Prof G Vijayaraghavan | Published on Mon 22 Apr 2019 04:54 PM IST
Prof G Vijayaraghavan: Vice chairman & director, dean, post-graduate medical studies, Kerala institute of Medical Sciences, Advisor emeritus, Royal College of Physicians of Edinburgh, UK
Flood of messages in whatsApp and e-mails during the last few years
"Since we cannot possibly eat enough cholesterol to use for our daily needs of the body functions, our body makes its own. When we eat more foods rich in this compound, our bodies make less. If we deprive ourselves of foods high in cholesterol -- such as eggs, butter, and liver — our body revs up its cholesterol synthesis. The end result is that, for most of us, eating foods high in cholesterol has very little impact on our blood cholesterol levels. In seventy percent of the population, foods rich in cholesterol such as eggs cause only a subtle increase in cholesterol levels or none at all. In the other thirty percent, these foods do cause a rise in blood cholesterol levels. Despite this, research has never established any clear relationship between the consumption of dietary cholesterol and the risk for heart disease… Raising cholesterol levels is not necessarily a bad thing either“.
These are the kind of dangerous misinformation that are going viral in the social media since the last 2 or 3 years. Patients are taking more time for consultation, friends are asking more questions and even doctors become confused following this barrage of statements in the social media. “Study where there is no link between cholesterol and heart disease”, “Cholesterol – Read about facts and myths”, “High cholesterol do not cause heart disease”; these are some of the sensational internet sites we start browsing. The misinformation leading to disinformation has flooded the internet sites so that the common man is being misled.
From where do you learn modern medicine? I often ask my colleagues and students.
Of course not from “WhatsApp or internet”; Nor from lay press like The Indian Express, The Hindu, Times of India, and the like. We learn medicine from standard medical text books, journals, national and international medical conferences and Continuing Medical Education programmes. We do refer to important internet sites. We always probe for the evidence base and the scientific background of each of the internet sites. We try to follow the guidelines. Guidelines are formulated after detailed deliberations of expert committees of highly reputed international organisations like the American College of Cardiology, American Heart association, European Society of Cardiology, World Federation of Cardiology and Cardiological Society of India. Guidelines are discussed and finalised at their annual meetings and published in highly acclaimed and reputed international journals. These are the sources that are reliable for continuing our medical education and not the social media”.
I did browse some of these internet sites and the source of these social media publications. I ended up with very few sources. One of the main source led me to “mercola.com”; described as the “World’s No 1 Health web site”. They based their conclusions on the 2010 dietary advice to the Americas by the US department of Agriculture, Health and Human Services. I went through the 210 page report and its executive summary. It in no way differs from the old “Adult Treatment Panel iii (ATP iii)” of the National Cholesterol Education Programme (NCEP) of the American Heart Association, which the whole world had been following from 2002.
In 2013 the American college of cardiology and the American heart association task force for practice guidelines published their new guidelines for lipid control as the ATP iv guidelines in the journal Circulation and the Journal of American College of Cardiology. They described 4 treatment groups who required cholesterol reducing drugs.
ATP iv stated that four treatment groups include:
1) Individuals with heart disease or strokes (CVD).
2) Individuals with LDL-cholesterol levels >190 mg/dL, such as those with familial hypercholesterolemia.
3) Individuals with diabetes aged 40 to 75 years old with LDL-cholesterol levels between 70 and 189 mg/dL and without evidence of atherosclerotic cardiovascular disease.
4) Individuals without evidence of cardiovascular disease or diabetes but who have LDL-cholesterol levels between 70 and 189 mg/dL and a 10-year risk of atherosclerotic cardiovascular disease >7.5%.
Persons with documented heart disease and strokes, diabetes mellitus, very high levels of individual risk factors, chronic kidney disease (CKD), are automatically at very high or high total cardiovascular risk. No risk estimation models are needed for them. They all need active management of all risk factors.Establishing at least 50% reduction of LDL Cholesterol is the target of treatment. No target cholesterol levels are to be aimed at. Many clinicians continued to estimate lipids periodically and checked whether the LDL Cholesterol has come down below 100mg/dl or 70 mg/dl as the case demands.
Mercola.com in their internet sites and through social media continued to spread the rumour that 2015 new guidelines may lift the limits on dietary cholesterol. These guidelines were published promptly by the departments of Agriculture, Health and Human Services. It stated that the diet should contain less than 10% each from added sugars and saturated fats and also limited the sodium intake to less than 2.3 Gms per day. It stated that:-
Healthy intake: Healthy eating patterns include fat-free and low-fat (1%) dairy, including milk, yogurt, cheese, or fortified soy beverages (commonly known as “soymilk”). Soy beverages fortified with calcium, vitamin A, and vitamin D, are included as part of the dairy group because they are similar to milk based on nutrient composition and in their use in meals.Other products sold as “milks” but made from plants (e.g., almond, rice, coconut, and hemp “milks”) may contain calcium and be consumed as a source of calcium, but they are not included as part of the dairy group because their overall nutritional content is not similar to dairy milk and fortified soy beverages (soymilk).The recommendation for the meats, poultry, and eggs subgroup in the Healthy U.S.-Style Eating Pattern at the 2,000-calorie level is 26 ounce-equivalents per week. This is the same as the amount that was in the primary USDA Food Patterns of the 2010 Dietary Guidelines.
Average intake of meats, poultry, and eggs for teen boys and adult men are above recommendations in the Healthy U.S.-Style Eating Pattern. For those who eat animal products, the recommendation for the protein foods subgroup of meats, poultry, and eggs can be met by consuming a variety of lean meats, lean poultry, and eggs. Choices within these eating patterns may include processed meats and processed poultry as long as the resulting eating pattern is within limits for sodium, calories from saturated fats and added sugars, and total calories.Harvard UniversitySchool of public health added to these by advising:
“While eggs may not be the optimal breakfast choice, they are certainly not the worst, falling somewhere in the middle on the spectrum food choice and heart disease risk. For those looking to eat a healthy diet, keeping intake of eggs moderate to low will be best for most, emphasizing plant-based protein options when possible”.
The intake of saturated fats should be limited to less than 10 percent of calories per day by replacing them with unsaturated fats and while keeping total dietary fats within the age-appropriate recommendations. The human body uses some saturated fats for physiological and structural functions, but it makes more than enough to meet those needs. Individuals 2 years and older therefore have no dietary requirement for saturated fats. Strong and consistent evidence shows that replacing saturated fats with unsaturated fats, especially polyunsaturated fats, is associated with reduced blood levels of total cholesterol and of low-density lipoprotein-cholesterol (LDL-cholesterol) levels.
Additionally, strong and consistent evidence shows that replacing saturated fats with polyunsaturated fats is associated with a reduced risk of CVD events (heart attacks) and CVD-related deaths.Some evidence has shown that replacing saturated fats with plant sources of monounsaturated fats, such as olive oil and nuts, may be associated with a reduced risk of CVD. However, the evidence base for monounsaturated fats is not as strong as the evidence base for replacement with polyunsaturated fats. Evidence has also shown that replacing saturated fats with carbohydrates reduces blood levels of total and LDL-cholesterol, but increases blood levels of triglycerides and reduces high-density lipoprotein-cholesterol (HDL-cholesterol). Replacing total fat or saturated fats with carbohydrates is not associated with reduced risk of CVD. Additional research is needed to determine whether this relationship is consistent across categories of carbohydrates (e.g., whole versus refined grains; intrinsic versus added sugars), as they may have different associations with various health outcomes. Therefore, saturated fats in the diet should be replaced with polyunsaturated and monounsaturated fats.The fat in some tropical plants, such as coconut oil, palm kernel oil, and palm oil, are not included in the oils category because they do not resemble other oils in their composition. Specifically, they contain a higher percentage of saturated fats than other oils.
I personally like the advice of American Heart association. Nutrition labels on food are helpful for choosing heart-healthy foods, but you must know what to look for. Many “low-cholesterol” foods have high levels of saturated fat and/or trans-fat — and both raise blood cholesterol. Even “low-fat” foods may have a surprisingly high fat content. Look for how much saturated fat, trans-fat, and total calories are in a serving. Also check the serving size; it may be smaller than you expect. Ingredients are listed in descending order of use, so choose products where fats and oils appear near the end of the ingredients list.
Healthy eating patterns limit added sugars to less than 10 percent of calories per day. This recommendation is a target to help the public achieve a healthy eating pattern, which means meeting nutrient and food group needs through nutrient-dense food and beverage choices and staying within calorie limits. When added sugars in foods and beverages exceed 10 percent of calories, a healthy eating pattern may be difficult to achieve. This target also is informed by national data on intakes of calories from added sugars, which accounts on average for almost 270 calories, or more than 13 percent of calories per day in the U.S. population.
What we should be eating?
We should continue to avoid all fried foods and stick on to grilled or steamed food stuff. Cooking oil has to be mostly polyunsaturated vegetable oils and maximum of 3 to 4 teaspoonful per person per day. Less is always better. Better to avoid butter, ghee, vanaspathi, coconut and palm oil, as well as coconut milk and coconuts in the diet. Hydrogenated oils are harmful to us and should be avoided. Plenty of green vegetables and fruits should be encouraged. Indians should encourage people to take papaya, watermelon, apple, pear, guava and avoid sugar rich grapes, mangoes and dates. Milk should be reduced to about 3 ounces per day and people should realize that man is the only animal which takes milk after infancy. Starchy food should be reduced to form only 30% of diet and sugary drinks should not be used. It is better to avoid all tubers as they supply only carbohydrates. People should be encouraged to eat more fish and skinned chicken and beef, mutton and pork to be reserved for special occasions only. We have to educate the public that weight gain is often not from breakfast, lunch or dinner, but from what you eat in between. Munching and snacking should be stopped if you want to control your weight. This kind of practical guidelines have to be popularized among the community to spread the message of cardiovascular disease prevention.
In 2016, The American College of Cardiology and The American Heart Association as well as the European Society of Cardiology published their guidelines which reiterated the statements in 2015 guidelines for the Americas and the rest of the world followed these guidelines. The carry home message for the medical community as well as the public is that “Essentially the cholesterol guidelines have not significantly changed since the ATP III (Adult Treatment Panel III) guidelines were published by the National Cholesterol Education Programme (NCEP) in 2002”. In 2017, the guidelines of the American College of Cardiology, the American Heart Association and the European Society of Cardiology have reiterated the same. These are the guidelines followed by the entire world for planning prevention of cardiovascular diseases in the community. For our survival; let us stick on to this scientific ‘evidence based medicine’ for serum lipid control as it has proven to reduce cardiovascular diseases.