Heart Disease (CHD) is responsible for one in every six deaths in the United
States as well as being the leading cause of death throughout the developed
world. Healthcare professionals have for many years sought to limit and control
CHD by focusing on prevention and, from a dietary perspective, on limiting
In an article published
in the journal Progress in Cardiovascular Diseases, Saint Luke’s Mid America
Heart Institute cardiovascular research scientist and James J.. DiNicolantonio,
PharmD, and James H. O’Keefe, MD, examined the question of whether that focus
may be misplaced and ask does sugar have a greater impact on coronary heart
disease than saturated fat?
The theory of dietary
saturated fats as the principal promoter of elevated serum cholesterol and
heart disease stems from research beginning in the 1950’s by an American
scientist Ancel Keys. It was this theory which was embraced by the American
Heart Association and the US federal government in the 1960s and 70s. However,
at the same time of Keys research, a British physiologist John Yudkin argued
that sugar intake was more closely related to incidence of and mortality from
Both Yudkin and Keys were
able to support their theories through observational studies in large part
because people eat foods, not isolated food constituents. Dietary sources of
saturated fat are also often dietary sources of sugar and people who eat lots
of sugar often also eat lots of saturated fat.
Along with co-author,
Sean C. Lucan, MD, MPH, MS, from the Albert Einstein College of Medicine,
DiNicolantonio and O’Keefe evaluated the evidence to date linking saturated
fats and sugars to CHD, considering basic science, epidemiology, and clinical
trial data related to CHD risk, CHD events, and CHD mortality. The authors
concluded that sugar consumption, particularly in the form of refined added
sugars, are a greater contributor to CHD than saturated fats.
“While the original
studies upon which the longstanding guidelines were based were largely
observational,” said DiNicolantonio, “We now have more than a half
century of data as well as increased understanding of how nutrition impacts the
body and specifically coronary heart disease.”
The metabolic aspects of
saturated fatty acids (SFAs) are complex but existing research suggests that
certain SFAs may actually confer measurable benefits for lipid profiles and CHD
risk. For instance, some SFAs increase high-density lipoprotein cholesterol
(HDL), which is often referred to as the “good cholesterol” as this
lipoprotein is associated with a reduced risk of CHD
Replacing saturated fats,
or any other component, from one’s diet almost inevitably means replacing it
with something else. When carbohydrates, particularly refined carbohydrates
like sugar, replace saturated fats, which can have a negative impact on lipid
profiles (HDL tends to fall and triglycerides tend to rise).
As stated earlier, people
don’t eat isolated fatty acids — they eat foods that are a mix of various
fatty acids and other food constituents. While high intakes from processed
meats may increase risk of CHD, higher intakes from dairy sources of saturated
fat may not only pose no risk but actually decrease risk.
Consuming a diet high in
sugar for just a few weeks has been shown to cause numerous abnormalities found
in patients with CHD, such as high total cholesterol, triglycerides, LDL,
oxidized LDL, uric acid, insulin resistance and abnormal glucose tolerance, low
HDL, and altered platelet function. The overall effect of consuming a diet high
in sugar on these numerous health markers is likely more detrimental to overall
health compared to increased consumption of saturated fat, which can increase
LDL but at the same time raise HDL.
Added fructose —
generally in the form of sucrose (table sugar) or high fructose corn syrup
(HFCS) in processed foods and beverages seems especially potent for producing
harm. Consuming these sugars can lead to resistance in leptin, which is a key
hormone in the maintenance of normal body weight. The overconsumption of added
fructose undoubtedly increases the risk for obesity, which is also a risk
factor for CHD.
Excess fructose also
markedly increases the risk for non-alcoholic fatty liver disease (NAFLD) —
the most common liver disease in the US and a strong independent risk factor
for CHD. The association between NAFLD and CHD is stronger than the link
between CHD and smoking, hypertension, diabetes, male gender, high cholesterol
or metabolic syndrome.
naturally in fruits and vegetables pose no increased risk for CHD. The problem
is refined sugars — with ultraprocessed foods being of greatest concern.
Products with added sugars represent 75% of all packaged foods and beverages in
the US and most commonly contain sucrose or HFCS, which seem to raise CHD risk
even more than other sugars such as glucose.
A diet high in sugar has
also been found to promote prediabetes and diabetes. And patients with both of
these conditions have a much greater risk for CHD compared to normal healthy
patients, particularly a severe narrowing of the left main coronary artery.
also tend to be sources of saturated fats but the harms associated with eating
these products may have nothing to do with the fat and everything to do with
processed foods themselves. Therefore, best advice is to avoid processed foods
rather than to simply avoid SFAs as avoiding SFAs might direct people away from
foods that are not only completely benign but actually beneficial (such as
dairy foods) but also steer people towards foods that may be harmful — i.e.
low-fat, ultra-processed, with huge amounts of hidden added sugars.
“After a thorough
analysis of the evidence it seems appropriate to recommend dietary guidelines
shift focus away from recommendations to reduce saturated fat and towards
recommendations to avoid added sugars,” said Dr DiNicolantonio. “Most
importantly recommendations should support the eating of whole foods whenever
possible and the avoidance of ultra-processed food.”
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