This document discusses the ambiguity surrounding dietary guidelines and scientific evidence regarding fat and saturated fat recommendations. It outlines the history of recommendations since the 1950s, when Ancel Keys first observed differences in heart disease and diets between workers and the wealthy in Naples, Italy. The document questions the strength of evidence supporting limits on saturated fat intake, citing several studies that found no significant association between saturated fat consumption and cardiovascular or heart disease risk. It suggests the available evidence is unsatisfactory and unreliable for making judgements about dietary fat and disease risk.

1. The Limits of S cientific
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Evidence and the Ethics of
Dietary Guidelines
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S ixty years of Ambiguity
Peter Attia, M.D.
Printed 7/3/2008 12:12:08 PM
Pres ident, Nutrition S cience Initiative
June 20, 2012
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Printed 7/3/2008 12:12:08 PM
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Source: Source 2

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Premature death
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Insulin resistance Cancer
Type 2 diabetes Asthma
Fatty liver disease Sleep apnea
Atherosclerosis Obesity Osteoarthritis
Hypertension Neurodegeneration
Printed 7/3/2008 12:12:08 PM
Stroke Gall bladder disease
Metabolic diseases
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4. U.S. obesity rates
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Printed 7/3/2008 12:12:08 PM
1 5%
1 971 201 0
31 milion peopl
l
*
Source: e Footnote
Source 1 1 1 milion peopl
l e

5. U.S. diabetes rates
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8%
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Printed 7/3/2008 12:12:08 PM
2%
1 970 201 0
4.2 milion peopl
l e 21 .1 milion peopl
l e
* Footnote
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6. 46
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UnitU.S. consumption of food not used
of measure, 1 6 point plain, delete if since U.S. obesity rates since 1 960, by
1 970 age
P ercent P ercent
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Printed 7/3/2008 12:12:08 PM
For men aged 20-74, from National Health and
Nutrition Examination Surveys (NHANES)
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7. 900
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800 81 8%
700
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Healthcare spending
600
500 5x
difference
400
Printed 7/3/2008 12:12:08 PM
300
200 Economic growth
1 68%
100
0
1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010
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Fat and Saturated Fat?
Recommendations
Printed 7/3/2008 12:12:08 PM
* Footnote
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“Intakes of dietary fatty acids and cholesterol are maj or
determinants of cardiovascular disease (CV and Type-2
D)
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diabetes (T2D), two maj causes of morbidity and mortality in
or
A mericans… In order to reduce the population’s burden from CV D
and T2D and their risk factors, the preponderance of the
evidence indicates beneficial health effects are associated with
Printed 7/3/2008 12:12:08 PM
several changes in consumption of dietary fats and cholesterol.
These include limiting saturated fatty acid intake to less than 7
percent of total calories… ”
D iet G uid el
ary ines Ad visory C ommit ee, 201 0
t
* Footnote
Source: Source

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Fat and Saturated Fat?
The Evidence
Printed 7/3/2008 12:12:08 PM
* Footnote
Source: Source

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“The available evidence from cohort and randomized controlled
trials is unsatisfactory and unreliable to make judgment about
and substantiate the effects of dietary fat on risk of CHD.”
Printed 7/3/2008 12:12:08 PM
FAO / O Expert C onsul at background paper, 2009
WH t ion
* Footnote
Source: Source
Skeaff, Miller, 2009. Annals of Nutrition and Metabolism. Sept. 1 5: 1 73-201 .

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“A meta-analysis of prospective epidemiologic studies showed
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that there is no significant evidence for concluding that
dietary saturated fat is associated with an increased risk of
CHD or CV D.”
Printed 7/3/2008 12:12:08 PM
Siri-Tarino et al. American Journal of C l
inical Nut ion, 201 0
rit
* Footnote
Siri-tarino et Source 0. AJC N. Mar; 502-509.
Source: al. 201

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A History Lesson
1 951 -1 961
Printed 7/3/2008 12:12:08 PM
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1 951
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Ancel Keys and his wife Margaret visit Naples, Italy.
They assess the cholesterol and fat content of the
diet among workers (no heart disease) and the
Printed 7/3/2008 12:12:08 PM
wealthy (heart disease). Margaret Keys measures
cholesterol levels.
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1 952
Keys presents his hypothesis at a WHO meeting in
Amsterdam: “fatty diet, raised serum cholesterol,
Printed 7/3/2008 12:12:08 PM
atherosclerosis, myocardial infarction.”
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1 961
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The American Heart Association
A 4-page A report from an ad-hoc committee that now
HA
includes Keys concludes that “the best scientific evidence
Printed 7/3/2008 12:12:08 PM
of the time” strongly suggests that A mericans would reduce
their risk of heart disease by reducing the fat in their diets,
and replacing saturated fats with polyunsaturated fats.
* Footnote
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1 961
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The Press
Keys tells Time that the ideal
Printed 7/3/2008 12:12:08 PM
heart-healthy diet should be
almost 70% carbohydrate and only
1 5% fat.
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The competing philosophies
Printed 7/3/2008 12:12:08 PM
Proponents
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“ We don’t have the luxury of
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time to find the truth before
making policy…”
Printed 7/3/2008 12:12:08 PM
--The McGovern Report
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The competing philosophies
Printed 7/3/2008 12:12:08 PM
Opponents/
skeptics
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Without definitive evidence, we
don’t know if we’re right.
Printed 7/3/2008 12:12:08 PM
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Selection bias
1 957-1 970
Each new research adds detail, reduces areas of
Printed 7/3/2008 12:12:08 PM
uncertainty, and, so far, provides further reason to believe.
Ancel Keys, 1 957
* Footnote
Source:
A . ug.
Source
Keys, 1 957. J MA A 24:1 91 2-1 91 9

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Framingham Heart Study
Positive data: Framingham “links” cholesterol to heart
disease.
Printed 7/3/2008 12:12:08 PM
Negative data: In women over 50 “cholesterol had no
predictive value.”
* Footnote
Kannel etSource: Source Med. J
al. Ann Int an;74(1 ):1 -1 2.

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Framingham Heart Study
[Unpublished] negative data: Framingham compares the diets of
men with cholesterol over 300 to those of men with cholesterol
under 1 70 and finds no associat with the amount or type
ion
Printed 7/3/2008 12:12:08 PM
of fat consumed.
Kannel, W.B., and T. Gordon. 1 968. The Framingham D iet S tudy: D iet and Regul ion of S erum C hol erol Section 24 of The Framingham
at est .
Study. An Epidemiol
* Footnote ogical Investigat of C ardiovascul D isease. Bethesda, MD: U.S. Department of Health, Education, and Welfare, Public
ion ar
Health Service, and National Institutes of Health.
Source: Source

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Framingham Heart Study
“There is considerable range of serum cholesterol within the
Framingham Study Group. Something explains this inter-individual
Printed 7/3/2008 12:12:08 PM
variation, but it is not diet (as measured here).”
Kannel, W.B., and T. Gordon. 1 968. The Framingham D iet S tudy: D iet and Regul ion of S erum C hol erol Section 24 of The Framingham
at est .
Study. An Epidemiol
* Footnote ogical Invest ion of C ardiovascul D isease. Bethesda, MD: U.S. Department of Health, Education, and Welfare, Public
igat ar
Health Service, and National Institutes of Health.
Source: Source

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More negative evidence
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Studies of Benedictine and Trappist monks, Navaj Indians,
o
Irish immigrants to Boston, Swiss A lpine farmers and Maasai
and other A frican pastoralists report no association of
saturated fat to heart disease.
Printed 7/3/2008 12:12:08 PM
Keys rejects them as having “no relevance to diet-cholesterol-
CHD relationships in other populations.”
Groen et *al. 1 962. AJC N. Jun:456-70., Page et al. 1 956. C ircul ion. May: 675-9. , Trulson et al. 1 964. JAD A. 225-9. , Mann et al. 1 964. J
Footnote
at
AtherosclSource: Source J ug: 289-31 2, Keys. 1 975. At
erosis Res. ul-A heroscl erosis, Sep-Oct;22(2):1 49-92.

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Selection bias
Revisit
Printed 7/3/2008 12:12:08 PM
* Footnote
Source: Source

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1 957
Oglesby Paul and colleagues study 5,400 male employees
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of the Western Electric Company.
They compare the 1 5 percent of men who reported eating
the fattest diets to the 1 5 percent who reported eating the
Printed 7/3/2008 12:12:08 PM
leanest.
“Worthy of comment, is the fact that of the 88 coronary
cases, 1 4 have appeared in the high-fat intake group and
1 6 in the low-fat group.”
* Footnote
Source: Source

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1 981
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Shekelle, Stamler et al. return to Western Electric
They compare heart disease morbidity and mortality to the
fat content of the diet in 1 957.
Printed 7/3/2008 12:12:08 PM
“The amount of saturated fatty acids in the diet was not
significantly associated with the risk of death from CHD.”
* Footnote
Source: Source

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1 981
Shekelle, Stamler et al. rationalize:
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“Although most attempts to document the relation of
dietary cholesterol, saturated fatty acids, and
polyunsaturated fatty acids to serum cholesterol
Printed 7/3/2008 12:12:08 PM
concentration in persons who are eating freely have been
unsuccessful, positive results have been obtained in [four]
investigations besides the Western Electric Study.”
* Footnote
Source: Source

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1 981
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Shekelle, Stamler et al. rationalize further:
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“If viewed in isolation, the conclusions that can be drawn
from a single epidemiologic study are limited. Within the
context of the total literature, however, the present
Printed 7/3/2008 12:12:08 PM
observations support the conclusion that the [fat]
composition of the diet affects the level of serum
cholesterol and the long-term risk of death from CHD in
middle-aged A merican men.”
* Footnote
Source: Source

32. Subtitle, 1 6 pt bold, delete if not used 1 981
Unit of measure, 1 6 point plain, delete if not used
Enter the media...
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Washingt P ost
on
“The new report strongly reinforces the view that a high-
fat, high-cholesterol diet can clog arteries and cause heart
disease.”
Printed 7/3/2008 12:12:08 PM
Shekelle in the New York Times
“The message of these findings is that it is prudent to
decrease the amount of saturated fats and cholesterol in
your diet.”
* Footnote
Source: Source

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The denouement...
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The A and NHLBI co-author a report called
HA
“The Cholesterol Facts.”
Printed 7/3/2008 12:12:08 PM
The Western Electric study is included as one of seven
“epidemiologic studies showing the link between diet and
CHD [that] have produced particularly impressive results”
and “showing a correlation between saturated fatty acids
and CHD” -- precisely what it did not do.
* Footnote
Source: Source

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State of the Evidence
The 1 970s
Printed 7/3/2008 12:12:08 PM
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1 970
A A
n merican Heart A ssociation committee recommends low-
saturated-fat diets (less than 1 0% of calories) for every
American, including “infants, children, adolescents, lactating
Printed 7/3/2008 12:12:08 PM
and pregnant women, and older persons.”
Inter-Society Commission for Heart Disease Resources. 1 970. C ircul ion. J 55-95.
at
* Footnote
Source: Source uly;A

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1 975
“Two strikingly polar attitudes persist on this subj with much
ect,
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talk from each and little listening between.”
--Henry Blackburn, New E ngl and Journal of Medicine
1 978
Printed 7/3/2008 12:12:08 PM
“It must still be admitted that the diet-heart relation is an
unproved hypothesis that needs much more investigation.”
--Thomas Dawber, New E ngl and Journal of Medicine
* Footnote
Source: NEJM. J 9; 1 05-7., Dawber, 1 978. NEJM. A 31 ; 452-8.
Blackburn, 1 975.Source an ug

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Clinical Trials
P re-1 977
Printed 7/3/2008 12:12:08 PM
* Footnote
Source: Source

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Low-fat diets?
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1 963
Hungarian researchers report a benefit of consuming a
maximum of 1 .5 ounce of fat per day.
1 965
Printed 7/3/2008 12:12:08 PM
British researchers report no benefit of consuming a
maximum of 1 .5 ounces of fat per day: “A low-fat diet has
no place in the treatment of myocardial infarction.”
* Footnote
Korányi,Source: Ther H ung. 1 1 :1 7, Research Committee, 1 965. Lancet Sep 1 1 ; 501 -4.
1 963. Source .

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Cholesterol-lowering diets?
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1 973*
Minnesota Coronary Study
9,000 men and women:
269 deaths in intervention [low SF, cholesterol] group.
Printed 7/3/2008 12:12:08 PM
206 deaths in control group.
* Results go unpublished for 1 6 years. Why?
“We were disappointed in the way they turned out.” (Frantz)
* Footnote
Frantz et al, 1 989. A
Source: Source rteriosclerosis. J
an-Feb; 1 29-35.

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The Tipping Point
January,1 977
Printed 7/3/2008 12:12:08 PM
* Footnote
Source: Source

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Recommendation #I
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Increase carbohydrate consumption
to 55 to 60% of calories
Recommendation #2
Reduce fat consumption to 30%
Printed 7/3/2008 12:12:08 PM
of calories
* Footnote
Source: Source

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he Fallback Position?
he Precautionary Principle
Printed 7/3/2008 12:12:08 PM
The question to be asked is not why should we
hange our diet but why not? There are [no risks]
hat can be identified and important benefits can
be *
Source:
Footnote
Source

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Cohort Studies
1 977-1 984
Printed 7/3/2008 12:12:08 PM
* Footnote
Source: Source

44. Total cholesterol does not predict
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future heart disease
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High LDL is a “marginal risk factor”
Low HDL is a 4-fold better predictor of risk than LDL and
the only reliable predictor of risk for men or women
over 50.
Printed 7/3/2008 12:12:08 PM
Caveats:
Saturated fat raises HDL.
Carbohydrates lower HDL.
* Footnote
Castelli Source:
et al, 1 977. C ircul ion.
Source at May; 767-72., Gordon et al, 1 977. Am J Med. May;707-1 4.

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1 981
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Honolulu, Framingham and Puerto Rico
Saturated fat and total fat negatively associated with risk
of heart attack
Printed 7/3/2008 12:12:08 PM
Saturated fat and total fat positively associated with
longevity
Gordon et Footnote . C ircul ion. Mar;500-1 5. Feinleib, 1 981 . Am J Epi. J
* al, 1 981 at ul;5-1 0.
Source: 983. C ancer Res. May; 2503s-2507s.
Feinleib,1 Source

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1 981 -3
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Low serum cholesterol (< 1 60 mg/ associated with a
dl)
higher risk of cancer.
Observed in every cohort study with 3 exceptions (all
Printed 7/3/2008 12:12:08 PM
Chicago cohorts studied by Jeremiah Stamler)
Gordon et Footnote . C ircul ion. Mar;500-1 5. Feinleib, 1 981 . Am J Epi. J
* al, 1 981 at ul;5-1 0.
Source: 983. C ancer Res. May; 2503s-2507s.
Feinleib,1 Source

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Authors concluded:
Things that raise HDL should be considered
Printed 7/3/2008 12:12:08 PM
to reduce the risk of CVD
* Footnote
Source: Source

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Why ignore HDL and
triglycerides for 20 years?
Printed 7/3/2008 12:12:08 PM
* Footnote
Source: Source

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1 982
The Multiple Risk Factor Intervention Trial (MRFIT)
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Cost: $1 1 5,000,000
7 year mortality:
41 .2/ ,000 (intervention) vs. 40.4/ ,000 (controls)
1 1
Printed 7/3/2008 12:12:08 PM
Wal S t
l reet Journal
“Heart attacks, a test collapses.”
* Footnote
Source: JAMA.
MRFIT, 1 982. Source Sep 24;1 465-77.

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J
anuary, 1 984
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The Lipid Research Clinics Primary Prevention Trial
Cost: $1 50,000,000
1 0 year mortality
35.8/ ,000 (intervention) vs. 37.3/ ,000 (controls)
1 1
Printed 7/3/2008 12:12:08 PM
Time Magazine
“Sorry, it’s true. Cholesterol really is a killer.”
* Footnote
LRC Source: Source
Program , 1 984. JAMA. J 20; 351 -64, 365-74.
an

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The authors conclude
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“Caution should be exercised before extrapolating the LRCPPT
findings to cholesterol lowering drugs other than bile acid
sequestrants.”
Printed 7/3/2008 12:12:08 PM
“The LRCPPT was not designed to assess directly whether
cholesterol lower by diet prevents CHD.”
* Footnote
LRC Source: Source
Program , 1 984. JAMA. J 20; 351 -64, 365-74.
an

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“It is now indisputable that lowering cholesterol with
diet and drugs can actually cut the risk of developing
heart disease and having a heart attack.”
--Basil Rifkind, NIH director of the LRCPPT, in Time
Printed 7/3/2008 12:12:08 PM
* Footnote
LRC Program Source JAMA. J 20; 351 -64, 365-74.
Source: , 1 984. an

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The Tipping
Point Tips
1 984
Printed 7/3/2008 12:12:08 PM
* Footnote
Source: Source

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The LRC results “strongly indicate that the more you
lower cholesterol and fat in your diet, the more you
reduce your risk of heart disease.”
--Basil Rifkind, NIH director of the LRCPPT, in Time
Printed 7/3/2008 12:12:08 PM
* Footnote
LRC Program Source JAMA. J 20; 351 -64, 365-74.
Source: , 1 984. an

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Why’d they exaggerate?
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“It’s an imperfect world. The data that would be
definitive is ungettable, so you do your best with
what is available.”
Printed 7/3/2008 12:12:08 PM
--Basil Rifkind, 2002
* Footnote
LRC Program, 1 984. JAMA. J 20; 351 -64, 365-74.
Source: Source
an

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Consensus Building
1 987 -1 989
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In sciences t are based on supposit
hat ion
Printed 7/3/2008 12:12:08 PM
and opinion, t obj is t command
he ect o
assent not mast t t
, er he hing it f.
sel
--Francis Bacon, Novum O rganum, 1 620
* Footnote
Source: Source

57. Subtitle, 1 6 pt bold, delete if not used
Unit of measure, 1 6 point plain, delete if not used
December, 1 984
Working Draft - Last Modified 1/29/2010 2:11:49 PM
The NIH consensus conference
Conclusion
There is “no doubt” that a low-fat diet “will afford significant
Printed 7/3/2008 12:12:08 PM
protection against coronary heart disease” to every A merican
over the age of two.
* Footnote
Consensus conference, 1 985. JAMA. A 1 2;253(1 4):2080-6.
Source: Source
pr

58. Subtitle, 1 6 pt bold, delete if not used
Unit of measure, 1 6 point plain, delete if not used
December, 1 984
Working Draft - Last Modified 1/29/2010 2:11:49 PM
The NIH consensus conference
Caveat
Printed 7/3/2008 12:12:08 PM
If there had been a true consensus, says Dan Steinberg
(chair of the consensus panel, co-PI of LRCPPT), “you wouldn’t
have had to have a consensus conference.”
* Footnote
Consensus conference, 1 985. JAMA. A 1 2;253(1 4):2080-6.
Source: Source
pr

59. Subtitle, 1 6 pt bold, delete if not used
1 989
Unit of measure, 1 6 point plain, delete if not used
National Academy of Sciences D iet and
H eal h: Impl ions for Red ucing
t icat
Working Draft - Last Modified 1/29/2010 2:11:49 PM
C hronic D isease Risk
(1 ,300 pages)
Printed 7/3/2008 12:12:08 PM
“Highest priority is given to reducing fat intake, because the
scientific evidence concerning dietary fats and other lipids and
human health is strongest and the likely impact on public
health the greatest.”
* Footnote
Source: Source
USDHHS 1 988.

60. Subtitle, 1 6 pt bold, delete if not used
Unit of measure, 1 6 point plain, delete if not used
Working Draft - Last Modified 1/29/2010 2:11:49 PM
Evidence, post-consensus
1 990 - t ay
od
Printed 7/3/2008 12:12:08 PM
* Footnote
Source: Source

61. Subtitle, 1 6 pt bold, delete if not used
Unit of measure, 1 6 point plain, delete if not used
Lifestyle Heart Trial (1 990)
28 patients in treatment arm,
Working Draft - Last Modified 1/29/2010 2:11:49 PM
20 patients received no intervention
1 year intervention
Treatment: smoking cessation, low-fat (1 0% max) vegetarian diet,
Printed 7/3/2008 12:12:08 PM
no flour, no sugar, stress management, vigorous exercise
Treatment group showed a significant reduction in
angiographically documented coronary atherosclerosis
* Footnote
Source: 1 990. Lancet 336:1 29-1 33
Ornish et al, Source

62. Subtitle, 1 6 pt bold, delete if not used
Unit of measure, 1 6 point plain, delete if not used
Meta-Analyses (2001 )
Cochrane Collaboration: “Reduced or Modified dietary fat for
Working Draft - Last Modified 1/29/2010 2:11:49 PM
preventing cardiovascular disease”
27 well-controlled randomized trials1 0,000 subj
ects followed for
an average of three years each.
Printed 7/3/2008 12:12:08 PM
No effect on longevity.
No “significant effect on cardiovascular events.”
* Footnote
Source:al,Source .
Hooper et 2001 C ochrane D atabase S yst Rev. (3):CD0021 37

63. Subtitle, 1 6 pt bold, delete if not used
Unit of measure, 1 6 point plain, delete if not used
Meta-Analyses (2006)
Cochrane Collaboration: “Multiple risk factor interventions for
Working Draft - Last Modified 1/29/2010 2:11:49 PM
primary prevention for coronary heart disease”
Multiple interventions include lowering blood pressure and
cholesterol1 0 well-controlled trials
900,000 patient years of observation
Printed 7/3/2008 12:12:08 PM
“The pooled effects suggest multiple risk factor intervention has
no effect on mortality.”
* Footnote
Ebrahim et al.Source Cochrane Database Syst Rev. Oct 18;CD001561.
Source: 2006.

64. Subtitle, 1 6 pt bold, delete if not used
Unit of measure, 1 6 point plain, delete if not used
Women’s Health Initiative (2006)
Working Draft - Last Modified 1/29/2010 2:11:49 PM
48,835 post-menopausal women randomized to a low-fat
diet or a control diet
A six years, total fat consumption was reduced by
fter
Printed 7/3/2008 12:12:08 PM
8.2% ; saturated fat was reduced by 2.9% .
“Modest” increases in fruits, vegetables and whole grains
* Footnote
Source: Source

65. Subtitle, 1 6 pt bold, delete if not used
Unit of measure, 1 6 point plain, delete if not used
Women’s Health Initiative (2006)
“The intervention did not reduce risk of CHD or stroke.”
Working Draft - Last Modified 1/29/2010 2:11:49 PM
“A low-fat dietary pattern did not result in a statistically
significant reduction in the risk of invasive breast cancer...”
“There is no evidence that a low-fat dietary pattern intervention
reduces colorectal cancer risk...”
Printed 7/3/2008 12:12:08 PM
“A low-fat dietary pattern among generally healthy
postmenopausal women showed no evidence of reducing
diabetes risk...”
Howard et al. 2006. JAMA. Feb 8:655-666. Prentice et al. 2006. JAMA. Feb 8:629-642.
* Footnote
Beresford Source: 2006. JAMA. Feb 8:643-654. Tinker et al. 2008. Arch Int Med. J 28:1 500-1 51 1 .
et al. Source ul

66. Subtitle, 1 6 pt bold, delete if not used
Diet trials (2003)
Unit of measure, 1 6 point plain, delete if not used
Low-carbohydrate/
high-fat vs. low-calorie, low-fat
Working Draft - Last Modified 1/29/2010 2:11:49 PM
Conventional LOW-FA HIGH-CA diet
T, RB
instruction
Women: 1 200-1 500 calories/ d
Men: 1 500-1 800 calories/
d
63 obese 60 % carbs, 25 % fat, 1 5 % protein
men and R
Printed 7/3/2008 12:12:08 PM
women
HIGH-FA LOW-CA diet instruction
T, RB
First two weeks < 20 g carbs/ d
Then gradually increase until stable weight
* Footnote
Source: 2003. NEJM.
Foster et al. Source May 22;2082-90

67. Subtitle, 1 6 pt bold, delete if not used
Unit of measure, 1 6 point plain, delete if not used
TGs TC
Working Draft - Last Modified 1/29/2010 2:11:49 PM
Diet trials (2003)
Foster et al
Printed 7/3/2008 12:12:08 PM
LDL HDL
Low carb/
conventional low fat
* Footnote
Source: 2003. NEJM.
Foster et al. Source May 22;2082-90

68. Subtitle, 1 6 pt bold, delete if not used
Diet trials (2007)
Unit of measure, 1 6 point plain, delete if not used A TO Z Trial
2 MONTHS
Group n kcal/
d CHO PRO FAT Weight LDL Trig HDL DBP
Working Draft - Last Modified 1/29/2010 2:11:49 PM
Atkins 77 1 381 ~
62g 97 84 -4.3 kg +2.3 -52.3 -0.4 -2.9
Zone 79 1 455 1 52 87 57 -2.0 kg -5.3 -24.8 -0.5 -2.1
LEARN 79 1 476 1 80 73 49 -2.8 kg -7.3 -1 7.2 -3.8 -1 .4
Ornish 76 1 408 220 60 33 -2.8 kg -1 0.1 -1 0.9 -5.3 -0.4
Printed 7/3/2008 12:12:08 PM
1 2 MONTHS
Group n kcal/
d CHO PRO FAT Weight LDL Trig HDL DBP
Atkins 77 1 599 ~
1 40g 84 78 -4.5 kg +0.8 -29.3 +4.9 -4.4
Zone 79 1 594 1 79 80 62 -1 .5 kg 0 -4.2 +2.2 -2.1
LEARN 79 1 654 1 94 79 61 -2.5 kg +0.6 -1 4.6 -2.8 -2.2
Ornish 76 1 505 1 95 68 50 -2.4 kg -3.8 -1 4.9 0 -0.7
* Footnote
Gardner et al. 2007. JAMA. March 7;969-77
Source: Source

69. Subtitle, 1 6 pt bold, delete if not used
Unit of measure, 1 6 point plain, delete if not used
Working Draft - Last Modified 1/29/2010 2:11:49 PM
Diet trials (2008)
Workplace Diet Trial
Printed 7/3/2008 12:12:08 PM
* Footnote
Shai et al. 2008. NEJM. J
Source: Source ul 1 7;229-41

70. Subtitle, 1 6 pt bold, delete if not used
Diet trials (2008)
Unit of measure, 1 6 point plain, delete if not used
Workplace Diet Trial
Test Low Fat Mediterranean Low Carb
Working Draft - Last Modified 1/29/2010 2:11:49 PM
Systolic BP, mm Hg -4.3 -5.5 -3.9
Diastolic BP, mm Hg -0.9 -2.2 -0.8
LDL-C, mg/
dl -0.05 -5.6 -3.0
HDL-C, mg/
dl 6.3 6.4 8.4
Printed 7/3/2008 12:12:08 PM
Triglyceride, mg/
dl -2.8 -21 .8 -23.7
T Chol : HDL ratio -0.6 -0.9 -1 .1
Hemoglobin A c, %
1 -0.4 -0.5 -0.9
C-reactive protein, mg/
l -0.6 -0.9 -1 .3
Red denotes p< 0.05 for within-group change from baseline.
Blue denotes p< 0.05 for comparison of Low Carb vs. Low Fat.
* Footnote
Shai et al. 2008. NEJM. J
Source: Source ul 1 7;229-41

71. Subtitle, 1 6 pt bold, delete if not used
Unit of measure, 1 6 point plain, delete if not used
Working Draft - Last Modified 1/29/2010 2:11:49 PM
Why the confidence?
P re-1 984
Printed 7/3/2008 12:12:08 PM
Populations with very low cholesterol levels have a low
incidence of heart disease
* Footnote
Source: Source

72. Subtitle, 1 6 pt bold, delete if not used
Unit of measure, 1 6 point plain, delete if not used
Working Draft - Last Modified 1/29/2010 2:11:49 PM
Why the confidence?
P ost 984
-1
Printed 7/3/2008 12:12:08 PM
Cholesterol-lowering drugs work
(statins, in particular)
* Footnote
Source: Source

73. Subtitle, 1 6 pt bold, delete if not used
Unit of measure, 1 6 point plain, delete if not used
Caveat
Working Draft - Last Modified 1/29/2010 2:11:49 PM
Drugs and diets are not comparable.
Drugs have multiple actions as do diets.
Printed 7/3/2008 12:12:08 PM
“Saying that statins reduce heart disease risk by lowering
cholesterol, is like saying that aspirin reduces heart disease
risk by reducing headaches.”
--Kronmal
* Footnote
Source: Source

74. President John F. Kennedy
Subtitle, 1 6 pt bold, delete if not used
Unit of measure, 1 6 point plain, delete if not used
Yale University commencement address
June 11, 1962
Working Draft - Last Modified 1/29/2010 2:11:49 PM
“ For the greatest enemy of truth is very often not the lie
Printed 7/3/2008 12:12:08 PM
– deliberate, contrived and dishonest – but the myth –
persistent, persuasive, and unrealistic. Too often we
hold fast to the clichés of our forebears. We subject all
facts to a prefabricated set of interpretations. We enjoy
the comfort of opinion without the discomfort of
thought.”
*
Source:
Footnote
Source