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We also published an analysis showing that improvements in dietary fat intake, exercise and stress management were individually, additively and interactively related to coronary risk. Judging the quality of a study by the number of patients is like judging the quality of a book by the number of pages.

There are so many other factors. Here's a blog in which I addressed this issue:. As Attilio Maseri, MD, an internationally known and respected cardiologist, wrote :. My colleagues and I conducted a demonstration project of patients from four academic medical centers and four community hospitals.

These patients were eligible for revascularization and chose to make these comprehensive lifestyle changes instead. We found that almost 80 percent were able to avoid surgery by making these comprehensive lifestyle changes. As I mentioned above, we found significant improvements in virtually all risk factors in almost 3, patients who went through my lifestyle program in 24 hospitals and clinics in West Virginia, Nebraska, and Pennsylvania. Also, as I wrote in my op—ed in The New York Times , my colleagues and I have conducted randomized controlled trials that these same diet and lifestyle changes reverse the progression of other common chronic diseases.

What happens to changes in blood pressure, cholesterol and weight are important only to the extent that they affect the underlying disease process for example, degree of atherosclerosis, blood flow to the heart, cardiac events, changes in prostate cancer , which is what we documented. As I wrote:. But replacing animal protein with well-balanced plant proteins is beneficial, and this is in the mainstream of what most scientists who do nutrition research believe.

These are not theoretical discussions; they are real people who have shown substantial improvements in their health and well-being—not just in risk factors but also in the underlying disease process. You can hear some of their stories here. And although no one likes to be falsely accused that almost everything they say is wrong, the bigger concern I have is that people who otherwise might have been motivated to make these highly beneficial diet and lifestyle changes may be discouraged from doing so by reading this essay by Ms.

Moyer in which, unfortunately, almost everything she writes about my work is wrong. All consumption estimates are imperfect, of course, including the U. But looking more closely at the report pdf he discusses—as others already have —one finds that it, too, shows that in the decades from to , when obesity and chronic disease rates skyrocketed, U.

USDA data also show pdf that between and U. Indeed, the USDA explicitly states that most of our increase in consumption of added fats has been due to the growing use of vegetable oils and related products. Ornish then cites a barrage of individual studies to back his claim that red meat and saturated fats are dangerous, including one that has not even been published in the peer-reviewed literature.

Another meta-analysis of 21 studies found no association between saturated fat intake and heart disease. Again, meta-analyses of observational studies are certainly not perfect, but because they analyze all relevant data, they circumvent the problem of cherry-picking. Ornish also dismisses the randomized controlled trials I cited in large part because the subjects in these trials did not adhere to the diets and reduce their fat intake enough.

But his claims about the dangers of saturated fat and red meat go beyond the science and in some cases contradict it. And although Ornish is right that I lack clinical experience, when analyzing evidence, distance can be useful.

I have no horse in this race. Credit: Nick Higgins. Already a subscriber? Sign in. Thanks for reading Scientific American. Create your free account or Sign in to continue. See Subscription Options. Go Paperless with Digital. Subhead: When it comes to good eating habits, protein and fat are not your dietary enemies Her article begins with a gross distortion of what I believe.

Finally, we need more quality and less quantity. The control group did not follow a low-fat diet. This is not surprising, since researchers gave the control group little support in following this diet during much of the study. There was no significant reduction in the rates of heart attack, death from cardiovascular causes or death from any cause. The only significant reduction was in the rate of death from stroke see Table 3 of the article.

Research shows that animal protein may significantly increase the risk of premature mortality from all causes , among them cardiovascular disease , cancer and type 2 diabetes. These results are in agreement with recent findings on the association between red meat consumption and death from all-cause and cancer Fung et al, ; Pan et al, Previous studies in the U. Our study indicates that high levels of animal proteins, promoting increases in IGF-1 and possibly insulin, is one of the major promoters of mortality for people age 50—65 in the 18 years following the survey assessing protein intake.

Based on previous longitudinal studies, weight tends to increase up until age 50—60 at which point it becomes stable before beginning to decline steadily by an average of 0. We speculate that frail subjects who have lost a significant percentage of their body weight and have a low BMI may be more susceptible to protein malnourishment. It is a common belief that the larger the number of patients, the more valid a study is. However, the number of patients is only one of many factors that determine the quality of a study.

In our studies we ask smaller groups of people to make much bigger changes in lifestyle and provide them enough support to enable them to do so. And because the degree of these lifestyle changes is much higher than a control group is likely to make on their own, and the intervention is potent, it becomes easier to show statistically significant differences even though the number of patients is smaller.

The first is the fact that the larger the number of patients that have to be included in a trial in order to prove a statistically significant benefit, the greater the uncertainty about the reason why the beneficial effects of the treatment cannot be detected in a smaller trial. Episodes of chest pain decreased by 91 percent after only a few weeks. After five years there were 2. Blood flow to the heart improved by over percent.

Given that weight bias, stigma and discrimination have direct impacts on health — raising levels of stress hormones and increasing systemic inflammation, contributing to anxiety and depression, and adding to shame, which in turn makes people less likely to engage in physical activity or other health-supporting behaviors — the author is actively asking her readers to contribute to harm by contributing to stigma and social isolation, which also produces adverse health effects.

As for rejecting your depressed friends? You are no longer worthy of my friendship! I also have issue with her recommendation to cut out friends who smoke. Speaking from my own experience, I find smoking disgusting. It stinks and it makes your clothes stink. Unlike being at a higher body weight, smoking is proven to be unhealthy for you and for anyone who inhales your secondhand smoke or is exposed to residue thirdhand smoke. If they wanted to quit and most did eventually they would do it in their own time, in their own way.

None of us is perfect. We all have our flaws and we all struggle in some way. Does the thought of suddenly fitting a lot of coffee dates, in-person book clubs and dinner parties into your schedule make you want to lock your doors, silence your phone and curl up with a book? Then taking a serious look at who you spend time with is probably important for your well-being.

Dietary Guidelines. For the first time, the federal government told Americans to eat more fruits, vegetables, whole grains, poultry, and fish, to eat fewer high-fat foods, and to substitute nonfat for whole milk. Even though many diet-heart studies focused on high-risk patients, and although the proposed massive Diet-Heart study of the late s and the early s was abandoned for lack of money and methodological problems, a host of scientific studies supported the low-fat approach.

By , the scientific consensus was that the low-fat diet was appropriate not only for high-risk patients, but also as a preventive measure for everyone except babies. From through the s, dietary fat was increasingly blamed not only for coronary heart disease but also for overweight and obesity. Although some scientists and physicians remained unconvinced by the data, the argument in favor of the low-fat diet for all carried the day, following the recommendations of the Consensus Report.

Here was a chance for the food industry to profit from scientific research and for Americans to participate in the reigning health crusade. This history of federal involvement in the American diet is essential for understanding how low fat conquered America in the s and s.

The United States Department of Agriculture USDA , established in , had two main duties: to ensure a sufficient and reliable food supply and to provide information on subjects related to agriculture, the latter charge being interpreted to mean making dietary advice available to citizens. In , the agency laid out five basic food groups: fruits and vegetables, meats and other protein foods, cereals and other starchy foods, sweets, and fatty foods.

In , the Food and Nutrition Board of the U. Academy of Sciences introduced Recommended Daily Allowances, or RDAs, and from the department has produced revised versions at regular intervals. This committee, which met until , was instrumental in the federal government's promotion of low-fat diets. During the nine years of hearings, the committee's focus shifted from its initial emphasis on hunger and the poor to chronic disease and diet. Committee members became convinced that Americans were not only eating too much, but were also eating the wrong foods.

The committee's work culminated in its early report, Dietary Goals for the United States , which promoted increased carbohydrate and reduced fat consumption along with less sugar and salt. The report recommended that Americans eat more fruits, vegetables, whole grains, poultry, and fish, less meat, eggs, and high-fat foods, and that they substitute nonfat for whole milk.

Critics, both scientific and industrial, called the diet-heart hypothesis unproved and the dietary recommendations disputable. Under pressure from many constituencies, but especially the food industry, the committee revised and reissued its report later in the year. With the publication of the Dietary Goals , the federal government officially supported the low-fat approach. By , a scientific consensus was emerging that a low-fat diet was needed to prevent the two leading causes of death, coronary heart disease and cancer.

Thus, by the s, in spite of protests from the food industry and skeptical scientists, federal agencies forged a consensus on dietary advice at the same time that a growing scientific consensus advocated low fat for everyone. Although the food industry had initially worried about the low-fat approach, by the s food producers had begun to realize that low fat could provide profit-making opportunities. In , after much controversy and negotiation, the USDA released its first and long-awaited food pyramid that lent full support to the ideology of low fat.

Wide press coverage gave the pyramid much publicity, and it quickly became an icon. Food companies would pay to label their foods with the AHA seal of approval.

By , endorsed food products started to appear in grocery stores, but there was a problem: fresh foods were not labeled. This exclusion could suggest to consumers that processed foods were the heart-healthiest.

Following protests, the AHA withdrew the program, but reinstated it in By , fifty-five companies were participating with over products certified, many of which were cereal products, including Kellogg's Frosted Flakes, Fruity Marshmallow Krispies, and Low-Fat Pop-Tarts.

Four ounces contain mg of sodium. Approving meats injected with salt seems to be at odds with the AHA's long-standing efforts to reduce hypertension.

Some hyptertensives are known to be salt-sensitive. Photo taken by me in Blacksburg, Virginia, summer Was low fat the only thing that mattered for good health? Had the ideology of low-fat taken such a hold that that sugar-laden refined processed foods qualified for AHA approval as heart-healthy?

No wonder consumers were confused and assumed that low fat was what really counted in terms of health. It was possible to think that if a food were low fat, one could eat to appetite. We begin to see how a profusion of products low in fat but high in sugar and calories might ironically promote the fattening of America, even while being labeled heart-healthy. The tradition of low-calorie, low-fat diets, and scientific and federal promotion of low fat could not have conquered America without the participation of the popular press.

Two popular health sources, namely, Prevention magazine f. Both have subscribed to and promoted the low-fat diet since the s. One of the main contributions of popular magazines, such as Prevention , the Ladies' Home Journal , and Family Circle , was to include numerous advertisements for low-fat foods, one of the main ways American women learned about low-fat products.

Prevention promoted the low-fat diet for both heart health and weight reduction in the s and s. Jane Brody, personal health columnist for The New York Times since , whose articles have appeared in at least other American newspapers, also promoted the low-fat diet for heart health and weight loss, following the USDA Federal Dietary Guidelines.

The attack on dietary fat and cholesterol dominated the s, as scientific studies implicated the American diet as a major cause of coronary heart disease. The first step in the program was the low-fat diet. Scientific studies suggested that those who ate foods low in animal fat and cholesterol had less cholesterol in their blood. Yet, there was no proof that a low-fat diet would reduce heart disease.

Dean Ornish had shown that lifestyle changes could halt or reverse atherosclerosis. Participants in his program reversed atherosclerosis, and cholesterol levels fell from an average of to , with low-density lipoproteins LDL reduced from to Even though Ornish's study involved only twelve participants, his results buttressed the dominant scientific belief that a low-fat diet could prevent, and might even reverse, heart disease. Scientists wondered if all Americans should try to lower their cholesterol levels.

But were these goals appropriate for all Americans? Another consideration was that studies up to then had been done only on middle-aged men, the group most afflicted by heart disease. Scientists had studied neither women nor the elderly in clinical trials of cholesterol reduction. Two studies helped scientists begin to answer the question concerning the general applicability of the low-fat diet as the way to lower cholesterol. The second attributed lower death rates to drug-induced cholesterol reduction.

Scientists interpreted these findings to mean that lowering cholesterol levels by any means had clear benefits for preventing heart attacks. But the studies did not show that lowering cholesterol levels increased longevity, and so long-term outcomes remained unclear. Throughout the s and s, Prevention 's dominant diet recommendation was the low-fat, high complex-carbohydrate diet, labeled the Prevention diet.

This long-standing association of low fat with low calorie would soon be upended, however, as the food industry flooded the market with low-fat—but fattening—foods. In many of these foods, sugar replaced fat so that low fat became high calorie.

The early s saw a move from low fat to no fat on the part of some popular health writers. Reflecting the influence of the Ornish studies, the message presented in Prevention in the early s in editorials, columns, and ads was that if low fat was good, no fat was better. In December , Editor Mark Bricklin introduced a new generation of nonfat foods. The nonfat cookies were a prime example of how, according to some scientists and science writers, low fat made Americans fatter. The low-fat diet reigned supreme in the late s, as scientists, the federal government, and popular health writers declared the low-fat, high-carbohydrate diet the gold standard for heart health and weight control.

Prevention writers warned of the dangers of the popular high-protein diets, even while acknowledging that people overdid the low-fat, high-carbohydrate foods. It seemed that too many Americans thought they could eat as much as they wanted as long as it was low or no fat. They had followed the advice to count fat grams and not calories—with the result that some had gotten fat on low and no-fat foods.

Researchers studied diets in countries where heart disease and obesity were rare to see if Americans could learn from other cultures. Subscribing to a universalizing model, they assumed that all human bodies functioned in the same way. The idea was that we could observe what other people ate, for example, the Chinese or the Japanese, see what effect their diets had on heart health and weight, and then, if need be, emulate them.

Investigators reasoned that if a diet worked for the Japanese or the Chinese, it should also work for Americans. Nutritional researchers gathered interesting data from these two Asian diets, leading them to suggest that Americans ate too much fat and protein to the neglect of vegetables.

A healthier diet would be vegetable based, with only modest amounts of fat and animal protein. But sometimes they departed from this dominant positivistic position.

Brody, for example, recognized sex differences in her discussion of how women's pattern of heart disease differed from that of men. In the early s, scientists found that males and females experienced heart disease differently. She reported on a study of , older adults that had found that losing weight had no effect on life span.

Although weight loss helped individuals manage diabetes and hypertension, the study found that obesity—and this term was not spelled out in the study—had few effects on mortality as people aged.

By the age of seventy-four, there was no relationship between being obese and a higher risk of dying. A major challenge to the use of diet as a way to reduce weight came from set-point theory. In the early s, Brody began to question the low-fat dogma on these grounds.

According to set-point theory, each person's weight has a fairly stable set point that resists gain or loss of weight. Although the set point may change with age and in some people can be overridden, the set point means that permanent weight loss is extremely demanding—if not impossible—for many people. Drawing on scientific studies, she explained that it was not clear that people could lose weight and keep it off.

In a break with her long-standing recommendation of the low-fat diet, she called for an individualized approach, suggesting that a one-size-fits-all diet might not be the most effective for all.

She had not lost faith in the low-fat diet, but as scientists continued to complicate the issues involved in weight loss and maintenance, Brody and others began to moderate their low-fat-for-all message.

Increasing knowledge of dietary fats also complicated the low-fat agenda. Again, Brody's solution was a low-fat diet for both heart health and weight loss. Meanwhile, challenges to low fat diet for heart disease prevention came from two other fronts: success with drug therapy and scientific dissent about the efficacy of the diet for heart health. In the s, statins' ability to reduce cholesterol levels suggested that drugs might be more effective than diet, thus challenging the hegemony of the low-fat diet as a recommendation for heart health.

The statins—with four on the market by —promised to change the emphasis on the low-fat diet as the major therapy for cholesterol reduction. Although statins, available since , had been shown to lower cholesterol, until the mids, it was not clear that they saved lives. But in , a scientific study showed that Merck's simvastatin not only reduced the risk of coronary heart disease, but also saved lives.

Kolata suggested that this finding would encourage more aggressive drug treatment of high cholesterol in patients at risk for coronary heart disease and could result in a major change in medical practice.

As far back as the s, a minority of scientists and popular health writers had questioned the low-fat diet. Some scientists had argued that it was the kind of fats—not the total amount—that mattered. This skepticism emerged full-blown in the s. He explained that because the scientific community had recommended the diet, people assumed there was proof that the diet worked, even though there was none. One leading obesity researcher, Dr. Jules Hirsch, physician-in-chief at Rockefeller University and one of the principal contributors to the notion of set-point theory, raised a different challenge.

Willett noted that substituting carbohydrates for fats could reduce high-density lipoproteins HDL levels while raising triglyceride levels. With such challenges, could the ideology of low fat maintain its position of authority? Responding to these critiques, Brody began to modify her recommendations. This diet was high in monounsaturated fat, but low in saturated fat, emphasizing beans, grain, vegetables and fruits, small amounts of yogurt and cheese, fish, eggs, poultry, and a little red meat.

At the end of the decade, Kolata wrote about the low-fat diet for heart disease prevention and therapy, noting that there was no longer scientific consensus on the heart-healthiest diet. Although the official recommendation since the s had been that carbohydrates replace fats in the diet, some scientists disagreed. Willett, for example, consistently argued that it was not total fats that mattered, but the type of fat.

He recommended that Americans forget low-fat diets and embrace good fats such as olive oil and nuts. At the same time, the Atkins diet resurfaced, generating renewed interest in this high-protein, high-fat, low-carbohydrate diet, with over five million copies of the paperback edition in print.

The Atkins diet had become a national phenomenon in the s, with ten million copies of Dr. Atkins Diet Revolution sold. Brody dismissed the diet, noting that no long-term studies had been done and arguing that much of the initial weight loss was water. She suggested that as the diet became boring and unpalatable, dieters consumed fewer calories—and lost weight. Brody opposed this diet, reporting that with sensible eating and regular exercise she had lost thirty-five pounds.

Her success convinced her that willpower and a low-calorie approach, along with exercise, could produce weight loss and maintenance. Eat more calories than your body uses and you will gain weight. Eat fewer calories and you will lose weight. The body, which is, after all, nothing more than a biochemical machine [my emphasis], knows no other arithmetic. Simple carbohydrates, much loved by Americans, were at fault, Atkins maintained: white flour, sugar, and potato products, those de-fatted processed products that had fattened America.

By the end of the century, Brody was moderating her low-fat position to declare that fat can be a friend! Recounting the history of low-fat diet advice, Brody noted a major shift within the scientific community. Following the findings of Willett and others, scientists were now claiming that it was not the total amount of fat but the kind of fat that mattered. Brody was converting to this point of view. The key to heart health now seemed to be reducing saturated and trans fats hydrogenated plant fat , but not all fats.

Ignoring scientific studies that supported set-point theory, she argued that if low fat was not the answer to weight loss, we must count calories and exercise. The twenty-first century ushered in new enemies and new approaches. Prevention readers were advised that if they wanted to be thin, they must cut out sugar and manage stress.

Scientists showed that stress-induced cortisol promoted abdominal fat—declared the most dangerous kind of fat. The index offered a scientific way for readers to choose healthful carbohydrates that proponents maintained would not promote weight gain. In the new millennium, there was little agreement on which diet was the best either for heart disease prevention or weight reduction.

It makes no difference if these calories are in fats or vegetables or cake or ice cream. Change was at hand on the diet front. In a breakthrough article , Brody moved away from the one-size-fits-all low-fat diet that she had promoted with a religious fervor for more than twenty years to suggest that perhaps different diets worked for different people.

Addressing the widespread confusion about fat and fats, she noted that no consensus existed among experts. She proposed that a one-size-fits-all approach no longer worked in a society as ethnically and culturally diverse as ours. It was becoming more and more apparent that the public health message promoting the low-fat diet had had unintended consequences: it had led some people to adopt an unhealthy diet—just as long as it was low fat. Writing about the high-fat, low-fat controversy in , Brody emphasized the importance of a balanced diet.

She pointed out that after three decades of popularity of the Atkins diet, scientists had still not tested it for long-term safety and effectiveness.

She argued that the high-protein diet attracted those who failed on the low-fat diet. Brody maintained that it was not low fat that was fattening Americans, but more calories. Americans were eating on average calories more per day, and they had not reduced their fat consumption—if one used the higher total calorie count to figure percentages. Brody reiterated that it was just calories that mattered—no matter what kind. The Mediterranean diet found new followers as critics challenged the low-fat diet in the face of what many scientists and physicians were calling an obesity epidemic.

Low-fat proponents had not foreseen that Americans would overindulge in refined low-fat carbohydrates. One of the unanticipated consequences of industrial food technology was the ability of the food industry to flood the market with highly processed low-fat—but fattening—foods. They argued that substituting refined carbohydrates for fats was not the answer, explaining that refined carbohydrates—whether low fat or not—raise triglyceride levels and lower both good and bad cholesterol.

They maintained that there was no evidence from clinical trials to show that reducing dietary fat would by itself lead to weight loss. Rather, ignoring set-point theory, they maintained that it was too many calories and too little physical exercise that led to weight gain. So, by , the most recent research challenged the low-fat ideology that had held sway for so long, but at least some research affirmed Brody and Kolata's position that what counted was calories consumed and energy expended.

Finally, in , the results of long-term studies on low-carbohydrate, high-protein, high-fat diets, such as Atkins, were published. But it turned out that many people who succeeded on the diet were vindicated. People lost weight—and for many for whom low-fat or low-calorie diets had not worked, it was the first time they had lost weight. So what if the first 5—7 pounds were water? Many lost far more than this. The studies found that, contrary to expectations, the diet did not damage heart and blood vessels; in fact, in some patients readings improved.

As proponents had claimed, cholesterol levels did not rise, triglyceride levels fell, and HDLs improved. At the end of a year, however, both the low-fat and the low-carbohydrate diets produced about the same results in terms of weight loss. This was the same argument opponents of the low-fat diet had used when they argued that the fattening of America coincided with the decades in which the low-fat diet reigned as nutritional orthodoxy.

After explaining why some people lost weight on the Atkins diet, Brody reiterated that it was only calories that mattered. Both the writers for Prevention and the science writers for The New York Times carefully reported on scientific studies. They reflected a great faith in the validity of the studies and the value of reporting them to the wider public.

They were not reluctant, however, to include their own point of view, comparing and interpreting these studies for readers. These writers reflect the larger American—journalistic—faith in science during these years before many questions were raised concerning the reliability of such clinical, epidemiological, and laboratory studies.

The popular media, in short, played a pivotal role in preaching the low-fat message, and, then, in more recent years, in questioning it. Several developments that came together in the s and s help explain how the ideology of low fat conquered America in those decades.

The dietary context was an established tradition of low-calorie, low-fat dieting for weight reduction that predisposed Americans to accept what was promoted as a heart-healthy diet. A plethora of diet-heart studies carried out by scientists and physicians suggested that a low-fat diet might prevent heart disease. These studies drew on research that had been done from the s through the s. By the late s, the federal government started promoting the low-fat diet, and shortly thereafter the food industry began to make low-fat products available and to advertise them widely.

Low-fat foods proliferated in the s and s, demonstrated by the number of products available in grocery stores and the ads that appeared in magazines and on television. The rise of the ideology of low fat seemed to correspond with major reductions in risk factors for heart disease. Was it coincidence, or could a causal effect be identified?

These figures suggest that something in the American experience with heart disease did indeed change. These figures did not clarify the role of the low-fat diet, and so its influence in primary and secondary prevention remained in question.