is a contribution from a member of THINCS,
The International Network of Cholesterol Skeptics
Letter to the editor of JAMA as a comment to a
paper by Hu FB and Willett WC. Optimal
diets for prevention of coronary heart disease. Jama 2002;288:2569-78
sent on Jan 22, 2003.
evidence that dietary cholesterol or saturated fat has importance for
I agree with Dr. Hu and
Professor Willett1 that dietary recommendations should be based
on the results from controlled and randomised clinical trials, not on
surrogate endpoints such as lipid levels. But then, why do the authors
themselves argue with such results?
I also agree that there is no scientific evidence
that dietary cholesterol has any importance; this has been shown in many
previous studies also.2 Considering the widespread fear of
dietary cholesterol the authors should have put more stress on that
finding, not even mentioned in the abstract of their paper.
What I disagree about is the demonising of the
saturated fatty acids (SFA). Hu and Willett claim that two of the nine
cohort studies found an increased coronary risk associated with an
overconsumption of SFA. But in one of them3 the significance
disappeared after correction for other fatty acids, and they did not
mention either that in one of the other cohort studies a low consumption
of SFA was significantly associated with a higher risk of coronary
There is no support from the dietary trials
either. The multifactorial Oslo study cannot be used as an argument,
because we do not know, whether it was the reduction of the smoking
habits, the difference in body weight (6-7 kg), or the reduction of SFA
that were of benefit. That leaves us with three trials where SFA was
reduced, the Dayton trial (10 cal% vs. 17 cal%), the Minnesota
trial (9.2 cal% vs. 18.3 cal%) and the Lorgeril trial (8.3 cal% vs.
11.7 cal%). In the latter total and CVD mortality was lowered
significantly, but which of the dietary measures that was of benefit is
unknown. It is doubtful that it was the decrease of dietary SFA because it
was only a small dedcrease and blood cholesterol was identical in the two
groups. In the Dayton trial total mortality was unchanged and coronary
mortality decreased nonsignificantly; and in the Minnesota trial coronary
and total mortality increased nonsignificantly. Furthermore, the authors
had excluded Woodhill et al.s trial (9.8 cal% vs 13.5 cal%) where total
and coronary mortality increased nonsignificantly.5 These
findings are in accordance with two previous meta-analyses of all
controlled, randomised, unifactorial dietary trials, showing no effect,
neither on coronary or total mortality.6,7
Ravnskov, MD, PhD
Magle Stora Kyrkogata 9
S-22350 Lund, Sweden
FB, Willett WC. Optimal diets for prevention of coronary heart disease.
U. A hypothesis out-of-date: The diet-heart idea. J
FB, Stampfer MJ, Manson JE, et al. Dietary
saturated fats and their food sources in relation to the risk of
coronary heart disease in women. Am
J Clin Nutr
P, Ascherio A, Korhonen P, et al. Intake of
fatty acids and risk of coronary heart disease in a cohort of Finnish
men. The alpha-tocopherol, beta-carotene cancer prevention study. Am
J Epidemiol 1997;145:876-887.
JM, Palmer AJ, Leelarthaepin B, McGilchrist C, Blacket RB. Adv
Exp Med Biol 1978;109:317-330.
U. The questionable role of saturated and polyunsaturated fatty acids
in cardiovascular disease. J
L, Summerbell CD, Higgins JPT, et al. Dietary fat intake and
cardiovascular disease: systematic review. BMJ 2001;322:757-763
February 14, 2003
Uffe Ravnskov, MD, PhD
Magle Stora Kyrkogata 9
RE: Letter # JLE30142
Dear Dr Ravnskov:
Thank you for your recent letter to the editor.
Unfortunately, in view of the many submissions we receive and our space
limitations in the Letters section, we are unable to publish your letter
in THE JOURNAL.
After considering the opinions of our editorial staff, we
determined your letter did not receive a high enough priority rating for
publication in JAMA. We are able to publish only a small fraction of the
several thousand letters submitted to us each year, which means that
published letters must have an extremely high rating.
However, we are forwarding a copy of your letter to the
author of the article. The author may or may not reply to you personally.
We do appreciate your taking time to write to us and thank you for the
opportunity to look at your letter.
Stephen J. Lurie, MD, PhD
Senior Editor, JAMA