It is funny how two lives can run parallel courses thousands of miles apart to eventually become intertwined. I am a cardiologist trained in interventional therapy (stents) for coronary artery disease (CAD) who has become a passionate advocate of lifestyle and prevention of CAD before stents are needed. I exercise daily using high-intensity protocols. I am appalled by the current status of hospital food. I emphasize the need for increased fruits and vegetables in the diet with reduced added sugars and value the pattern of eating in the Mediterranean (MED) basin as a model for balanced nutrition. I am a student of the voluminous nutritional research by Dr. Ancel Keys, the world renowned physiologist who introduced the MED Diet to the United States in 3 best-selling books after decades of seminal research on diet-heart relationships. Finally, I have recently traveled to Museum of the MED Diet in Pioppi, Italy, and the winter residence for nearly 40 years of Dr. Keys and his wife Margaret.

Dr Aseem Molhatra is a cardiologist practicing in London who is 20 years younger than me but who shares the same credentials listed above. I praise the fact that he fights for better nutrition for children with a campaign to lower added sugars in the diet and shuns processed junk foods. However, we have quite different opinions in terms of the role of dietary saturated fats, mainly from animal sources such as red meat, butter, full fat dairy, cheese, and eggs. Dr. Molhatra gained international attention with an editorial in the British Medical Journal titled “Saturated Fat is Not the Major Issue.” He presented selected references he used to conclude that the health of the public suffered when it was led towards a low fat diet rich in added sugars. He blamed the research of Dr. Keys, who he claims “demonized” saturated fats. He relies on a meta-analysis in 2010 on the topic and a randomized trial examining different versions of a MED diet on CAD outcomes. His National Obesity Foundation, which receives funding from meat producers and pharmaceutical manufacturers, has been criticized for a recent proposal on managing obesity in the U. K.. The irony is that his NOF report was accused of “cherry-picking” studies to support its claims, the very same claim that has been erroneously hurled dozens of times at Dr. Keys since his death. Dr. Malhotra recently released a documentary on his visit to Pioppi, Italy, The Big Fat Fix. Finally, he was recently featured in the New York Times holding a cup of coffee with butter and coconut oil blended into it while advocating for more cheese, eggs, and bacon in the public diet.

Space does not permit a full listing of all the issues I have with Dr. Molhatra’s new documentary. I will not comment further on the fact that he used multiple videos and photographs from the collection of the University of Minnesota without copyright permission (personal communication Henry Blackburn, MD) or that he climbed the fence of private property that was Dr. Keys home in Italy. I will also not respond to a strange claim that in his late 80s’s (Dr. Keys lived until just shy of his 101st birthday), he was unable to publish a paper on HDL cholesterol, with the implication that it was some sort of fundamental change in his thinking on the role of saturated fat and CAD. Both his son Henry Keys and Dr. Blackburn deny there was any such manuscript (personal communications, Henry Keys, MD and Henry Blackburn, MD). For sake of brevity, the following comments are offered in bullet points.

1) The 2010 meta-analysis mentioned above on which Dr. Malhotra relies was resoundingly criticized by a leading cardiovascular epidemiologist Jeremiah Stamler in the very same issue, a rather unusual event for a medical journal. Neither the authors nor Dr. Malhotra have responded to Dr. Stamler’s lengthy review of the study. The fact that Dr. Krauss, senior author on the meta-analysis, has long received funding from the meat and dairy industry, is overlooked by Dr. Malhotra.

Finally, the fact that in more recent publications the same research group has noted the benefits for preventing CAD by reducing dietary saturated fats substituting polyunsaturated oils, fruits, vegetables, fish and nuts is missing from the documentary.

2) The “demonization” of Dr. Keys began soon after his death in 2004 and can be attributed to errors in research on his long career by Gary Taubes and others. His is accused of manipulating American food policy to favor low fat, high sugar foods. Nothing could be further from the truth. Indeed, Keys never testified before the U.S. Senate working on such policies. A review of Dr. Keys’ best-selling books, co-authored with his wife, are replete with recipes substituting butter and cheese with copious amounts of olive and other vegetable oils. They would never be categorized as low fat meals. Dr. Keys and over a dozen co-authors performed the first long term observational study of widely different cultures in the Seven Countries Study. Their research was the first to identify that while both Finland and Crete had diets with about 40% of calories from fat, deaths for CAD was low in Crete due to the reliance on vegetable oils low in saturated fats while highest in the world in Finland where butter and cheese were the staples of the diet. Finally, Dr. Keys called for a reduction in dietary sugar as early as 1959 in his books, decades before Dr. Malhotra was born. The reality was that in analyses from the Seven Countries Study, dietary sucrose did not predict CAD with anywhere near the statistical power that dietary saturated fat, particularly butter, did.

3) The MED diet was given a new and dangerous spin in Dr. Malhotra’s film. While visiting the Museum of the MED Diet in Pioppi, he alters the MED diet food pyramid into something very different, a low carb-high fat (LCHF) plan. He removes the base of cereals, pasta and bread and emphasizes this again later in the film when he places the bread basket far out of reach. Instead he adds butter, full fat dairy and cheese, and even coconut oil to his prescription pad for the MED diet. This alteration of the MED diet pyramid, including foods like coconut not indigenous to the Mediterranean basin, might be easily overlooked. In reality, this is an obvious perpetuation of the LCHF diet promoted for decades beginning with Robert Atkins, MD and others. The actual MED diet, as studied in PREDIMED and other trials, emphasizes the central role of cereals. By removing carbohydrates as breads and cereals and adding in high saturated fat ingredients, this LCHF diet raises major concerns for CAD. A LCHF diet is associated with an increase in all-cause andCAD mortality in large databases. That a cardiologist would promote a LCHF diet in view of this known risk is concerning at best and seemingly dangerous at worst.

Another critic of Dr. Keys and the Seven Countries Study, Nina Teicholz, accused Keys of fudging his data, recognizing it is hard for Keys to respond since his death! She implies that he misled the public into the current obesity epidemic. While the topic is complex, and the recent reports of sugar industry payoffs (unrelated to Dr. Keys) 50 years ago are very concerning, the real fudging can be found in The Big Fat Fix. This documentary and the other writings of Dr. Malhotra ignores the copious new data on the confirmed risk of dietary saturated fats and CAD. Also ignored is the documentation that a no added fat, plant based diet can reverse CADand improve blood flow to the heart. His writings and film contribute greatly to the confusion amongst the public about what to eat. Dr. Malhotra lectures about confusion as a classic strategy from the tobacco industry “playbook” to delay the public view linking smoking to cancer. We should be alarmed that the Big Fat Fix is taking a page out of that same playbook at the risk of the wellbeing of the public. This is not a personal attack as I know Dr. Malhotra to be an intelligent and personable individual. Rather, for the sake of the health of CAD patients, known and developing, I call upon him to rethink his passion for adding saturated fats to the diet of patients with known or occult heart disease and instead join me in advocating for diets with more fruits and vegetables low in added sugars. The olive branch that includes olive oil is extended. Physicians swear to “primum non nocere” or “first do no harm”. As there is no safety data for his recommendations in heart patients, Dr. Malhotra would be wise to review that credo. Meat, dairy products and artificial foods usually high in saturated fat remain the main felon in CAD with added sugars an obvious accomplice.

Dr. Joel K. Kahn, MD, FAAC

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