets
model of dietary saturated fat clogging a current plumbing approach (unclogging discussed above were compared with a
pipe is just plain wrong. A landmark a pipe) to the management of coronary typical western diet.
systematic review and meta-analysis of disease is revealed by a series of randomised
observational studies showed no associa- controlled trials (RCTs) which prove that LDL CHOLESTEROL RISK HAS BEEN
tion between saturated fat consumption stenting significantly obstructive stable EXAGGERATED
and (1) all-cause mortality, (2) coronary lesions fail to prevent myocardial infarc- Decades of emphasis on the primacy of
heart disease (CHD), (3) CHD mortality, tion or to reduce mortality.5 lowering plasma cholesterol, as if this was
(4) ischaemic stroke or (5) type 2 diabetes an end in itself and driving a market of
in healthy adults.1 Similarly in the DIETARY RCTS WITH OUTCOME proven to lower cholesterol and low-
secondary prevention of CHD there is no BENEFIT IN PRIMARY AND SECONDARY fat foods and medications, has been
benefit from reduced fat, including satu- PREVENTION misguided. Selective reporting may partly
rated fat, on myocardial infarction, In comparison with advice to follow a low explain this misconception. Reanalysis of
cardiovascular or all-cause mortality.2 It is fat diet (37% fat), an energy-unrestricted unpublished data from the Sydney Diet
instructive to note that in an angiographic Mediterranean diet (41% fat) supple- Heart Study and the Minnesota coronary
study of postmenopausal women with mented with at least four tablespoons of experiment reveal replacing saturated fat
CHD, greater intake of saturated fat was extra virgin olive oil or a handful of nuts with linoleic acid containing vegetable oils
associated with less progression of athero- (PREDIMED) achieved a significant 30% increased mortality risk despite significant
sclerosis whereas carbohydrate and (number needed to treat (NNT)=61) reductions in LDL and total cholesterol
polyunsaturated fat intake were associated reduction in cardiovascular events in over (TC).7
with greater progression.3


The inflammatory processes that
contribute to cholesterol deposition
within the artery wall and subsequent
plaque formation (atherosclerosis), more
closely resembles a pimple (figure1).
Most cardiac events occur at sites with
<70% coronary artery obstruction and
these do not generate ischaemia on stress

Lister Hospital, Academy of Medical Royal Colleges,
Stevenage, UK
Philip R Lee Institute for Health Policy Studies, San
Francisco, California, USA
Department of Medicine, UCSF School of Medicine,
San Francisco, California, USA
Department of Cardiology, University Hospital Geneva,
Geneva, Switzerland
Department of Cardiology, University College London,
London, UK
Correspondence to Dr Aseem Malhotra, Lister
Hospital, Academy of Medical Royal Colleges,
Stevenage, UK; aseem_malhotra@hotmail.com Figure 1 Lifestyle interventions for the prevention and treatment of coronary disease.
Br J Sports Med Month 2017 Vol 1 No 0 1
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A high TC to high-density lipopro- This occurs independent of weight loss Br J Sports Med 2017;1:12.
tein (HDL) ratio is the best predictor and suggests even a little activity goes a doi:10.1136/bjsports-2016-097285
of cardiovascular risk (hence this calcu- long way. Article author(s) (or their employer(s) unless
lation, not LDL, is used in recognised Another risk factor for CHD is envi- otherwise stated in the text of the article) 2017. All
rights reserved. No commercial use is permitted unless
cardiovascular risk calculators such as ronmental stress. Childhood trauma can otherwise expressly granted.
that from Framingham). A high TC to lead to an average decrease in life expec-
HDL ratio is also a surrogate marker for tancy of 20 years. Chronic stress increases
insulin resistance (ie, chronically elevated glucocorticoid receptor resistance, which 1 de Souza RJ, Mente A, Maroleanu A, et al. Intake of
serum insulin at the root of heart disease, results in failure to down regulate the saturated and trans unsaturated fatty acids and risk
type 2 diabetes and obesity). And in those inflammatory response. Combining a of all cause mortality, cardiovascular disease, and
over 60 years, a recent systematic review complete lifestyle approach of a healthful type 2 diabetes: systematic review and meta-analysis
of observational studies. BMJ 2015;351:h3978.
concluded that LDL cholesterol is not diet, regular movement and stress reduc- 2 Schwingshackl L, Hoffmann G. Dietary fatty acids in
associated with cardiovascular disease tion will improve quality of life, reduce the secondary prevention of coronary heart disease:
and is inversely associated with all-cause cardiovascular and all-cause mortality.10 It a systematic review, meta-analysis and meta-
mortality.8 A high TC to HDL ratio is time to shift the public health message regression. BMJ Open 2014;4:e004487.
drops rapidly with dietary changes such 3 Mozaffarian D, Rimm EB, Herrington DM. Dietary
in the prevention and treatment of coro-
fats, carbohydrate, and progression of coronary
as replacing refined carbohydrates with nary artery disease away from measuring atherosclerosis in postmenopausal women. Am J Clin
healthy high fat foods. serum lipids and reducing dietary satu- Nutr 2004;80:117584.
rated fat. Coronary artery disease is a 4 Rothberg MB. Coronary artery disease as clogged
chronic inflammatory disease and it can pipes: a misconceptual model. Circ Cardiovasc Qual
A SIMPLE WAY TO COMBAT INSULIN be reduced effectively by walking 22min a
Outcomes 2013;6:12932.
RESISTANCE (CHRONICALLY HIGH 5 Malhotra A. The whole truth about coronary
day and eating real food. There is no busi- stents: the elephant in the room. JAMA Intern Med
LEVELS OF SERUM INSULIN) AND ness model or market to help spread this 2014;174:13678.
INFLAMMATION simple yet powerful intervention. 6 Chakrabarti S, Freedman JE. Review: nutriceuticals
Compared with physically inactive indi- as antithrombotic agents. Cardiovasc Ther
viduals, those who walk briskly at or Contributors AM wrote the initial draft with further 2010;28:22735.
revisions and edits from RFR and PM. 7 Ramsden CE, Zamora D, Majchrzak-Hong S, et al.
above 150 min/week can increase life Re-evaluation of the traditional diet-heart hypothesis:
expectancy by 3.44.5 years indepen- Competing interests RFR served as a consultant for analysis of recovered data from Minnesota coronary
dent of body weight.9 Regular brisk one day in May 2015 for Amgen. AM is a co-producer experiment (1968-73). BMJ 2016;353:i1246.
of the documentary The Big Fat Fix. 8 Ravnskov U, Diamond DM, Hama R, et al. Lack of
walking may also be more effective than
running in preventing coronary disease. Provenance and peer review Not commissioned; an association or an inverse association between
externally peer reviewed. low-density-lipoprotein cholesterol and mortality
And just 30min of moderate activity a in the elderly: a systematic review. BMJ Open
day more than three times/week signifi- 2016;6:e010401.
cantly improves insulin sensitivity and 9 Moore SC, Patel AV, Matthews CE, et al. Leisure time
helps reverse insulin resistance (ie, lowers physical activity of moderate to vigorous intensity and
mortality: a large pooled cohort analysis. PLoS Med
the chronically elevated levels of insulin To cite Malhotra A, Redberg RF, Meier P. Br J Sports 2012;9:e1001335.
that are associated with obesity) within Med Published Online First: [please include Day Month 10 Blackburn EH, Epel ES. Too toxic to ignore. Nature
months in sedentary middle-aged adults. Year]. doi:10.1136/bjsports-2016-097285 2012;490:16971.

2 Br J Sports Med Month 2017 Vol 1 No 0

Downloaded from http://bjsm.bmj.com/ on May 1, 2017 - Published by group.bmj.com

Saturated fat does not clog the arteries:

coronary heart disease is a chronic
inflammatory condition, the risk of which can
be effectively reduced from healthy lifestyle
Aseem Malhotra, Rita F Redberg and Pascal Meier

Br J Sports Med published online April 25, 2017

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