Fear sugar, not fat! UK cardiologist Dr Aseem Malhotra on carbs and hearts


Dr Aseem Malhotra
Dr Aseem Malhotra

British interventional cardiologist Dr Aseem Malhotra is one of the speakers at the Old Mutual Health Convention, a low-carb, high-fat (LCHF, aka Banting) health summit taking place at the Cape Town International Conference Centre from February 19 to 22. Malhotra is currently consultant clinical associate to The Academy Of Medical Royal Colleges, and science director of Action on Sugar, a voluntary group of Action on Sugar is a group of 23 specialists concerned with sugar and its effects on health. The group is  working to reach a consensus with the food industry and the UK government over the harmful effects of a high sugar diet, and bring about a reduction in the amount of sugar in processed foods.

On Saturday, February 21, he will speak on ‘The impact of dietary changes in the context of modern medicine’, and on Sunday, February 22, he will speak on ‘Sugar, advocacy or activism?’ Here he speaks to British Journal of Sports Medicine editor Liam West and gives fascinating insight into the impact of diet on heart disease, and why we should all get over our ‘fear of fat’. – MS


Hi there.  My name is Liam West.  I’m a junior doctor in the Oxfordshire deanery and I’m part of the BJSM editorial team.  On today’s podcast, I’m joined by Dr Aseem Malhotra, a consultant interventional cardiologist who hasbeen the central catalyst in igniting the debate around the harms of excess sugar consumption in the UK. He has achieved this, in part, by his commentaries in the BMJ and his regular columns that he writes for The Guardian newspaper about heart disease and other health topics.

We will put a link to this in the blurb for the podcast, so don’t worry about searching for them now.  Significantly, Dr Malhotra has managed to galvanise the leading academics, the media, and politicians into making sugar reduction a health priority.

LW: Before we start, it is quite important to clarify the two distinct issues surrounding the debate of this diet.  One question is whether endurance and other performance athletes actually need carbs in their diet.  At BJSM, we will be covering this issue in a podcast in a few weeks, so keep your eyes peeled for that.  The second debate surrounding this diet is the public health issue between the link of carbohydrates, health, and obesity, which we’re going to discuss today.  To start us off Aseem, could you comment on the impact of a low-carb, high-fat diet in comparison to modern treatments for heart disease?

AM: Firstly, we need to look at this in a bigger picture and a wider perspective.  Currently, we have a real problem with obesity.  It’s a public health crisis.  We know that 60% of the UK’s adult population are either overweight or obese.  One in three children are now overweight or obese by the time they leave primary school, which is very disturbing and the trends are on the increase.  What I believe we have failed to do in our healthcare system and even amongst knowledge of the wider public, is acknowledging the impact of diet on health and how important that is.  According to the Lancet Global Burden of Disease reports, poor diet contributes to more disease and physical inactivity than smoking and alcohol combined.  To answer your question specifically, one thing I have looked into is ‘what is the actual, best evidence base for dietary interventions on reducing cardiovascular risk and improving cardiovascular outcomes’.

The best evidence base from around the mouse-control trials comes from the traditional Mediterranean diet but certainly, one that is higher in fat content than is currently recommended by both the US and UK dietary guidelines.  One of the most impressive studies that was published relatively recently in the New England Journal of Medicine, compared a high fat Mediterranean diet with a low fat traditional Mediterranean diet.  What they found was, in a large group of about several thousand high-risk people for heart disease or diabetic patients for example, there was a significant 30% reduction in risk of heart attack, stroke, or death within the space of around four-point-eight years, but that risk reduction happened quite quickly.  In that intervention group, their total calories from fat was around 41%.

It was also low in sugar and low in refined carbohydrates so this clearly, is evidence from around the mouse-control diet data that higher fat consumption in terms of the Mediterranean diet has a big effect, specifically in terms of what foods are thought to contribute in reducing that risk.  It was nuts and extra virgin olive oil, in particular so at least four tablespoons of extra virgin olive oil per day and a handful of nuts, which was more walnuts, almonds, and hazelnuts (more specifically), which people would consider to be quite high in fat.  Let’s look at four tablespoons of extra virgin olive oil.  It’s probably about 500 calories.  When you compare that with a say, a can of Cola where you have nine teaspoons of sugar – and we know from the epic interact study that was published quite recently, it showed that the consumption of one of those sugary drinks per day was associated with a 22%  increase in the development of Type 2 Diabetes.

This is where the whole discussion around calories and fat etcetera, comes into specifically, where those calories come from – that’s what’s most important.

It’s an incredible misconception.  I wish I were taught this in medical school, really.

Me too, Liam.  I don’t remember having a single lecture on evidence-based nutrition and a lot of my understanding around nutrition or certainly, diet’s impact on health has only happened in the last few years and I do interventional cardiology.  We put stents in people.  We treat people for heart disease and we’ve very active in terms of treatment of acute heart attacks.  Again, to come back to your question and to put it in perspective, we look at modern treatments for heart disease.

A Mediterranean diet for secondary prevention for people, who have had heart attacks, is almost three times as powerful at reducing risk of death, than taking a statin, so the NNT (numbers needed to treat) is around 30.  When you look at statin for heart disease (and they have a very beneficial effect in people with established heart disease), the NNT is 83.

When you look at people who don’t have heart disease primary prevention, we know that low-risk patients is at ten percent risk over ten years, where there’s been a lot of controversy recently about guidance from Nice, on whether we should mass medicate significant proportions of the adult population with Statin, it doesn’t reduce mortality.  It will prevent about one in 140 from having a non-fatal heart attack.  There’s a similar/small increase of risk in developing Type 2 Diabetes, and that’s even when you don’t get into the whole area about side effects and the interference with the quality of life.  From my point of view, having nuts or extra virgin olive oil regularly as part of your diet every day – the NNT for that is around 61, which is much stronger than taking statin.  It doesn’t mean “don’t take a statin”, but I think people should be aware of the evidence base before they make informed decisions.

Many of our listeners should be aware, and they can tell their patients.

Absolutely.  We’ve sequestered really important information in healthcare – information that’s there, that’s published around the mouse-control trials – but what we as doctors tell our patients and what we’re even aware of ourselves, has been limited to some degree and unhelpful.  Therefore, we’ve over-treated people.  We’ve adopted a strategy of ‘a pill for every ill’.  Of course, modern medicine has a big role to play in people’s health, but I think we’ve overdone it in many instances.  In my personal view, we’ve done that with Statins and at the same time, neglecting the impact of diet.

Superb.  I think you’ve converted me.  I’m sold.  Let’s try to get to more of the people who believe in the science behind this.  I think you covered the debate around cholesterol and heart disease very nicely there.  You actually, recently busted the myth of saturated fat and heart disease in a BMG commentary that became one of the most-read articles in the world, in 2013 – so congratulations there.  Many of our listeners are actually general practitioners or family medicine physicians.  They’ll be listening to this in their cars or hopefully, while doing some physical activity.  Can you give them some evidence behind this and motivate them, to give some tips on how to convey this to their patients?

The top line (and I’ll elaborate on this) is to eat whole foods.  Eat real food.  The problem we have surrounding the issues of obesity and related diseases, whether it’s Type 2 Diabetes, high blood pressure, cardiovascular disease, or even cancer is about the consumption of processed food.  We look at saturated fats.  What many people don’t appreciate and realise is that there are many different types of saturated fatty acids.  In fact, there are scores of them.  The emerging evidence (something I’ve looked into and that has now been backed up with further studies) is that if you have saturated fats from non-processed dairy such as full-fat yoghurt and cheese, there is an association with a decreased risk of heart disease and Type 2 Diabetes. Saturated fatty acids come from processed foods and particularly, meats.  For example, a high consumption of meat may well be implicated in increased risk.

The problem we’ve had is that we’ve promoted this “low fat is good for you” message and that message actually, doesn’t have any strong evidence-base behind it (for two reasons that I’ve alluded to before).  If you have fats from things like olive oil and nuts for example, that is going to be protective.  Within saturated fat, you have different saturated fatty acids.  What’s happened is that the food industry has exploited this low-fat message and many of these foods that people purchase and think are health for them; many have the opposite effect.

A low-fat yoghurt for example, is very commonly consumed.  People think it’s healthy.  Some of these products (and we’ve looked into them with actual sugar) have 5/6/7 teaspoons of sugar in them.  How much sugar should we consume?  The World Health Organisation’s recommended limits for the average adult per day are six teaspoons per day.

Some of these products already go over your limit and for the average four to eight-year old child (and many parents will be listening to this) US dietary guidelines suggest they should have no more than three teaspoons per day of added sugar.  We know that dietary survey data here in the UK.(and it’s probably an underestimate because people don’t necessarily report correctly how much they’re eating) suggests that the average Brit consumes at least two to three times the amount of added sugar that is recommended from the World Health Organisation.

Some incredible stats there.  I think the message there is really, get all tweeters to get the message across with a #don’tfearthefat.  We should be a little bit more welcoming to that.  You’ve touched on cholesterol.  You’ve touched on fat.  You’ve just started to touch on sugar there.  You recently posted a very good piece, stating that sugar is now enemy number one in the Western diet.  Can you take our listeners through that and why you think we should raise the public awareness and maybe, even enforce more regulation on the food manufacturers?

Sure.  I think the key point here from a scientific point of view, are the issues around what we call non-milk extrinsic sugars.  Simply, that means added sugars – anything added to food – but also includes things like fruit juice, honey, and syrups and that’s where the problem lies.  These added sugars (refined sugars) (1) have absolutely no nutrition value.  In addition to that, the body doesn’t require any carbohydrates from added sugars for energy.  Therefore, you have something, which doesn’t add any value to your body and it doesn’t do anything positive for you.  Then you come to the adverse consequences of it.  Well, we know that consumption of just one sugary drink per day is associated with increasing risk of Type 2 Diabetes.  One of the most interesting studies that was published out of Stanford in early 2013 by a chap called Sanjay Basu and Robert Lustig (whom you’re probably aware is a paediatric endocrinologist in San Francisco and is co-author on this), was a very large study, which looked at sugar consumption and availability worldwide.

What they found was that for every extra 150 calories one consumed above their normal quota of sugar per day versus calories from another source, there was an 11-fold increase in the prevalence of Type 2 Diabetes – independent of body weight and independent of physical activity.  That means that even if you are a normal weight, sugar will cause you potential harm if you consume in excess.  I’ve always been very active.  I captained sports teams at school and university.  I go to the gym every day for health benefit reasons and not for obesity, and I thought that having a little bottle of Lucozade was good.  It would give me energy with something I needed.

I started looking at the data and thought “my God, there’s actually quite a lot of sugar in Lucozade”, and then, the BMJ did an investigation where they busted a myth and said: “These drinks don’t enhance performance and you don’t need them for extra hydration.”

Certainly, for most people, there may be an argument for elite athletes taking these drinks. Tim Noakes could probably elaborate on that a bit more.  I stopped drinking Lucozade, but I calculated that over a period of around ten years, I probably spent close to about £7000.00 just on buying these drinks because I thought they were good for my exercise performance.  I stopped drinking them.  It didn’t change my performance in any way.  I could still run my 5k in the same amount of time.  I just drank water instead.  Even from a personal perspective, I’ve gone through that.

Let’s put it in a box.  Sugar is bad and sugar is expensive, but we may take a little bit of time before we can get our patients to actually, change their diet if they want to.  In the meantime, has it been shown that exercise can mitigate against the harms of sugar?  Is there anything there?

You ask a very good question, Liam.  Many of these different things that we do are positive for our health.  No one can deny that even doing a 20-minute brisk walk has tremendous benefits for your health.  However, I don’t think exercise mitigates from the harms of sugar.  In the same way, I don’t think exercise would mitigate against the harms of smoking a cigarette.  One cigarette won’t kill you.  A teaspoon of sugar won’t kill you, but over time, these products have a very adverse effect on your body.  There’s one mantra, which I think gives a very strong message to people that we haven’t acknowledged enough, is that food can be the most powerful form of medicine or the slowest form of poison and added sugar is one of those poisons.

That is a great mantra.  Okay, I think we’ll leave that there.  Then, I think we’ll just end by discussing why there’s such an apparent conflict between dieticians and clinicians about this diet.  Surely, it’s only serving to confuse the public on what choice of diet to follow and making it harder for them to choose that.  Do you think we should maybe have a standardised model of nutrition toward all specialities?

Yes, I think so.  I can’t really speak that much for the dieticians.  My understanding from the dieticians’ point of view is that it can be argued as a very simplistic way of looking at what people eat, based upon the amount of calories they should consume.  You then compartmentalise it into managing how much fat, saturated fat, and carbohydrates etcetera.  I think that’s been unhelpful because I personally think it’s naïve for anyone to think that a calorie of bread, alcohol, sugar, Omega-3, or fibre has the same effect on the body.  They don’t.  They have different effects and our “calorie is a calorie” model has been overly simplified to the point where many people will buy food products based upon their calorie content, and not the quality of those calories.

What we need to do is concentrate on good nutrition and stop counting calories.  Certainly, many dieticians (not all of them) largely, do a tremendous job.

They look purely at the point of view of what people should be eating, whereas clinicians are looking at evidence-base and impacts on health.  That’s where I come from – the point view, which is ‘what are the best foods to eat, based upon evidence in terms of reducing risk of heart attack, stroke, cancer, Type 2 Diabetes, and all these aspects of health’ and yes, I agree.  I think we need to have a proper debate, an open and transparent one, and one that has been free of industry influence.

Only yesterday, a BMJ investigation that hit the news, uncovered the many members of the Scientific Advisory Committee on Nutrition, had received considerable research funding from the food and sugar industry – up to millions of pounds.  For anyone to think that won’t bias their views in any way is naïve.  I think that the public deserves to know that people, who are advising them on what to eat, are receiving research funding from the companies that want to sell them products, many of which are harming their health.

The debate needs to be had.  I don’t think any of these scientists have knowingly or individually, done anything deliberately wrong but I think that it has introduced a bias (whether it’s unwitting or not) into the decisions they make.

Thank you very much there, Aseem.

Thanks Liam.  It’s been a pleasure.

I learned quite a lot and hopefully, our listeners will too.  The conference that we mentioned at the start is a low-carb/high-fat diet going on in Cape Town next week (19th to 22nd).  How can you follow the conference?  Firstly, you can follow on Twitter.  Follow the BJSM handle on @BJSM_BMJ or follow Aseem on @DrAseemMalhotra during the event.  Follow the #LCHF.  Blogs will be posted each day and we’ll be doing subsequent podcasts with other keynote speakers.  Thank you very much for listening.  Have a physically active day, and don’t fear the fat.