Are Saturated Fats Really All That Bad?
I’ve been thinking a lot lately about saturated fats. Weird, huh?
The American Heart Association recommends that Americans limit the amount of saturated fats they eat to less than 7 percent of total daily calories. If you eat 2,000 calories a day, no more than 140 of them should come from saturated fats. That’s about 16 grams of saturated fats.
In over two decades of clinical practice, I’ve never run across a patient willing to do that calculation. Not many physicians could tell you the “seven percent rule.”
One of the two major themes of Gary Taubes’ book, Good Calories, Bad Calories, is that dietary saturated fats are not particularly harmful to our health, if at all. From what I’ve been taught, this is sacrilegious. “Saturated fats are a major cause of heart disease and strokes,” I’ve heard and read over and over. In brief, this is the Diet-Heart Hypothesis or the “lipid hypothesis”: Dietary saturated fat, total fat, and cholesterol are directly related to coronary heart disease and other forms of atherosclerosis.
In his review of Taubes’ book, Dr. George Bray didn’t even address Taubes’ point about saturated fats, writing instead, “read and decide for yourself.”
That started me thinking either that the Diet-Heart Hypothesis is indefensible or that Dr. Bray is lazy. I don’t think he’s lazy. Dr. Bray is a Grand High Pooh-Bah in the fields of obesity and nutrition.
The American Heart Association in 1957 recommended that polyunsaturated fats replace saturated fats.
U.S. public health recommendations in 1977 were to reduce fat intake to 30% of total calories to lower the risk of coronary heart disease. Slowly, some fats were replaced mostly with carbohydrates, highly refined ones at that. This shift tends to raise triglycerides and lower HDL cholesterol levels, which may themselves contribute to atherosclerosis. Current recommendations are, essentially, to keep saturated fatty acids as low as possible.
One concern about substituting carbohydrates for fats is that blood sugar levels rise, leading to insulin release from the pancreas, in turn promoting growth of fat tissue and potentially leading to weight gain. Some believe that the public health recommendation to reduce total fat (which led to higher carbohydrate intake) is the reason for the dramatic rise in overweight and diabetes we’ve seen over the last 30 years.
Note that if intake of saturated fats is inadequate, our bodies can make the saturated fats it needs from carbohydrates. These are generally the same saturated fats that are present in dietary fats of animal origin. The only exceptions are the two essential fatty acids: alpha-linolenic acid and linoleic acid.
Why would saturated fats be harmful? Apparently because they raise blood levels of cholesterol (including LDL cholesterol - “bad cholesterol”), which is thought to be a cause of atherosclerosis, which increases the risk of coronary heart disease and stroke. I don’t recall seeing any mention of a direct toxic effect of saturated fats (or fatty acids) on arterial walls, where the rubber meets the road. [Saturated fats are broken down in the small intestine to glycerol and fatty acids.]
Dietary saturated fats also raise HDL cholesterol - “good cholesterol” - although not to the degree they raise LDL.
Let’s not forget many other factors that cause, contribute to, or predict coronary heart disease and atherosclerosis: smoking, family history, high blood pressure, obesity, diabetes, oxidative stress, homocysteine, systemic inflammation, high-glycemic index diets, C-reactive protein, lack of exercise, and others. I discussed dietary factors in my April 14, 2009, blog post.
Often overlooked in discussion of dietary fat effects is the great variability of response to fats among individuals. Response can depend on genetics, sex, fitness level, overweight or not, types of carbohydrates eaten, amount of total dietary fat, etc. And not all saturated fats affect cholesterol levels.
Many of the journal articles listed as references below support the idea that the link between dietary saturated fats and coronary heart disease is not strong, and may be nonexistent. Read them and you will find that:
- Some studies show no association between dietary saturated fats and coronary heart disease.
- Some studies associate lower rates of coronary heart disease with higher saturated fat intake.
- Higher saturated fat intake was associated with less progression of coronary atherosclerosis in women.
- Lowering saturated fat intake did not reduce total or coronary heart disease mortality.
“Read and decide for yourself,” indeed. I think you’ll begin to question the reigning dogma.
For example, here’s a conclusion from the Hooper article (from 2001):
In this review we have tried to separate out whether changes in individual fatty acid fractions are responsible for any benefits to health (using the technique of meta-regression). The answers are not definitive, the data being too sparse to be convincing. We are left with a suggestion that less total fat or less of any individual fatty acid fraction in the diet is beneficial.
And a conclusion of the J.B. German article:
At this time [2004], research on how specific saturated fatty acids contribute to coronary artery disease and on the role each specific saturated fatty acid play in other health outcomes is not sufficient to make global recommendations for all persons to remove saturated fats from their diet. No randomized clinical trials of low-fat diets or low-saturated fat diets of sufficient duration have been carried out; thus, there is a lack of knowledge of how low saturated fat intake can be without the risk of potentially deleterious health outcomes.
Zarraga and Schwartz (2006) conclude:
Numerous studies have been conducted to help provide dietary recommendations for optimal cardiovascular health. The most compelling data appear to come from trials that tested diets rich in fruits, vegetables, MUFAs [monounsaturated fatty acids], and PUFAs [polyunsaturated fatty acids], particularly the n-3 PUFAs. In addition, some degree of balance among various food groups appears to be a more sustainable behavioral practice than extreme restriction of a particular food group.
Here’s another of my favorite quotes on this topic, from the J.B. German article:
If saturated fatty acids were of no value or were harmful to humans, evolution would probably not have established within the mammary gland the means to produce saturated fatty acids . . . that provide a source of nourishment to ensure the growth , development, and survival of mammalian offspring.
Take-Home Points
The connection between dietary saturated fat and coronary heart disease is weak.
[I may be excommunicated from the medical community for this. You won’t hear it from most physicians or dietitians. They don’t have time to spend 80 hours on this topic, so they stick with the party line. And maybe I’m wrong anyway.]
The scientific community is slowly moving away from the original Diet-Heart/Lipid Hypothesis. It is being replaced with stronger anti-atherosclerosis theories that promote:
- fruit and vegetable intake
- whole grain intake
- low-glycemic index eating
- increased consumption of plant oils and fish
- moderate intake of nuts
- ? moderate intake of low-fat diary (e.g., DASH diet) [less consensus on this point]
So, saturated fats and dietary cholesterol are being crowded out of the picture, or ignored. In many cases, saturated fats have literally been replaced by poly- and monounsaturated fats (plant oils). Several clinical studies indicate that’s a healthy change, but it may be related more to the healthfulness of the plant oils than to detrimental effects of saturated fats.
The original Diet-Heart Hypothesis won’t die until the American Heart Association and U.S. public health agencies put a gun to its head and pull the trigger. That will take another 10 years or more.
If you want to hedge your bets, go ahead and limit your saturated fat intake. It probably won’t hurt you. It might help a wee bit. By the same token, I’m not going on an all-meat and cheese, ultra-high-saturated fat diet; I don’t want to miss out on the healthy effects of fruits, vegetables, whole grains, fish, nuts, and low-glycemic index carbohydrates. Some would throw red wine into the mix. This “prudent diet” reflects what I hereby christen The 21st Century Diet-Heart Hypothesis.
If you’re worried about coronary heart disease and atherosclerosis, spend less time counting saturated fat grams, and more time on other risk-reducing factors: diet modification as above, get regular exercise, control your blood pressure, achieve a healthy weight, and don’t smoke. More bang for the buck.
What do you think?
Disclaimer: All matters regarding your health require supervision by a personal physician or other appropriate health professional familiar with your current health status. Always consult your personal physician before making any dietary or exercise changes.
Selected References Contradicting or Questioning the Diet-Heart Hypothesis (updated February 17, 2012):
Astrup, A., et al (including Ronald Krause, Frank Hu, and Walter Willett). The role of reducing intakes of saturated fat in the prevention of cardiovascular disease: where does the evidence stand in 2010. American Journal of Clinical Nutrition, 93 (2011): 684-688.
[The authors believe that replacing saturated fats with polyunsaturated fats (but not carbohydrates) can reduce the risk of coronary heart disease (CHD). For the last four decades, low-fat diets replaced fat with carbohydates. So they believe saturated fatty acids cause CHD or polyunsaturated fatty acids prevent it. I see no mention of total fat intake in this article written by major names in nutritional epidemiology and lipid metabolism. “In countries following a Western diet, replacing 1% of energy intake from saturated fatty acids with polyunsaturated fatty acids has been associated with a 2–3% reduction in the incidence of CHD.” “Furthermore, the effect of particular foods on CHD cannot be predicted solely by their content of total saturated fatty acids because individual saturated fatty acids may have different cardiovascular effects and major saturated fatty acid food sources contain other constituents that could influence coronary heart disease risk.”]
A Feb. 19, 2012, press release from the Harvard School of Public Health covered much of the same ground. It’s titled “Time to Stop Talking About Low-Fat, say HSPH Nutrition Experts.”
Siri-Tarino, Patty, et al. Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease. American Journal of Clinical Nutrition, January 13, 2010. doi:10.3945/ajcn.2009.27725
Skeaff, C. Murray and Miller, Jody. Dietary fat and coronary heart disease: Summary of evidence from prospective cohort and randomised controlled trials. Annals of Nutrition and Metabolism, 55 (2009): 173-201.
Halton, Thomas, et al. Low-carbohydrate-diet score and the risk of coronary heart disease in women. New England Journal of Medicine, 355 (2006): 1,991-2,002.
German, J. Bruce, and Dillard, Cora J. Saturated fats: What dietary intake? American Journal of Clinical Nutrition, 80 (2004): 550-559.
Ravnskov, U. The questionable role of saturated and polyunsaturated fatty acids in cardiovascular disease. Journal of Clinical Epidemiology, 51 (1998): 443-460.
Ravsnskov, U. Hypothesis out-of-date. The diet-heart idea. Journal of Clinical Epidemiology, 55 (2002): 1,057-1,063.
Ravnskov, U, et al. Studies of dietary fat and heart disease. Science, 295 (2002): 1,464-1,465.
Taubes, G. The soft science of dietary fat. Science, 291 (2001): 2535-2541.
Zarraga, Ignatius, and Schwartz, Ernst. Impact of dietary patterns and interventions on cardiovascular health. Circulation, 114 (2006): 961-973.
Mente, Andrew, et al. A Systematic Review of the Evidence Supporting a Causal Link Between Dietary Factors and Coronary Heart Disease. Archives of Internal Medicine, 169 (2009): 659-669.
Parikh, Parin, et al. Diets and cardiovascular disease: an evidence-based assessment. Journal of the American College of Cardiology, 45 (2005): 1,379-1,387.
Bray, G.A. Review of Good Calories, Bad Calories. Obesity Reviews, 9 (2008): 251-263. Reproduced at the Protein Power website of Drs. Michael and Mary Dan Eades. [Perhaps this doesn’t belong here.]
Hooper, L., et al. Dietary fat intake and prevention of cardiovascular disease: systematic review. British Medical Journal, 322 (2001): 757-763.
Weinberg, W.C. The Diet-Heart Hypothesis: a critique. Journal of the American College of Cardiology, 43 (2004): 731-733.
Mozaffarian, Darius, et al. Dietary fats, carbohydrate, and progression of coronary atherosclerosis in postmenopausal women. American Journal of Clinical Nutrition, 80 (2004): 1,175-1,184.
Related editorial: Knopp, Robert and Retzlaff, Barbara. Saturated fat prevents coronary artery disease? An American paradox. American Journal of Clinical Nutrition, 80 (2004): 1.102-1.103.
Yusuf, S., et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet, 364 (2004): 937-952. [ApoB/ApoA1 ratio was a risk factor for heart attack, so dietary saturated fat may play a role if it affects this ratio.]
Hu, Frank. Diet and cardiovascular disease prevention: The need for a paradigm shift. Journal of the American College of Cardiology, 50 (2007): 22-24.
[Dr. Hu de-emphasizes the original diet-heart hypothesis, noting instead that “. . . reducing dietary GL [glycemic load] should be made a top public health priority.”]
Oh, K., et al. Dietary fat intake and risk of coronary heart disease in women: 20 years of follow-up of the Nurses’ Health Study. American Journal of Epidemiology, 161 (2005): 672-679.
Parker, Steve. Time to abandon the diet-heart hypothesis? Advanced Mediterranean Diet Blog, May 1, 2009.
Parker, Steve. New study confirms the heart-healthy Mediterranean diet. Advanced Mediterranean Diet Blog, April 14, 2009. [Examination of the Mente study listed above.]
Selected References Supporting the Diet-Heart Hypothesis (by no means exhaustive)
Ascherio, A. Epidemiologic studies on dietary fats and coronary heart disease. American Journal of Medicine, 113 (supplement) (2002): 9S-12S.
Griel, Amy and Kris-Etherton, Penny. Beyond saturated fat: The importance of the dietary fatty acid profile on cardiovascular disease. Nutrition Reviews, 64 (2006): 257-262.
[Primarily a response to the Mozaffarian article above.]
Erkkila, Arja, et al. Dietary fatty acids and cardiovascular disease: An epidemiological approach. Progress in Lipid Research, 47 (2008): 172-187.
July 6th, 2009 at 6:15 pm
Interesting. I didn’t know there was controversy over saturated fat. I guess if you eat lots of fruits and veggies and stay away from high-calorie junk food, you’ll get less saturated fat anyway, as you suggest, and I don’t think there’s a controversy over whether eating from the garden is healthy–unless you’re eating the weeds, of course.
Leigh Ann Otte
Managing Editor
My Family Doctor magazine
July 7th, 2009 at 2:03 am
Hi, Leigh Ann. I didn’t know saturated fats were controversial either until about a year ago when I stumbled upon some low-carb eating blogs like “Weight of the Evidence.”
When you eat low-carb, you have to replace carbs with either fat or protein - usually both. So you would have to come to terms with whether saturated fats are harmful or not. The low-carb bloggers pointed out the contradictory studies. Only recently did I have the time to really dig into it.
-Steve
July 7th, 2009 at 7:44 am
I agree Steve, the evidence for any danger of saturated fats for heart disease is ambiguous and clouded by dogma. I think it is fair to say the impact is likely small and we can eat moderate amounts of meat and be healthy, as long as there is still room for all the other good foods and total calories don’t get too high. That limits meat by nature.
What concerns me is that no one talks much about the other issues with saturated fat. For instance, I read a paper last week that linked saturated fat to pancreatic cancer. Granted this was not a very good paper, but still there is more to life than heart disease.
You clearly spent a lot of time on this, thank you!!!
July 7th, 2009 at 10:36 am
I’m glad to hear from you, Darya. Although I have a degree in Zoology and studied many different sciences in college, I don’t “do science” on a daily basis. The practice of medicine involves both art and science.
Anyone interested in a scientist’s view of food/nutrition should see Darya’s blog, http://SummerTomato.com
-Steve
July 9th, 2009 at 2:24 pm
I think part of the equation that gets lost is what people tend to eat when they have a diet high in saturated fat - potato chips, donuts, french fries, etc. When it’s unsaturated fat, it tends be associated with higher quality, nutritious foods. I think part of the equation is processed vs unprocessed foods, especially the carbs that get paired up with the fat/oil. I’m guessing that eating steak along with an olive oil dressing salad, cherries, and a glass of wine would be healthy compared to a hamburger and french fries despite having similar saturated fat amounts. It’s a ‘can’t see a tree for a forest’ type of deal.
July 10th, 2009 at 5:58 am
[…] Are Saturated Fats Really All That Bad? <<And while we’re stepping on people’s beliefs, check out Dr. Steve Parker’s well-researched article about saturated fats and their lack of correlation to coronary heart disease. Uh-oh. (Advanced Mediterranean Diet Blog) […]
July 10th, 2009 at 10:39 am
Another great post Steve. LDL may go up a bit w/ increased saturated fat intake BUT as Taubes and others like William Davis, MD, cardiologist and the Drs. Eades, have pointed out: LDL is not all the same; there are six or seven different LDLs that are totalled in an LDL number; it is the small particle VLDL that is harmful; the rest of the LDL is large, pillowy, stuff like HDL; carbohydrate intake drives the amount of dangerous VLDL in the blood. That’s right; it’s the carbs. Taubes has an excellent discussion of the blood pressure lowering effects of carbohydrate elimination/restriction. Pages 145-153 I think. That’s right too; it’s not dietary salt but dietary carbs that drive blood pressure higher. Well, I don’t have to ask you if you’ve gotten around to reading Taubes. Cheers.
July 15th, 2009 at 7:59 am
Hi Steve,
Really interesting article. I totally see where you’re coming from, and as a dietitian I often struggle with this one - I’ve heard so much about the push to lower sat fats being more about selling drugs for the big boss drug companies, than actually improving people’s health. I’d hate to think I was a “mouth piece” for such companies only interested in lining their pockets!!
As a doctor, do you prescribe cholesterol lowering meds to your patients?
July 16th, 2009 at 7:16 am
Hi, Melanie. I do indeed prescribe cholesterol-lowering drugs, especially statins. I’m convinced they do prevent heart attacks and prolong life in properly selected patients.
Nevertheless, I’m not sold on a recent push in the U.S. to prescribe statins (Crestor, specifically) to all middle-aged people with a high C-reactive protein levels. I blogged about it here:
http://advancedmediterraneandiet.com/blog/?p=88
July 26th, 2009 at 10:26 am
I agree with most of what you have to say, but I’m very skeptical about grains, whether whole or not. I’m trying to avoid all grains and cereals, and my Type 2 diabetic blood glucose seems to do better without them.
July 27th, 2009 at 7:07 am
Hi, Jim. I’m reading “Atkins Diabetes Revolution” now. The authors would definitely tend to agree with you on grains.
Yet, I keep reading research reports touting the health benefits of grains. Here’s the latest one, in the July 22, 2009, issue of American Journal of Clinical Nutrition, by Nettleton, et al:
Background: Empirically derived dietary patterns show strong cross-sectional associations with cardiovascular disease (CVD) risk factors in the Multi-Ethnic Study of Atherosclerosis (MESA).
Objective: We investigated associations between dietary patterns and risk of incident CVD in 5316 men and women.
Design: White, black, Hispanic, and Chinese adults aged 45–84 y and free of CVD and diabetes completed food-frequency questionnaires at baseline. Dietary patterns were derived by using principal components analysis. Incident CVD events (n = 207) identified over a median of 4.6 y were verified by death certificates and medical records.
Results: The Fats and Processed Meat dietary pattern was associated with a greater risk (hazard ratio quintile 5 compared with quintile 1: 1.82; 95% CI: 0.99, 3.35), and the Whole Grains and Fruit dietary pattern was associated with a lower risk (0.54; 0.33, 0.91) of CVD after adjustment for demographic and lifestyle confounders. Associations between CVD and the Whole Grains and Fruit dietary pattern remained strong after adjustment for waist circumference, blood pressure, lipids, or inflammatory markers.
Conclusions: Data from this multiethnic cohort reinforce findings from predominantly white cohorts, ie, that “healthy” and “unhealthy” dietary patterns empirically exist and that these patterns are important lifestyle predictors of CVD incidence.
-Steve
August 5th, 2009 at 4:32 am
[…] compares and contrasts Ancel Keys’ Diet-Heart/Lipid Hypothesis with the Cleave-Yudkin Carbohydrate Theory. In Dr. Hujoel’s view, the latest research data […]
August 5th, 2009 at 4:46 am
[…] compares and contrasts Ancel Keys’ Diet-Heart/Lipid Hypothesis with the Cleave-Yudkin Carbohydrate Theory. In Dr. Hujoel’s view, the latest research data […]
August 28th, 2009 at 12:15 pm
[…] seriously questioning the Diet-Heart Hypothesis, I’m seeing very low-carb eating in a much more favoable light, at least for overweight […]
December 1st, 2009 at 2:40 pm
[…] In Part 1, Taubes examines the scientific evidence for what he calls the fat-cholesterol hypothesis. More commonly known as the diet-heart hypothesis, it’s the idea that dietary fat (especially saturated fat) and cholesterol clog heart arteries, causing heart attacks. Taubes finds the evidence unconvincing. He’s probably right. […]
December 8th, 2009 at 10:12 am
[…] The article author, Dr. Steven R. Smith, states the usual concern that high-fat (especially saturated fat), high-protein, low-carb diets may cause cardiovascular disease such as atherosclerosis (hardening of the arteries). He doesn’t mention the scientific evidence showing little or no role of total and saturated fat in cardiovascular disease. […]
December 9th, 2009 at 2:07 am
[…] In Part 1, Taubes examines the scientific evidence for what he calls the fat-cholesterol hypothesis. More commonly known as the diet-heart hypothesis, it’s the idea that dietary fat (especially saturated fat) and cholesterol clog heart arteries, causing heart attacks. Taubes finds the evidence unconvincing. He’s probably right. […]