If you are wondering who is Deep Thought and what do you mean by 42 is the answer to the ultimate question of life then don’t panic! You are in for a treat. You must read (a few books) or at least watch (movie) Douglas Adams’ wonderful creation, The Hitchhiker’s Guide to the Galaxy. A hilarious and sarcastic take on everything that goes around us. Why in the world am I thinking about the ultimate question of life? Let me warn you… this is a very long write-up split into 3 parts (Unum, Duo, and Tres) with a lot of technical jargon.
Ok, what is the deal with people between the ages of 21 and 81 celebrating their birthdays (if you can hear this in Jerry Seinfeld’s voice – even better)? They did absolutely nothing on the day of their arrival and since then (in most cases). Why the heck are they celebrating then? OK, enough of Jerry Seinfeld’s shtick.
I shun social events (especially birthday parties) like plague but when my neighbor, an octogenarian, invited me for his birthday party I could not refuse. The protagonist of the event celebrated his 82nd birthday a few weeks ago. I like him because he looks like Samwise Gamgee of the Lord of the Rings fame and reminds me of the laughing Buddha.
Anyways, I awkwardly walked around his home for a few minutes and when I finally met him on his big day all I could say was, “Many happy returns of the day, Sam.” His name is not Sam and he knows why I call him that and he gets a kick out of it. He smiled and said, “You young bucks seek longevity but we old lions prefer quality of life. I will take one good year eating tasty food over ten miserable years on all this medication.” He had a couple of by-pass surgeries in the past, still suffers from various other ailments, and swallows almost 25 tablets a day.
We had a very interesting conversation on Longevity (L) vs Quality of Life (QoL) that day. I am going to refer to it as L vs. QoL (kind of like P versus NP) from here on. Sounds intelligent but L vs QoL is much easier to solve than P versus NP. Not surprisingly, we both came to the same conclusion that QoL should take precedence over L and L should be a dependent variable of QoL.
Sam and I chatted for a little while longer but we both were killing time for the cake. While we were waiting, he shared a few of his life lessons and I congratulated him on his accomplishment of seeing 1,000 full moons (81 years*12 full moons/yr + (81/3 – 1 extra full moon every third year) = 999) in his life. He complemented my complement. He felt happy and I felt smart. Peaches and plums!
Finally it was cake time and he got a piece of gluten free-fat free-sugar free cupcake specially made for him by his dear wife of 55 years. The horror – total violation of human rights! Only thing that came to my mind was, “God! Nobody deserves this type of torture!” The rest of us got a piece of a pineapple cake but I could not eat mine. I still can’t forget the disappointment on his face. Being a rebel, I shared a small piece of the pineapple cake with him when no one was looking. It was peaches and plums again. He did not say a word for a full 5 minutes and finally uttered these words, “Oh wow! This is how life should taste like. I am feeling this way for the first time in over two years.” Sam’s wife walked by just at that moment and she felt really bad for him. She said, “Sam has this obesity problem. I am simply following his doctor’s advice and put him on a low-fat diet.” Sam quickly intervened, “that idiot doctor put me on a so-called healthy diet at the age of 40 and I had my first by-pass at 55. As if that was not enough he put me on a salad diet for the next 15 years and guess what, I had my second by-pass at 70. If my math is right I am up for my third by-pass in 3 years. Actually I can’t blame him. Who is the bigger idiot, the idiot or the idiot that follows an idiot?” My immediate response was, “I don’t think you are obese because of your diet. Something else must be the root cause.” His wife sympathized with him but felt helpless. She is just following his doctor’s orders.
He made a strong impression on me and that feeling of helplessness hit me hard. I felt bad for him but I was also intrigued. I enquired if he really followed the diet all these years or cheated regularly. He confessed to cheating probably once or twice a year when his wife was not around but he said in a low voice, “She is worried about me and always keeps an eye on me.” Sam is a lucky fella! Anyways, as we were wrapping up our conversation he asked me if I could do him a favor, “Do you think you can use your wicked logic to convince my wife to let me eat some real food with butter, almonds and pistachios? I have been on this diet for 40 years. I am sick and tired of eating all this grass with no flavor and always feeling hungry. ”
Mark Twain’s sage advice flashed in my head, “Get your facts first, then you can distort them as you please”. So, I decided to get to the bottom of this. I focused my research over the past few weeks on obesity and effects of fat consumption on cardiovascular disease so that I can come up with some clever logic to convince Sam’s wife to let him eat some butter. Little did I know what I was getting into, I was in for a fat surprise!
I don’t want to keep you intrigued. Here are the two key takeaways:
- Simple carbohydrate consumption contributes more to obesity than fat consumption.
- I am not even sure if consumption of natural fats has anything to do with the heart disease.
Before we get into fat consumption and cardiovascular disease, let us get our basics right. General dietary guidelines are for most people to get 60% of their total calories from Carbohydrates, 20% from Proteins, and the remaining 20% from Fats. But a lot of people get a lot more calories from carbohydrates especially the simple and processed ones (sugar, cereals, juices, non-fat snacks, quick microwave meals, etc.)
What is our body’s fuel and how does it extract energy from these food sources? Glucose (monosaccharide) is the primary fuel for all our cells and excess glucose gets converted into glycogen and fat depending on our needs. But the way our body metabolizes carbs is very different from the way it metabolizes fat. You see, it is much easier for our body to digest carbohydrates than fats (carboxylic acids). Not all carbs are the same and watch out for Fructose (mostly found in fruit juices and sweeteners.) Apparently unlike other types of monosaccharides, Fructose in the presence of glucose gets converted into fat directly in the liver. The next time you are chugging down that gallon of Florida Orange Juice thinking healthy food, think again.
Here is a simplified version of our digestion process. When we eat our meals (combination of carbohydrates, proteins and fats) the digestion process starts in our mouths (chewing is very important). Our food (or Chyme -pronounced with a K) eventually makes it down to our smaller intestine and that is where the real magic happens with the help of various enzymes. Simple carbohydrates get digested very quickly and get converted into glucose. Carbohydrates and proteins followed by fats get digested in that order into glucose, amino acids and fatty acids respectively. As soon as glucose hits our blood stream (sugar level in the blood rises), insulin (an important hormone secreted by pancreas to manage sugar level) is released to let all of our cells to know that they can now burn glucose instead of fat. High level of sugar in the blood for prolonged periods of time is believed to be dangerous. Think of insulin as a key to all our locked cells (muscle cells, heart cells, various tissue cells, etc.) Pancreas supplies insulin in the presence of sugar (our cells need a password) most of the time. I found an article talking about how insulin level spiked when whey protein powder was consumed. Apparently some foods can raise insulin level without raising blood glucose level. Watch out! When insulin receptors on our cells lock on to insulin, our cell doors open and glucose from our blood gushes in. It is a much slower process without the insulin. This is a very important point to understand.
The more simple carbs we eat the higher the blood sugar level tends to be and therefore pancreas secretes more insulin to manage all that fuel (glucose). Remember higher insulin level means less fat burning. And excess glucose is converted into glycogen and fat. That is right… fat! Also if we keep eating high-carb foods eventually our bodies could become insulin resistant (i.e., insulin receptors on our cells become inactive and that makes us diabetic.) See, the more carbs we eat the higher the insulin spike will be and since we burn simple carbs quickly our insulin level also drops off relatively quickly. This causes hunger pangs and we seek more glucose, i.e., more carbs. Insulin plays a vital role in managing our obesity. We will get into this a lot more in Part Tres.
I finally understood Sam’s comment about always feeling hungry. The more glucose we produce by consuming simple carbs, the more fat we accumulate and the more fat we gain, the more calories we consume. The vicious cycle continues. Sugar is really an addictive drug. This is one of the reasons why low calorie high carb (even if they are from fresh veggies) diets rarely work in the long run. We can’t run on a deficit for ever. Eventually carb cravings kick in.
I think I got a ballpark idea on why Sam stayed obese even after eating so called healthy foods all these years. He has been eating too many carbs and a lot of them simple and processed. Well, it is more complicated than that as he could have some hormonal imbalance but we can discuss that at length in Part Tres.
Let us briefly talk about what made us connect consuming fat with cardiovascular disease first and then we can delve deep into potential causes and measures we can take to fight the disease. The whole “fat is bad” debate started in early 1950s on a global scale. What triggered the debate? A lot of middle aged men in the US started dropping like flies right around and after World War II from various heart ailments. An answer, actually a simple answer, was badly needed (apparently going through two World Wars, one great depression and consuming bucket loads of sugar were not good enough reasons.)
A smart but very ambitious Physiologist named Ancel Keys from the Land of ten thousand lakes (food on-a-stick… eh! State fair is a lot of fun) found an answer. At least he thought he did and published a very interesting chart and blamed it on fat intake. A picture is worth a thousand words. The chart below is a perfect example of that.
Dr. Ancel Keys, a very well educated man with two PhDs, observed that as calorie intake from fat (he had a beef with saturated fat) as percent of total calories increased, mortality from heart disease among men aged between 55 and 59 during the years of 1948 and 1949 increased exponentially. He highlighted 6 countries to support his hypothesis: The US, Canada, Australia, UK, Italy, and Japan. Note that Japan was still struggling from the aftermath of WWII and they were eating a lot of rice at that time. Southern Italy was also in a bad shape after WW II. It is clear from the chart that as fat intake increased from 10% of total calories to 40% of total calories, mortality from cardiovascular disease jumped from about 65 deaths per 100,000 people to more than 700 deaths per 100,000 people.
Disclaimer: I plotted the above chart by gathering data points from Dr. Malcolm Kendrick’s book (The Great Cholesterol Con) using a hand ruler. My numbers may not match the official numbers exactly but they are pretty darn close I think.
Also note that Dr. Ancel Keys did not calculate the exponential equation and R-squared value. I did. But look at the fit – 0.99 R2 (almost perfect.) Without saying much he established causation with a single chart. Fat is a killer! Please refer to Correlation does not mean Causation article for more entertainment.
Remember what Sherlock Holmes said, “It is a capital mistake to theorize before you have all the evidence. It biases the judgment.” Dr. Ancel Keys cornered himself by making such a strong statement and that biased his judgement for rest of his life. But let us not demonize Dr. Keys. We all have done that. How many times have we not tried to convince others of our opinions with limited facts? In some cases, we knowingly distort facts in our favor. That’s why we are fakers.
Fortunately for us, scientists are a suspicious bunch. They don’t like it one bit if any of their colleagues get all the glory. Don’t you know that the scientific establishment is like a box full of crabs? These Scientist Crabs never let any of their fellow maverick Crabs get (think) outside the box. Just kidding!
A lot of scientists quickly discounted Dr. Keys’ chart and two scientists, Dr. Jacob Yerushalmy (a biostatistician) and Dr. Herman Hilleboe, MD called Dr. Keys on his selection bias by publishing their own chart in 1950. You see, the fat versus mortality from heart disease data are available for 22 countries but Dr. Keys only picked 6 countries to make his point. Yerushalmy and Hilleboe published a chart with all the 22 countries. Here is that chart.
What the… Exactly! The fit is not as strong as it was before. A meager 0.3 R2! Nothing to get all excited. Note that the data points from Dr. Ancel Keys chart are slightly different from Yerushalmy and Hilloboe’s and that is due to the difference in years of observation: One was from 1948-49 and the other was from 1950.
If any of you with really sharp eyes like to say, “Well, Mr. Faker dude I still see an upward trend. You can’t fool me. Fat is a killer.” Oh! You should not have said that. You should never wrestle with a pig in mud. I love me data so much. I have some wonderful charts to confuse the heck out of you. What is that famous saying…“If you can’t dazzle them with diligence baffle them with bullshit.”
A couple of data points in that chart are probably messing with your eyes (Japan and may be Ceylon (Sri Lanka)). You must ask two important questions when you see data such as these (horizontal cone like dispersion):
- Is there or could there be a problem with the data? How come the death rates changed so much in some of the countries between 1948-49 and 1950?
- Can we be so sure that fat alone can cause this much damage (especially as suggested in Dr. Keys’ chart)?
As a logician one must immediately wonder about the quality of the data. Let us discuss this a little later. But let us look at a couple of European countries, Italy and Denmark in particular to answer the second question. Italian fat intake was ~20% with ~240 deaths per 100,000 people from heart disease. Danes’ fat intake was close to 40% with about 260 deaths per 100,000 people. In other words, there was almost no difference. How can this be? If we believe Dr. Ancel Keys chart and use the exponential equation to fit the data, Dane’s mortality rate from heart disease should have been over 900 per 100,000 people and not 260. Something is amiss about this data. Should we not look for other factors as well to explain this death conspiracy?
There are three kinds of lies: lies, damned lies, and statistics (Mark Twain attributed this to Benjamin Disraeli, British Prime Minster from the 19th century). If you are wondering why most statistical reports get such a bum rap, let me display the power of statistics and selection bias.
Let us say I have a personal interest in showing zero correlation between fat intake and mortality from cardiovascular disease. Then all I have to do is to choose 6 other countries that fit my hypothesis and contest Dr. Keys’ observation.
Holy smokes, Batman! We went from an R2 of 0.99 to 0 by changing the countries. I took the same data points from the 22 country chart but only plotted countries of my choice. I can hear your brain making some uncomfortable noises. You are not completely convinced. Let me perform another trick for you. Here is another chart with 9 European countries (3 better than Dr. Keys). See, I am not making this stuff up.
If anyone asks about Finland, I will make up a crazy story about Finns and justify my case. I can even present myself as an unbiased scientist by displaying the Finland data by saying, “Data are data. You can’t argue with the data.” I hope you can see my point and why statistics can be both useful and misleading. We have only shown so far that there is no correlation between fat intake and mortality from heart disease by picking and choosing a few countries. Let us go a step further and say the exact opposite of what Dr. Keys was saying: Increase in fat intake decreases mortality. Here is a chart to prove that.
Look at the fit, an excellent 0.96 R2 to rival Dr. Keys’ 0.99. He chose 6 countries and so did we. Also did you notice how gingerly I fit these data points using linear and exponential curves? My data points, my curves – lay off the curves!
Of course, if we want to show that the whole fat vs mortality hypothesis is entirely bogus all we have to do is pick a different set of countries. The following chart illustrates that.
This is a compelling chart. At ~38% fat intake as % of total calories, mortality from heart disease varied from as low as 200 to as high as 700 per 100,000 people. This fat consumption vs mortality from heart disease hypothesis is a whole lot of horse manure… Eh!
By the way they all eat grass but cow’s dung comes in pies, horse’s in balls, and goat’s in pellets. Do you know why? But I digress.
And finally, if we want to be mysterious we can invoke the appearance of mystical chalice. Mighty Lord acts in mysterious ways and here is the chart for all you non-believers.
This is my favorite. God loves the Dutch and The Danes but hates the Finns and the Americans. Heck God even dislikes the nice people from the Land Down Under. Unacceptable!
Unfortunately, the damage has been done. Most people think that consumption of fat makes them fat and unhealthy. Sumo wrestlers don’t think so. Apparently Sumo wrestlers consume anywhere between 10,000 and 20,000 calories a day and most of that (> 60%) from carbohydrates. If eating fat makes us fat easily then why do you think Sumo wrestlers consume carbs to fatten up? A gram of fat has more than twice the number of calories as in a gram of carbohydrate. They could eat half the amount and get the same number of calories from fat. I will let you ponder on that.
While you are pondering on Sumo wrestlers’ diet, let me share a funny personal incident with you on the prevalence of this fat misconception. A friend of mine and I were walking around a nice city in the land of plenty a couple of decades ago and saw a doughnut shop. We could not resist and here is the funny part. I ordered two chocolate donuts, my friend ordered two cream filled donuts and a large cup of coffee. At the pick-up point my friend explicitly asked for non-fat milk for his coffee as he was on a non-fat diet at that time. The store clerk literally fell of his chair laughing so hard. He famously said, “The non-fat milk is on the house. Good luck with your diet, sir!”
So, let us wrap up this part of the discussion by addressing the first question we posed earlier:
Is there a problem with the fat vs heart disease data?
Let us look into that:
- How did they measure fat calories as % of total calories?
Answer: They did not measure the number through control studies or surveys. An International body calculated the number as follows – Total fat produced in each country + Fat Imports – Fat Exports. In other words, the consumption is really not consumption but total available fat in the country. So, any fat used in canned foods and/or wasted fatty food was still considered as consumption. It is very likely that the data collectors overestimated the fat consumption.
- How did they measure mortality from heart disease?
Answer: They used death certificates to determine the cause of death. One could only imagine the quality of this data set from late 1940s. How many of these countries do you think performed autopsies to accurately determine the cause of death? Some cultures and religions consider autopsy as a violation of belief in the sanctity of the human body. Besides, Mexico, Portugal, Chile, Ceylon…Pa-lease.
I found a few articles talking about how Masai and Inuit people have low mortality rates from heart disease even after consuming almost 50% of their total calories from fat. I don’t know but quality of this data can be a suspect. Heck, I have very little confidence in the data collected in most of the developed world.
Finally, I also read that French had lower mortality rate from heart disease but their mortality rate from cancer was much higher than the rest of the developed world. Also, Japanese had low mortality rate from heart disease but they were not so lucky when it came to mortality rate from strokes (it was high).
See, I don’t care about a particular diet lowering a particular type of mortality risk. I am interested in lowering overall mortality rate. Surprisingly most of the studies fail to identify consumption of fat as a statistically significant factor for overall mortality. But Vegan proponents would probably tell you animal products are bad and you are more close to a rabbit or an Orangutan when it comes to diet and they pick and choose their data to support their shtick. What if you are a vegan and want to be Batman? Not to worry! Vegans would let you be a fruit bat! Caveman proponents on the other end would tell you all you need is red meat and they have their own data sets to justify their assertions. It’s just crazy!
- Ambitious people can be dangerous. Ambitious people with IQs above 100 can be deadly. Watch out for these folks.
- Always question the source and integrity of any data – no matter how credible the presenter appears to be. Actively look for bias.
- People with agendas always find causations where none exist. Remember correlation does not mean causation.
- Always pay attention to analyses and opinions of smart but socially inept geeks.
- After all of these wonderful charts, I still don’t know jack squat about the relationship between consumption of fat and mortality from heart disease.
You are right. If only life were that simple and all we have to do is to lower our fat intake, bada bing, bada boom mortality rate goes down!
After a lot of push back from many non-mainstream scientists, mainstream experts came back with a slightly modified hypothesis. Now they think saturated fat as an accomplice and cholesterol as the real culprit. Call me cynical but the mainstream’s track record in this area has been subpar. And nobody is going to spoon feed us with everything we need to know. Even if someone did, I am not sure we can accept it without our own due diligence.
The problem with us humans is we want to simplify everything. I saw an interesting quote by HL Mencken in Dr. Malcolm Kendrick’s book, The Great Cholesterol Con, and it is worth repeating here:
“For every complex problem there is an answer that is clear, simple, and wrong.”
Unfortunately, Life is complicated. Answers don’t come by that easy. I requested Sam for more time to come up with my wicked logic to solve his butter cravings but suggested him to cut back on simple sugars. Please proceed to Part Duo for more kicks and giggles on cholesterol.