The Dr. Aseem Malhotra interview

That Dr. Malhotra is a top Doctor and expert cardiologist is beyond question. However, Chris Woollams, a former Oxford University Biochemist and founder of CANCERactive, feels that some of the conclusions in this article about saturated fat, while they may well be accurate for cardiovascular disease, are positively dangerous for people trying to avoid or beat cancer. People reading this interview are strongly advised to read the warning from Chris at the end of the article and/or go to: Why the Pioppi Diet is dangerous if you want to beat cancer 
The Pioppi Diet; A lifestyle Diet
The UK is awash with lifestyle advice; food, fitness and wellbeing are hot news, subjects of great media fascination and ever bigger business. Yet information overload has failed to boost the nation’s health or dent the obesity epidemic: the NHS is drowning not only from patient overload but a two-thirds increase in prescription medication over this past decade. 2.7 million UK prescriptions are dispensed every day – or one billion every year.

The advent of Dr Aseem Malhotra to the top table of public health debate is therefore welcome and timely: this London cardiologist, anti-sugar and anti-obesity expert is also the brains behind a documentary called the Big Fat Fix which premiered last year in parliament. His voice on the nation’s health, wellbeing and way forward is authoritative, clear and credible: a Mediterranean diet, no sugar, judicious exercise, a good night’s sleep and stress reduction are his four pillars of wisdom when it comes to avoiding or reversing heart disease,  type 2 diabetes and other serious conditions. A former consultant clinical associate to the Academy of Medical Royal Colleges, Malhotra became, at 38, the youngest member appointed to the board of Trustees of the King’s Fund.  His conviction that less medicine is more and that serious chronic conditions can be reversed by straightforward lifestyle changes is radical enough seriously to rattle Big Pharma.  But Dr Malhotra feels duty bound to challenge the drug industry; there’s a Gandhi quote close to his heart: ”Silence becomes cowardice when the occasion demands speaking out the whole truth and acting accordingly."  

Both Dr Malhotra’s parents are doctors. He grew up deeply interested in health and sport, captaining school and University of Edinburgh teams. His father taught him to cook as a teenager and for the past 20 years he’s prepared his evening meals from scratch. ‘Yet at medical school’ he says ‘I can’t remember learning anything useful about the effect of nutrition OR lifestyle on health, other than the impact of smoking reduction on the population. His own diet was ‘good solid fuel’ for an avid runner with a stressful career - sugared cereal, toast and orange juice for breakfast, a panini for lunch and pasta for dinner. His daily sugar intake was around 40 teaspoons, when six is now the maximum recommended level. Five years ago he went cold turkey on the sweet stuff, cut out refined carbohydrates, learned to love butter and whole fat milk.  He recalibrated his diet to include at least four tablespoons of extra virgin oil daily ‘which along with a handful of nuts I consider a medicine in terms of properties that help reduce heart disease risk’, plus lot of fibrous non-starchy vegetables. He eats seeds, olives, avocados and breakfasts that include eggs and berries. He tends to eat organic with grass-fed meat and butter. ‘If the dietary advice I was given at medical school was right’ he says ‘I should be a walking time bomb with soaring cholesterol levels and advancing heart disease.  But I have lost a stone in weight; I have never been healthier. I’m convinced my diet is protecting me against heart disease, premature ageing, cancer and dementia. Recent US research by Tufts university proved that even a whole tablespoon of butter a day would not raise the risk of heart disease. I personally would refer to low-fat spreads as poisonous and wouldn’t recommend them to family or friends.  I advocate butter 100 per cent – there’s no reason to fear it and it makes food tastier as well. Marketing tells people to eat low-fat foods, which is so misleading that it’s an absolute scandal. The likelihood is that it will only detract you from eating really good, nutritious food.’

Malhotra’s nutritional enlightenment began when he was a specialist registrar at Harefield Hospital, 2008- 2011. ‘A patient who’d been treated for a heart attack was given junk food on the ward when we were trying to advise him to eat well. We’d obviously got it wrong and looking around there was widespread ignorance about how food impacts on health. I began to explore the science and found much good, but not widely publicised research: adopting a Mediterranean diet after a heart attack is almost three times more powerful at saving one’s life than taking a statin which at that stage was being hailed as the so-called miracle drug with no side effects. The reality is that that if we had been getting everything right, we wouldn’t be in this health crisis right now.’

Malhotra believes that converting the population to lifestyle change must begin by banning added sugar:  ‘When we look at the biggest public health successes, increasing longevity by about 30 years since 1900, it’s pretty much all come from legislation and regulation. When I was growing up Benson & Hedges sponsored major cricket matches – that was the norm.  We still normalise sugary drinks and junk food as part of the sporting experience  - all that does is reinforce ongoing acceptability among the public. So we need to change the law and ensure that doctors are good at giving lifestyle medicine as well as handing out prescriptions. We need to be totally transparent with patients and give them informed choice to try lifestyle change before pills and procedures.’ 

Dr Malhotra says he came increasingly to appreciate the power of commercial influence on medical science, ‘and that many of us were basing clinical decisions on biased information. That therefore is unethical. The medical model is a complete mess. The complete failure of the system at every level will not be mended by tinkering around the edges. This major crisis requires a complete overhaul of the system. There’s a cancer at the heart of modern medicine and for that to be cured would need full exposure in the style of the Chilcot enquiry on the Iraq war. The pharmaceutical industry has to do things differently and conduct studies at an ethical level that does not prevail at the moment The industry has a fiduciary responsibility to shareholders but it has no legal obligation to provide the best treatment for patients, although most people would like to think it does. And the real scandal is that doctors, institutions and medical journals who have a responsibility for scientific integrity collude with the industry for financial gain. This should be a conversation that everyone is talking about right now – at coffee shop tables, with taxi drivers, your postman – everywhere.’

‘One reason why we are in this mess is that we’ve been given the wrong dietary advice, based on our obsession with lowering cholesterol. This originated from  cardiovascular disease and associated mortality rates that increased from the early 20th century, peaking in the 1960s. It was attributed to saturated fat in the diet, prompting a drive to reduce fat.  Unfortunately the real culprits are refined carbohydrates and sugar, which constantly drive up glucose and insulin, and reduce the body’s capacity to deal with prolonged surges of insulin. If, instead, we’d increased consumption of carbohydrates from fibrous vegetables we wouldn’t have this problem. 

Public Health England has told food giants to cut sugar levels by 20 per cent before 2020. A soft drinks sugar tax starts April 2018, although the Food and Drink Federation has said that overall reduction ‘won’t be technically possible or acceptable to UK consumers.’   ‘When we talk about sugar’ says Dr Malhotra, ‘ we are not talking about a food, but something for which the body has NO biological requirement and is, in my view, a root cause of many chronic diseases.  150 calories from a spoonful of sugar is not the same as 150 calories from a protein or fat source.  A little bit of sugar daily (up to three teaspoons) won’t kill you, but a lot of sugar over time certainly will cause considerable harm: the average citizen has four to seven times too much from largely hidden sources such as ketchup, salad dressings and even bread.  

‘A high quality study of US adults found a trebling in cardiovascular mortality among those who consumed more than 25 per cent of calories from added sugar versus those who consumed less than 10 per cent. But health improvements can come fast: a study of 43 Latino and African-American children with metabolic syndrome (see below) showed that in just 10 days they significantly reduced their health risk by reducing 28 per cent of added sugar calories to just 10 per cent.

Dr Malhotra tries to fast once a week for 24 hours: “ I think it’s something people should try to adopt. It makes sense that if you have a period of time without food your insulin levels are going to drop – and emerging science supports this. 

‘For the purpose of health, exercise is very good, which is why I co-authored and edited a paper called Exercise – a Miracle Cure. But it needs to be the right exercise. I used to be a very keen runner, but I’ve pretty much stopped: run if you love to, but be aware that you won’t live any longer than someone who has a brisk walk every day, accruing cardio vascular benefits without stressing the body. And remember – you can’t outrun a bad diet.’

‘Alcohol’ says Dr Malhotra, ‘is a major cause of morbidity in this country both in the emergency room  (50 per cent of head injuries from falls relate to alcohol consumption) – and from chronic liver disease.   ‘But if you look at the Mediterranean areas where wine consumption is intrinsic to the diet, it is actually about wine being taken with meals, not separately in the pub. The body responds to alcohol in quite a similar way to how the liver has to deal with sugar. Again it provides you with energy, but not nutrition. The polyphenols in red wine seem to be protective, but the optimum dose is a single large red glass a day.’ 

Many people have concerns about the hormones in dairy foods, but Malhotra postulates a link between reduced risk of heart disease and type 2 diabetes in people who consume full fat dairy, ‘At the very least, full fat is not harmful unless people have an intolerance. Increasing emerging research suggests that yoghurt and some non-processed cheeses are very good for the gut, helping the diversity of bacteria.’ 

‘The Mediterranean diet’ says Dr Malhotra, ‘ is a powerful factor in reducing systemic inflammation in the body which seems to be a major factor around the development of many chronic diseases such as Type 2 diabetes, obesity, heart disease, dementia and cancer. There’s also a huge overlap between inflammation and insulin resistance. This is basically when the body becomes resistant to the effect of insulin, which is such an important hormone involved in many metabolic processes in the body. In particular it is the fat-storing hormone. It’s the hormone that, when secreted in excess over a long period of time, will lead on to type 2 diabetes. Independently, insulin resistance is linked to many cancers and is also the prime factor for heart attack. Very few people know that. Markers in the blood can be highly predictive of insulin resistance which also overlaps with another major indicator of incipient disease – the metabolic syndrome

‘This is essentially defined by having three of five risk factors; high triglycerides in the blood, Low HDL or ‘bad’ cholesterol,  increased waist circumference or belly fat, raised blood pressure, and type 2 diabetes. It’s not widely knows that increased waist circumference is much more predictive of disease than BMI. ‘BMI is useless as an indicator. I would say that there is no such thing as a healthy weight. The important truth is that up to 40 per cent of people with normal BMI will harbour the same metabolic disturbances as people with obesity.  This is not to downplay the greater risk to health in someone obese compared to someone with a normal BMI, but people of “healthy” weight should not deceive themselves that everything is fine – nothing could be further from the truth. A primary dietary culprit is added sugar consumption. The body can metabolise a bit of sugar, but when it gets to excess, which of course varies from person to person, then it’s going to increase your risk of chronic disease. And the combined costs of type 2 diabetes and obesity to the NHS and the UK economy exceed £20 billion. 

“If you have any three of the symptoms above, you have Metabolic Syndrome. We know that 66 per cent – that’s two-thirds of people admitted with heart attack actually have this, yet 75 per cent of them will have normal cholesterol levels. If you have a heart attack PLUS Metabolic Syndrome you are 50 per cent more likely to be readmitted within a year or to die. This is not being emphasised by doctors as I feel it should be.  I believe that Metabolic Syndrome is right at the root of everything I look for in patient health, certainly as a cardiologist, and the reason it’s not mentioned is, in my view, because there is no market for the model of solutions.

Dr Malhotra stresses that there is no drug to target insulin resistance. ‘The simple way to combat metabolic syndrome and insulin resistance is to institute lifestyle change involving a healthy diet, mindful movement such as a 30 minute walk, and doing all you can to reduce stress levels whether by meditation, yoga or pilates.  Regarding stress, we should remember the significance of social interactions, somewhat lost in modern society. Population studies show that, observationally, social isolation is in itself a big risk factor for early death and for chronic diseases especially in the elderly. Strong intimate relationships are good for wellbeing, so it doesn’t take rocket science to recognise that depression can ensue without them. We must realise that health and happiness are interlinked. Long shifts – and I’ve been there – are stressful, and it’s easy to compensate with comfort and junk food. If eating junk food meant that we were a happy population that would be fine. Clearly it doesn’t.’   

We can transform both our health and the economy much faster than you’d think. Dr  Malhotra cites GP David Unwin who has saved £45,000 in diabetes medication by telling patients to cut out sugar and refined carbs from their diets in order to improve blood glucose levels. If all GP practices across England adopted this protocol, it would save £423 m in diabetes medication alone. 

 

“The pharmaceutical industry model is to get as many people as possible taking drugs for the longest possible period. That’s how it makes profit. Here’s the no-brainer: unless we drastically overhaul the current model of medicine prescription, our population health will worsen, and the economy will not thrive because an unhealthy population is an unproductive population. We should heed the Hippocratic maxim “Let food be thy medicine and medicine thy food.” It’s not just over-prescription of antibiotics leading to dangerously resistant strains of bacteria that threatens.  Painkiller prescription is up by 25 per cent over the last five years and anti-depressants for teenagers up 50 per cent.  A quarter of hospital admissions among the elderly are due to negative reactions to prescription drugs. Cardiologists, says Dr Malhotra, are currently having to wind back the harms from the great statin con. ‘It’s crucial to understand that I am not against statins as such but I am against lack of transparency in their prescription. Let’s have a little healthy scepticism about the ‘published data’ which is almost all pharmaceutical industry-published data. The hard science says that a statin will prolong the life of just one in 83 people who have suffered a heart attack, meaning that 82 people won’t benefit in living longer. In only probably one of 40 will statins prevent or delay a non-fatal heart attack. But my own clinical experience, good quality observational data and patient surveys tell us that the likelihood of someone developing statin side effects which interfere with the quality of life are more likely one in three or one in five. Heart attacks are so feared, says Dr Malhotra, that people opt for medication despite the potential side effects and despite the fact that unless your risk is more than 20 per cent, there is no mortality benefit.’

Dr Malhotra believes that a collective effort across the UK could catapult our society into good health: ‘If we reduced the amount of medication people are taking, based on a frank discussion looking at the risk and side effects for each patient, if we simultaneously improved people’s lifestyle and if everyone worked together, I believe that we would solve the healthcare crisis within a year. We would reverse type 2 diabetes and we would be able to save and sustain our NHS.’ 

Warning - by Chris Woollams, former Oxford University Biochemist and founder of CANCERactive.
I have several serious concerns about the Pioppi diet having studied the Mediterranean Diet myself for more than a decade.
Firstly, I am concerned about the issue of Saturated fat. In his book ’The Pioppi Diet, A 21-day Lifestyle Plan’, Malhotra claims that the people of Pioppi ate good volumes of saturated fat and that basically it did them no harm. He is a cardiologist. And there is a meta-study in 2010 and another in 2014 showing that people who consume the highest levels of saturated fats have no more cardiovascular problems or risk than those who ate little.
Go to: Saturated fat has no influence on cardiovascular risk
So far so good.
However, this is simply not the case for cancer. There are two reviews, one on prostate and the other on breast cancer linking teenage consumption of saturated fats with those cancers later in life and there are a number of studies showing that saturated fat increases hormonally driven cancers, for example, aggressive prostate cancer. The Karolinska showed that cows’ dairy consumption and prostate risk was almost a straight line graph; breast cancer nearly so. Milk is a proven risk factor for prostate cancer. Then there is research showing high blood fat levels cause more metastases and reduce survival times. Only recently, saturated fat was shown to increase lung cancer risk.
What may be good for heart disease is, frankly, DANGEROUS for people trying to avoid or beat cancer. I have pulled research on breast, prostate, lung, ovarian and colorectal cancers and their increased risk if you consume high levels of saturated fats.
Go here to read:  Review on Saturated Fat and increased cancer risk and lowered survival
Next, I worry whether parts of this book are actually correct anyway. The locals around the Mediterranean coast did eat grains - bread, pasta and so on. Pasta (noodles) is very much part of the Spanish, French and Italian diets along with rice. Bread is too. Cows’ dairy?? No. Maybe a cheese from a goat or a ewe, but from cows? Very little.
So where is the fat coming from in the coastal communities? Fish, olive oil and nuts and seeds - it is largely UNSATURATED FAT.  And that definitely is healthy. While saturated fat reduced survival in lung cancer patients, unsaturated fat increased survival by 16 per cent.

The Cleveland Clinic presented two research studies linking a compound TMAO from choline and l-carnitine in unsaturated fats in cows’ dairy, red meat and eggs to increased risk of strokes and cardiovascular disease, but showed a compound DMB could control TMAO in the body. DMB is found in Extra Virgin Olive Oil and red wine. Gut bacteria seem crucial to this system.
So, I believe the Rainbow diet is much more accurate reflection of why the Mediterranean Diet is so healthy than the Pioppi diet, in that it focusses on unsaturated fat, includes whole carbohydrates, and the emphasis is on colourful vegetables and fruits, nuts and seeds, fish and lifestyle - keeping moving, less time spent sitting, red wine, a real coffee, fresh air, sunshine, family and friends, and so on.
Ironically, Malhotra chose Pioppi.  Pioppi was the home of Dr Ancel Keys, who died in 2004 at the age of 100. He identified that the reason for the longevity was that the locals ate LOW LEVELS of saturated fat! Pioppi is actually the centre of dietary orthodoxy. The locals do eat carbs and low levels of saturated fat.
Go to: The Rainbow Diet - and how it can help you beat cancer
 

Dr Malhotra’s website: http://doctoraseem.com/

Dr Malhotra’s book, The Pioppi Diet, is being published by Michael Joseph (£8.99) on June 29, 2017