Virtually all the truths about preventing heart attacks that physicians and patients have held dear for more than a generation are wrong and need to be abandoned, Malhotra writes. He musters a passel of recent research that suggests that the "obsession" with lowering a patients' total cholesterol with statins, and a public health message that has made all sources of saturated fat verboten to the health-conscious, have failed to reduce heart disease.
Indeed, he writes, they have set off market forces that have put people at greater risk. After the Framingham Heart Study showed a correlation between total cholesterol and risk for coronary artery disease in the early 1970s, patients at risk for heart disease were urged to swear off red meat, school lunchrooms shifted to fat-free and low-fat milk, and a food industry eager to please consumers cutting their fat intake rushed to boost the flavor of their new fat-free offerings with added sugar (and, of course, with trans-fats).
The result is a rate of obesity that has "rocketed" upward, writes Malhotra. And, despite a generation of patients taking statins (and enduring their common side effects), the trends in cardiovascular disease have not demonstrably budged.
Malhotra cites a 2009 UCLA study showing that three-quarters of patients admitted to the hospital with acute myocardial infarction do not have high total cholesterol; what they do have, at a rate of 66%, is metabolic syndrome -- a cluster of worrying signs including hypertension, high fasting blood sugar, abdominal obesity, high triglycerides and low HDL ("good" cholesterol).
Meanwhile, research has shown that when people with high LDL cholesterol (the "bad" kind) purge their diet of saturated fats, they lower one kind of LDL (the large, buoyant particles called "Type A" LDL), but not the small, dense particles ("Type B" LDL) that are linked to high carbohydrate intake and are implicated in heart disease.
Recent research has also shown that Mediterranean diets -- admittedly skimpy on red meat but hardly light on saturated fats -- have outpaced both statins and low-fat diets as a means of preventing repeat heart attacks. Other research suggests that the saturated fat in dairy foods may protect against hypertension, inflammation and a host of other dysfunctions increasingly linked to heart attacks.
"It is time to bust the myth of the role of saturated fat in heart disease and wind back the harms of dietary advice that has contributed to obesity," writes Malhotra.
Whether physicians at the front lines of health have gotten the message, a change in thinking is evident, at least, among some of medicine's leaders. But it's not easy to tune out years of what Malhotra calls "the mantra that saturated fat must be removed to reduce the risk of cardiovascular disease."
"When saturated fat got mixed up with the high sugar added to processed food in the second half of the 20th century, it got a bad name," noted UC San Francisco pediatric endocrinologist Robert Lustig. On the question of which is worse -- saturated fat or added sugar, Lustig added, "The American Heart Assn. has weighed in -- the sugar many times over."
Real food includes saturated fat, Lustig said, and real food lives up to the principle that food should confer wellness, not illness. "Instead of lowering serum cholesterol with statins, which is dubious at best, how about serving up some real food?"
[For the record, 5:20 p.m. Oct. 22: An earlier version of this story misspelled the name of cardiologist Aseem Malhotra.]