Downloaded from http://bjsm.bmj.com/ on November 13, 2017 - Published by group.bmj.com Editorial 7500 high-risk patients. Furthermore, the Saturated fat does not clog the arteries: Lyon Heart study showed that adopting a Mediterranean diet in secondary coronary heart disease is a chronic prevention improved hard outcomes for both recurrent myocardial infarc- inflammatory condition, the risk of tion (NNT=18) and all-cause mortality (NNT=30), despite there being no signif- which can be effectively reduced from icant difference in plasma low-density lipoprotein (LDL) cholesterol between the two groups. It is the alpha linoleic healthy lifestyle interventions acid, polyphenols and omega-3 fatty acids 1 2,3 4,5 present in nuts, extra virgin olive oil, vege- Aseem Malhotra, Rita F Redberg, Pascal Meier tables and oily fish that rapidly attenuate inflammation and coronary thrombosis.6 Coronary artery disease pathogenesis and testing.4 When plaques rupture (analogous Both control diets in these studies were treatment urgently requires a paradigm to a pimple bursting), coronary throm- relatively healthy, which make it highly shift. Despite popular belief among bosis and myocardial infarction can occur likely that even larger benefits would doctors and the public, the conceptual within minutes. The limitation of the be observed if the Mediterranean diets model of dietary saturated fat clogging a current plumbing approach (‘unclogging discussed above were compared with a pipe is just plain wrong. A landmark a pipe’) to the management of coronary typical western diet. systematic review and meta-analysis of disease is revealed by a series of randomised observational studies showed no associa- controlled trials (RCTs) which prove that LDL CHOLESTEROL RISK HAS BEEN tion between saturated fat consumption stenting significantly obstructive stable EXAGGERATED and (1) all-cause mortality, (2) coronary lesions fail to prevent myocardial infarc- Decades of emphasis on the primacy of 5 heart disease (CHD), (3) CHD mortality, tion or to reduce mortality. lowering plasma cholesterol, as if this was (4) ischaemic stroke or (5) type 2 diabetes an end in itself and driving a market of 1 in healthy adults. Similarly in the DIETARY RCTS WITH OUTCOME ‘proven to lower cholesterol’ and ‘low- secondary prevention of CHD there is no BENEFIT IN PRIMARY AND SECONDARY fat’ foods and medications, has been benefit from reduced fat, including satu- PREVENTION misguided. Selective reporting may partly rated fat, on myocardial infarction, In comparison with advice to follow a ‘low explain this misconception. Reanalysis of 2 cardiovascular or all-cause mortality. It is fat’ diet (37% fat), an energy-unrestricted unpublished data from the Sydney Diet instructive to note that in an angiographic Mediterranean diet (41% fat) supple- Heart Study and the Minnesota coronary study of postmenopausal women with mented with at least four tablespoons of experiment reveal replacing saturated fat CHD, greater intake of saturated fat was extra virgin olive oil or a handful of nuts with linoleic acid containing vegetable oils associated with less progression of athero- (PREDIMED) achieved a significant 30% increased mortality risk despite significant sclerosis whereas carbohydrate and (number needed to treat (NNT)=61) reductions in LDL and total cholesterol polyunsaturated fat intake were associated reduction in cardiovascular events in over (TC).7 with greater progression.3 PREVENTING THE DEVELOPMENT OF ATHEROSCLEROSIS IS IMPORTANT BUT IT IS ATHEROTHROMBOSIS THAT IS THE REAL KILLER The inflammatory processes that contribute to cholesterol deposition within the artery wall and subsequent plaque formation (atherosclerosis), more closely resembles a ‘pimple’ (figure 1). Most cardiac events occur at sites with <70% coronary artery obstruction and these do not generate ischaemia on stress 1Lister Hospital, Academy of Medical Royal Colleges, Stevenage, UK 2Philip R Lee Institute for Health Policy Studies, San Francisco, California, USA 3Department of Medicine, UCSF School of Medicine, San Francisco, California, USA 4Department of Cardiology, University Hospital Geneva, Geneva, Switzerland 5Department of Cardiology, University College London, London, UK Correspondence to Dr Aseem Malhotra, Lister Hospital, Academy of Medical Royal Colleges, Stevenage, UK; aseem_ malhotra@ hotmail. com Figure 1 Lifestyle interventions for the prevention and treatment of coronary disease. Malhotra A, et al. Br J Sports Med August 2017 Vol 51 No 15 1111 Downloaded from http://bjsm.bmj.com/ on November 13, 2017 - Published by group.bmj.com Editorial A high TC to high-density lipopro- This occurs independent of weight loss To cite Malhotra A, Redberg RF, tein (HDL) ratio is the best predictor and suggests even a little activity goes a Meier P. Br J Sports Med 2017;51:1111–1112. of cardiovascular risk (hence this calcu- long way. Published Online First 1 April 2017 lation, not LDL, is used in recognised Another risk factor for CHD is envi- Br J Sports Med 2017;51:1111–1112. cardiovascular risk calculators such as ronmental stress. Childhood trauma can doi:10.1136/bjsports-2016-097285 that from Framingham). A high TC to lead to an average decrease in life expec- HDL ratio is also a surrogate marker for tancy of 20 years. Chronic stress increases REFERENCES insulin resistance (ie, chronically elevated glucocorticoid receptor resistance, which 1 de Souza RJ, Mente A, Maroleanu A, et al. Intake of serum insulin at the root of heart disease, results in failure to down regulate the saturated and trans unsaturated fatty acids and risk of all cause mortality, cardiovascular disease, and type type 2 diabetes and obesity). And in those inflammatory response. Combining a 2 diabetes: systematic review and meta-analysis of over 60 years, a recent systematic review complete lifestyle approach of a healthful observational studies. BMJ 2015;351:h3978. concluded that LDL cholesterol is not diet, regular movement and stress reduc- 2 Schwingshackl L, Hoffmann G. Dietary fatty acids in associated with cardiovascular disease tion will improve quality of life, reduce the secondary prevention of coronary heart disease: a and is inversely associated with all-cause cardiovascular and all-cause mortality.10 It systematic review, meta-analysis and meta-regression. 8 BMJ Open 2014;4:e004487. mortality. A high TC to HDL ratio is time to shift the public health message 3 Mozaffarian D, Rimm EB, Herrington DM. Dietary drops rapidly with dietary changes such in the prevention and treatment of coro- fats, carbohydrate, and progression of coronary as replacing refined carbohydrates with nary artery disease away from measuring atherosclerosis in postmenopausal women. Am J Clin healthy high fat foods. serum lipids and reducing dietary satu- Nutr 2004;80:1175–84. 4 Rothberg MB. Coronary artery disease as clogged rated fat. Coronary artery disease is a pipes: a misconceptual model. Circ Cardiovasc Qual chronic inflammatory disease and it can A SIMPLE WAY TO COMBAT INSULIN Outcomes 2013;6:129–32. be reduced effectively by walking 22 min a 5 Malhotra A. The whole truth about coronary RESISTANCE (CHRONICALLY HIGH day and eating real food. There is no busi- stents: the elephant in the room. JAMA Intern Med LEVELS OF SERUM INSULIN) AND ness model or market to help spread this 2014;174:1367–8. INFLAMMATION 6 Chakrabarti S, Freedman JE. Review: nutriceuticals simple yet powerful intervention. as antithrombotic agents. Cardiovasc Ther Compared with physically inactive indi- Contributors AM wrote the initial draft with further 2010;28:227–35. viduals, those who walk briskly at or revisions and edits from RFR and PM. 7 Ramsden CE, Zamora D, Majchrzak-Hong S, et al. above 150 min/week can increase life Competing interests RFR served as a consultant for Re-evaluation of the traditional diet-heart hypothesis: expectancy by 3.4–4.5 years indepen- one day in May 2015 for Amgen. AM is a co-producer analysis of recovered data from Minnesota coronary dent of body weight.9 Regular brisk of the documentary The Big Fat Fix. experiment (1968-73). BMJ 2016;353:i1246. 8 Ravnskov U, Diamond DM, Hama R, et al. Lack of walking may also be more effective than Provenance and peer review Not commissioned; an association or an inverse association between running in preventing coronary disease. externally peer reviewed. low-density-lipoprotein cholesterol and mortality And just 30 min of moderate activity a © Article author(s) (or their employer(s) unless in the elderly: a systematic review. BMJ Open day more than three times/week signifi- otherwise stated in the text of the article) 2017. All 2016;6:e010401. 9 Moore SC, Patel AV, Matthews CE, et al. Leisure time cantly improves insulin sensitivity and rights reserved. No commercial use is permitted unless otherwise expressly granted. physical activity of moderate to vigorous intensity and helps reverse insulin resistance (ie, lowers mortality: a large pooled cohort analysis. PLoS Med the chronically elevated levels of insulin 2012;9:e1001335. that are associated with obesity) within 10 Blackburn EH, Epel ES. Too toxic to ignore. Nature months in sedentary middle-aged adults. 2012;490:169–71. 1112 Malhotra A, et al. Br J Sports Med August 2017 Vol 51 No 15 Downloaded from http://bjsm.bmj.com/ on November 13, 2017 - Published by group.bmj.com Saturated fat does not clog the arteries: coronary heart disease is a chronic inflammatory condition, the risk of which can be effectively reduced from healthy lifestyle interventions Aseem Malhotra, Rita F Redberg and Pascal Meier Br J Sports Med 2017 51: 1111-1112 originally published online April 25, 2017 doi: 10.1136/bjsports-2016-097285 Updated information and services can be found at: http://bjsm.bmj.com/content/51/15/1111 These include: References This article cites 10 articles, 4 of which you can access for free at: http://bjsm.bmj.com/content/51/15/1111#BIBL Email alerting Receive free email alerts when new articles cite this article. Sign up in the service box at the top right corner of the online article.