Heart Disease

So, a diet low in fat, cholesterol, and sodium, plus regular aerobic exercise, produces a dramatic reduction in artery and heart disease. Are there any other benefits?

As a matter of fact, reduction in heart disease risk is just the first in a long list of benefits. I mentioned it first because it is the primary health risk in our society and is by far our biggest killer.

Stroke, Aneurysms, Claudication

In terms of other diseases, consider first the diseases caused by the same atherosclerotic mechanism. When the coup-de-grace event-a blood clot forming on or getting stuck in an advanced atherosclerotic plaque formation-occurs in the coronary arteries, that's a heart attack. When it happens in the arteries feeding the brain, you have a thrombotic or embolic stroke.

When atherosclerosis occurs in the aorta, which is the largest artery leaving the heart, or in other large arteries that feed the rest of the body, it can cause an aneurysm, which is associated with swelling, weakness, and clotting in the damaged artery wall. The clot can break off and subsequently lead to a stroke. Expanding aneurysms tend to rupture, and surgery is generally indicated to avoid these events, although the operation is fatal in a significant fraction of cases.

Atherosclerosis in the leg arteries can cause claudication (a symptom of peripheral vascular disease), a painful condition. Claudication is dangerous for the same reasons that an aneurysm is dangerous. There are many other variations of the problems that can be caused by atherosclerosis, which account for enormous suffering in addition to the rising death toll.

What about cancer?

Cancer

Good question. Cancer is another prevalent disease that is dramatically reduced by a low-fat low-cholesterol diet. The nutritional issues of cancer are not identical, however, to that of heart disease. Cancer and heart disease have different sensitivities to dietary fiber and polyunsaturated fat, as we will discuss.

Cancer progresses in several stages: initiation, promotion, and progression. Initiation happens quickly and may be caused by a carcinogen casually introduced to the body's tissues. For most adults, this step has already taken place somewhere in the body. In other words, most of us have potentially precancerous lesions. For most women, initiation of cancer in their breasts takes place during puberty. These lesions are not detectable and will not evolve into full-blown cancer without the growth or promotion phase in which a precancerous growth evolves into a cancerous tumor. The final and usually fatal stage is progression, in which a tumor metastasizes (spreads from its original site) causing the creation of new tumors throughout the body. Fat is the primary fertilizer or growth promoter advancing the development of a tumor during the crucial promotion stage. It also assists the progression stage.¹

There is a direct almost linear, relationship between the percentage of fat in the diet and the risk of a wide variety of cancers. If we examine different societies around the world, we find the lowest rate of cancers such as breast, ovarian, colon, uterine, and prostate among the societies that eat a very low fat (i.e., 10-to-14-percent-calories-from-fat), low-cholesterol diet (see chapter 15, "Ranking the Killers: How to Save a Million American lives a Year").² Indeed, in these societies, these cancers are almost nonexistent. At the other extreme is the United States, with its extremely high level of fat in the diet and extremely high level of these cancers.

With regard to colon cancer, a high-fat diet creates a hospitable environment for anaerobic(literally, "living without oxygen") bacteria in the large intestine. These bacteria are good at converting bile acids from the intestinal tract into such potent cocarcinogens as deoxycholic and lithocholic acids as well as estrogenlike breast carcinogens.³ Conversely, a low-fat diet creates an inhospitable environment for anaerobic bacteria and instead encourages aerobic ("with oxygen") bacteria that do not produce cancer-causing chemicals and have other benefits. A collaborative study conducted in the United States, Canada, and China found that consumption of saturated fats in meat and dairy products was linked to a four-to-seven-times-higher rate of colon cancer among Chinese-Americans than among their counterparts in China.⁴

The high-fiber content typical of most low fat diets reduces the transit time through the intestines. This also inhibits the creation of carcinogens.⁵ The high-fat, low-fiber American diet is particularly conducive to the development of colon cancer, the second most common cancer in the United States. In comparison, the Finns, who eat a high-fat but high-fiber diet, have a high rate of coronary heart disease but a low rate of colon cancer.⁶

In a study of Italian women, conducted by Dr. Paolo Toniolo of New York University Medical Center, it was found that those eating a 26-percent-calories-from-fat diet had one-third the incidence of breast cancer as those eating a diet of 40 to 50 percent calories from fat.⁷ Because few women in the study ate a diet lower than 26 percent calories from fat, the study did not examine lower levels. Other studies, however, have shown that the incidence of breast (and other) cancer for women who eat a diet that is 20 percent calories from fat is again significantly lower than women who eat 26 percent calories from fat. Other population studies show that the trend continues on down to 10 percent, where the incidence of these cancers is virtually nil. Extensive animal studies have shown the same findings. In addition to inhibiting the crucial promotion phase of cancer, a low-fat diet boosts the immune system, which helps to combat cancer as well as other diseases.

Lung cancer is primarily a result of smoking, isn't that right?

Only in part. A dramatic indication of the impact of fat in the diet on cancer risk can be seen in the rate of lung cancer in Japan. Smoking is extremely prevalent in Japanese society, far more so than in American society. Two out of three Japanese men smoke (compared to one out of three American men), yet the rate of lung cancer in Japan is the lowest in the industrialized world!⁸ This is a result of the low level of fat in the Japanese diet Heart disease is also very low in Japan, despite the high rate of smoking. Interestingly, vegetarian smokers in the United States also have lower rates of lung cancer.⁹

So you can smoke if you eat a low fat, that is, l0-percent-calories-from fat, diet?

No, not at all. The very high level of tobacco usage in Japan does contribute significantly to the health problems that do exist there, most notably their high rate of hypertension. This condition, which is caused by the high levels of both salt in the diet and smoking, leads to intracerebral hemorrhage, a form of stroke and a major cause of death in Japan. There are other serious health problems, such as emphysema, which are related to smoking in the Japanese people. But the low incidence of lung cancer and heart disease in societies that smoke but eat a very low fat diet is just another piece of evidence of the powerful beneficial effects of reducing fat in the diet.

Are there cancer studies that looked specifically at Americans?

Yes, a particularly interesting study, conducted at Harvard University's School of Public Health and reported in the January 1992 issue of the Journal of the National Cancer Institute, studied more than 7,000 male health professionals since the mid-1980s.¹⁰ It found that the men who ate the highest proportion (of low-fat and high-fiber foods were 3.6 times less likely to develop precancerous colon polyp growths as compared to men who ate a high-fat, low-fiber diet. It also reported that the men who ate red meat on a regular basis instead of chicken and fish had an 80 percent greater risk of developing polyps. An editorial accompanying the report suggested that high-fat, low fiber foods may damage genes that are responsible for preventing the uncontrolled growth (i.e., cancer) of the colon and rectum cells.

The Low-Cholesterol Controversy

I have heard that while high blood cholesterol levels are bad, that very low levels are also bad.

There have been reports in the news media of correlations between low levels of blood cholesterol and the incidence of certain diseases, including certain cancers, alcoholism, and even suicide.

However, these reports totally mix up cause and effect. High blood cholesterol levels do cause significantly increased rates of atherosclerosis, which is the cause of almost all heart disease. But low blood cholesterol levels, on the other hand, do not cause cancer or alcoholism. The opposite is the case--certain cancers, such as colon cancer, can cause low blood cholesterol levels. This often occurs at a very early stage of the cancer, even years prior to diagnosis.¹¹ It seems that the cancer cells are voracious consumers of cholesterol in the blood and effectively cleanse the blood of cholesterol.¹²

How do we know that it a the cancer causing the low cholesterol level and not the other way around?

The direction of the causality is clear from examining both population studies and cancer studies and is well accepted by cancer specializts. Consistently, societies that eat diets very low in fat have very low cholesterol levels. And, equally consistently, these societies have extremely low rates of both heart disease and cancer. The same result is found for Americans who eat very low fat diets. The typical pattern that is found for persons in the United States who do develop certain cancers, such as colon cancer, is that the person was eating the "normal" American diet (i.e., high in fat and low in fiber) and had a high serum cholesterol level. Then only as the preclinical cancer developed did their cholesterol levels decline.

So cancer of the colon is a cure for heart disease?

It does appear to be an effective way to slow down or even halt atherosclerosis. The cancer can dramatically lower cholesterol levels, and if the patient lives long enough may cause a regression of the atherosclerotic plaque. But this is not the way you want to ameliorate your atherosclerosis, by replacing one life-threatening disease with another. A diet low in fat and cholesterol will dramatically lower the risk of both heart disease and cancer.

So these people who have very low blood cholesterol levels and get cancer were eating high-fat, as opposed to low fat, diets?

That's exactly right. If someone is eating the "normal" American diet (i.e., high in fat) and has a very low cholesterol level (150 or less), then that might be an indication of a developing cancer; one that may not be diagnosed for several years.

If the person has always had a low cholesterol level, then it could just be "tolerant" genes. A pattern that might cause concern would be high blood cholesterol levels that fell significantly for no apparent reason, that is without the person having changed their diet Indeed, that is the pattern we see in those individuals that have low cholesterol levels and develop cancer. You have to keep in mind that this is an odd group: people who are eating high-fat diets and then develop low cholesterol levels without altering their eating patterns.

Another unhealthy cause of low cholesterol levels is alcoholism.

You mean that excessive consumption of alcohol can also improve one's cholesterol levels?

Yes, alcohol damages the liver which is responsible for regulating blood cholesterol levels. The impact of damaging one's liver is unpredictable, but in certain individuals it appears to result in very low levels of cholesterol in the blood. Note, that among its many negative consequences, alcoholism is associated with high levels of violence including suicide. Cancer is also associated with higher levels of suicide. But in both these cases, low blood cholesterol is the result of these disease, not the other way around.

Has there also been something about a link between very low blood cholesterol and stroke?

There have also been reports of an association between very low blood cholesterol levels and intracranial hemorrhage, a form of stroke. People with very low blood cholesterol levels have a small increased risk of intracranial hemorrhage only in the presence of very high blood pressure (hypertension). This has been noted in societies that eat extremely high levels of sodium such as Japan.

Following the guidelines of the 10% solution (which includes low-fat consumption, moderation of sodium intake and exercise) is very effective in lowering blood pressure levels. There is no increased incidence of intracranial hemorrhage in individuals (or societies) that have very low blood cholesterol levels and normal (or low) blood pressure. In fact, we see the opposite: dramatically reduced levels of stroke, particularly the forms of stroke caused by atherosclerosis, which are dominant in this country.

In societies that eat diets that are low in both fat and sodium, such as many of the counties of China, we find that the individuals have lifelong low blood pressure levels, and have extremely low rates of all forms of stroke.

What about polyunsaturated fat- isn't that better than saturated fat?

Polyunsaturated Fat

Another major issue in the relationship between fat and cancer is the role of polyunsaturated fats. Polyunsaturated fats are often promoted as "good" fats, and that represents another important misconception. The conception of polyunsaturated fat as good, or perhaps benign, stems from the observation that people who substitute polyunsaturated fat for saturated fat lower their total serum cholesterol levels. Thus, it is said that polyunsaturated fat "lowers" cholesterol. This point is heavily promoted in advertisements for corn oil and other products that are high in this type of fat. In actuality, polyunsaturated fat raises serum cholesterol levels; it just does this less than saturated fat does. Consequently, substituting polyunsaturated fat for saturated fat will cause cholesterol levels to go down somewhat, but not nearly as much as cutting out both types of fat.

Okay, so polyunsaturated fat a not good, per se, but if it does indeed raise cholesterol levels less than saturated fat, it would seem at least a step in the right direction to use polyunsaturated fat rather than saturated fat.

Not exactly. The effect on total cholesterol level is only a small part of the story of polyunsaturated fat. In this one regard, polyunsaturated fat is somewhat "less bad" than saturated fat. But in a number of other aspects, it is actually worse. First of all, polyunsaturated fat causes a significant reduction in the level of HDL, the good cholesterol, in the blood.¹³ Saturated fat also does this to some extent, but polyunsaturated fat is substantially worse than saturated faun this regard. Thus, while substituting polyunsaturated fat for saturated fat does cause some reduction in the total level of cholesterol in the blood, some of this is a reduction in the good cholesterol. Therefore, the ratio of total serum cholesterol to HDL, which, as I mentioned, is a key predictor of heart disease risk, does not necessarily improve at all. Now, if we regard saturated fat as being devastating to one's health, which is correct in my view, and if polyunsaturated fat causes a ratio of cholesterol to HDL that is not significantly better, then on these grounds alone, we can consider that eating polyunsaturated fat is also devastating.

A seven-year study conducted by Dr. David H. Blankenhorn at the Atherosclerosis Research Institute of the University of Southern California School of Medicine in Los Angeles, and published the Journal of the American Medical Association, found that the more polyunsaturated fats were consumed by a group of middle-age men who had undergone coronary bypass surgery, the greater was their risk of developing new lesions in their arteries. Conversely, reducing all fats, including polyunsaturated fats, was found to provide significant protection against heart disease.¹⁴

But there's more. While saturated fat is a significant contributing factor to the development of cancer, polyunsaturated fat is actually worse.¹⁵ This is widely recognized by cancer specializts and is one reason that the fat guidelines that are promulgated restrict the level of polyunsaturated fat Polyunsaturated fat also appears to suppress the immune system more than saturated fat.¹⁶

Are there short-term impacts of eating fat?

Blood Sludging

Fat causes blood cell aggregation or blood sludging. Within hours of eating a meal with a significant fat content, red blood cells begin to stick to one another, making it impossible for them to pass through the smaller capillaries that provide oxygen to the body's tissues.¹⁷ If you eat a meal that is high in fat you will temporarily deprive your brain of significant oxygen, which is one reason that people often feel groggy after eating a meal rich in fat.¹⁸

The difference between saturated and polyunsaturated fat in this regard is that the declogging of the capillaries appears to take significantly longer with polyunsaturated fat.¹⁹ Thus, it is quite possible when eating a daily diet high in polyunsaturated fat to have a semi permanent condition of clogged capillaries. This clogging is a different mechanism than the clogging of our arteries. It is caused by blood cell aggregation rather than formation of cholesterol-rich plaque deposits, but the effects are also quite negative on our health.

It sounds as if polyunsaturated fat is as bad as saturated fat.

Wait, there's more. Polyunsaturated fats are also known to interact with oxygen to form free-radicals (powerful molecules that can damage cell membranes), which are associated with premature aging and the development of cancer.²⁰ They are also associated with the formation of gallstones.²¹ Recent studies have also shown that margarine (which is high in polyunsaturated fat) actually raises LDL levels the same way saturated fat does, because of the hydrogenation process (a chemical process that converts liquid fats to solid fats).²² Hydrogenation causes naturally occurring cis-fatty-acids to be converted to trans-fatty-acids, which have been indicted in raising LDL levels and lowering HDL (the good cholesterol) levels and have caused cancer in animal studies. There are no human societies that have anything approaching a good record of health while eating a diet that is high in polyunsaturated fat.

With all of these effects, I find the ads for products high in polyunsaturated fat both misleading and disturbing. Corn oil, which is very high in polyunsaturated fat, is far from a benign substance. The widely promoted fact that it is "low in saturated fat" and "has no cholesterol at all" does not change the fact that its high-polyunsaturated-fat content is in at least some ways worse than saturated fat. Yet people are under the impression that they are eating more healthily by choosing products with polyunsaturated fat.

So no fat is really good for you, then.

Monounsaturated Fat and Omega-3 Fat

There are two fats that are better than either saturated fat or polyunsaturated fat Monounsaturated fat which is the primary fat in olive oil for example, also raises cholesterol levels less than saturated fat. So substituting it for saturated fat does bring down total serum cholesterol levels. Unlike polyunsaturated fat, however, it does not suppress HDL levels, so total cholesterol-to-HDL ratios do improve.²³ It is definitely not as good as cutting out added fats altogether, but it is indeed a "less bad" fat. It also does not clog capillaries as badly as polyunsaturated fat. The term polyunsaturated comes from the fact that in polyunsaturated fat there are many unsaturated links in the long fat chains. This often does not occur naturally in food, but can be the result of the manufacturing process used to make these oils. Monounsaturated fat means there is a single unsaturated link in the fatty acid chain. This is the fat that occurs naturally in such foods as olives and avocados. If olive oil is made simply by squeezing the olives,then the product is high in these monounsaturated fat molecules. Not being bound together in these long chains, it is more easily digested and does not cause as much blood cell aggregation. It is also not implicated as much in the promotion phase of cancer.

For these reasons, the southern Europeans, who use a lot of extra virgin oil, first-pressed and unrefined) olive oil, rather than corn oil or saturated animal fats, do have significantly lower rates of heart disease and cancer than people in the United States or other parts of Europe. But their rates are not nearly as low as Asian societies that restrict all forms of added oils and fats.

As I discussed before, the special type of fat in certain fish, caved omega-3, appears to have beneficial properties in most-but, unfortunately, not all-people. For many people, it is indeed a "good fat," but only in limited quantities.

Are cancer rates low in Japan?

Breast, colon, and prostate cancers, all of which are at high rates in the United States, are very low in Japan, although rates have increased since World War II as a result of the rising level of fat in the diet. The one cancer that is prevalent in Japan-stomach cancer-is linked to two aspects of the Japanese diet that are not healthy and that do not follow the recommendations of the 10% solution. First of all, their extremely high salt level-even higher than the excessive sodium level of the American diet-appears to contribute to stomach cancer. The Japanese consume a lot of salt in soy sauce and preserved foods, which not only contain high concentrations of sodium but nitrates and nitrites, which are also linked to stomach cancer. Furthermore, the Japanese eat a great deal of dried, salted fish, smoked fish, pickled vegetables, and charcoal-cooked foods, all of which have been found to have a significant correlation with stomach cancer.²⁴ In other societies in which people eat a diet low in fat and sodium and do not smoke, charcoal-broil, or extensively pickle their foods (such as rural counties of China), stomach cancer is virtually nonexistent, as are these other cancers.

Any other diseases on your list?

Hypertension

The next issue is hypertension, that is, high blood pressure. Both people in our society who follow the dietary recommendations we have been discussing and whole societies that follow them rarely have hypertension. In fact, following this life-style is the best possible treatment for hypertension. Many of the drugs that are prescribed are very dubious in their effectiveness. They do reduce the measured blood pressure levels, but do not affect the underlying conditions that caused the hypertension in the first place. Diuretics, for example, have actually been found to increase the risk of heart disease when compared to no treatment at all for hypertension!²⁵ Since one of the main reasons for treating hypertension is that high blood pressure is a significant additional risk factor for the development of heart disease, this is a disturbing finding. The MR FIT study, which followed 13,000 men, found that after 7 years, men on hypertension drugs, particularly diuretics, had a substantially higher level of electrocardiogram abnormalities and had a death rate 50 percent higher than expected.²⁶ The thiazide-type diuretics have also been found to increase cholesterol levels, increase glucose levels, and increase triglyceride levels, all of which are implicated in the risk for development of atherosclerosis. They also increase uric acid levels, which can cause gout and other

problems.²⁷ Many hypertensive drugs also have significant side effects that reduce the quality of life and sense of well-being. For example, diuretics have been found to decrease potassium levels, which can make you tired, cause cramps in the legs, cause heart arrhythmias, and increase the likelihood of cardiovascular mortality. Increased levels of impotency have also been found with the diuretic drugs. Beta blockers, another class of hypertensive drugs, have been found to decrease levels of HDL (the good cholesterol), increase levels of glucose, and have been linked to an increased incidence of impotence. Doctors frequently complain that their patients fail to take their hypertension medicine. The reason for this is not that these patients are lazy or inattentive. It is not simply a matter of finding it too much trouble to take a pill. The resistance has more to do with the fact that very often a patient's body knows better than anyone else what is best for it.²⁸

In our society and other societies that eat a similar diet it is considered "normal" for a person's blood pressure to rise with age, but this does not occur in societies that avoid our high-fat, high-salt diet. In societies that eat a low fat and low-sodium diet, such as the peoples of New Guinea and Botswana and the Yanomamo of Brazil and Venezuela, blood pressure stays at the same low rate throughout life.²⁹ Other examples include unacculturated populations of the Pacific islands, Central and South America, Africa, and Australia.³⁰ It is not the case that blood pressure must necessarily increase with age. One of the reasons for the increasing level of blood pressure with age in our society is that increasing levels of arterial plaque result in increasing resistance to blood flow.

High blood pressure is a common medical problem of Japanese people because of the extremely high level of sodium in their diet. But despite their hypertension, Japanese people have low rates of heart disease because of the low fat level of their diet. However, their high blood pressure levels contribute to another medical problem, that of intracerebral hemorrhage, a form of stroke caused by the high blood pressure itself, even in the absence of atherosclerosis.³¹ (This is different from the thrombotic and embolic forms of stroke, which are common in the United States.) The pressure simply causes a blood vessel to rupture, and the hemorrhage of blood into the brain can cause massive damage. This type of stroke is one of the leading causes of death in Japan and is also common in this country. A low fat low sodium diet prevents hypertension and all forms of stroke.

Okay, what's next?

Type II Diabetes

Another major issue is type II diabetes, which is an inability to properly control blood glucose or sugar levels. Type I diabetes, formerly called juvenile-onset diabetes because it primarily strikes during childhood, is caused by the failure of an abnormal pancreas to produce a sufficient quantity of insulin (a hormone, secreted by the pancreas, that controls the level of glucose in the blood).³² Failure to control blood glucose at near normal levels can result in multiple organ damage and even death, and until the availability of insulin earlier this century, the life expectancy of children with diabetes was limited. Type II diabetes, previously called adult-onset diabetes because it usually develops after the age of 40, has a completely different origin. It is caused by the inability of the cells to properly utilize insulin for the metabolism of glucose; the cells become relatively insensitive to the insulin that is in plentiful supply in the bloodstream.³³ In fact, the insulin levels of a type II diabetic are often higher than that of nondiabetics.³⁴ In particular, individuals with glucose intolerance, considered an early form of type II diabetes, typically have insulin levels several times the normal level.

The early symptoms of type II diabetes can be subtle-frequent urination and thirst for example-and are often overlooked. The long term complications can be severe. Diabetes is a significant independent risk factor for the development of coronary heart disease and can lead to other complications such as visual impairment and kidney damage.³⁵ Treatment is generally either insulin injections, similar to the treatment for the type I diabetic, or oral medications to control blood glucose levels.

Yet there is a treatment, generally overlooked, that allows most individuals with type II diabetes to respond far more effectively than they do to either injections or medications. Indeed, in many individuals, this approach appears to significantly reduce or eliminate all symptoms or indications of diabetes. The treatment is, again, the 10% solution. The most important aspect of this treatment is limiting fat to 10 percent of calories. Eating a low-fat diet will significantly improve the body's ability to utilize insulin to control blood sugar levels naturally. Limiting the consumption of simple sugars is also worthwhile so as not to overly tax the body's ability to process sugar. The bulk of the recommended diet consists of complex carbohydrates. While complex carbohydrates are converted to sugar in the body, this process is a gradual one and, thus, sugar and insulin peaks are avoided.

In several studies of type II diabetics who undertook a four-week course in life-style adjustment that emphasized the type of diet and exercise described here, most individuals were able to terminate their usage of diabetes medication while achieving normal blood glucose levels. These studies, conducted at the Pritikin Longevity Centers, which incidentally are noted for having pioneered this dietary and life-style approach to treating and averting disease, included a three year follow-up study. This study indicated that those diabetics who continued to adhere to the guidelines-which was an encouraging 50 percent of the original sample of subjects-were able to control their blood glucose levels without medication. Those that reverted to the "normal" American life-style also returned to dependence on medication because of high blood sugars and the return of multiple features of diabetes.³⁶

Well, what's wrong with dependence on medication? Isn't that easier than the type of life-style modification you're advocating?

That's a very good question, actually. I'm definitely not antimedication in general. There are many conditions for which medications are quite literally lifesavers or help an individual avoid great suffering. On the other hand, it is often the case that the available medications are not as effective as we would like, or they have undesirable side effects. These issues are of particular concern when talking about medications that must be taken for a lifetime.

Consider type II diabetes. Research by Dr. George King at the Joslin Diabetes Center in Boston and other researchers has discovered that one of the causes of increased atherosclerosis in type II diabetics is not the glucose imbalance at all, but rather the increased level of insulin. Insulin is a growth promoter and speeds up me atherosclerotic process. While the sugar imbalance, itself, does cause other problems, the mechanism underlying the worst effect of diabetes, the accelerated onset of coronary heart disease, appears to be caused by the greatly increased levels of insulin in the blood.³⁷ The pancreas of the type II diabetic is essentially pouring out large amounts of insulin to try to overcome the resistance of the cells in using the insulin. Thus, the use of insulin injections to further increase the level of insulin would appear to be counterproductive in this regard. If administered in high enough doses, it can bring down the glucose level in the blood, but, obviously, it also further increases the insulin level. It reminds me of the recent findings on some of the hypertensive medicines: they do indeed bring down the measured levels of blood pressure, but actually make coronary heart disease risk higher than no treatment at all.

Well, what about those noninsulin medications?

While they are not increasing insulin levels, they also are not bringing down the levels of insulin, which, as I mentioned, can be substantially higher than normal. They also have side effects and can reduce the quality of life and the sense of well-being, which is also a factor in some of the hypertension medicines.

So why isn't the dietary approach more widely prescribed?

It is followed to some extent in some places. For example, the Joslin Center of the Joslin Diabetes Foundation has been a pioneer in the use of dietary treatment of diabetes, following a tradition set by Dr. Elliott P Joslin, himself, around the turn of the century, when he treated type I diabetics with a low-calorie diet. While Elliott Joslin's diet was not specifically low fat, its very low calorie level (under 800 calories per day) did have the effect of reducing fat grams. This reduction in both calories and fat grams made whatever level of insulin these children did have more effective and significantly extended their lives. Today, doctors at the Joslin Center recommend a 20-percent-calories-from-fat diet (for patients with type II diabetes and elevated cholesterol levels), which is an important step in the right direction, although the evidence strongly suggests that even greater results could be achieved by adopting a 10% percent calories-from-fat diet.

A doctor at the Joslin Center has described to me some of the challenges in using a dietary treatment. Dietary counseling is generally not recognized as a medical treatment and, thus, is usually not reimbursed by medical insurance and other third-party providers of medical funds. Yet, it is often not effective to simply give someone a pamphlet and say, "Cut your fat intake to 10 percent of calories"-or even 20 percent.

If a pamphlet doesn't work, maybe this book will.

Let's hope that's the case. That is why I wrote it.

It is interesting to note that the approach to nutrition for treatment of diabetes has changed direction 180 degrees over the last several decades. Since diabetes is primarily known as an inability to digest sugar, it was originally felt that people should, therefore, avoid sugar. In addition to sugar, it was recommended that people should avoid complex carbohydrates as well, since complex carbohydrates are composed of complicated arrangements of simple sugar molecules. That leaves only protein and fat as sources of nutrition. We now understand that fat is a primary causative agent for type II diabetes. In the susceptible individual, high fat levels in the diet and in the blood cause the insulin receptors on the cells to become relatively insensitive to insulin. In most type II diabetics, a low-fat diet along with elimination of excess weight restores the sensitivity to insulin and eliminates the metabolism profile associated with diabetes. With relatively normal glucose metabolism restored, insulin levels come down as well. So the 1950s diet for diabetics was the perfect diet to make their diabetes as bad as possible.

Any other conditions worth mentioning?

Another form of glucose imbalance, called hypoglycemia, refers to blood glucose levels that are too low. This situation results in feelings of anxiety, ravenous appetite, and other, both short-and long-term, symptoms. Hypoglycemia also appears to be easily controlled by adopting the 10% solution, generally within a couple of weeks of dietary modification.

You haven't mentioned protein. Isn't it important to get enough protein in your diet?

Protein

Another misconception is that it is important to get "enough protein," and the label "high in protein" is often used on products as if that were a good thing. Protein insufficiency is almost unheard of in developed societies. In fact, even in undeveloped societies, the major dietary problem is not usually related to getting sufficient protein, but to getting sufficient calories.³⁸ Protein insufficiency in the absence of calorie insufficiency is rare anywhere in the world.

In fact, the American diet often contains about twice as much protein as is needed, and this high level is not benign.³⁹ An excess of protein in the diet leads to high levels of urea, which acts as a diuretic, depleting the body of important minerals such as calcium. This is a significant contributing factor to the development of osteoporosis and other conditions.⁴⁰

Evidence strongly suggests that several forms of arthritis(particularly gouty arthritis) are also linked to the high levels of both fat and protein in the diet.⁴¹ There are also links to gallstones, gout, glaucoma, cataracts, and other forms of hearing and vision impairment.⁴² For example, cholesterol deposits can clog the blood vessels in the connective tissue between the small hearing bones, thus causing hearing loss.

That's quite an indictment.

It is as if we were running our engine on the wrong fuel. It's not going to run as well. In time, the engine will break down. Our genetic inheritance determines just how it will break down and when. Some of us are more impervious than others to the effects of the poisonous diet that our society eats.

In the case of atherosclerosis and the development of coronary heart disease, there are blood measurements that one can take, primarily of the total serum cholesterol and HDL levels, that provide a reasonable estimate of risk for that disease. This risk level is compounded further by other life-style and health indicators, such as smoking, diabetes, hypertension, and so on. But just because you have good levels of cholesterol and HDL does not mean you have a low risk of developing the other degenerative diseases caused by the civilized diet. For example, women tend to have high levels of HDL prior to menopause, and this provides a certain level of protection from heart disease during this period of time.⁴³ However, high levels of HDL are connected to high levels of estrogen, which appear to be linked to a high risk of breast, endometrial, and ovarian cancer.⁴⁴ The 10% solution provides protection from both heart disease and these cancers, so I feel it is a mistake to reject a healthy diet just because one's cholesterol levels are in the low risk range.

You've mentioned diet and exercise and avoiding smoking. But what about stress? I hear a lot about that.

Stress

Stress plays a complex role and certainly can contribute to disease, particularly coronary heart disease, once the process of atherosclerosis is established. There is evidence that once atherosclerosis progresses to a certain stage, the activation of a syndrome called "fight or flight," which is the hallmark of stressful situations, can cause greater inflammation in the arteries and accelerate the process of atherosclerotic plaque formation.⁴⁵ It also can cause increased platelet clumping and vasoconstriction (narrowing of blood vessels) and, thus, induce the development of a blood clot, thereby causing the coup de grace of a heart attack, stroke, or other such incident.⁴⁶ There is evidence that chronic stress can suppress the immune system, which is crucial in fighting cancer and other diseases.⁴⁷

We will talk more about stress in chapter 8, "The Mind-Body Connection," because the kind of stress that is damaging is not necessarily the type that causes us to respond to a challenge we find meaningful, but rather the chronic kind that causes us to fight against ourselves. Note that the rate of heart attacks did not go up in Europe or the United States during the enormously stressful period of World War II. As I mentioned, the only change noticed was the dramatic drop in heart attacks in the rationing countries during the period of rationing.

Basically, if you build a strong foundation by eating the right diet and by exercising, you can withstand more stress, although, again, we have to distinguish between an unhealthy stress and an energizing challenge. For people who have developed atherosclerosis to the point where they have angina pain, then management of stress becomes very important in that they want to avoid both the angina pain and the potential for a heart attack. Stress produces adrenaline, which causes blood flow constriction and can trigger a heart attack. Thus, for such individuals, modifying one's life to avoid stress is as important as the other dietary and life-style recommendations.

Suppose I like my diet and life-style the way it is. If I die a few years early, so be it.

You have just articulated a very common attitude. I have three reactions to this point of view. First, the impact is often more than "a few years." Atherosclerosis and the heart attacks and strokes that result, plus the various forms of cancer that are among the degenerative diseases caused by the civilized diet, are the primary causes of premature death. We are often talking about decades lost, not a few years. Right now, a third of all Americans die in middle age (40 to 65). Almost all of these deaths are the result of atherosclerosis, stroke, or cancer, all degenerative diseases caused principally by a high-fat or high-salt diet and all largely avoidable through the dietary and life-style recommendations we have been discussing.

Second, don't count on dying.

Come again?

People imagine that the diseases caused by their high-fat diets and other negative life-style factors will simply reduce their life expectancy by a few years, and that's the end of it, so to speak. Now it's true that the first symptom of atherosclerosis is often sudden death. But more often we're talking about many years of gradual debilitation and suffering.

You sound like a fun guy.

What do you mean?

All this talk about dying and suffering, I mean, you can't go around worrying about this stuff all the time.

Okay, I'll grant you that these topics are not the most enjoyable things to talk about. But that brings me to my third reaction, which has to do with the, immediate benefits of the 10% solution. We'll talk in more detail about that in a moment, but suffice it to say you will feel better immediately in a number of important ways.

Perhaps, but it still doesn't sound like fun. You know, people like to let loose and have a good time now and again.

Did I say you couldn't have a good time?

I'm not sure.

Do you have to eat fat to have fun?

Well, I do like to eat sweets occasionally.

You can still eat sweets, although not the ones you're currently used to. You'll have to take my word for it, at least for a little while, but this diet is a lot more enjoyable and diverse than it may appear at first. An important phenomenon is the profound change that actually takes place in your own tastes and preferences. You need to keep an open mind about this. The experience is likely to be different than you expect.

People sometimes act like I was suggesting that they give up sex. But sex is a natural desire.

So is eating.

Yes, the desire for food is natural. But the desire for high-fat, high sodium foods is not That desire is learned. And you can unlearn it

Given your own dramatic improvement, why shouldn't everyone wait until they hit, say, 40, and then make the switch to the 10% solution?

You do cause permanent damage to your body the longer you eat the "civilized" way. The sooner you stop consuming toxic levels of fat and adopt a healthy diet and life-style, the greater the likelihood of avoiding heart disease, cancer, and other problems. Symptoms of aging, such as wrinkling of the skin, are greatly ameliorated. It also feels a lot better to be at your optimal weight

Weight Loss

This is all very interesting, but I have to admit that the opportunity to drop some of these excess pounds would be particularly motivating. I'm not all that overweight, but I have been trying for more years than I can remember to get closer to my ideal weight.

Interesting you should say that, because high on the list of undesirable conditions caused by the high-fat, high-protein, high cholesterol diet and frequently sedentary life-style that our society follows is varying degrees of obesity. Look around you and you will see an epidemic of obesity. In societies with a low fat diet such as Japan, there is virtually no obesity. In the United States, many people are overweight and a significant fraction of them are endangering their health in the process. Being 20 percent or more over your ideal weight is a significant added risk factor for heart disease, diabetes, and other illnesses. It is also, frankly, unpleasant to carry around all that extra baggage.

It doesn't look great to be overweight either.

It's useful to have vanity on the side of good health. This one factor is probably more motivating than everything else we have discussed.

All right, so what miracle weight loss program do you have for me?

I have a "miracle" weight-loss program that immediately enables you to start losing weight slowly and gradually, a weight-loss program that requires you to make major changes in your eating habits and that requires you to maintain these changes long after the weight loss is completed.

Remind me not to have you write my advertising copy.

Okay, maybe the above does not make a good advertisement. But here is the good news. The diet is enjoyable. Unlike most other diets, you do not feel deprived. You will never feel hungry. Perhaps most important, it works.

There are other diets where people take off weight.

True, but do they keep it off? For most diet programs, more than 90 percent of the dieters put back the weight lost within a year.⁴⁸ With this program, you will take the weight off and never put it back.

Sure, if you keep on dieting forever, you can keep the weight off forever. What's the big deal with that?

The problem, perhaps, has to do with the word diet. The word implies a temporary period of deprivation in which you discipline yourself to gain some benefit, generally weight loss. The period is necessarily temporary because it is impossible to deprive oneself indefinitely. The word diet also refers to the normal eating patterns of a person or society. In this context, I am using the word in the second sense, although the association with the first meaning is never quite lost.

You're confusing me now.

My point is that the only way to take weight off and keep it off is by permanently changing your eating habits to a healthy pattern of eating.

And that, I suppose, means the 10% solution.

Yes, indeed. It is relatively easy to lose weight by following the guidelines of the 10% solution, and, assuming you maintain this lifestyle, relatively difficult to put the weight back on. Weight will come off gradually and naturally and you will gravitate toward a healthier weight.

So all you have to do is follow the guidelines of the 10% solution?

That's the most important thing, but there are some other considerations as well if you are going to lose weight You will need to moderate your calorie intake to some extent. You will find, however, that you can eat a rather large quantity of food and still lose weight with this approach.

I'm sure you can eat a lot of lettuce and still lose weight.

True, lettuce has almost no calories at all. But I lost about two pounds a week, 40 pounds in all, while eating over 2,000 calories a day. And with low-fat foods, you can eat a large quantity for 2,000 calories. I never felt hungry or deprived. And I ate very little lettuce.

This is basically a calorie-controlled diet. And since the food a so low in fat, it tends to be low calorie, isn't that right?

It is true that you are losing weight by controlling calorie intake combined with exercise. It is also true that by avoiding excessive fat you are avoiding the largest source of calories. Fat has more than twice the calorie content per gram as carbohydrates or protein. But these are not the most important factors. Studies examining different groups of people eating the same number of calories but varying percentages of fat found that the groups eating a lower percentage of calories from fat lost significantly more weight.⁴⁹ Fat not only has more than twice the calories per gram, it is metabolized differently. Carbohydrates are stored in the body as glycogen and are more likely to be burned for fuel, whereas fat is much more likely to end up as, well, fat. The fat content of our diets is a major factor in controlling our set-point which is the weight that our body tries to maintain.⁵⁰

It sounds like more of a discipline, not less. With calorie-controlled diets, you only need to watch your calories. With the 10% solution, there are all these other guidelines as well.

Yes, there are more guidelines, but in an important way, they require less discipline, or at least involve less deprivation. If you simply control calories, you end up eating a rather small quantity of food. Also, there are some vicious cycles in the normal eating pattern that make discipline very difficult. The typical high-fat high-sugar desserts often lead to a surge of insulin in the blood, which in turn leads to low blood sugar, which in turn leads to cravings for more sweets. In contrast, the low-caloric density and high-fiber content of complex carbohydrates enable you to eat a relatively large quantity of food and to feel full and satisfied while consuming a limited number of calories.

Your diet is high in complex carbohydrates. Those are sugar, too, aren't they?

Complex carbohydrates are composed of long chains of sugar molecules. They are broken down into sugars in the blood, but are digested slowly and, thus, do not stimulate the sudden high level of insulin that simple sugars do. The high level of fat in the "normal" diet also tends to interfere with glucose metabolism and is a primary factor, as I mentioned earlier, in type II diabetes and hypoglycemia.

Okay, but let's get back to discipline. Explain to me how this a not a huge discipline.

It certainly requires some discipline to start out Your mission here is not a temporary diet, but something more profound: a permanent change in eating habits and attitudes. It requires a serious level of discipline for the first month, then less for the second, and so on. People who approach it with a serious commitment find it a lot easier than they expect. And something happens that most people don't expect: your tastes change. When you first start drinking skim milk or using it on your cereal, it tastes like water. After a while, it tastes like milk, and you find that whole milk is objectionable-it tastes too rich, too heavy. Your desire for foods you may now feel you could never do without-steaks, french fries, potato chips, fried foods in general, cakes and other rich desserts-gradually goes away.

I've tried changes that are much more limited than those you are recommending and found them very difficult to keep up. So I just don't know how successful I could be with such major changes.

I've had exactly the same experience with making minor changes before I made this fundamental change in my eating patterns. The minor changes are actually harder because they are not self-sustaining. They involve deprivation and can be enforced by personal discipline for only so long. The more meaningful changes I am recommending here do not result in deprivation. Even though they involve making a greater change in habits, they are not sustained by endless discipline. They are sustained because of the greater level of satisfaction and feeling of well-being they engender.

If I can sum up the approach you are advocating, you make the short term sacrifice of changing your habits to attain long-term gains, which is to say weight loss as well as dramatically reduced risks of heart disease, cancer, and other diseases.

Immediate Benefits

The long-term gains are certainly there, but there are also very significant immediate or short-term benefits from the 10% solution-some of which I've previously discussed. I'll review a few of these. I've mentioned that within hours of the typical high-fat meal in our society, massive aggregation of red blood cells, or blood sludging, occurs. The resulting blockage of the capillaries deprives the body's tissues and brain of oxygen, which can cause a wide range of symptoms, including difficulty in sleeping, irritability, and other unpleasant side effects. The improved circulation afforded by a low-fat diet has significant effects on energy level and alertness.

Since the 10% solution is very high in complex carbohydrates, it is necessarily high in fiber, which improves bowel regularity and digestion in general.

The exercise increases the intake of oxygen and stimulates the production of endorphins, which improves mood.

A high-fat diet suppresses the immune system. Conversely, following a low-fat diet particularly in combination with exercise, encourages a strong immune system. This helps to fight diseases, both big and little.

Swings in sugar metabolism are eliminated, thus avoiding the anxious and rundown feeling that results from low blood sugar. Food cravings in general are replaced with a healthy and controllable appetite. Weight loss is much easier.

Even your complexion is greatly aided by a low fat diet. Pimples generally clear up on a very low fat diet.

I have spoken with many people who have tried the 10% solution. Most report a greater sense of well being within several weeks. Most people with conditions such as hypertension, type II diabetes, elevated cholesterol levels, and others that require medication, are able, with a dodoes supervision, to significantly reduce and usually eliminate these medications. Since many of these medicines have significant side effects that reduce the sense of well-being, eliminating their use also provides immediate benefits.

So you get long-term benefits by getting short-term benefits. There's got to be a cost in there somewhere.

Let's return to the analogy of fuel for your automobile. If you feed it the wrong fuel, it's not going to run very well, and eventually the engine will corrode and break down. If you change to the right fuel for that engine, you have the immediate benefit of the car running more smoothly, more efficiently, and with greater energy. You also have the long-term benefits of the car not corroding, and remaining in good condition for a much longer period of time. Our engines also require a certain type of fuel. We evolved over millions of years to eat a certain way. We have in recent centuries, and in particular in recent decades, departed quite dramatically from the right fuel.

There is a cost, of course, in adopting the 10% solution. It is the effort required to change your habits. It is time-consuming, in that you have to learn the guidelines and what they mean in your everyday life. You then have the emotional challenge of actually changing and sticking to it. It definitely takes effort. It's not a quick or effortless "cure." On the other hand, it is not as hard as you may think.

One counterintuitive, but psychologically sound, observation is that adopting the 10% solution is actually easier in a profound way than adopting a 20 or 25 percent solution or other halfway measures. If you are strict about the change during a period of transition, your tastes actually change. You lose your desire for high-fat foods and many of these will begin to appear unappetizing. You will discover the tastes of grains and vegetables that were previously smothered with high-fat, high-salt condiments and sauces. But if you make occasional exceptions in order to make the change "easier," your tastes will never change, and the new diet will continue indefinitely as a constant discipline, which will ultimately fail.

The dietary aspects of the 10% solution are similar in this regard to some of the other changes we have discussed. If you stop smoking, you get immediate benefits in that you breathe more easily and feel better in general. You certainly get long-term benefits, as well, in terms of dramatically reduced risks of a variety of diseases. But it does take effort in changing what is for many people along-standing habit and addiction.

Consider exercise. There are immediate benefits in elevation of mood, improved breathing, improved ability to sleep, and so on. The long-term benefits are also well documented in terms of reduced risks of heart disease, cancer, and other diseases. Here again, you need to go through a period of adjustment. When you first exercise, just walking a mile can be strenuous and difficult Yet the experienced jogger or walker can go three or bur nines or more without any strain. These people are fit for exercise; their capacity to do it has been built up overtime.

Similarly, your fitness for the dietary changes improves in the same way. People vary in their initial reactions. Some take to this dietary approach easy and quickly. Others struggle with it for a few weeks or months. But your "fitness" for proper eating improves over time, just as surely as does fitness for physical exertion.

I emphasize the dietary aspect of this fife-style because it is the aspect most poorly understood and perhaps the most important But the other issues of avoiding harmful drugs such as nicotine, as well as exercising, are also important parts of what I am calling the 10% solution.

It sounds like commitment is an important factor here.

Yes, commitment is certainly vital, especially in the beginning. One thing I have noticed is that these changes are easier to make if one's resolve is higher. Those who approach these changes with a very high degree of commitment usually report back that making the change was not such a big a deal after all. Those with less resolve find it much harder. If you are wishy-washy about it, you will probably find it impossible.

It is unfortunate that most people do not get the necessary level of resolve until some episode scares them into taking their health seriously. Not everyone is lucky enough to have some angina pain warn them of their advancing atherosclerosis. It is also easier to fight cancer before you get it Of course, if you are fortunate enough to have fought a previous episode of cancer successfully, then the 10% solution is an ideal way to prevent its return.

It would be beneficial, though, if more people took these issues seriously before death stares them in me face. Granted, most people don't receive vital information on diet and life-style until they are at considerable risk-that is, if they receive any such information at all. But it still amazes me how many people choose to remain oblivious to these issues, even after a life-threatening episode.

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