Dr Aseem Malhotra: Mediterranean diet is heart healthy – if it’s high-fat

The Mediterranean diet is good for hearts as long as it is also high in fat, says Dr Aseem Malhotra, a British interventional cardiologist. He is science director of Action on Sugar, a group of 23 specialists working to reduce sugar consumption in that country, and is a speaker at the low-carb, high-fat Summit in Cape Town. Here he talks to me about why he decided to attend, and his views on heart disease and statins. – MS

Dr Malhotra, thank you very much for taking the time to talk to me.

It’s an absolute pleasure, Marika.

Thank you.  You once wanted to be a professional cricketer.  Cricketing’s loss is cardiology’s gain.  Why didn’t you  become a cricketer?

I’ve always had a passion for sport.  I played at a good level in cricket, in my school days.  I used to open the batting for my grammar school, which produces many good cricketers, including Mike Laverton, the former English captain.  I had to make a decision in my late teens to pursue a career in medicine.

Did your parents guide you in that one?

Well, my dad was actually very keen that I do cricket.  He’s a doctor but he was a very big cricket fan himself.

What kind of doctor is he?

He’s a general practitioner, but he played a lot of cricket with some of the great cricketers in his university days – cricketers like Kapil Dev, etcetera – in India.  Cricket runs in our blood and I made a decision that (probably the right one) that I was also very attracted to becoming a cardiologist.  For a long time, I wanted to do cardiology and I think I thought “well, I don’t think I’m going to be the next Tendulkar”, and therefore, I’d probably be better off doing cardiology.

What made you decide to specialise in cardiology?

Medicine obviously runs in the family and that had an influence on me (in a positive way) although I had decided I didn’t want to do general practice.  Both my parents were GP’s and growing up in a family of two GP’S, I felt like I was almost already a GP because you all about the work.  I was always interested the human body and science, but I had very up close and personal experiences of people with their hearts.

When I was young, my grandfather died of a very rare heart condition, called amyloidosis.  He was a very fit man.  It was tragic, he died in his early sixties, and he could have lived much longer.  That isn’t something that runs in families but it was heartbreaking.  I had a brother, who had a small hole in his heart, but he had Down’s syndrome and at the age of 13, he picked up a regular virus.  At the time, we didn’t know what happened, but he basically, went into crashing heart failure within the space of a week of being well, and it’s likely that he had something called myocarditis, which can happen.  I’ve treated patients with this.  He passed away.

I’m sorry to hear that.

Thank you.  It’s a long time ago, but I think those things definitely influenced in my thinking about cardiology.  When I went to medical school, I was fascinated with the heart.  We know that heart disease is the biggest killer in the Western world.

It is in South Africa, too.

To some degree, there was the romantic aspect of the heart that I liked as well, and I just pursued that career.

Why did you come to Cape Town, to this conference – the first international low-carb, high-fat conference?  It has been very controversial and many doctors have said that they’re staying away because they don’t agree with the basic premise.

Sure.  I’ve come here because I think there are many important messages, which need to be spread and I wanted to be part of that process.  For me, Tim Noakes has been inspirational.  I think he’s an amazing man and I think he’s a great scientist.  One way in which Tim stands out for me is the fact that he  made a U-turn on his own advice and what he was following, and very few people can do that.  I think that’s a real credit to him and a real strength.  I’ve had a lot of respect for Tim and I’ve engaged with him over the last few years on this issue.

Karen Thomson sent me a lovely email, saying that she’s organising this conference with Tim and obviously, told me about her background and the fact that her grandfather was Christiaan Barnard.  I didn’t hesitate to say I’m going to be there.  It’s unfortunate that there are people who have criticised this.  There’s a rather polarised view from some people.  I would have said they would have been better off coming along to the conference to hear what people have to say and then, make an informed decision.

By simply saying “this is dangerous” and “this is wrong” is actually, part of the problem with modern medicine now – with people’s inability to listen to people who have differing views.  We need to get this message out there, that the current dietary advice has been unhelpful.  It has probably been a big contributor to the obesity epidemic.  We need to change it and we need to change it radically.

I heard you talking to another delegate and you were saying that an incredibly high percentage of people who have a heart attack, actually, don’t have raised cholesterol.  What’s the percentage?

I wrote about this in one of my BMJ articles.  I found a references paper in America.  It was a very large study in which, it was found that 75% of people admitted with a heart attack, had normal cholesterol levels.  That suggests that cholesterol isn’t as big an issue as we think it is.

What about saturated fat?  Do you believe that saturated fat causes heart disease? 

I think there are a number of things to say here.  Overall, I don’t think the evidence that saturated causes heart disease, is convincing but I think we need to be even more specific because there are many different types of saturated fats.  Very few people realise this and one of the studies I spoke about today, looked at the association between saturated fat and the blood (influenced by diet) and the risk of developing Type 2 Diabetes, which as you know, is one of the major risk factors for heart disease.

What they found is that different saturated fatty acids (and there are scores of different ones) had different ones and they come from different foods.  What’s interesting is that saturated fatty acids that came from full fat cheese and yoghurt for example, were associated with a decreased risk in developing Type 2 Diabetes.  The other interesting thing, which many people don’t realise, is that the liver produces saturated fatty acids themselves and the saturated fatty acids that were associated with the increase of Type 2 Diabetes were being driven by sugar, starch, and alcohol.

 I’ve learned so much at this conference.  I’m learning every day.  We certainly don’t need to fear fat?

You’re absolutely right.  Firstly, having a high, total fat consumption and that’s one low/nearly absent in refined carbohydrates is going to be  the best diet for your health and reducing risk of heart attack, stroke, cancer, and dementia.  That’s been proven in many good quality studies and most of the positive effects that we have demonstrated so far, in terms of reducing those risks, are from foods such as nuts, extra virgin olive oil, and oily fish for example.  Yes, to some degree, whole fruits and vegetables and a diet, which is absent in low in refined sugars and refined carbohydrates.

In your talk earlier, you mentioned that a very healthy diet for the heart is proving to be a high fat Mediterranean diet and that there’s some research for that.  Where is the research?

There was a study called the PREDIMED study, which was published in the New England Journal of Medicine in 2013.  That was a randomised controlled trial.

That was the gold standard?

Nutrition studies are rare and this was about people who were at high risk of developing a heart attack, or Type 2 Diabetics who didn’t have a heart attack.  The trial was terminated early because what they found was within 4.8 years, those people who were on a high fat Mediterranean diet, which was supplemented with olive oil or nuts, actually had a significantly reduced risk of having a heart attack, stroke, or dying.  It was a 30% (what we call relative risk) reduction, compared to a traditional Mediterranean diet that was low fat and was higher in refined starches.

What’s interesting is that the total fat consumption in the high fat Mediterranean diet was 41%.  Now the current dietary guidelines tell us we shouldn’t see more than 30%.  How do you square all of that?  Clearly, the current dietary guidelines aren’t the best evidence-based guidelines for your health.  I don’t believe they are.  They need to change and they need to change.

They need to change soon – according to Zoe Harcombe and others, there was no scientific basis for introducing them in the first place.

I think there was some observational data.  Ancel Keys’ study for example.  He associated saturated fat with cholesterol and heart disease.  There were flaws in that study.  What Zoe’s paper was very good at highlighting is the randomised control trial data we had up to that point, didn’t that show that reducing saturated fat, reduced mortality and that’s key.

What’s your view of statins?

I think statins have a role.  They are very power drugs, used in the secondary prevention of heart disease – these are the people, who have heart attacks.  We can’t deny the fact that we have good randomised control trial data, that if you take a statin when you’ve had a heart attack, it will reduce the risk of death.  The absolute risk reduction is about 1 in 83.  If you’re somebody who’s had a heart attack and you are put in the statins, which is very reasonable to do; we know that taking that statins means there’s a 1 in 83 chance (if you take that statins daily) that within five years, the statins itself is going to reduce your risk of death.  However, when you then go into lower risk groups and people who, for example, don’t have heart disease, are otherwise healthy, and have a less than 20% risk of having a heart attack over 10 years, that will not prolong your life.  There’s no mortality benefit.

Is there any science behind it?

There is data that suggests that it will prevent a non-fatal heart attack, in one in 140 that take it.  That means that for you as an individual, there’s a less than 1% chance that it’s going to prevent a non-fatal heart attack.  However, we know also know that Statins are associated with increasing risk of Type 2 Diabetes, to a level which is similar (if not slightly higher).  You then have to make a decision.  It’s not going to prolong your life.  It’s going to prevent non-fatal heart attack in a small number, but you’re more likely to get Type 2 Diabetes.

On a personal level, given that information I wouldn’t choose to take it but if a patient wants to take it with that information, I’m fine with it as long as I’ve properly communicated that benefit and risk to them.  That’s even before you get into the discussion about side effects.  There’s been a lot of controversy about the side effects of Statins.  Unfortunately, part of that controversy has happened because most of the trial data that was done by industry-sponsored studies were clearly designed to just, look at benefits.  They’re known to under report on side effects.  For me, it’s about what interferes with the patients’ quality of life.  That’s what’s most important and that’s most important for most of us.

Most of what we do in medicine: We don’t cure things.  We can cure a few things.  We have antibiotics for infections and certain cancers can be cured, but most of what we do in medicine is palliation.  We’re there to relieve suffering.  That’s my job, as a doctor.  When somebody comes through the door to see me, I want to do what I can to improve their quality of life when they exit the door.  If they’re experiencing disabling side effects from the Statins – and I’m not going to get into the controversy of what percentage of people have side -, which we know exists in terms of reports of muscle pains and reduced energy, then what’s the point of taking that statins and living in misery for a very, marginal benefit.  That’s my personal view and I think that I’m very happy to have that conversation with my patients, and help them make a decision.

On that note, we only have one double-blinded randomised control trial on statins, independent on industry, which we’re specifically looking at in women.  The incidence of reduced energy/fatigue.  Again, this is a gold standard of study.  What they found is that up to 40% of women taking a low dose of Statins, reported reduced energy and fatigue.  Now, that’s not life threatening, but I would rather not be on a pill that’s going to give me some potential/marginal benefit and just, feel lethargic all the time.

It doesn’t really make much sense.

It doesn’t make sense to me.

To finish off now – your Action on Sugar Group.  You are the science director.  How much progress have you been able to make in reducing sugar in food?

It’s a very good question, Marika.  Firstly, Action on Sugar is a group of experts – respected scientists whom I’ve involved in this, are campaigning to ensure that we reduce our sugar consumption.  The first part of that campaign is raising awareness about the fact that sugar has become almost unavoidable.  It’s in many processed foods.  We know that there is good evidence now, to show that increasing sugar consumption is implicated in a host of diseases, including Type 2 Diabetes and cardiovascular disease (even in people of normal weight).  It’s not just about obesity.  In fact, it’s beyond obesity.

It’s about the diseases, associated with obesity.  It’s an unnecessary source of calories with no nutritional value.  You don’t need any carbohydrates for added sugar.  We know all of that stuff but actually, the main ultimate aim is to ensure that the whole population reduces our sugar consumption.  In the UK for example, we know that the average UK/British adult is consuming at least two to three times the World Health Organisation limit for sugar consumption.

And adolescents?

In adolescents, it’s higher to some degree.  It may be four or five times that.  Sugary drinks is one of the common sources, so we have called for sugar drinks tax.  We know that tax on sugary drinks will reduce consumption but actually, what we want the government to do is to get the food industry to reduce the amount of sugar they’re adding to processed foods.   Much of the sugar that people are consuming is hidden.  As we know, in the States and in the UK, 50 percent of sugar consumption is in foods people don’t really think have sugar in them – things like bread, ketchup, and salad dressing for example.

What we want to do is get the food industry to reduce the amount of sugar they’re spiking our food with and we’ve called for a reduction of 40% over four to five years.  According to the Department of Health in the UK, that would be enough to potentially, reverse the obesity epidemic, so it would have a big impact.

That’s wonderful news.

We’ve gotten attention.  The politicians are listening.  They’re asking for what we think but we haven’t had the regulation yet and that’s what we need.  If we’re really going to have an impact on the entire population, it has to happen through regulation.  There’s no doubt.