'Big Fat Fix' Film Challenges Mediterranean Diet

An Interview With Cardiologist Aseem Malhotra

Interviewer: Tricia Ward; Interviewee: Aseem Malhotra, MBChB, MRCP


October 05, 2016

Editor's Note: Cardiologist Aseem Malhotra, MBChB, MRCP, talks about his new documentary The Big Fat Fix, which sent him to Pioppi, Italy, the village where Ancel Keys researched diet and cardiovascular health. A regular contributor to the BMJ and major UK newspapers on the topic of dietary health, Dr Malhotra believes that the demonization of fat let sugar off the hook as the real culprit in the diabetes, obesity, and cardiovascular disease epidemic, and that we need to rethink our approach to exercise.

Aseem Malhotra, MBChB, MRCP

theheart.org | Medscape: How did you become interested in diet?

Dr Malhotra: Originally I trained as an interventional cardiologist. My journey to becoming a campaigner against the epidemic of obesity and its related diseases plaguing the western world began in the hospital.

I was working as a trainee (a registrar, as we say in the UK) and I treated a middle-aged man with emergency stenting for ST-segment elevation myocardial infarction. The next day, when I was talking to him about following a healthy lifestyle, quitting smoking, taking all of his medications, and following a good diet, he was actually served a burger and fries. He asked me, "How do you expect me to change my lifestyle when you're serving me the same crap that brought me in here in the first place?"

If our food environment was allowing our patients to be served junk food, then something had to change.

theheart.org | Medscape: What did you do to initiate change?

Dr Malhotra: I got involved with a group called the Academy of Medical Royal Colleges, which is essentially a prestigious academic body that represents every doctor in the UK. I joined their Obesity Steering Group as the junior doctor representative because I'd written a few pieces in the Guardian and the Observer newspapers. Through that, I met various professors involved in nutrition and public health policy, and after a year of reviewing evidence to tackle obesity, we came up with a 10-point plan.[1]

Around that time, I started writing for the BMJ and began looking more closely at the research on nutrition and cardiovascular disease. My first realization (and it's something we don't learn about in medical school) was that most cardiovascular disease can be prevented by addressing lifestyle factors. According to the Lancet global burden of disease reports, poor diet contributes to more disease and death than physical inactivity, smoking, and alcohol combined.[2] That's extraordinary.

There is good evidence that dietary changes can rapidly reduce cardiovascular risk. We have the Lyon Heart Study,[3] conducted in patients post–myocardial infarction (MI), and the number needed to treat to prevent early mortality is 30. Following a Mediterranean diet after having an MI is more effective than statins.[4] We have a huge imbalance. Overtreatment is a big problem, and at the same time, we have neglected lifestyle medicine.

theheart.org | Medscape: You have been critical of the emphasis on saturated fat in dietary recommendations. Can you speak to that?

Dr Malhotra: I wrote an editorial in the BMJ in 2013[5] called "Saturated Fat Is Not the Major Issue," which was peer-reviewed and got a lot of coverage worldwide. It basically said that we have been wrong in declaring saturated fat the most important dietary factor driving cardiovascular disease. We have neglected sugar, and sugar is the major problem.

I assessed the quality of the research on saturated fat that led to the dietary guidance in the US and the UK, and I came to the conclusion that the unfair demonization of fats and saturated fat is actually driving the epidemics of type 2 diabetes and obesity (both very much related to cardiovascular disease).

When you look at the data in terms of what's going to be most effective in reducing cardiovascular disease, those foods tend to be higher in fats, specifically oily fish, extra virgin olive oil, and nuts (and, of course, people have to eat lots of vegetables). Everything's upside down and it's a problem.

theheart.org | Medscape: How did the documentary The Big Fat Fix come about?

Dr Malhotra: Filmmaker and former international athlete Donal O'Neill, from Northern Ireland, got in touch with me. He had made a couple of documentary films, including Cereal Killers (as in sugared-cereals) and Run on Fat. His films have similar themes to my work, so we decided to make a documentary looking at the roots of the Mediterranean diet and how that influenced the nutritional guidelines. The biggest influence was from the US scientist Ancel Keys.[6]

We went to Pioppi, Italy, where for over 30 years Keys spent around 6 months a year doing research on the best dietary plan for cardiovascular health. It's a village with a population of around 200 people, and their average life expectancy is around 90 years.

theheart.org | Medscape: At one point in the film, you visit the Ancel Keys Museum and look at the Mediterranean diet pyramid, but you think it's incorrect.

Dr Malhotra: The reason it's off is that the base of the pyramid is full of starchy carbohydrates, basically pasta and bread. I would argue that they shouldn't be at the base—for two reasons.

First, people who are insulin resistant or who have type 2 diabetes have a condition of carbohydrate intolerance. Their blood glucose responds badly to refined and starchy carbohydrates.

Second, when you look at the components of the Mediterranean diet with consistent evidence of benefit, they're green vegetables, cauliflower, tomatoes—you name it. Non-starchy vegetables should be at the base of the food pyramid. The reason I say "non-starchy" is because potatoes are not good for people with type 2 diabetes.

My personal view is that the modern Mediterranean diet is probably very different from the one of 40 or 50 years ago when Ancel Keys did his research. If you will pardon the language, we have bastardized the Mediterranean diet. We interviewed a chef who is the son of a family friend of Ancel Keys, and he told us that with pasta they stop after the first course. Pasta has been turned into a main course when, in fact, it was traditionally a small portion eaten as a starter.

Image courtesy of Dr Malhotra

theheart.org | Medscape: Isn't there a general issue with excess portion sizes beyond pasta?

Dr Malhotra: There is no doubt that we have an oversupply of cheap junk food. I wrote about this in the BMJ in May 2013[7]: Around a third of sugar consumed in the United States comes from sugary drinks,[8] what you call sodas; about one sixth of sugar consumption comes from foods that people normally think of as junk food, such as ice cream, candy, and cookies. But around 50% of all the sugar consumption in the United States comes from hidden sugars.[9]

We have evolving research telling us that excess sugar is associated strongly with cardiovascular mortality.

Why pick on sugar? First of all, there is no nutritional value whatsoever from added sugar. There is no biological requirement for it, and it's a source of excess calories in the diet.

We have evolving research telling us that excess sugar is associated strongly with cardiovascular mortality. A paper published in JAMA Internal Medicine in 2014[10] showed that people who consumed more than 25% of their calories from sugar had an almost threefold increase in cardiovascular mortality compared with people who got less than 10% of their calories form sugar.

There is also some evidence suggesting that when you're not getting good nutrition because of all the added sugar, you end up overconsuming.[11] One could look at sugar as a kind of appetite stimulant that doesn't give you any benefit.

theheart.org | Medscape: There is broad acceptance that sugar is a concern, but there is more controversy about dietary fat. The argument is that low-fat diets are healthful, provided you don't replace the fat with carbohydrates. How would you rate the Ornish-style low-fat diet[12] versus a Mediterranean diet?

Dr Malhotra: I haven't looked specifically at that and I'm not in any way criticizing it. I know that the Ornish program is a combination of a low-fat diet with other interventions, including stress reduction, smoking cessation, and exercise. You can't tease out that the benefits were tied to the low-fat diet. I think people can have a very healthy diet which is low-fat. The problem is that when you replace fat with refined carbohydrates and sugar, which a lot of people do when they try to follow a low-fat diet, that dietary patten increases your risk for type 2 diabetes.

When you look at the PREDIMED study,[13] for example, which was a primary-prevention randomized controlled trial in about 7500 middle-aged participants (57% were women) at high risk for cardiovascular disease, they found a significant event rate reduction in people who followed a traditional Mediterranean diet supplemented with either four tablespoons of extra virgin olive oil (which is 500 calories, by the way) or a handful of nuts. The intervention group got 41% of total calories from fat compared with the control group, who got 37% of calories from fat; that's only a difference of 4%, but it translated into a number needed to treat of 61 for a risk reduction in the composite endpoint of cardiovascular death, heart attack, and stroke, albeit primarily driven by stroke reduction.[14]

theheart.org | Medscape: You are also critical of the emphasis on low-density lipoprotein cholesterol (LDL-C).

Dr Malhotra: There is a consensus of opinion that the lower the blood cholesterol, the better. As we point out in the film, this misses the point because when you're assessing someone's cardiovascular risk, the QRISK calculator looks at the total cholesterol–to–high-density lipoprotein cholesterol (HDL-C) ratio. That's more important. Triglycerides and HDL-C seem to be better predictors than LDL-C.

When you look at PREDIMED and the Lyon post-MI study, there was no significant difference in LDL-C levels between the two study groups. I'm not saying that LDL-C is not a risk factor; certainly it seems to be consistent in middle-aged people, especially men. But it's been grossly exaggerated, and the benefits of a healthy diet on hard outcomes are independent of cholesterol lowering.

We're overly focused on LDL-C when we should be focusing on insulin resistance. One of the reasons is because there's never been an effective drug that's targeted insulin resistance. Therefore, there's been no market for that message.

Coronary disease is an inflammatory condition, not one caused by dietary fat—and the public health messaging needs to reflect that.

theheart.org | Medscape: You emphasize extra-virgin olive oil in the diet, saying that it can help reverse inflammation and potentially atherosclerosis. Is that based on the PREDIMED-Navarra analysis of carotid intima media thickness?[15]

Dr Malhotra: Yes, and it's in keeping with other good-quality observational and lab-based studies.[16] When you look at inflammatory markers and the polyphenols in foods like olive oil, nuts, and vegetables, they rapidly attenuate inflammation.[17,18] In my lectures, I always say that stenosis doesn't kill people—atherothrombosis does.

That's really important because that evidence is clear-cut. Look at coronary stenting in stable disease: It doesn't improve prognosis,[19] even if you put a stent in an 80% lesion. I'm not saying that stents don't have a role in stable disease. They can have symptomatic benefits in the minority of cases where medical therapy has failed, but they don't have prognostic benefit.

Of course, the ideal scenario is that people don't get coronary disease so they won't get plaque rupture. When you look at the DART trial showing that eating oily fish post MI reduces all-cause mortality, the impact was quite rapid.[20] Coronary disease is an inflammatory condition, not one caused by dietary fat—and the public health messaging needs to reflect that.

The evidence clearly shows that the biggest decline in mortality from cardiovascular disease in the past several decades is because of the decline in smoking and tobacco consumption. The example often given is Helena, Montana.[21] In 2002, they brought in a public smoking ban, and within 6 months, there was a 40% absolute reduction in MI hospital admissions. Then the tobacco lobby came in and the law was rescinded, and the admission levels went back up again. We can explain that because even 30 minutes of passive smoking increases platelet activity, making you more prothrombotic and prone to plaque rupture, especially if you've got underlying coronary disease.[22]

I think there is good evidence that dietary changes have a similar impact via a similar mechanism in reducing plaque rupture, and olive oil is one of the foods that has that benefit.

theheart.org | Medscape: Another food that you mention in the film, which is probably a little more controversial, is coconut oil. There have been some meta-analyses that show lipid profiles going in the wrong direction (an increase in LDL-C) with coconut oil consumption.[23]

Dr Malhotra: I'm sure there is some individual variability, but Walter Willet, who is probably considered one of the chief nutritional scientists in the world, notes that coconut oil preferentially increases HDL-C.[24] So even if your LDL-C increases slightly, your overall cholesterol profile improves. This is not a license for people to gorge on coconut oil. What's really important is that people cut out the sugar and the refined carbohydrates. Then you can have coconut oil as part of your healthy diet but I wouldn't put it at the base of the food pyramid. Personally, I add it to my diet because it gives me energy and makes me feel full, and it's very stable for cooking.

theheart.org | Medscape: Typically, dietary studies focus on nutrients (low carb, low fat, high protein) rather than actual foods. Would you agree that the discussion needs to move to dietary patterns and actual foods?

Dr Malhotra: I completely agree. We need to move away from focusing on these so-called macronutrients and focus more on whole foods, with the exception of appreciating the adverse effects of sugar. We need guidelines based on foods that can fuel wellness, not illness.

My concern is that about 40% of Americans are considered prediabetic.[25] If you have prediabetes, you need to reduce carbohydrate consumption.

There is an example from the UK of a family practitioner named Dr David Unwin who advised his patients with type 2 diabetes to stop eating refined and starchy carbohydrates.[26] Simple advice, no calorie restriction, and he told them to eat fats, including saturated fat.

Within a year, he managed to save £45,000 (about $60,000) compared with practices in his area. Some of his patients reversed their diabetes, or you could say that they went into remission and stopped their medications.[27] Extrapolate that across the healthcare system and this would save about £423M (about $530M).

theheart.org | Medscape: In addition to the Pioppi villagers' diet, you also looked at their way of life. What did you learn from that?

Dr Malhotra: We tried to identify the secrets to their longevity and we realized that it's more about lifestyle. Diet is, of course, extremely important, but their overall lifestyle was conducive to good health in terms of not only the foods they were eating (very little to no processed food), but also the fact that they spend a lot of time outside in the sunshine (getting vitamin D), walking around in a relatively stress-free, serene environment.

theheart.org | Medscape: Most people don't live in a stress-free environment. What should they be doing?

Dr Malhotra: It's very difficult to specifically measure stress, but we know it's a big problem. People who have chronic stress from a young age, where there's a childhood trauma, have an average life expectancy that's 20 years less than other people.[28]

One way to deal with it is to make sure that it is emphasized and discussed. We're beginning to explore that further to give people tools that they can use on a daily basis, such as taking time out to engage in what we call "mindfulness." For example, four to five times a day when sitting in my office, I will engage in deep breathing exercises for about 2 minutes and try to switch off. Other strategies are to go on long walks, get some fresh air—obviously exercise helps. We have to think of these things almost like a prescription that needs to be encouraged.

theheart.org | Medscape: Speaking of sitting in the office, the film suggests getting up every 45 minutes.

Dr Malhotra: There are good data that prolonged sitting is a big risk factor—"Sitting is the new smoking," as the saying goes.[29] If people get up every 45 minutes for 5 minutes or so, and walk around or do some squats, that's a very useful intervention.

The whole concept of counting calories and burning calories in the gym is complete nonsense.

theheart.org | Medscape: The film also says that the way we currently approach exercise is not right. Why?

Dr Malhotra: The whole concept of counting calories and burning calories in the gym is complete nonsense. People need to stop doing that. You should exercise for health, not for weight loss. A lot of people get their dose of the gym for 25 minutes or they wake up in the morning, go for a half-hour run, and then they go to work and sit all day. We should be moving throughout the day in short bursts, and we should avoid sitting for long periods.

When it comes to longevity, at least in athletes, there's a very good observational study in the BMJ showing that former Olympic athletes don't live any longer than golfers or cricket players.[30] This means that a little bit of movement goes a long way. One of the dangers with not exercising properly is that you increase your risk for injury. In Pioppi, there are no gyms; they just walk everywhere and are outside a lot.

When it comes to weight, it's what you eat that matters most. Between 50% and 75% of the calories we burn come from doing nothing at all (your basal metabolic rate). If the body requires all of this energy just to function, shouldn't we be fueling it with the right kind of foods? That's a better way to think than counting calories.

theheart.org | Medscape: The title of your film is The Big Fat Fix, which suggests something nefarious (similar to The Big Fat Surprise, the book by Nina Teicholz). Do you think people are hiding data or is it the usual case of incremental scientific data and knowledge, things are slow to change?

Dr Malhotra: I think it's a combination. The data are there and we've sequestered it. The whole issue of overmedication and overtreatment is tied to transparency of information with patients. I wrote an editorial in JAMA Internal Medicine about the fact that we should be telling patients that coronary stents don't improve prognosis.[31] Most people undergoing coronary stenting think the procedure will prevent heart attacks and prolong life. We should be talking with them about evidence-based lifestyle changes.

For patients with type 2 diabetes, the medications that lower glucose don't have any impact on all-cause mortality, cardiovascular mortality, or strokes.[32] How many patients are explicitly told this? I'm not suggesting that we say, "Don't take the drugs." But we should tell patients that the benefits are marginal and that making these lifestyle changes will have a much bigger impact on their health without side effects, and will result in a better quality of life. [Editor's note: The sodium-glucose cotransporter 2 [SGLT2] inhibitor empagliflozin[33] and the glucagonlike-peptide 1 [GLP-1] agonist liraglutide[34] have been shown to lower CV mortality in patients with type 2 diabetes in recent randomized trials.]

There was a very good commentary on stress in Nature called "Too Toxic to Ignore."[35] It mentions a pilot study that shows that people who adopt lifestyle changes, including dietary changes, exercise, and stress reduction, even in middle age, can see an effect on genes that control the aging process.

This is powerful information. Lifestyle changes do no harm and only do good. We don't learn any of this in medical school. I am pleased that this interview will be on theheart.org because it will encourage a healthy debate.

theheart.org | Medscape: What is your ultimate goal? Is it to get guidelines changed and to have nutrition and lifestyle medicine taught in medical school?

Dr Malhotra: All of the above. The US dietary guidelines[36] lifted the restrictions on total fat consumption. The saturated fat discussion is ongoing, but I suspect that will also change. From my reading of the evidence, this isn't carte blanche to eat lots of meat, but we should not demonize full-fat dairy, and we need to reduce sugar consumption. Once you get the baseline right—lots of vegetables, olive oil, oily fish, etc.—then having a bit of unprocessed meat is not going to do any harm.

We also need to get this into the medical curricula and have more research dedicated to this area. Finally, we need to be more transparent with patients. I tell my patients that these are the benefits of the drugs, but what's really important is that you make the recommended lifestyle changes. And it's never too late to do that.

theheart.org | Medscape: The film was funded by crowdsourcing, correct?

Dr Malhotra: That's a really important point. We wanted to keep the message clean from commercial influence. It was funded through Kickstarter, which is crowdsource funding via social media. One of the things I've campaigned about is how conflicts of interest bias people's views and, in my opinion, bias science and messaging. We raised the money in 3-4 weeks from over 800 contributors.

The premiere was hosted in the UK Parliament by the chair of the All Party Parliamentary Group for Diabetes, Keith Vaz MP, who has been influential in lobbying and campaigning for a sugary-drinks tax (a soda tax, in your language) which will come into law in 2017.

The proudest moment for me was when Professor Parveen Kumar, the woman who co-wrote the Clinical Medicine text book used by medical students worldwide, gave the movie a glowing review and basically said that all doctors should watch this film. I am also pleased to share that my medical school, Edinburgh, will be hosting a screening on October 20.

theheart.org | Medscape: Finally, where is the movie available? Can people download it?

Dr Malhotra: Yes. It $4.99 to download from the website thebigfatfix.com. We plan to get it translated into many different languages. It's about 80 minutes long.

Follow Tricia Ward on Twitter: @_triciaward

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Editor’s Note: An earlier version of this interview incorrectly stated that the intervention group in the PREDIMED study got 37% of total calories from fat versus 41% for the control group. Those numbers were inadvertently reversed. This has been corrected.


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