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Response to a subscriber
People often are very attached to their diets, and reluctant to change their minds about diet and health. I regularly receive emails from people who advocate for different diets asking me to consider my company’s dietary recommendations. The emails are varied but basically fall into two categories: testimonials (I eat a high fat diet and have never felt better!); or “research” that supposedly refutes the benefits of a plant-based diet.
A health professional advocating for a keto diet recently asked me to respond to a study that this person says shows that vegetarians have a higher risk of stroke. Here is my response:
A study published in the British Medical Journal concluded that fish eaters and vegetarians had lower rates of ischemic heart disease than meat eaters, but that vegetarians had higher rates of hemorrhagic and total stroke.[1] In response, the Paleo and Keto promoters were ecstatic and the plant-eaters were deflated. All groups grossly misreported and misunderstood the significance of the study’s findings.
The results were drawn from the EPIC-Oxford study, which includes approximately 65,000 men and women who were recruited from the UK between 1993 and 2001. A baseline questionnaire asked four questions concerning consumption of meat, fish, dairy and eggs. These questions were used to classify participants into groups:
Meat eaters – participants who ate meat regardless of whether or not they ate fish, dairy or eggs
Fish eaters – participants who did not eat meat but did eat fish
Vegetarians – participants who did not eat meat or fish but consumed dairy and/or eggs
Vegans – participants who did not eat meat, fish, dairy or eggs
There were so few vegans that the vegan group was combined with the vegetarian group.
The baseline questionnaire also included a food frequency section with 130 food items which asked subjects to evaluate dietary intake during the previous year. Some specific dietary records were obtained to validate the FFQs, but in order to calculate food intakes, the frequency of consumption for each food and beverage was multiplied by a standard portion size. To calculate nutrient intake, food composition tables were used.
Data were also gathered on factors like education, smoking, physical activity, dietary supplement use, oral contraceptives, hormone replacement therapy, and socioeconomic status. Follow-up questionnaires were completed by most of the participants.
Issues With Self-Reported Data
The first issue with this study is the use of self-reported data, which is notoriously inaccurate. For example, according to one research group, the self-reported dietary data provided by Americans as part of the USDA’s National Health and Nutrition Examination Survey (NHANES) is essentially meaningless due to the disparity between what people say they eat and what they actually eat. The authors write that memory-based dietary information is “fundamentally and fatally flawed” and should not be used in public policy discussions or in developing dietary guidelines for Americans.[2]
The authors report that in a high percentage of surveys, respondents report that they consumed fewer calories than what would be required just to meet calorie needs to sustain basal metabolic rate (calories burned while at complete rest – doing nothing all day). These data indicate that most people should be losing weight, but the opposite is true – most people report maintaining or gaining weight, which means that the information they are providing about their food intake cannot be correct.[3]
Lead researcher Ed Archer says that surveys involving self-reported data are not better than nothing, but rather “They are worse than nothing, because they give us the illusion of knowledge.” Furthermore, it is impossible to quantify the level of underreporting to make the data useful. Instead, he says, there is underreporting and over-reporting in every category and there is no discernible pattern. The best we can expect to get from these surveys are “…an interesting insight into people’s perceptions about what they eat.”
In the case of the EPIC study, not only were data self-reported, but part of the self-reporting included asking people how many times they ate or drank 130 items during the previous year. Ask yourself these questions:
How many times did you eat an apple during the last 12 months?
How often do you eat asparagus?
How many potatoes or servings of potatoes do you think you have per week on average?
I’ve never spoken with anyone who can provide information that would be remotely accurate using this method of data collection.
Problems With Definitions
Another issue with the study was the criteria for the vegetarian category. The vegetarians reported eating dairy, eggs, or both. Eggs are high in cholesterol and fat, with just one egg containing 275 mg of cholesterol and 20% of calories from saturated fat. A study published in the Canadian Journal of Cardiology showed that those who consume the most eggs have a 19% increased risk of cardiovascular disease, and just one egg per day can increase the risk of CVD for diabetics. The researchers wrote, “Patients at risk of cardiovascular disease should limit their intake of cholesterol. Stopping the consumption of egg yolks after a stroke or myocardial infarction would be like quitting smoking after a diagnosis of lung cancer: a necessary action, but late.”[4]
Dairy is the leading source of saturated fat in westernized diets.[5] Just one ounce of cheddar cheese contains 6 grams of saturated fat, and just a half cup of vanilla ice cream contains 4.5 grams of saturated fat.
Additionally, one can eat a diet that qualifies as “plant-based” (vegetarian or vegan) but is quite unhealthy due to the inclusion of junk foods. Potato chips, beer, and many cookies and pastries may be vegan, but they are not health-promoting. And many of the meat and cheese substitutes are just as high in calories and fat as the foods they replace in the diet.
The bottom line is that all of the groups were consuming foods high in saturated fat and cholesterol. Since the vegans were such a small population that they were added to the vegetarian group, it’s highly unlikely that their elimination of animal foods would have made a difference in the findings from the cohort.
What the Results Really Showed
Analysis of this highly flawed data showed that vegetarian diets were associated with 10 fewer cases of ischemic heart disease per 1000 population over a 10-year period; and 3 more cases of total stroke per 1000 population over 10 years. It’s surprising that there were any differences at all since the diets were quite similar in terms of fat and cholesterol intake. Even so, the researchers attributed the lower incidence of ischemic heart disease in the fish eaters and vegetarians to their lower body mass index, lower incidence of hypertension, lower cholesterol, and lower incidence of diabetes.
Acknowledged Limitations
The authors admit that while the cohort was large, a limitation of the study is the fact that the data were self-reported. The researchers stated that they did not collect data on drug treatment, including statin drugs. If enough at-risk meat-eaters who met the criteria for benefitting from statin drugs were included in the study, this may have given drugged meat-eaters a slight advantage. Finally, the authors admit that confounding from both other dietary and non-dietary factors is possible, which could skew the results.
Lessons from Other EPIC Findings
Other questionable/useless information has been reported from EPIC researchers. For example, a study published in 2010 reported that eating more servings of fruits and vegetables did not significantly reduce the risk of cancer, writing that a “high intake of vegetables, and fruits and vegetables combined, is associated with a small reduction in overall cancer risk.”[6] Analysis of this study show that the “higher intake” of fruits and vegetables was about 150 grams of fruits and vegetables per day – the equivalent of about one cup of cherry tomatoes or 1.5 medium bananas. This hardly constitutes “high intake.” Even so, if applied to the general population even this small amount of plant-eating could prevent about 2.5% of cancers, which makes the headline a bit misleading.[7]
Conclusions
This study is a lot of fuss about nothing. It’s an observational study which is plagued by poor study design and which reports data which are virtually meaningless. A health professional citing such a study to refute the benefits of a plant-based diet would benefit from taking my research and writing course, which starts next Tuesday, to learn how to accurately read and report research findings.
Igniting the Curiosity Gene: Research and Writing - Starts Tuesday Feb 27
You will learn how to:
accurately read and interpret published articles and data
use your skills to help patients/clients make INFORMED decisions about their health
write articles and papers and deliver lectures/presentations on any health-related topic.
This is a must for anyone who wants to be a good clinician.
Consists of eight live and interactive teleconference classes; in between each class you are required to complete a research assignment or write a referenced paper.
Tuition: $845.00
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Special Note
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Until this systemic problem is resolved, all practitioners – both licensed and unlicensed – are at risk of being investigated by licensure boards. In some cases, investigations can lead to criminal prosecutions.
Our lawyers have prevented licensure revocation for many doctors and restored the licenses of several, often without the usual practice restrictions the state likes to impose. MAFA’s executive staff has a long history of successfully fighting restrictions on the practices of unlicensed professionals in several states and winning some of those battles as well.
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[1] Tong T, Appleby PN, Bradbury KE et al. “Risks of iscaemic heart disease and stroke in meat eaters, fish eaters, and vegetarians over 18 years of follow-up: results from the prospective EPIC-Oxford study.” BMJ 2019 Sep;366:14897
[2] Archer E, Pavela G, Lavie C. “The Inadmissibility of What We Eat in America and NHANES Dietary Data in Nutrition and Obesity Research and the Scientific Formulation of National Dietary Guidelines.” Mayo Clin Proc July 2015;90(7):911-926
[3] Archer E, Hand G, Blair S. “Validity of U.S. Nutritional Surveillance: National Health and Nutrition Examination Survey Caloric Energy Intake Data, 1971-2010.” PLoS One October 9, 2013 DOI: 10.1371/journal.pone.0076632
[4] Spence JD, Jenkins DJ, Davignon J. “Dietary cholesterol and egg yolks: not for patients at risk o vascular disease.” Can J Cardiol 2010 Nov;26(9):e336-339
[5] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3546624/table/nutrients-04-02097-t005/?report=objectonly
[6] Boffetta, P, Couto, E, Wichman J, et al. “Fruit and Vegetables Intake and Overall Cancer Risk in the European Prospective Investigation into Cancer and Nutrition.” J Natl Cancer Inst 2010;102(8):529-537
[7] http://www.scientificamerican.com/article/fruits-and-veggies-cancer/