Thursday, September 04, 2014

Book Review: 'The Big Fat Surprise' by Nina Teicholz

By Michael R. Eades, M.D.
13 May 2014

This review of The Big Fat Surprise by Nina Teicholz is the most difficult and demanding I have ever written. It is demanding for a couple of reasons.
First, it is psychologically demanding on me because I want to write a review so good it inspires everyone to buy the book immediately and read it. Why? Because I think it is one of the most important books on nutrition ever written. Maybe the most important. And I feel a responsibility to inspire as many people as I can to get their hands on it.
Second, this book is so brimming with valuable information that I was almost paralyzed in trying to figure out which parts to excerpt. A book review always comes with excerpts, and this book presented me with such a bounty of choices, it took me forever to decide which to use.
I can categorically tell you that there are not enough superlatives – at least not in my vocabulary – to adequately describe how wonderful and important this book is. But I’m going to try because I really believe it is that good.
I met Nina Teicholz five or six years ago when I was in New York. She told me she had converted from a low-fat to a low-carb diet and that she was writing a book. We really didn’t discuss the book she was writing, so I was clueless. We kept in sporadic touch via email and exchanged a scientific paper or two, but that was about it. I hadn’t heard from her in a couple of years when last September out of the blue I got an email from her saying the first draft of her book was finished. She asked if I would mind reading it and giving her feedback.
I hate these requests because it is really time consuming to read an entire manuscript. And if it sucks, what do you say? I’ve written a number of books in my time, and I know how much effort goes into writing one. Even a bad one. So I hate to be put in the position of having to say to someone, Your book is a loser.
But, Nina’s request came when I was traveling and had some airplane time on my hands, so I said, Sure, send it on.
What she sent was a number of files, some in Word, some pdf. And she didn’t send the entire book, just the first half of it.
I started to read and was absolutely riveted. Instead of trying to carve out time to read her manuscript, I started carving out time from reading her book to do all the other things I needed to do. It was that good.
As I was approaching the end of the part she sent, I emailed asking for the rest. Which she sent, and which I voraciously devoured.
I made a few suggestions – a very few – and we emailed back and forth a bit. Then a few months later, her publisher sent me a bound review copy of basically the printout of her manuscript. It wasn’t typeset as most galleys are. I read this version and made copious notes. Here are what a typical couple of pages in my copy looks like. You can now see why it was difficult for me to decide what small parts to excerpt.
BFS pages The Big Fat Surprise
Since then, I’ve received the actual typeset galleys, which I have also read. So, I’ve gone through this book three times. All I’m asking is for you to go through it once. I guarantee you will thank me for pushing it on you.
Nina Teicholz is a married mother of two living in New York City. She is an investigative journalist and food writer by trade. When she first moved to New York, she was following a low-fat, USDA Food Pyramid style diet. Her life changed when she began writing restaurant reviews. She ate whatever the chefs she was reviewing sent out, which was often “paté, beef of every cut prepared in every imaginable way, cream sauces, cream soups, foie gras – all the foods [she] had avoided [her] entire life.”
She ate an enormous amount of fatty food, and despite her worries to the contrary, her cholesterol numbers didn’t go through the roof. But best of all, she lost the ten pounds she had been struggling to shed.
Her editor at Gourmet asked her to write an article about trans fats. The article ended up getting her a book contract, and the research she did for it launched her on her Herculean task of researching and writing The Big Fat Surprise (BFS). She tells the story of how we Americans went from eating enormous amounts of saturated fat (all the while suffering virtually no heart disease) to now eating fats in restaurants that, when heated, throw off a shellac-like substance so toxic it requires workers in hazmat gear to clean up after them.
The more I probed, he greater was my realization that our dietary recommendations about fat—the ingredient about which our health authorities have obsessed most during the past sixty years—appeared to be not just slightly offtrack but completely wrong. Almost nothing we commonly believe today about fats generally and saturated fat in particular appears, upon close examination, to be accurate.
Finding out the truth became, for me, an all-consuming, eight-year obsession. I read thousands of scientific papers, attended conferences, learned the intricacies of nutritional science, and interviewed pretty much every single living nutrition expert in the United States, some several times, plus scores more overseas. I also interviewed dozens of food company executives to understand how that behemoth industry influences nutrition science. The results were startling.
There’s a popular assumption that the profit-driven food industry must be at the root of all our dietary troubles, that somehow food companies are responsible for corrupting nutrition recommendations toward their own corporate ends. And it’s true, they’re no angels. In fact, the story of vegetable oils, including trans fats, is partly about how food companies stifled science to protect an ingredient vital to their industry.
Yet, I discovered that on the whole, the mistakes of nutrition science could not be pinned on the nefarious interests of Big Food. The source of our misguided dietary advice was in some ways more disturbing, since it seems to have been driven by experts at some of our most trusted institutions working toward what they believed to be the public good.
Based on my own research on Paleolithic man and his diet, I knew that early man ate mainly meat. And the meat he ate wasn’t what we today consider the choice cuts. Not T-bones and tenderloins, but viscera, marrow, brain, and fat pads—all sources of saturated fat were doubtless his foods of choice. I also knew that prior to the early years of the 20th century, heart attacks were rare. So rare, in fact, that they were almost nonexistent. Doctors could go through their entire careers without seeing one.
What I didn’t know was that during this heart-disease-free period, folks in the United States were up to their elbows in animal foods and saturated fat. Same in Great Britain. In fact, people ate more meat then than they do now. But today cardiovascular disease is the leading cause of death. (Take a look at these two old papers (clickhere and here) Nina referenced to see the change.)
I had fallen victim to the myth that the agrarian pre 1900s America meant everyone ate grains and vegetables and a smattering of meat when they could get it. As Nina goes to great lengths to point out in The Big Fat Surprise, that ain’t how it was.
Not only did the Americans of European origin eat mainly meat, so did the Native Americans.
Meanwhile the Native Americans of the Southwest were observed between 1898 and 1905 by the physician-turned-anthropologist Aleš Hrdlička, who wrote up his observations in a 460-page report for the Smithsonian Institute. The Native Americans he visited were eating a diet predominantly of meat, mainly from buffalo, yet, as Hrdlička observed, they seemed to be spectacularly healthy and live to a ripe old age. The incidence of centenarians among these Native Americans was, according to the 1900 US Census, 224 per million men and 254 per million women, compared to only 3 and 6 per million among men and women in the white population. Although Hrdlička noted that these numbers were probably not wholly accurate, he wrote that “no error could account for the extreme disproportion of centenarians observed.” Among the elderly he met of age ninety and up, “not one of those was either much demented or helpless.”
Hrdlička was further struck by the complete absence of chronic disease among the entire Indian population he saw. “Malignant disease,” he wrote, “if they exist at all — that they do would be difficult to doubt — must be extremely rare.” He was told of ‘tumors’ and saw several cases of the fibroid variety, but never came across a clear case of any one kind of tumor, nor any cancer. Hrdlička wrote that he saw only three cases of heart disease among more than two thousand Native Americans examined, and “not one pronounced instance” of atherosclerosis. Varicose veins were rare. Nor did he observe cases of appendicitis, peritonitis, ulcer of the stomach, nor any “grave disease” of the liver. Although we cannot assume that eating meat was responsible for their good health and long life, it would be logical to conclude that a dependence on meat in no way impaired good health. [My italics]
To put these census numbers in a little perspective, I took a look at the most recent statistics for centenarians. In 2012, in the United States, the rate of centenarians per million people was 173. So even if Hrdlička was correct about the 1900 census being somewhat off, it is still amazing that a group of buffalo-eating, primitive people sported as many centenarians as we do today with our antibiotics, parasite-free clean water and our state-of-the-art medical care.
How did we go from a meat-eating, butter-slathering, lard-cooking society to the fat-fearful, heart attack prone, constantly dieting people of today? The blame for that can be laid directly at the doorstep of one man.
Ancel Benjamen Keys.
Ancel Keys came up with the diet-heart hypothesis and singlehandedly catalyzed the movement that led us where we are today. And he did it because he let his monstrous ego override whatever modicum of scientific integrity he had.
Here’s what happened.
In a 1952 presentation at Mt. Sinai in New York (later published in a paper that received enormous attention), Keys formally introduced this idea, which he called his “diet-heart hypothesis” [fat in the diet -> increased blood cholesterol -> heart disease]. His graph showed a close correlation between fat intake and death rates from heart disease in six countries.
It was a perfect upward curve, like a child’s growth chart. Key’s graph suggested that if you extended the curve back down to zero fat intake, your risk of hear disease would nearly disappear.
This connect-the-dot exercise in 1952 was the acorn that grew into the giant oak tree of our mistrust of fat today. All the ailments that have been ascribed to eating fat over the years—not just heart disease but also obesity, cancer, diabetes, and more—stem from the implantation of this idea in the nutrition establishment by Ancel Keys and his perseverance in promoting it. Now, as you eat a salad with a lean chicken breast for lunch and choose pasta over steak for dinner, those choices can be traced back to him. The influence of Keys on the world of nutrition has been unparalleled.
Six Countries Graph The Big Fat Surprise
Keys traveled the world promoting his fat-causes-heart-disease theory using this famous six-countries chart. While presenting at a conference in Geneva, Switzerland, however, he ran into a serious scientist who was highly skeptical.
Jacob Yerushalmy, founder of the Biostatistics Department at Berkeley, realized Keys had cherry picked his data, and that had all the data been included, the graph showing the strong correlation between fat consumption and heart disease would have resolved into a bunch of dots scattered willy-nilly on the page.
Yerushalmy and his colleague Herman Hilleboe published a scathing rebuttal of Keys’ work. You can click on their paper, Fat in the Diet and Mortality from Heart Disease: A Methodologic Note, which I have put in my Dropbox, so you can see what a real scientific smack down looks like. Reading it almost makes me feel sorry for Keys.
How did Keys respond when this paper came out?
Nina interviewed Henry Blackburn, Key’s longtime associate who was there when Keys got the word.
“I remember the mood I the lab when that study came out,” he said.
“The mood…Not good”? Nina asked.
“Mmmmmm,” replied Blackburn, followed by a long pause.
His savaging at the hands of Yerushalmy and Hilleboe strengthened Keys’ resolve to forge ahead. Not to forge ahead and do good science, but to forge ahead to prove his point.
The skeptical response to his Geneva talk and the resultant paper
represented a humiliating but important moment for him: “*the* pivotal moment in Keys’ life,” remembers Blackburn. After the confrontation in Geneva, “[Keys] got up from being knocked around and said, ‘I’ll show those guys’ … and he designed the Seven Countries Study.”
What Keys did was spend the rest of his career wallowing in the confirmation bias. Instead of following the scientific method and trying to refute his diet-heart hypothesis, he made it his mission to look for anything and everything that confirmed it. And ignored or belittled any conflicting data.
Keys’ formidable powers of persuasion along with his academic credentials led over time to his diet-heart hypothesis being accepted by just about everyone. Anyone who dared to disagree was attacked with great vitriol in the pages of any journal in which the opposing argument appeared.
Thanks to his non-stop promotional abilities, Keys ran roughshod over his detractors, and in his annus mirabilis, 1961, scored three major triumphs. First, he graced the cover of  Time, he wrangled the American Heart Association (AHA) into his low-fat corral, and he got the National Institutes of Health (NIH) to buy into his theory. The AHA and NIH coups were particularly important because the first was an enormous lobbying agency and the second was the largest source of funding. With these two aboard Keys could both promote his anti-fat ideas to doctors and the public and could get the funds to do studies to confirm his bias.
As the diet-heart juggernaut rolled on, Americans cut their fat intake, and what fat they did eat, they made sure was polyunsaturated.
Which posed an enormous problem for Big Food. Saturated fats have certain cooking properties that are difficult to reproduce with polyunsaturated fats. But Big Food had had already developed trans fats, so they switched to them. Trans fats had been around for a half century, so they were there for the taking. And take they did. Soon just about every processed food had replaced saturated fats with trans fats, which they didn’t call trans fats in those days. They called them polyunsaturated fats. And everyone thought of them as health foods.
Keys final triumph was when the United States Government itself tumbled to the diet-heart hypothesis.
A non-scientist named Nick Mottern ended up writing the final report that came out of Washington recommending a diet in which fat in general was slashed, saturated fat was reduced to 10 percent of calories and the recommended dose of carbohydrates was 55-60 percent. A huge change from the lard-eating years during which most doctors had never seen a heart attack.
The public was kind of blah, as the public usually is with government reports. But Big Food had a different take. They were ecstatic.
The promotion of carbohydrate-based foods, such as cereals, bread, crackers, and chips, was exactly the kind of dietary advice large food companies favored, since those were the products they sold. Recommending polyunsaturated oils over saturated fats also served them well because these oils were a major ingredient of their cookies and crackers and were the principal ingredient in their margarines and shortenings. The pro-carbohydrate, anti-animal-fat orientation of Mottern’s emerging report thus suited food manufacturers just perfectly.
First, the AHA and the cardiologists were the only physician groups buying into the low-fat diet. But sooner or later, they all toppled like dominoes. One of the last holdouts was the pediatricians. Kids didn’t get heart disease, so why should they cut their fat, drink skim milk, etc? But soon they fell into line, too.
In one of the more disturbing descriptions in BFS, Nina describes studies done by British researchers on African children. Gambian children were put on low-fat diets (most of their fat calories were polyunsaturated and came from nuts and vegetable oils) after weaning and were compared to English babes who got a majority of their calories from whole milk and meat. Both groups of growing toddlers got the same number of calories, but
by the age of three, the Gambian babies weighed 75 percent less than they should, according to standard growth charts, while the Cambridge  babies were growing according to expectations and weighed, on average, 8 pounds more than the Gambians.
Writes Nina:
As an American parent, it’s hard to read this study without immediately running to see the fat content of one’s own “early weaning” foods—with unsettling results. While rice porridge, the first solid food fed to Gambian infants, was analyzed as containing 5 percent energy as fat, a jar of Earth’s Best Whole Grain Rice Cereal (an organic brand) that an American parent might feed a baby has zero grams fat. Later on, when Gambian babies were eating rice with groundnut sauce, at 18 percent fat, an American child might get barely 1 percent fat from a salubrious-sounding jar of Earth’s Best Vegetable Turkey Dinner (and this is one of the few dinner options with meat). Government data show that American children have reduced their intake of fat including saturated fat in recent decades.
If the results of the studies on Gambian children are any indication, American kids raised on the low-fat diet could be in for some health problems down the road. Already, children in other countries that haven’t stupidly encouraged reduced consumption of fat for children are passing US kids in height.
This is just one of many truths revealed in BFS that made me want to punch through a wall. Believe me, there are many, many more. Which is why it’s so important that this meticulously researched book reaches a wide audience. Only then will some changes be made and future generations spared the low-fat idiocy.
As with all things that bring about a nagging discomfort, the low-fat diet began to wear on people. And they began to yearn for something new. Some kind of regimen with maybe a little more fat. And who came to their rescue? Non other than our old friend Ancel Keys.
During the years Keys had been promoting his diet-heart hypothesis, he had been traveling the world and spending a lot of time in Italy at the palatial estate he built overlooking the sea south of Naples. (I’ve always wondered how he could afford such a place on an academician’s salary, but I guess that’s another story.) In his time in Italy and other countries bordering the Mediterranean, Key’s took note of the parts of the diet these different peoples ate that matched up with his own dietary philosophy and more or less combined all the disparate diets into one. And he published a study on the diet of the people from Crete that was to lay the foundation of what has now become the Mediterranean Diet with a capital D versus the Mediterranean diet with a small d that actually represents what the various peoples involved actually eat.
In 1975, Keys reissued his 1959 cookbook, Eat Well and Stay Well, with a few changes to Eat Well and Stay Well the Mediterranean Way, which was basically a repackaging of his low-fat diet under the term Mediterranean. This was the first time the Mediterranean Diet with a large D came into the lingo. Keys had pretty much retired by this time, so the banner was taken up by other scientists from Italy and Greece.
The story of how these scientists, using Keys’ bogus data from Crete (which in and of itself is a unbelievable story), teamed up with what amounted to a PR firm for the olive oil industry to seduce scores of American scientists and food writers is one of more fascinating parts of BFS. It was a perfect storm. The scientists and food writers were ripe to be lured into spending time on the Mediterranean coast, imbibing wine and eating the food. These all expense paid trips were ostensibly medical conferences, but in reality, they were marketing ploys. Food writers and journalists were looking for something new and exciting to write about. The masses, wearied of their tasteless low-fat fare, were ready to start adding fat back into their diets, even if it was in the form of olive oil. And the olive oil industry was more than ready to oblige. And to fund.
A handful of researchers started working on studies of the Mediterranean Diet, but there really wasn’t a Mediterranean Diet. There were a lot of people around the Mediterranean eating diverse diets, but no single Mediterranean Diet. So each research group basically created its own idea of the Mediterranean Diet and studied it.
To say you will be surprised to learn not only the structures of these various Mediterranean Diets but the outcome of the studies is a vast understatement.
I’m forever being accosted at parties and other events with questions about diet. When I explain what I do, I can’t tell you how many people then tell me they eat a Mediterranean Diet or that their doctor put them on a Mediterranean Diet. Even doctors believe the Mediterranean diet is the one diet that has stood the test of vigorous scientific investigation.
If only they knew.
Since the government got into the low-fat diet business, the health of the populace has gone to hell. We’re in the midst of an obesity epidemic the proportions of which now make the old TV star Jackie Gleason, who went by the moniker The Fat Man, look absolutely normal. Even worse, we’re in a diabetes epidemic that threatens to break the bank if it isn’t reversed.
As all this has been happening, the populace had been chewing through about 18 billion (billion with a B) pounds of soybean oil (through 2001), most of which had been partially hydrogenated. Partially hydrogenated fats are trans fats, of course, but few people knew what they were until recently. Which is just how Big Food wanted it.
By carefully grooming scientists and funding their research, Big Food had managed to keep the deleterious effects of trans fats from becoming public knowledge. Which was important because, as Nina writes, trans fats “were the backbone of Big Food.”
They had a scare early on by the Malaysian producers of naturally saturated tropical oils, which would have easily taken much of the market from trans fats had the public but known. But the American Soybean Association (ASA) was not about to let that happen, so they mounted an attack on tropical oils, branding them as dangerous saturated fats. Which, of course, they were. Saturated fats, that is, but certainly not dangerous.
One of the people Nina interviewed, David Drake, a top exec at the ASA, tells how one of their marketing people came up with the name “tree lard” for the tropical oils. Funny and clever. But devastating for the tropical oils.
Despite the work and outrage of a couple of scientists Big Food managed to keep marginalized, trans fats continued to quietly glide along under the surface of the consciousness of almost everyone. The masses thought they were eating polyunsaturated fats and Big Food kept them in the dark. How much in the dark?
..from the day hydrogenated oils were introduced in the form of Crisco in 1911 right up until the year 2005, nearly a century later, not one major scientific conference was devoted to the discussion of trans fats.
It really beggars belief.
Nina’s description of the Waterloo for trans fats is fascinating. They went from being unknown and in everything to being identified, vilified and banned in record time. And in a real twist of fate, their demise came about virtually overnight based on the same type of shoddy science that scared everyone off of saturated fats. Not that trans fats aren’t bad, because they are, but it is ironic that they were excoriated and killed off by the same kind of public-relations-driven schlock science that gave them their preeminence in the first place. I suppose it’s only fair.
The most frightening part of The Big Fat Surprise comes next. It is the absolute must read chapter. It details what has come after trans fats, and it’s not pretty. It’s a big step into the unknown, and those steps typically lead to an end that is not good.
Big Food finds itself in a real quandary. People read labels, and the great unwashed masses still think saturated fat is bad. So when they grab up a package and look at the label to see the saturated fat content
…any tick upwards in these fats by even 0.5 grams might alienate [Big Food’s] customers.
Says one Big Food exec Nina interviewed
Everyone is so sensitive to saturated fat content. That’s just our basic reality.
So Big Food can’t use saturated fats, even tropical oils, and now they can’t use trans fats, so what’s a packaged food manufacture to do? You don’t really want to know, but for your health’s sake, you better read about it to find out.
Nina ends her book with a redemption of saturated fats. She goes into great detail on why saturated fats are not just not bad for you, but are actually good for you. And they are. Trust me. Once you’ve read this final chapter, you’ll know why.
If you are a low-carb dieter, yet you’ve had this kind of nagging doubt about eating saturated fat, this last chapter is for you. What if all the experts are right?, you’ve probably asked yourself. Hell, I’ve asked it myself. I eat a ton of saturated fat, so I’m literally betting my life that saturated fat isn’t harmful. Reading The Big Fat Surprise will relieve you of a lot of angst. It will convert even the fiercest of skeptics, unless they’re so mired in their ideology that they can’t be budged. But just as we saturated fat eaters have suffered our angst, they will now suffer theirs.
As I wrote at the start, there are not enough superlatives to describe this book. It’s a life changer.
I predict that within a few years, one of two things will have happened as a result of this important book.
Either Nina will be burned at the stake. Or we will all be eating our food cooked in lard, butter, beef tallow and duck fat, just as we ate it back in the days before Ancel Keys came on the scene. We’ll eat the way we ate when a case of heart disease was an anomaly.
Buy this book now. You will not be disappointed. Give it to every lipophobe you know who is able to read. It will change many minds.
Thanks for hanging in there with me for this very long review. If you’ve read the book, or when you do, feel free to write your own review in the comments section. I look forward to reading them all.

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