The Time-Lag Diet-Heart Hypothesis - Last Ditch of Opposition to LCHF

In their “Against the Grain” Lancet letter, Jim Mann and co. cited a 2012 Swedish study[1] that correlated a rise in butter and fall in carbohydrate consumption with a later rise in serum cholesterol levels in Sweden, after decades of cholesterol-lowering advice was overturned by a LCHF revolution beginning in 2004.

Recently, the Swedish blog Diet Doctor published this graphic showing the continuing decline in heart disease mortality. The LCHF revolution in 2004 hasn’t exactly slowed the decline. In fact, one could say the decline in MI incidents in men had stalled before 2004, and the decline in MI incidents in women didn’t really start till then.[2]

These data sets raise some questions. Cholesterol is supposed to be raised by meals high in saturated fat; in feeding studies this is an immediate effect, and does not involve any more than a few hours’ time-lag, whereas there seems to be a lag of years in the Swedish correlation.

Does this time lag point to the possibility that MI incidence will rise in future if the rise in cholesterol is maintained?

For the purpose of the question I will ignore for now some obvious problems; it is not obvious from Johansson et al that the people actually eating LCHF are experiencing the rise in cholesterol, nor is it determined that they are not losing weight (the BMI of the Swedish population overall continues to rise). In fact, the study of an entire population, in which only a minority, albeit a large one, is eating an LCHF diet, while the rest are subject to other contemporary trends, can only provide a relatively crude and inaccurate critique of LCHF.

A further problem is created by the use of serum cholesterol as the risk marker, rather than a more reliable measurement such as LDL:HDL or total cholesterol:HDL, or TG:HDL.

Taking the Swedish data as given, and as if it represented a homogenous group (which it does not), what grounds do we have for concern?

In a 1999 paper[3] Law and Wald hypothesised that the “French Paradox” can be explained by the existence of a twenty year (or greater) time lag between high consumption of animal fat, increases in serum cholesterol, and the appearance of increased heart disease.
“For decades up to 1970, France had lower animal fat consumption (about 21% of total energy consumption v 31% in Britain) and serum cholesterol (5.7 v 6.3 mmol/l), and only between 1970 and 1980 did French values increase to those in Britain.”
If this hypothesis, which seemed reasonable in 1999, was correct, heart disease mortality in France would have risen since 1992, the year cited by Law and Wald. 

Life expectancy at birth for a woman in France is 85, for a man 78.5.
Life expectancy at birth for a woman in New Zealand is 83.1, for a man 79.4
Age adjusted CHD mortality is 29.25 per 100,000 in France, 76.51 in New Zealand. Even allowing for the French vagary in coding coronary deaths, which according to Law and Wald accounted for 20% of the difference between French and British CHD mortality, France continues to occupy a very low place in the league tables of cardiac mortality[4], 20 years later. France is not unique among European countries; higher intakes of saturated fat correlate with lower incidence of CHD mortality across the continent, including in countries with higher life expectancy and lower rates of alcohol-related mortality.



More evidence against the time-lag hypothesis can be found in the historical ecological narrative from New Zealand. The following graphic comes from Blakely and Woodward’s recent book The Healthy Country? A History of Life and Death in New Zealand.




1950 was the year that rationing ended in New Zealand and sales of cigarettes, sugar, red meat and butter returned to normal (in the case of sugar and cigarettes, after 11 years of significant restriction). The 1967 peak of IHD mortality exactly correlates with the peak of butter consumption (the main source of saturated fat in the New Zealand diet, mostly in the form of shortening in sweet biscuits and cakes and as a spread on white bread).
If atherosclerosis is normally a long-drawn out process, notwithstanding exceptions to this assumption, why would there be an immediate rise in mortality when intake of sugar, cigarette smoke, and fat (in the context of high refined-carbohydrate foods) climbs?
This is explicable if atherosclerosis itself is not a particularly lethal process, and if atherosclerotic plaques rapidly become unstable under conditions of elevated blood pressure, oxidation, inflammation, hyperinsulinaemia, glycation, drug or chemical toxicity, and so on, so that instability in a plaque precipitates a heart attack.

The time-lag hypothesis of heart disease represents the last-ditch stand of opposition to LCHF. It is the “long term safety” quibble that by its nature is difficult to answer (but really, if you care, there is no shortage of LCHF Mediterranean diets to choose from – LCHF with olive oil is still LCHF).

It was answered in useful fashion recently by the latest paper from Jeff Volek’s team[5], and by the latest Harvard epidemiology paper on linoleic acid[6].

If you only read the abstract of this meta-analysis, you’ll think this was the finding from the Harvard team, which included Frank Hu and Walter Willet.

“A 5% of energy increment in LA intake replacing energy from saturated fat intake was associated with a 9% lower risk of CHD events (RR, 0.91; 95% CI, 0.86-0.96) and a 13% lower risk of CHD deaths (RR, 0.87; 95% CI, 0.82-0.94). These data provide support for current recommendations to replace saturated fat with polyunsaturated fat for primary prevention of CHD.”

Well maybe, but according to the paper itself,

“Substituting 5% energy intake from LA for the same amount of energy from carbohydrates was associated with an 13% lower risk of CHD deaths (RR, 0.87; 95% CI, 0.81-0.94) and an 13% lower risk of CHD deaths when substituting for the same amount of energy from SFAs (RR, 0.87; 95% CI, 0.82-0.94). This systematic review and meta-analysis support a significant inverse association between dietary LA intake, when replacing either carbohydrates or saturated fat, and risk of CHD.”

This is the kind of dishonesty that gives abstracts a bad name, though Farvid did give the carbohydrate connection an airing in her press interviews.

If you eat more fat and less carbohydrate, you’re going to eat more LA (whether this is necessary in the context of a low-carbohydrate diet is another question) as a matter of course. And interestingly, the Swedish increase in fats wasn’t just butter – the sale of oil for cooking has also increased, while margarine for cooking has decreased (seriously, who cooks with margarine? The thought of this makes my toes curl).



This is reminiscent of the Richard Lehman quote “Where people eat more saturated fat, they often eat more unsaturated fat. For all I know this may help to explain why nearly everyone everywhere is enjoying their food more and living longer.”[7]

Edit: I had overlooked the implications of this passage in the Law and Wald paper,

"This slow increase in mortality from ischaemic heart disease after an increase in serum cholesterol concentration contrasts with the much more rapid decrease in mortality from ischaemic heart disease after a reduction in serum cholesterol. The randomised controlled trials of reducing serum cholesterol concentration show that the maximal reduction in mortality from heart disease is largely attained after about two years.67 Slow inception and rapid reversal are not inconsistent, and one should not be used to suggest that the other is incorrect. The relative risk of smoking related diseases also increases slowly after starting smoking but falls soon after stopping smoking"                                      

Their reference 67 states that,

"The randomised Trials, based on 45,000 men and 4000 ischaemic heart disease events show that the full effect of the reduction of risk [lowering cholesterol] is achieved by five years"

If this is true for one risk factor, the relatively unreliable one of total cholesterol*, why would it not be true for other, more reliable risk factors, such as total cholesterol:HDL and  inflammatory markers?

Can the NZ mortality data be explained by the hypothesis that rapid reversal of risk, after slow inception, can itself be rapidly reversed? The parallel is with alcoholic liver disease, which takes years to develop, will be reversed relatively quickly if one stops drinking, but progresses more rapidly if one starts drinking again.

Thus, removal of sugar and cigarette smoke (for example) led to a rapid reversal of a slowly acquired risk (assuming mortality rates were growing before rationing), but when these factors became prevalent again, the risk returned quickly.

* "In the seven countries study, at a cholesterol value of 5.2 mmol/l, the CHD mortality rates were five times higher in northern Europe than in Mediterranean southern Europe." [8]

---

[1] Associations among 25-year trends in diet, cholesterol and BMI from 140,000 observations in men and women in Northern Sweden Johansson et al. Nutrition Journal 2012, 11:40  doi:10.1186/1475-2891-11-40

[2] Heart attacks 1990-2013 - Myocardial infarctions in Sweden 1990-2013 ISBN: 978-91-7555-237-8

[3] Why heart disease mortality is low in France: the time lag explanation. Law, M. and Wald, N. BMJ. May 29, 1999; 318(7196): 1471–1480. PMCID: PMC1115846

[4] http://www.worldlifeexpectancy.com/world-health-review/france-vs-new-zealand

[5] Effects of Step-Wise Increases in Dietary Carbohydrate on Circulating Saturated Fatty Acids and Palmitoleic Acid in Adults with Metabolic Syndrome, Volk B.M. et al. PLoS ONE 9(11): e113605. doi:10.1371/journal.pone.0113605

[6] Dietary Linoleic Acid and Risk of Coronary Heart Disease: A Systematic Review and Meta-Analysis of Prospective Cohort Studies. Farvid, M.S. et al. doi: 10.1161/CIRCULATIONAHA.114.010236

[7] http://blogs.bmj.com/bmj/2014/04/22/richard-lehmans-journal-review-22-april-2014/
[8] Ferrières J. The French paradox: lessons for other countries. Heart 2004;90(1):107-111.

Dr Wilhelm Ebstein (1836-1912); the Father of LCHF, on Gout, 1884

"It is difficult to label Wilhelm Ebstein because he was a clinician, pathologist, chemist, basic scientist, teacher, and writer. It is a mystery that so few know him because he was extremely productive and made many significant medical contributions.

....
Ebstein wrote 237 articles: 72 were about metabolic diseases, 38 dealt with gastrointestinal diseases, 16 were about infectious diseases, 12 were concerned with heart disease, 15 dealt with medical history, and the remainder were about various subjects that interested him.

....
He has been called the “forgotten founder of biochemical genetics” because he believed that obesity, gout, and diabetes mellitus were inheritable cellular metabolic diseases. 

....

His book discussing the use of a low-carbohydrate diet for obesity was popular, and several editions were published."

From J. Willis Hurst, M.D. 2009, Profiles in Cardiology – Portrait of a Contributor: Wilhelm Ebstein (1836-1912).

The history of low-carb diets can be said to begin with John Rollo’s Two Cases of the Diabetes Mellitus book (1779), Brillat Savarin’s Physiology of Taste (1825) and Banting’s Letter on Corpulence (1864). However none of these is really a high fat diet except perhaps Brillat Savarin’s, and all three, though good guesses from heuristic experiments, often self-experiments, do not draw on any great body of scientific research.
Dr Wilhelm Ebstein was a 19th century German physician who made considerable contributions to many branches of medicine, and whose research into the cause and treatment of metabolic diseases – corpulence, obesity and gout, as well as dyspepsia – developed, and supported with clinical and laboratory research, the argument for replacing starch with fat, and for keeping protein (albumen) moderate, in the treatment of these conditions. He does so persuasively and arrives, time after time, at judgments that remain relevant today. His dietary prescriptions are placed in a context of advice about exercise, sleep, and clothing that is also modern and conservative.
Ebstein was highly critical of Banting's diet, as being too low in fat and high in protein for anyone to want to consume long-term. He believed that restriction of fat was unnecessary, as fat in a carbohydrate-restricted diet did not contribute to adiposity and instead, by increasing satiety and supporting overall health, contributed to weight loss.
The Regimen to be Adopted in Cases of Gout, which appeared in 1884, two years after Ebstein’s work on the Treatment of Corpulence, sets out the scientific and clinical case for using a high-fat diet to treat a metabolic disease, gout, as well as the corpulence and dyspepsia associated with it.
I present below a series of excerpts from this work, which is available online.


     "According to Haughton's researches, the daily amount of uric acid secreted by flesh-eaters as contrasted with vegetarians is on an average 4.5 to 1.5. From Eanke's experiments we have, at the same time, the important fact that the nature of the diet has less influence on the elimination of uric acid than it has on that of urea. We must conclude from the experiments of H. Eanke that the secretion of uric acid is increased by the ingestion of food, apart from the nature of that food. Nevertheless, without reference to the fact that exclusive flesh diet increases the uric acid secretion, this diet has so many other inconveniences and dangers for the human organism, that it must be specially renounced when there is a disposition to gout independent of it.
On the other hand, purely vegetable foods, even though less uric acid may be secreted by their use, are unsuitable for many reasons as an exclusive means of support for persons in general, not to speak of gouty subjects in particular. Both animal and vegetable foods after all contain the same materials, although in different proportions, and experience shows us that it requires a perfectly healthy condition of the intestine to digest purely vegetable diet. For this reason vegetarians themselves, who should on principle reject any food of animal origin, do not, as a rule, reject the use of milk, cheese, and butter. The intestinal canal in gouty patients is very susceptible to functional disturbances, and if we select a purely vegetable diet, the actual quantity of nourishment to be taken will be so great as to overpower the efforts of the bowel to manage it.

     "Amongst those things which Cantani recognizes as absolutely prejudicial in gout are the carbohydrates and fats. I agree with Cantani in restricting the use of the carbohydrates as far as possible. Under certain circumstances I forbid some of them entirely. To begin with, I may say that such restriction is necessary, for experience shows us that it is precisely under the influence of the carbo-hydrates that most severe forms of dyspepsia arise. Be then the bond between gout and dyspepsia what it may, let gout be the cause or the consequence of dyspepsia (I believe that in by far the majority of cases we have to deal with the latter state of affairs), be these things as they may, the limitation of the carbohydrates in general forms a very important part of the treatment of one of the most important symptoms of gout ; a symptom which as often as not will disappear under an alteration of the regimen in this direction. The articles which it is of most importance to limit temporarily, or better still permanently, are those which are distinguished by excess of starch, which is ultimately converted into sugar.
As regards fats the case is quite different.

…………………………………..

     "I thought it would be useful to make some experiments myself as to how the secretion of uric acid was affected by moderate quantities of fat. A trustworthy healthy man, thirty years of age, was put under a diet containing fat in exactly known proportions. The urine was carefully collected and examined by Herr Jahns, apothecary to the university here. The determination of the uric acid was done in the usual way by treating the urine with muriatic acid, in the proportion of "0048 to every 100 c.c. of the mixture of urine and muriatic acid. The quantity of uric acid dissolved by the water used to wash the filtrate was put against the colouring- matter deposited, and not reckoned. The urea was determined by Liebig's method, as modified by Pfluger.

     "From these experiments this much may be gathered, that in a daily consumption of butter up to 120 grams, no increase of the secretion of uric acid takes place. If the prohibition of butter and fat in the regimen for gouty patients is based on the assumption that fat increases the production of uric acid, the statement cannot be justified as far as the secretion of the acid by the urine is concerned.

     "The butter was exceedingly well tolerated by the individual experimented on.

     "There is, then, no other ground for excluding fats from the mixed diet which we recommend in gout. All reasons which can be adduced against its allowance prove themselves weak ; and weighty indeed must be the reasons which would justify us in rejecting so important an article of diet as fat. But there are a number of circumstances which show us that fat is a very valuable food in gout, always within necessary bounds, and with adaptation to individual circumstances.

     "As regards Temple's recommendation that the individual experience of the patient should be taken into account, I grant at once that a certain amount of latitude should be allowed to him in the quantity and choice of different articles of diet. We can do this all the easier, inasmuch as amongst gouty patients we find a very great number of them to be highly intelligent, and (the two things are unfortunately not identical, as experienced physicians can ratify) relatively a goodly number of men who are both intelligent and amenable to scientific instruction. But a system of directions is not merely desirable, but also necessary, in order to keep the patient, for example, from lasting injury inflicted by a course of diet which an apparent success might delude him into thinking was a useful one. The essential point of these directions is to secure the due nourishment of the patient without overloading his highly sensitive stomach. In this respect fat is excellent. Its power of checking hunger, known to Hippocrates, plays an important part. In my book on "Corpulence and its Treatment" I have gone more fully into this point. In any case the use of fat does not allay the feeling of hunger by spoiling the patient's appetite, and causing nausea or other dyspeptic symptoms ; but, on the contrary, those forms of dyspepsia which are due to a diet over-rich in starchy foods are alleviated when part of the starch is replaced by fat. I have frequently, by this simple change in the bill of fare, seen obstinate dyspepsia, that had resisted every form of treatment, give way in the shortest time, and this, too, in gouty people. I grant that idiosyncrasies exist here as everywhere else, and that occasionally people are found who do not care for fat, or even good butter, to begin with, and who assert that they cannot bear these substances. In my experience such cases are very rare. I do not remember any such patient who for any length of time objected to good butter. But I may say that those persons who object to good fat as unbearable or unpleasant are very few compared with the great number of those who, in spite of their representations to the contrary, are forbidden fat by their medical attendants. Besides this, I have observed that where an idiosyncrasy against fat does exist, it is generally easily conquered in by far the majority of cases, especially if the patients observe that their prejudice was ill founded, and that their troubles get better under a diet in which fat has a place. I consider that fats are only really contra-indicated in those cases which are developed in consequence of mechanical insufficiency of the stomach (that is, where the muscular elements of the stomach are insufficient to empty its contents into the bowel in the normal fashion. That fat is advantageous in diseases of the stomach is asserted by earlier unprejudiced observers. I may state that so prominent a clinical teacher as C. Bartels, of Kiel, refused to eliminate fat from the diet of patients suffering from dilatation of the stomach, an affection which certainly forms a fruitful soil for the development of dyspeptic symptoms.
      "That fats of the best quality (and it is only such we should use both for the healthy and the sick) do not injure digestion is proved by physiological observations. The experiments of Frerichs in his classical work on digestion could only confirm the experiences of earlier observers, such as Tiedemann and Gmelin, Boucharclat and Sandras, Blondlot, Bernard and Barreswil, to the effect that fats suffer no actual change in the stomach, except that they are melted by the heat. C. A. Ewald has expressed himself in a like sense. Even though we accept as correct the statement of Ph. Cash, that the neutral fats are split up in the stomach into glycerine and fatty acids, yet physiological and pathological experience proves that no particular embarrassment arises from accepting the proposition.

     "In determining what fats are to be employed, regard must be had to individual circumstances. Furthermore, I may here remark that I have never seen disturbances of the alimentary canal arise from the introduction of an adequate quantity of fat into the diet of gouty patients ; on the contrary, fat suits them very well : and I may say this much, that the gouty process seems to be anything but unfavourable to the absorption of fat. The carbohydrates, although playing, according to Voit, a similar important part in keeping up the condition of the body as regards albumen, ought to be reduced to a relatively small quantity, on account of their greater indigestibility, in all cases where the gouty patient is inclined to dyspepsia. As a matter of fact, they may be unhesitatingly set aside in favour of that quantity of fat which is suitable to individual circumstances.

     "Another point to notice is this : We know that when hard work is required, a dietary into which fat enters is absolutely necessary. We shall see that we can give no better advice even to the gouty, and all of the gouty disposition, than to exercise their natural strength. A suitable ingestion of fat is by far the most appropriate and convenient method of enabling the patient to do that. The consumption, then, of a suitable quantity of fat being a point which was known, even in antiquity, to have a beneficial effect in satisfying the appetite of gouty patients, and in counteracting the tendency to excess, the next thing that is worthy of observation is, that there should be but scant choice in the details of the dietary. The danger which the variatio delectat brings with it is a specially great one in the case of the gouty, for if they take in any degree too much even of the kind of food which is allowed them, they run against the principle of limitation which is of such importance in the treatment. The gouty individual stands in the first rank of those who must eat merely to live. If ever he found any pleasure in living to eat he must wean himself from it as soon as possible. Sweets apart, our gouty friend may be as ticklish as he likes, but he must never be a glutton. He must cease to eat as soon as the first feeling of satisfaction comes on ; nor must he give way to the false appetite which comes on after this, and which if gratified brings him to the non possumus stage.

     "The reader will see that these principles agree in general with those which I have prescribed for the corpulent ; and as corpulence and gout go very often hand and hand, there is no difficulty in carrying out the treatment, but the same regimen will meet both indications. As a matter of course, gouty persons with a tendency to corpulence must be refused many things which a healthy fat man would be allowed to take. Amongst these things we may reckon many sorts of vegetables, such as cabbages and so forth. Whatever diet is used, it must be so adjusted and prepared as to give as little trouble to the stomach as possible, and so be best adapted to the nutrition of the individual. Potatoes, in so far as they are allowed in general, and leguminous vegetables had better be prepared as purees; and meat must be scraped or grated, and lightly fried in butter, for those who have bad teeth. Patients must be strictly enjoined to eat slowly and chew well, and if their teeth are defective should provide themselves with artificial sets. By acting on these principles and prescribing certain changes, both quantitative and qualitative, adapted to individual cases, we shall be able to limit corpulence in those patients who are inclined to it. We shall also find this to be the best means of supporting gouty patients who are not corpulent, and of keeping up their bodily condition so far as the gout will allow. Unfortunately, gout often enough causes severe derangements of nutrition, and it is specially incumbent on the medical attendant to limit and avert such derangements by means of dietetic prescriptions, never, however, allowing himself to give any impetus to the gout by denying the patient what is absolutely necessary. I consider it to be a thing not at all permissible, and very bad practice, to attempt to subdue gout by starvation cures and such like methods of treatment, which simply lower the strength of a patient, who has dangers enough to combat without this. Every case must be treated according to its own individual merits, within the framework of the principles laid down here, and no attempt must be made to cut the treatment to a uniform pattern throughout. Where corpulence has to be reduced it must be done slowly. Those cures for corpulence which act quickly are particularly unsuitable in the case of gout.

     "As regards relishes, such as condiments in general, vinegar, &c., only that quantity should be taken which is absolutely necessary to make the food palatable. Dishes which require much condiment to make them acceptable ought, as a rule, to be entirely avoided. Apart from many other disadvantages which the unrestricted use of condiments entails, they produce direct irritation of the mucous membrane of the intestinal canal if they are taken in any quantity ; and it is a primary indication with us to irritate the intestines as little as possible in cases of gout. Fruit, on the contrary, we may freely recommend to the gouty and those who have a tendency to gout.

     "Wohler, relying on facts observed by himself, has taught us that the vegetable acids with alkaline bases become changed into carbonates in the animal economy, and in view of the disadvantages which are entailed by a prolonged use of the alkaline carbonates, he recommends as a substitute the vegetable acids. The use of these is justified by the fact that they are not only pleasant, but can be continued for a long time without injury to digestion. Such fruits, therefore, as cherries and strawberries, which contain an organic acid, can be taken with good results, and are less injurious to digestion than the alkaline carbonates. Wohler mentions the so-called cherry cure, which enjoyed a special reputation in gout. He also takes notice of the strawberry cure, which was the means by which Linnaeus cured himself of a long-standing gout. Similarly, other fruits may be employed with advantage. I recommend them as far as possible as an integral portion of the diet. But when the cure is confined exclusively to the use of fruits, as, for example, in the grape cure, we must be very cautious. Dyspeptic troubles are easily induced by such means, and the mischief thus wrought counterbalances any good that may be derived from the fruit.

      "As regards the question of drink, pure water is in general the best drink for anyone, and gouty people are no exception."

The Dietary habits of Otto von Bismarck

What Bismarck ate at the Siege of Paris (1870) :

Bismarck's secretary, Dr Moritz Busch, who kept a detailed account of the great man's tabletalk, reveals that when he was not throwing out brutally cynical observations on how to deal with France, or complaining at his treatment by Moltke and the King, or discoursing on the joys of hunting in his native Pomerania, conversation tended to revolve around the theme of food. At length the Iron Chancellor would propound to his court his special recipes for roast oysters; grumble that once upon a time he could devour eleven hard-boiled eggs for breakfast but now he could only manage three; boast how in his diplomatic training he and his fellows practised drinking three-quarters of a bottle of champagne while negotiating. 'They drank the weak-headed ones under the table, then they asked them all sorts of things... and forced them to make all sorts of concessions... then they made them sign their names." It was a revealing insight into the art of "blood and iron" diplomacy.
   Early in October, somewhat reluctantly, Bismarck moved his headquarters to Versailles, where the King had already set up court. There the gluttonous obsession with the pleasures of his vast stomach continued, spiced by a liberal flow of offerings from adulators at home that prompted the faithful Busch to make entries like the following:
"Today's dinner was graced by a great trout pastry, the love-gift of a Berlin restaurant keeper, who sent the Chancellor of the Confederation a cask of Vienna March beer along with it, and - his own photograph!" Even within Paris, few can have been so concerned with what they were eating: "December 8th... we had omelettes with mushrooms, and, as several times previously, pheasant and sauerkraut boiled in champagne..." December 13th... we had turtle soup, and, among other delicacies, a wild boar's head and a compote of raspberry jelly and mustard, which was excellent". By comparison with some of these bizarre collations, a simple salmi de rat might almost have seemed more digestible, and at times even Bismarck rebelled. On December 21st he interrupted a mealtime discussion on the French sortie of the previous day to exclaim : "There is always a dish too much. I had already decided to ruin my stomach with goose and olives, and here is Reinfeld ham, of which I cannot help taking too much, merely because I want to get my own share... and here is Varzin wild boar too!"

Archibald Forbes, the correspondent of the Daily News with the Saxon forces to the north of Paris, recorded eating as a guest of the 103rd regiment in the front line a sumptuous Christmas dinner comprising sardines, caviare, various kinds of Wurst, boiled beef and macaroni, boiled mutton, and ending with luxuries long unheard-of inside Paris - cheese, fresh butter, and fruit.

- from The Fall of Paris, Alistair Horne.

Bismarck's health problems at this time included varicose veins.

In his younger days, gastronomy was Bismarck's ruling passion. Once he started attending the Diet his intake increased even more. In 1878 Bismarck presided over the division of Africa by the colonial powers at the Conference of Berlin while eating pickled herrings with both hands. By 1883 he was very bloated, over 17 stone, which made him ill and very bad tempered so for months he lived on a diet of herrings. By 1885 he was down to 14 stone. So the lesson that can be learnt from this is, if at first you don't recede diet, diet again.
A chronic insomnia sufferer, the Iron Chancellor would nightly devour caviar to give him a thirst for strong beer to help him to sleep. His favorite tipple was Black Velvet, a mixture of champagne and Guinness. He was also partial to burgundy wine.
- From Trivial biographies

Note that the Bismarck Herring name for pickled herrings persists to this day.



After the publication of Banting's "Letter on Corpulence," his diet spawned a century's worth of variations. By the turn of the twentieth century, when the renowned physician Sir William Osler discussed the treatment of obesity in his textbook The Principles and Practice of Medicine, he listed Banting's method and versions by the German clinicians Max Joseph Oertel and Wilhelm Ebstein. Oertel, director of a Munich sanitorium, prescribed a diet that featured lean beef, veal, or mutton, and eggs; overall, his regimen was more restrictive of fats than Banting's and a little more lenient with vegetables and bread. When the 244-pound Prince Otto von Bismarck lost sixty pounds in under a year, it was with Oertel's regimen. Ebstein, a professor of medicine at the University of Göttingen and author of the 1882 monograph Obesity and Its Treatment, insisted that fatty foods were crucial because they increased satiety and so decreased fat accumulation. Ebstein's diet allowed no sugar, no sweets, no potatoes, limited bread, and a few green vegetables, but "of meat every kind may be eaten, and fat meat especially." As for Osler himself, he advised obese women to "avoid taking too much food, and particularly to reduce the starches and sugars."
- from Good Calories. Bad Calories, Gary Taubes

Otto von Bismarck lived to be 83, and wrote his memoirs Gedanken und Erinnerungen, or Thoughts and Memories during his final years. 

Where did the butter go? Part 2

I had a look for an Edmonds Cookbook to prove my "peak butter = peak baking" thesis and came across something even more interesting; a League of Mothers Cook Book from what appears to be the 1970's (because metric equivalents are given; NZ went metric in the early 1970's*), however it is a reprint of a book I can trace back to 1951 (and perhaps much earlier if the Art Deco cover is any indication).

In New Zealand, mothers had their own union

Rivers of butter flow through its pages, and sugar keeps pace. This recipe caught my eye because of its name. Lake Monowai is a lake in Fiordland, and T.S.S. Monowai was a famous passenger liner on the Pacific sealanes and a troopship during WW2 (she carried commandos to Gold Beach in Normandy on D Day, landing them on June 6th).



Monowai Biscuits

6 oz butter      
1 teacup sugar
1 egg
1 1/2 cups flour
1 teaspoon baking powder
1 packet Butterscotch Instant Pudding
3 tablespoons cornflour
1 cup sultanas

Cream butter and sugar, add egg, then Instant Pudding and beat well. Add other dry ingredients and lastly sultanas. Roll into balls and flatten with fork or end of cotton reel. Bake from 10 minutes at 375° F

In the narrative of New Zealand CHD mortality, and that of other similar countries, surely there is your 1967 "heart attack on a plate". These things, and buttered white bread, were where almost all the butter went. Tupperware really took off in New Zealand after 1973, because there was already so much that needed to be put in it (I remember Mum's Tupperware parties as a recurring theme in my youth, and the trays of cooling biscuits, scones and slices as daily fixtures).

Here's a diet where the main sources of energy are butter, white flour, white sugar, milk, red meat and beer. Cigarettes will be smoked, everyone gets second hand smoke, cars have leaky exhausts, and farmers use DDT, dieldrin, 2,4T and so on. None of this would last. The diet is deficient in vitamin E, selenium, and EFAs and often in folic acid as well. It is possible to get scurvy from eating takeaway food. This is barely possible today.

If you want to extrapolate from the saturated fat in this diet to the saturated fat in a paleo or LCHF diet, well good luck to you. You could make better predictions by rolling dice.



* "To give metrication a human face, a baby girl whose parents agreed to co-operate was named Miss Metric.News and pictures of her progress were intermingled with press releases about the progress of metrication."
The league of Mothers


I have in the past posted some weird songs about diet, but this is the weirdest to date, and the catchiest. 





 

Where did the Butter go?

As I've said before in this blog, butter consumption in New Zealand was high in the 1940's, was halved by wartime rationing (1943-1948), rose again to its 1942/43 peak by the mid 60's, and is now a quarter what it was then.

How did people in the 1940's and 1960's manage to eat that much butter? I've tried, and I can't do it, even on LCHF. And people back then didn't have French cookery books, Julia Childs was still working for the OSS (she didn't appear on NZ TV till the late 1980's, after Kiwis started drinking wine).

This is how we did it

Wikipedia’s entry on “New Zealand Cuisine” notes that “Scotland provided the largest number of British ancestors of today's Pākehā. The Scottish legacy on food could be seen through a traditional preference of sweet foods, and a wealth of baking dishes to celebrate important occasions, reflected through cakes, scones, muffins and other mainly sweet baking dishes. The country's most iconic recipe book, the Edmonds Cookery Book, originally began as publicity material for a baking powder company, and contains a high proportion of baking recipes”.

Rationing of sugar and butter in the late 1940s affected this culture of baking in particular; recommendations for substitute shortenings (using lard or dripping) were published, but there was little that could substitute for sugar.

The 1940 per capita butter consumption figure was dropped in October 1943 from 415g/week to 227g/week (8oz) by rationing (today’s per capita consumption 112g/week), and Kiwis were advised to use dripping or lard as shortenings in place of the missing butter. Coal miners, saw millers, bush workers and freezing chamber hands were granted an additional 4oz/week after vociferous protests. Fresh pork, needed for US Army rations, became unavailable and meat was limited to 1.13kg/week in 1944 but fatty offcuts such as lamb flaps, as well as offal, were exempt, and meat rationing ended in September 1948. Poultry, milk and fish were not rationed, cheese and eggs were only rationed in some areas, and wages and employment increased as a result of the war.
“Butter consumption in New Zealand fell, as a result, from 48 lb a head in 1942–43 to 36 lb a head in 1944–45 and 31 lb a head in 1945–46.”
For comparison, the latest (2012) New Zealand butter consumption figure is less than 13 lb a head; in the USA, 5.6 lb; in France, 17.6 lb.
Sugar was rationed from April 1942 to August 1948, to 340g/week (12oz) – almost 50g/day, with an extra allowance in the jam-making season, for a reduction in consumption of 10,000 tons per year.[i] (Possibly treacle was not rationed, but there were shortages of all imported consumables after 1939 - wartime rationing in NZ was about shipping, not production.)
Tobacco, sweet biscuits and confectionary were often in short supply during the rationing years. Petrol was rationed between 1939 and 1950.
In 1972, John Yudkin used this graph to illustrate how wartime rationing reduced sugar consumption in the UK, corresponding to decreases in IHD incidence.
 

I've seen the baking effect for myself. My family of four normally goes through 450g butter and 150g sugar a week. But a few years ago the daughter took "food science" at school. For the first year she was taught to make confectionary with artificial colours and flavours plus special effects. Then she learned to bake. What is it with schools, hospitals, and nutrition?
On the weeks she experimented with baking at home (she eventually baked the best cheesecake I've ever tasted, so props to her) the butter supply was likely to run out before shopping day. Not to mention the sugar disappearing like there was a hole in the bag. Don't get me started on the eggs.
So there's your high-saturated fat, high-cholesterol diet, such as kiwis enjoyed in the peak heart attack years.
It's all kind of adding up.

Blakely and Woodward, from "The Healthy Country?"

---

[i] War Economy, Baker JVT, Historical Publications Branch 1965 http://nzetc.victoria.ac.nz/tm/scholarly/tei-WH2Econ-c17-35.html

Saturated Fat intake equivalent to 130g Butter a day is not significantly associated with higher heart disease risk in Finland.

[edited 4/11/14]

If you saw Professor Rod Jackson on NZ TV the other day, he was arguing, ably it has to be said, that the whole Big Fat Surprise / Time magazine cover, and by extension LCHF, risks reversing gains made against heart disease in recent years.
If you're advocating a high fat diet and saying saturated fat is not that important, if it's important at all, that's a serious charge, and worth taking seriously.

For the defence:
Another epidemiological analysis, a long-term follow up (21.4 year) of a population (1,981 men) was released last week.

Dietary Fatty Acids and Risk of Coronary Heart Disease in Men

The Kuopio Ischemic Heart Disease Risk Factor Study

During the average follow-up of 21.4 years, 183 fatal and 382 nonfatal CHD events occurred. SFA or trans fat intakes were not associated with CHD risk. In contrast, monounsaturated fat intake was associated with increased risk and polyunsaturated fat intake with decreased risk of fatal CHD, whether replacing SFA, trans fat, or carbohydrates. The associations with carotid atherosclerosis were broadly similar, whereas the associations with nonfatal CHD were weaker.
The association between MUFA and CHD mortality was, though statistically significant, and I believe one that has turned up before, small enough that I am not losing any sleep over it.
The interesting feature of this study was the high level of saturated fat in the diet, as seen in this PDF of supplementary data.
You will notice that calories increase stepwise with SFA, and it occurred to me that in real, gram, amounts, the difference in SFA intake between quartiles is even greater than that of SFA as %E. The conversion is easily done (Kcal ÷ 100 × %E ÷ 9 - being mathematically challenged, I am as
pleased as a dog with two tails to have thought of that on my own).

Here are the "real" median daily SFA consumption figures by quartile:

Q1 32g

Q2 42.5g

Q3 52g

Q4 67g

Now, 67g of saturated fat is a lot. It's equivalent to more than 130g of butter per day. Fat was 45.4%E in quartile 4. No more cardiovascular mortality than people eating half as much.
Some might say that 32g, or 13.4%E in the lower quartile is already too much saturated fat, but there are plenty of epidemiological studies showing the same flat line at lower intakes. No dose-response.




SFA really does stand for SFA.



There are no total mortality stats. I assume (dangerously of course, it would be better to know, but in line with similar studies) there was no difference there either, even in the higher PUFA group who had somewhat lower IHD mortality (which they could equally get by replacing carbohydrate, TFA, SFA or MUFA with PUFA). The PUFA intake associated with protection wasn't high, both the 4.8%E and 6.3%E quartiles did equally well. They ate more margarine, more fish, and more meat, for fewer calories than the lower PUFA quartiles. Nuts weren't a food measured, and vegetable oils made a minute contribution (olive oil had nothing to do with the small correlation between MUFA and IHD - I'm willing to bet that olive oil consumption would have cancelled out or reversed this association, which seems to belong to margarine and meat, probably pork, without extra fish).
PUFA from margarine plus fish, probably wasn't associated with reduced all-cause mortality, or we'd have heard about it. Nuts, on the other hand, are regularly associated with lower IHD and all-cause mortality.
There's a difference between trading one cause of death for another (what seems to happen when we increase PUFA promiscuously, including oil and margarine) and reducing mortality from all causes (what seems to happen when we eat more PUFA as nuts and fish).
High PUFA consumers were much less likely, high SFA consumers much more likely, to live in a rural area. BMI stayed fairly consistent across SFA quartiles, except the lowest quartile (with lowest dairy consumption) was a little heavier, despite the increasing calories and decreasing leisure-time exercise across quartiles. Rural life seems to be a fair substitute for leisure-time exercise.
Eating more SFA is associated with higher LDL in this study, but not with greater IHD mortality.
Eating more PUFA is associated (less consistently) with lower LDL, and with (somewhat) lower IHD mortality.
Go figure.

One limitation of this study is that four-day food diaries taken in the 1980s were the only food data used. The Finnish diet changed from the 1980s to the present day; did the participants' diets change enough to affect the outcome? The authors tested this by separating the first 10 years, which showed the same trend, but I can think of a better test; if the diets had changed significantly by the high-SFA consumers beginning to eat less SFA and substituting PUFA (the only change to SFA that would have made a difference), the protective association with PUFA would have been lost. It wasn't. Which doesn't mean that smaller effects weren't swallowed up in the changes of time; but anything major, I think, would still have stood out. The PUFA association is still much what we would predict from other studies in other countries with stable food habits.

If you are interested in the background to the KIHD study, Uffe Ravnskov has a chapter on Finland in The Cholesterol Myths, which is available for free here. Kuopio is part of the "rest of Finland", used as control in 1972, then brought into the national risk factor reduction program in, I believe, the 1980s.

CHD mortality in Finland was declining before the cholesterol and other risk-factor lowering program began

Another interesting feature of the Finnish story is the role of coffee, especially boiled coffee, in elevating LDL, and the association of boiled coffee alone with IHD mortality. Again there is no linear association between LDL elevation and risk of IHD; it is the quality of the coffee that matters. A switch from boiled to filtered coffee was part of the 1980's risk reduction program.

From Coffee consumption and death from coronary heart disease in middle aged
Norwegian men and women, by A. Tvderdal et al (link)

It makes no difference whether coffee is boiled or filtered if the aim is preventing liver disease.

The World's Longest-Running Refined Seed Oil Experiment

This table is from Dr Malcolm Kendrick's latest blog post, which is about the possibility of a retrospective "publication bias" deleting findings that don't support the lipid hypothesis on certain websites. The data, from the European Heart Study 2008, has been tabulated by Dr Kendrick to show the correlation between saturated fat consumption and CHD mortality between countries.

 

What's striking is the big gap between the countries of the former Soviet Union and the Western European states (and, for some reason, Israel). France, with the lowest CHD mortality, has the world's highest per capita butter consumption, Switzerland is similar, and olive oil countries don't come out too badly either. The UK, with its chicken twizzlers, mars bars, and fish fingers, and Israel, with its combination of soy oil plus high tech medical care, don't come out quite so well.

The massive rate of CHD in former Soviet states is attributable to many things - industrial and agricultural pollution, smoking and alcohol, untreated chronic infections, overwork, malnutrition, higher birthrate, lower incomes (the US CHD rate in 2008 was 126 per 100,000 - this is both sexes, age adjusted, so not exactly comparable to Dr Kendrick's table; see here for more age-adjusted data and discussion). To look at the correlations between these things and CHD is enough to question the existence of any diet-heart link whatsoever. What significance does a RR of 1.17 have in a world where RRs of 11.13 exist?

If, however, we must look at these statistics in diet-heart terms, one thing stands out to this student of history. Russia is the world's oldest producer, and consumer of vegetable seed oils. The sunflower was brought to Europe by the Spanish around 1510, and were established in the Netherlands (then part of the Spanish Empire) soon after. Peter the Great then brought the sunflower to Russia after his visit to the Netherlands in 1698. In 1716 a patent was granted in Great Britain for a method of extracting oil from sunflower seeds, and during the 1840s the Tsarist government of Russia began the manufacture of sunflower oil on an industrial scale.
Because the Lent restrictions of the Russian Orthodox Church forbade the consumption of fat, this seemed like a good idea at the time (once again the ascetic impulse will be the driver for a dietary change later to be justified and entrenched by theories about health).
The Great Soviet Encyclopaedia of 1979 naturally downplays the Tsarist achievement.

There were about 10,000 small vegetable oil and fat production shops and about 400 licensed, poorly equipped oil and fat plants in tsarist Russia. The vegetable oil output in 1913 was 538,000 tons; in addition, the equivalent of 192,000 tons of soap was produced (figured at a 40-percent fatty-acid content).

Under Soviet power, the vegetable oil and fat industry has become one of the major sectors of the food-processing industry, relying on advanced technology and a stable raw materials base. There are enterprises of the vegetable oil and fat industry in all of the Union republics. The largest are combines in Krasnodar, Moscow, Tashkent, Dushanbe, Irkutsk, Saratov, Kirovabad, Sverdlovsk, Gomel’, and Kazan, which account for 45 percent of the USSR’s total output of vegetable oil, about 65 percent of its margarine, and more than 75 percent of its soap and detergents.

In 1972 the vegetable oil and fat industry accounted for 5.4 percent of the gross output of the food-processing industry of the USSR, 2.5 percent of the work force, and 2.7 percent of the fixed industrial production assets.

The USSR is the world’s second largest producer of vegetable oils, soap, and margarine (after the USA). It accounts for more than 14 percent of the world’s vegetable oil. The output of vegetable oil in the USSR is growing steadily; production in 1972 was 3.6 times that of 1940 (see Table 1).

Owing to the increase in agricultural production, state purchases of oil-yielding crops in 1972 were twice the 1940 figure. The oil content of sunflower seeds, which account for 50 percent of all seeds processed by industry, has risen significantly. The material and technical basis for the vegetable oil and fat industry has grown. Production capacities for processing oil-yielding seeds have been increased primarily by modernizing existing extraction plants and building new ones. Introduction of the extraction method of processing oil-yielding seeds has made it possible to increase labor productivity, mechanize and automate production processes, and sharply increase the oil output from raw materials (see Table 2).

The proportion of oil-yielding raw materials processed by progressive extraction methods increased from 9.9 percent in 1940 to 81 percent in 1972.

Production in the margarine and soap industries is fully mechanized.

In the other socialist countries the vegetable oil and fat industry is based primarily on local raw materials. The volume of production has generally satisfied the needs of these countries. In 1972 the vegetable oil output in Rumania was 360,000 tons; in Poland, 213,000 tons; in Yugoslavia, 165,000 tons; in Bulgaria, 145,000 tons; in the German Democratic Republic, 131,-000 tons; in Czechoslovakia, 88,000 tons; and in Hungary, 80,000 tons.

The production of vegetable oil in certain capitalist countries was as follows: 830,000 tons in Italy (1972), 801,000 tons in the Federal Republic of Germany (1971), and 520,000 tons in France (1971). In the USA vegetable oil production in 1972 came to 4.6 million tons; the output of margarine was 2.6 million tons, and that of soap and synthetic detergents was 3.5 million tons.

And so on - the communist love of boring statistics was useful after all.
But wait - there's more. If the Tsars boosted the seed oil industry, the Bolsheviks, for political reasons, destroyed whatever dairy industry there was in Russia during their genocidal campaign against the "kulaks", which they defined as any farmer rich enough to own a cow, plus anyone they didn't like or who opposed their seizures of food, summary executions, and so on.
To destroy the dairy farmers they needed a substitute - so Soviet Russia, beginning in the 1920s, became the first large scale producer of soy products. The USSR was the first nation in Europe and the second nation in the Western world (after the USA) to become a major producer of soybeans. Soybean production, which reached significant levels in the mid-1920s, rose to a remarkable peak of 283,000 tonnes in 1931, but had fallen back to a low of 54,000 tonnes in 1935, after which it increased steadily. At the time of this peak, starting in 1931, the USSR built a large Soybean Research Institute in Moscow, attracted some of the top soybean and soyfoods researchers from western Europe (Rouest, Berczeller), and did extensive soyfoods research, focusing on soymilk and tofu, during the early 1930s.

So by any utopian diet-heart, lipid hypothesis theory of history, those former Soviet states should have had CDH beat years ago.
By the test of reality, on the other hand, you would be better off living in France on butter, cheese, cream and, hey, if you like it why not, olive oil.