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Why Has the American Approach to Heart Disease Failed?


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A recent New York Times article correctly suggests that diet and lifestyle changes are far more effective ways to prevent and treat heart disease than statins and stents. But what diet, and what lifestyle? Is it as simple as avoiding “artery-clogging saturated fat,” as the author suggests? Read on to find out why the American approach to heart disease has really failed.

Heart disease in America is on the rise.
Saturated fat has been demonized for decades as the primary cause of heart disease. istock.com/a_namenko

Jane Brody wrote an article in The New York Times called “Learning from Our Parents’ Heart Health Mistakes.” She argues that despite decades of advice to change our diet and lifestyle in order to reduce our risk of heart disease and improve our heart health, we still depend far too much on drugs and expensive procedures like stents.

She says:

Too often, the American approach to heart disease amounts to shutting the barn door after the horse has escaped.

To support this argument, she refers to a recent paper published on the Tsimane, an indigenous population in the Bolivian Amazon. The study found that the rate of coronary atherosclerosis in the Tsimane was one-fifth of that observed in the United States (and the lowest that has ever been measured). Nearly nine in 10 Tsimane had unobstructed coronary arteries and no evidence of heart disease, and the researchers estimated that the average 80-year-old Tsimane has the same vascular age as an American in his mid-50s.

I certainly agree with Ms. Brody so far, and her analogy that the American approach to heart disease amounts to shutting the barn door after the horse has escaped is spot on.

The problem is what comes next, as she attempts to answer the question of why the Tsimane have so much less heart disease than Americans:

Protein accounts for 14 percent of their calories and comes primarily from animal meats that, unlike American meats, are very low in artery-clogging saturated fat. [emphasis mine]

Does Saturated Fat “Clog” Your Arteries?

Artery-clogging saturated fat? Are we still using that phrase in 2017?

As I’ve written before, on average, long-term studies do not show an association between saturated fat intake and blood cholesterol levels. (1) (I say “on average” because individual response to saturated fat can vary based on genetics and other factors—but this is a subject for another article.)

If you’re wondering whether saturated fat may contribute to heart disease in some way that isn’t related to cholesterol, a large meta-analysis of prospective studies involving close to 350,000 participants found no association between saturated fat and heart disease. (2)

Does saturated fat really “clog” your arteries?

Are “Clogged Arteries” the Cause of Heart Disease?

Moreover, as Peter Attia eloquently and thoroughly described in this article, the notion that atherosclerosis is caused by “clogged arteries” was shown to be false many years ago:

Most people, doctors included, think atherosclerosis is a luminal-narrowing condition—a so-called “pipe narrowing” condition. It’s true that eventually the lumen of a diseased vessel does narrow, but this is sort of like saying the defining feature of a subprime collateralized debt obligation (CDO) is the inevitable default on its underlying assets. By the time that happens, eleven other pathologic things have already happened and you’ve missed the opportunity for the most impactful intervention to prevent the cascade of events from occurring at all.

To reiterate: atherosclerosis development begins with plaque accumulation in the vessel wall, which is accompanied by expansion of the outer vessel wall without a change in the size of the lumen. Only in advanced disease, and after significant plaque accumulation, does the lumen narrow.

Michael Rothenberg also published an article on the fallacy of the “clogged pipe” hypothesis of heart disease. He said:

Although the image of coronary arteries as kitchen pipes clogged with fat is simple, familiar, and evocative, it is also wrong.

If Heart Disease Isn’t Caused by “Clogged Arteries,” What Does Cause It?

The answer to that question is a little more complex. For a condensed version, read my article “The Diet-Heart Myth: Why Everyone Should Know Their LDL Particle Number.” For a deeper dive, read Dr. Attia’s article.

Here’s the 15-second version, courtesy of Dr. Attia:

Atherosclerosis is caused by an inflammatory response to sterols in artery walls. Sterol delivery is lipoprotein-mediated, and therefore much better predicted by the number of lipoprotein particles (LDL-P) than by the cholesterol they carry (LDL-C).

You might think that I’m splitting hairs here over terminology, but that’s not the case. It turns out that this distinction—viewing heart disease as caused by high LDL-P and inflammation, rather than arteries clogged by saturated fat—has crucial implications when it comes to the discussion of how to prevent it.

Because while it’s true that a high intake of saturated fat can elevate LDL particle number in some people, this appears to be a minority of the population. The most common cause of high LDL-P in Americans—and elsewhere in the industrial world—is almost certainly insulin resistance and metabolic syndrome. (I explain why in this article.)

And what is one of the most effective ways of treating insulin resistance and metabolic syndrome? That’s right: a low-carbohydrate, high-fat diet!

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News Flash: Diets High in Saturated Fat May Actually Prevent Heart Disease

Perhaps this explains why low-carbohydrate, high-fat diets (yes, including saturated fat) have been shown to reduce the risk of heart disease.

For example, a meta-analysis of 17 low-carb diet trials covering 1,140 obese patients published in the journal Obesity Reviews found that low-carb diets were associated with significant decreases in body weight, as well as improvements in several CV risk factors, including decreases in triglycerides, fasting glucose, blood pressure, body mass index, abdominal circumference, plasma insulin, and C-reactive protein, as well as an increase in HDL cholesterol. (3)

(In case you’re wondering, low-carb diets in these studies had a null effect on LDL cholesterol: they neither increased nor decreased it.)

Saturated Fat Is a Red Herring

Instead of focusing so much on saturated fat intake, which is almost certainly a red herring, why not focus on other aspects of the Tsimane’s diet and lifestyle that might contribute to their low risk of heart disease? For example:

  • They are extremely active physically; Tsimane men walk an average of 17,000 steps a day, and Tsimane women walk an average of 15,000 steps a day—and they don’t sit for long periods. Ms. Brody does mention this in her article.
  • They don’t eat processed and refined foods. We have been far too focused on calories and macronutrient ratios and not enough on food quality. We now know that hunter–gatherers and pastoralists around the world have thrived on both high-carbohydrate, low-fat diets (like the Tsimane, who get 72 percent of calories from carbohydrate) and low-carbohydrate, high-fat diets (like the Masai and Inuit). But what all hunter–gatherer diets share in common is their complete absence of processed and refined foods.

Perhaps if we stopped focusing so much on the amount of fat and carbohydrate in our diet and started focusing more on the quality of the food we eat, we’d be better off.

And of course we also need to attend to the many other differences between our modern lifestyle (which causes heart disease) and the ancestral lifestyle (which prevents it), including physical activity, sleep, stress, light exposure, play/fun, and social support.

The Tsimane study illustrates exactly why an evolutionary perspective on diet, lifestyle, and behavior is so important. It helps us to generate hypotheses on what aspects of our modern way of life may be contributing to chronic diseases like atherosclerosis and gives us ideas about what interventions we need to make to prevent and reverse these diseases.

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Join the conversation

  1. Saturated fat does not cause heart disease except for the 10% of the poulation that it does. Peter Attia points this out regularly in his podcast and blogs I know because it happened to me. No it is not the APO gene. There are many genes which affect fat metabolism, FTO and para to mention a few.

  2. Every article I read on here is more enlightening to me. My question is, are there any studies/science that indicate the true dangers of high triglycerides and the need to control them via medication? Any info you can provide or point me to for further research would be greatly appreciated.


    • If you’ll do a little research on the internet you’ll find that high triglycerides don’t help at all but getting sufficient amounts of “real” vitamin C daily can protect you from the triglycerides to some degree. Of course if you have high blood pressure then that will work against you when it comes to clogged arteries.
      Getting enough daily Vit C takes some work, especially if you’re not taking “real” natural Vit C????
      For example, Bears (and most mammals) don’t get arteriosclerosis even though Bears gorge themselves with as much fat as possible during the summer then sleep (no exercise) for 4-6 months. Why??…….because most mammals produce their own Vit C. Humans do not!! Without sufficient amounts of Vit C your body can not properly repair internal damage to your arteries. If you have high triglycerides your body will use them to cover (repair) the damage (in the absence of sufficient Vit C). The triglycerides keep piling on until your arteries become too clogged for the heart to get enough oxygen.


      • If you read posts by Zoe Harcombe, for example, you won’t fear cholesterol at all. Only exception would be Familial Cholesterol, but even then, the old info about “high” cholesterol/triglycerides is being updated all the time. Look at new resources like Chris’s site here and others like him; otherwise you’ll find a lot of misinformation if you follow mainstream dieticians and other “health experts.”

  3. Here is an excellent review and analysis of the latest American Heart Association Statement on Cardiovascular disease


    It seems AHA is reducing emphasis on the significance of LDL levels and looking more at triglycerides, VLDL, and HDL-C.. They don’t put much emphasis on LDL particle size as they think the correlation is due to it being linked with triglycerides but I suppose the dietary and lifestyle recommendations would be the same anyway

    • Sorry, but I wouldn’t trust a single word that comes out of the mouth of The AHA. They are in bed with the Soybean manufacturers and other Big Food, so they are industry-bought and can’t be trusted.

    • Regarding diet and lifestyle, it is well established but not widely enough known, that a high sodium/potassium ratio increases risk of heart disease and hypertension:

      Sodium-to-Potassium Ratio and Blood Pressure, Hypertension, and Related
      Vanessa Perez, and Ellen T. Chang
      Adv Nutr vol. 5: 712-741, 2014 (open access)

      The following articles report that approximately halving sodium and doubling potassium intake, together with some increase in magnesium leads to improved mood by several measures:

      Dietary electrolytes are related to mood
      Br J Nutr. 2008 Nov;100(5):1038-45
      Torres SJ, Nowson CA, Worsley A.

      The actual diets are reported in:


      None of this is surprising considering that a high Na/K ratio increases intracellular sodium, and so disturbs the cross membrane voltage and ion gradients which drive numerous processes in every cell in our body. Drugs can’t fix this – but reducing sodium and increasing potassium intake is relatively easy. Potassium gluconate, dissolved in water, is a relatively new form of potassium supplementation, which has a much milder taste than other potassium supplements. The US RDA for potassium is 4.7 grams.

      • Have you read The Salt Fix, which just came out last month? Very eye-opening science behind our need for salt and how we’ve been mislead for years about needing to cut back. Great book and highly endorsed by any doctor worth their ‘salt’ 😉

  4. Did you miss the story in JAMA on September 10th, 2016? I mean, why all this hand-waving when the Journal of the American Medical Association, which reaches most medical professionals, exposed the worst mass-murder conspiracy in history.

    Three Harvard nutritionists, the most respected nutritionists in the world, published an article in the New England Journal of Medicine in 1967 blaming fats and cholesterol as the cause of coronary heart disease, the world’s biggest killer.

    There were two huge problems with this. First, their own research had shown the real causes were carbohydrates and sugar. Second, they were bribed by the Sugar Lobby to lie to the world.

    As a result, since 1967, billions of people around the world who take their lead from America in dietary pronouncements have gone to an early painful death from lifestyle diseases which include obesity, cancer, type 2 diabetes, dementia, arthritis, and more.

    Stop dancing around the periphery and as an American, take some damn responsibility and get your story straight.

    I mean, how hard is it when a simple Google search yields 4,700,000 results!


  5. Hello Chris Kresser, the article speaks right. In the name of Development and the luxurious life, we are traveling the life journey towards unhealthy. I hope Stress-free, quality food, and regular warm up will help a bit to a healthy life. Thanks for sharing valuable information.

  6. What’s worse than heart disease is the quality of life that most people live today. In the modern world, we are like the walking dead… low energy… brain fog… moody… unhealthy… and unhappy… it doesn’t have to be that way.

    I’d be willing to bet that a return to ancestral living would not only improve quality of life, but it would improve all cause mortality too (inclusive of heart disease).

    Since we are on the topic of heart disease, I’d say getting cold (really cold) is pretty darn important to improving heart health… We have 60,000 miles of blood vessels within us that almost never get the movement they need. In the modern world, we just put on some clothes… turn on the heater… turn on the hot water… or we avoid cold altogether by staying inside.

    We need to take our blood vessels for a walk too. We do this by hot and cold exposures. In the process, vasoconstriction and vasodilation (movement) takes place. Those 60,000 miles of blood vessels are lined with smooth muscles that finally get a workout.

    This is easy to implement… start with cold / hot shower contrasts for 20 or 30 seconds at a time. You will notice that your ability to withstand cold will increase considerably after only a few days. Like any other stressor, we adapt… it’s gets easier… and it starts to feel amazing.

  7. I recently had a full panel done on my cholesterol, everything is good except my LDL-C and my ApoB are slightly elevated (ldl-c: 112/ apoB: 85 mg/dL) and my HDL-L is very low (6104 nmol/L) but LDL-P is great (1110 nmol/L)

    I’ve read on Chris’s website that this can be related to either insulin resistance (which, I had my insulin levels checked and they are within range (insulin: 8.3 uIU/mL) (prolactin 6.9 ng/mL), A1c (5.3) and my fasting glucose is at 84 so I’m not sure if that could be the cause or he also says this could be from an infection like h-pylori but my hs-crp and lp pla2 activity are all very low so maybe it’s just low grade? Anyone ever experience anything like this? What tests did you do afterwards to figure out what might have caused it?

    I go to see my FMD tomorrow but if anyone has any insight that I can take to him tomorrow for a better direction to maybe go that would be helpful.

    I thought maybe I could increase my HDL but from what I’m reading HDL isn’t quite the magical answer that everyone might suggest. :/ although I’m sure that it does need to come up quite a bit.

    I do have a desk job and am not as active as I need to be so this could also be the cause for the numbers as well, specifically the HDL.

    I follow a very strict AIP diet ONLY organic and consume around 5-8 servings of veggies a day, sometimes more and try to consume around 50-75 grams of starchy veggies a day. I eat meat with every meal and I try to switch it up quite a bit and I’ve been adding in even more seafood every day. I have been adding a smoothie to my morning regime but I try not to go above 25 grams of sugar a day and I always make sure to include a fat with it. Every plate I make has veggies/protein/starch/fat except breakfast which is where I leave out the starch.

    I am considering following the Mediterranean Paleo approach to see if those numbers will come down and if my HDL will increase.

    I really am quite pleased with the numbers though especially since American medicine likes to tell us that fat is the devil and I literally eat good fats everyday. Maybe I need to cut back on how much I consume though?

    Any thoughts?

  8. Definitely agree. Simply stated, the closer to organic you can get the better. I’ve cut out an immense amount of sugar and processed foods from my diet. Surprising in my industry as a Chiropractor, I stumble across many clients whose pain correlates to weight problems, so it all funnels down.