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Transcript in English

MOT: A fatty bubble bursts

Yle TV1, Monday Sept. 13th, 2010

Reporter Martti Backman

> (Numbers in brackets refer to sources listed in this link)

(Image: Oili Ikävalko squeezes an orange, other activities in the kitchen. Cut to Uffe Ravnskov frying bacon and eggs.)

Voiceover (VO): Two breakfasts, two perceptions of healthy food.

Oili Ikävalko: "I’ve already gotten used to this over many, many years. In the winter I cook oatmeal and even warm it in the microwave oven, although that is not very tasty.”

Uffe Ravnskov: "There is absolutely no evidence to support the assertion that animal fats are dangerous."

Ikävalko: "I’ve stopped eating meat over 30 years ago, including chicken. Fish is the only exception."

Ravnskov: "Man is an animal. How could it be dangerous to eat animals. It is a totally sick idea."

Ikävalko: "And then, all milk products, but skimmed of course."

Ravnskov: "You cannot increase your cholesterol by eating cholesterol. The reason is that, if you eat a lot of cholesterol, the production of cholesterol in the liver is reduced. The liver produces three to four times more cholesterol daily than you normally get from food. If you eat a lot of cholesterol, its production decreases; if you eat too little, it will increase."

Ikävalko: "Well now, this is muesli and nuts, with sour milk."

VO: Swedish medical researcher Uffe Ravnskov believes that everything that we have been told about dietary fats and cholesterol is wrong. In his view, the so called saturated fats like butter, milk and other animal fats are healthy food for humans.

(Image: Ravnskov pours a glass of milk and begins to eat his scrambled eggs and bacon)

VO: Oili Ikävalko in turn, has sought to scrupulously comply with the nutritional recommendations by avoiding fats and meat, and eating mostly simple vegetarian food.

(Image: Ikävalko begins to eat her muesli breakfast)

VO: Director-General of the Finnish Health and Welfare Institute, Professor Pekka Puska rose to international fame in the 1970’s, with the North Karelia Project.

The project changed the contents of the Finnish diet. Away with butter, cream and animal fats; replace them with margarine, vegetable oils, vegetables and grain products. The conclusion of the study project in North Karelia was considered robust enough to prove that, high-fat foods cause coronary heart disease, and death.

Pekka Puska: "Yes, it has a significant, adverse impact and it is based precisely on malignant cholesterol, which has a very central role in vascular obstruction."

VO: Pekka Puska is not alone with this view. On the contrary, most of the leading experts in nutritional and cardiovascular research agree with him. But the consensus has begun to crack. More and more doctors and researchers have begun to doubt the foundations of the doctrine. Uffe Ravnskov was one of the first among the skeptics.

Uffe Ravnskov: "Everyone will tell you that, if you eat too much animal fats you are exposed to both heart disease and stroke, but there is no scientific evidence that would have been able to prove this. There is no link. I would argue that the conclusion is rather the opposite. There are six to eight studies which have shown that the risk of stroke is greater among those that have been eating less saturated fat than the others."

VO: It is really difficult to refer to a study, which would prove an undeniable link between fatty food and heart disease. Professor Puska does not even try. Instead, he points out the bad guy in the drama, cholesterol, believed to be the mediator between high fat intake and illness.

Puska: "In drug tests, when cholesterol is lowered, the incidence of heart disease declines. I consider the evidence to be extremely strong. And then again, the fact that diet, along with certain genetic factors, affects blood cholesterol levels quite substantially. This has been demonstrated in tightly controlled laboratory level studies around the world, with always in the way that saturated fat raises blood cholesterol and unsaturated, specifically polyunsaturated reduces it, and therefore it is an essential recommendation to move away from these hard fats to soft vegetable and fish oils."

VO: Animal fats and blood cholesterol levels have indeed been shown to have a link in laboratory experiments. But what about real life?

(Image: country scenes from the Finnish archipelago)

VO: We are in Iniö, a small municipality in the Turku archipelago of the Baltic sea. Researchers from the University of Turku have compared the food habits and health of the people in Iniö to those of North Karelia and the Turku and Pori districts on the mainland. (1)

According to the study, the people of Iniö had best adopted the nutritional recommendations of Dr. Puska’s national authority. They ate only half as much butter that the people in other regions and doubly the amount of margarine than the people in the control areas. In addition, the Iniö folks drank much more skimmed milk than the others, who preferred whole milk.

According to the fat theory, their cholesterol levels should have been significantly lower than those of the controls. But the result of the measurement was the opposite. Iniö men's cholesterol value was on average 7.3 mmol, compared to 6.2 mmol elsewhere in Finland. In women, the difference was even greater.

If we still believe in the fat theory, we would expect that the high cholesterol levels should have caused more deaths due to cardiovascular disease in Iniö. But here comes another surprise. Cardiovascular mortality is lower in Iniö that elsewhere in Finland.

Oili Ikävalko is also living proof ot the conclusion that there is no link between fatty foods and serum cholesterol. She has carefully avoided all intake of animal fats and eaten lightly, but still her cholesterol was high, 7.8 mmol.

The conclusion: the fat theory was falsified, at least in tiny Iniö.

What about the rest of the world?

Puska: "Well, the classic studies, since the seven countries’ study concluded that those countries where the diet includes a lot of saturated fat or little unsaturated fat, they have a lot of coronary artery disease, and vice versa."

VO: At last, a reference to a study! Let us have a look at the "Seven countries’ study”. (2)

The American Ancel Keys collected data from seven countries. He compared the inhabitants’ cholesterol levels with the number of heart attacks. He found that, where there was high cholesterol, there were also a lot of heart attacks and vice versa. Finland was ranked at the top: high cholesterol values and high mortality. The Japanese, with their low cholesterol and low mortality were at the other end of the table. Look at the Japanese and the Finns, the study concluded.

Result of the comparison seemed to show without doubt that cholesterol kills.

(Image: Graphics ot Keys’ study results.)

Inside the examined countries there was however, no connection between heart attacks and cholesterol. Dr. Keys stressed that coronary artery disease was five times higher in Finland than in Japan due to a different diet, but he did not explain why the disease was five times higher in eastern than in western Finland, although the food eaten and cholesterol levels were quite similar.

Other countries also showed high regional variability in heart disease mortality, although cholesterol levels were close to each other. Corfu, Greece, had 10 times more deaths of heart attack than the neighboring island of Crete, even if their cholesterol levels were lower. If the fat theory is correct, the connection between cholesterol and cardiovascular deaths should of course be consistently in the same direction.

A graph of the seven countries study drafted by Uffe Ravnskov shows that the connection between cardiovascular deaths and cholesterol disappears completely if the North Karelian data is removed from the study. Now it looks as if the observation points have been shot with a shotgun.

What then led to the difference between North Karelia and western Finland in cardiovascular mortality, if it wasn’t the food?

North Karelia underwent a very dramatic demographic change in the 1960’s and 70’s. High unemployment, migration to urban centers to Sweden had a huge impact – social networks crumbled.

(Image: Insert from an old TV documentary: "North Karelia is full of anxiety, depression and apathy.")

Ravnskov: "What a stress – this causes stress. This leads to increase in cholesterol levels, and if there is something that exposes people and causes myocardial infarction it is stress. So the explanation is totally different from what has been assumed."

VO: In the follow-up report to the famous seven-country study after 25 years, the connection between nutritional fats and heart disease mortality was left in the background, simply because the fats had no effect anymore.

In Finland, the North Karelia Project led by Pekka Puska was still considered to demonstrate that a poor lifestyle, especially dietary fats resulted in a record of heart disease mortality in the province. The problem was addressed by a strong public awareness campaign aimed at reducing animal fats and increasing the use of margarine and vegetable oil consumption.

Puska: "Everything has gone as we hoped: diets have changed, the cholesterol level decreased, and therefore heart disease mortality has declined much more than expected, when we took on the project as young and eager researchers committed to the fight against heart disease in North Karelia."

(Image: Chart displaying the decrease in heart disease mortality.)

VO: A rapid decline in heart related deaths did indeed seem to prove the researchers’ assumption of a lethal role for butter and animal fats. But what was not expected, was the fact that heart attacks fell by even more in the adjoining province of Kuopio, where people ate butter and other animal fats as before.

In fact, cardiovascular mortality decreased throughout Finland at the same pace without special advocacy. The chart also shows that the decline in cardiovascular deaths had already started a couple of years before the North Karelia Project began.

Puska: "I have no doubt that it is predominantly due to the fact that the whole country has gone through similar changes as those achieved in North Karelia, concerning diet and smoking. Certainly it is a complicated issue, and it is very difficult to distinguish all components of change from each other."

VO: Puska believes that about half of the decline in cardiovascular mortality was caused by reduction in dietary fat intake. Dr. Jukka Salonen, a member of the research team who investigated the effects of various components thinks differently:

Salonen: "The significant decline in smoking, which occurred in North Karelia in the 70's and 80's, was the main factor. In statistical analysis, more than half of the decline in coronary heart disease was explained by it."

VO: Jukka Salonen dissociated himself from the simplified conclusions of the North Karelia Project in an essay published in the prestigious medical journal Lancet.

Salonen: "The Project Director, and many researchers exaggerated and gave a too unequivocal positive image about what the study carried out in North Karelia did to the decline in coronary heart disease in the province and later in the rest of Finland. I think this was never proven in an unambiguous way."

Puska: "He (Salonen) sent a number of observations (to conclusions) where he had been one of the original authors. - - There were indeed a number of divergent views on certain points of detail, yes."

Salonen: "I wanted to stick to good scientific practice and I do not want to confuse health policy with scientific interpretations."

VO: There is a problem for the health propaganda that strongly points a finger to animal fats. It is an inconvenient fact that there is no hard evidence linking butter and other animal fats to cardiovascular disease.

The Health and Welfare Institute (formerly the Institute of Public Health) led by Pekka Puska, commissioned a large study 13 years ago. In the opening remarks to this “Setti-study” it was stated that studies concentrating on the connections between dietary fats and coronary heart disease had not established unequivocal results to prove the classical hypothesis of the impact of diet to coronary disease. (3)

On this basis, the Setti-researchers began to look for that link, i.e. to prove that butter ruins the heart and margarine is good for it. And what they found?

Puska: "I do not remember in detail, but as I’ve said, in many studies it is very difficult - - At the other end there is human nutrition - - we are not talking about a controlled environment, but large population studies, and to connect the diets directly to the disease, has been difficult…"

VO: No wonder that the Health and Welfare Institute does not want to look back at the Setti-study. It showed that consumption of butter had no effect on heart disease risk, but instead margarine increased the cardiovascular disease mortality.

Puska: "As we now view this study, we should look at summaries by experts around the world, and it is perfectly clear that there is a very strong recommendation is to switch from saturated to unsaturated fats, and again, milk and milk fats unfortunately, are those where the saturated fat percentage is very high".

VO: Expert summaries and recommendations, they are aplenty. But where the clear scientific evidence of the dangers of animal fat?

The observation of the Setti-researchers, finding no risk associated with animal fats has been confirmed in at least two other Finnish studies: a risk factor study in Kuopio, and the 30-year follow-up study to the Finnish section of the seven countries’ study.

During the past decade, numerous studies from Sweden, Norway, Britain and the U.S. have said the same thing: there is no evidence of the dangers of animal fats to blood vessels and the heart.

Puska: "I am a bit amused when from time to time someone says that ‘are you familiar with a study that invalidates the whole cholesterol theory’. As if one study could annul the enormous amount of work done around the world – I do count on these extensive expert summaries."

VO: In Malmö, Sweden, it was found five years ago that there wasn’t any connection between animal fat and coronary heart disease in the male population. In women cardiovascular mortality even decreased slightly with increased intake of animal fats. The researchers concluded that there is no solid support for the already traditional recommendations concerning nutritional fats. (4)

The Swedish Professor Bengt Vessby discovered in 2004 that, there were much more milk fats in the blood of healthy individuals than in patients who had suffered a heart attack. The healthy individuals had consumed more butter and cream that those that suffered heart problems. (5)

The Norwegian professor Jan Pedersen confirmed this finding in a study published two years later. (6)

The British Professor Peter Elwood has, in two studies published in recent years, reached the conclusion that high intake of milk and milk products is associated with a lower risk of developing heart disease. Milk was even demonstrated to protect against heart disease. (7.8)

(Image: Transition to Sweden. Cows grazing in a verdant oak grove.)

VO: For 12 years, doctor and researcher Sara Holmberg followed the eating habits and health of nearly two thousand Swedish men living in the countryside. The men enjoyed a relatively high milk intake. Many drank a lot of their own cows’ milk fresh from the barn.

Heavy consumption of milk fat was not shown to increase cardiovascular risk in Holmberg’s study.

Sara Holmberg: "Then we discovered that those who ate a lot of fat had a lower risk of developing cardiovascular disease than those who consumed less fat. And particularly interesting was that, we found a connection between (animal) fat intake and fruit and vegetable consumption. Those who ate fruits and vegetables daily had a very low cardiovascular risk if they also ate a lot of fat."

VO: Conclusion: eating fruits and vegetables protects against cardiovascular disease, but only if you simultaneously eat a lot of animal fat. How, then, should one enjoy strawberries in the summer?

Holmberg: "With whipped cream! Or, as is my custom, fruit salad with cream is very good."

Puska: "Most of the studies we are talking about here are descriptive ones, therefore, they are not based on experimental setups."

VO: Experimental research is therefore needed to prove the fat theory. Here is one study, published four years ago:

This clinical trial conducted in the U.S. involved almost 50.000 women, who were divided into two groups. The first group was fed a lot of animal fat, the other avoided it. No significant difference in mortality or morbidity between the groups was observed. (9)

Different ethnic cuisines are also proof that greasy food does not cause heart disease. – The French eat more butter, cream and creamy cheese than all other Europeans, and yet there is less cardiovascular disease in France than anywhere else.

Neighboring Switzerland is the second healthiest European country measured by cardiovascular morbidity. And the Swiss also eat a lot of hard animal fats – in that respect they are second only to the French. In Switzerland cardiovascular mortality decreased after World War II. The cause must have been a decline in devouring cheese and chocolate? Wrong. As their coronary health improved, the Swiss increased their intake of animal fats by another 20 percent.

There is not much left of the acclaimed lightweight diet of the Mediterranean environment. For example in Italy, in the early part of the 1990's, people ate 70 percent more animal fats than 25 years earlier. Cardiovascular mortality probably increased dramatically? Wrong. Cardiovascular deaths fell by 61 percent.

Also in Japan, known for its’ low-fat national diet, the use of animal fats has increased considerably during the last 40 years. Despite the change, fatal heart attacks have declined in all age groups there.

Could it be that, after all, some factor other than animal fat causes coronary heart disease in Western countries? An answer to this question has been sought by examining people who also eat a lot of animal fats but are otherwise spared of the scourges of western lifestyle. We must look at some native peoples.

The Maasai of Kenya enjoy an extremely one-sided diet, with only milk, meat and blood. Vegetables and fiber they fed to their cows and goats. A Maasai man typically drinks two to three liters of fatty milk per day. During parties, meat consumption may be up to five kilos per capita.

The fat theory would suggest that, Kenya suffers an outright epidemic of coronary heart disease. Wrong again. Their cholesterol levels are among the world's lowest and heart disease is almost unheard of.

(Image: Back to Finland)

Matti Järvilehto (professor of animal physiology, University of Oulu) "Well, plenty of butter, if I eat bread at all. I eat relatively little bread, and when I put butter on it, my basic principle is that if the piece of bread is this thick, the layer of butter should be as thick as the bread. "

VO: Professor Matti Järvilehto sees the human species as a product of evolution, and that’s why he also likes to follow a bestial diet.

Järvilehto: "Yes, very likely humans have received their nutrition mostly from other animals, so that animal fats have been an important factor in the evolution of digestion and metabolism."

VO: Due to current recommendations throughout the Western world, butter and lard have been replaced by polyunsaturated like vegetable oils and their hardened derivative, margarine. This gives concern to a zoologist.

Järvilehto: "The amounts of polyunsaturated fatty acids in our diets have been increased much too much, and I bet at the expense of health."

Pyry-Pekka Suonsivu (General Practitioner, Raahe, Finland): "I had begun to accumulate some overweight, I was tired a lot and felt bad over all.”

VO: Physician Pyry-Pekka Suonsivu decided to put himself to a nutritional test.

Suonsivu: "I used butter and fats, animal fats, eggs, bacon, meat, rich with vegetables, but no potatoes, no cereals."

VO: One month later Suonsivu looked at his laboratory results with trepidation.

Suonsivu: "But my triglyceride levels had plummeted, liver enzyme levels returned to normal and I felt awfully good and lost a lot of weight, so at that point I began to think about whether all that I had believed about nutrition was actually true.”

VO: At the population level, simultaneously with a large reduction in fat and animal fat consumption the number of people with weight problems and obesity has increased sharply.

Suonsivu, "Obviously this has contributed to the increase in metabolic syndrome."

VO: Also the increase in intestinal problems has been connected to the increase in soft dietary fats. Taija Somppi is a physician who encounters the problem daily.

Taija Somppi: "Well, I have recommended my patients to abandon vegetable oil spreads and use butter instead. And then the other thing is, people eat so much carbohydrates, high-speed carbohydrates, bread, pasta, stuff like that, and for many that also causes symptoms."

Pekka Puska: "Surely it is a bit bit of a paradox that this nutritional debate has been connected to the observation that people are gaining weight – dietary recommendations are criticized for obesity. If people followed the recommendations, I am sure they could keep their weight under control. "

VO: During the past two years, three large international meta-analyses have published. They have assembled hundreds of individual studies on links between fats and heart disease. The total number of subjects in the studies is 800.000 people. (10, 11, 12)

All three analyses concluded that, the link between saturated animal fat consumption and cardiovascular mortality and cardiovascular disease was nonexistent.


Instead, one meta-analysis found that polyunsaturated vegetable oils strongly increase cardiovascular deaths. This result was found to apply to practically all oils with the exception of olive oil and rapeseed oil with certain reservations.

A veteran of the fat wars, former Valio (dairy company) Research Director, Professor Kari Salminen is not surprised.

Salminen: "The arguments against saturated fat have practically evaporated in recent years. And the recommendation to reduce saturated fat in the Finnish diet has led to serious problems: one is that an increase in the proportion of carbohydrates has been recommended and, unfortunately, it has caused the amount of especially rapid energy-producing carbohydrates to increase. And this is a big problem. "

Järvilehto: "Many benefit from the fat theory at the moment. One of the beneficiaries is, of course the food industry, specifically margarine industry… And in addition, a huge research funding is directed towards the study of cholesterol."

Puska: "Well, there is a huge amount of research, from animal tests to nutrition surveys, population studies, on lowered cholesterol, and in my view, the evidence is overwhelming. I would consider it irresponsible, if we could not continue to work on this basis in Finland."

VO: When Uffe Ravnskov’s ideas were last presented on Finnish television in 1993, his book ended up being burned. (Archive pictures of the book-burning.)

Ravnskov: "It is very difficult to challenge such general truths. Nor should we forget that it is very difficult for a scientist to stand up and say that, what he has believed throughout his career and what has been published many studies is actually wrong."

VO: On October 18th, MOT will continue on the theme of fat by looking at cholesterol medication, its effectiveness, impact and cost.

Oili Ikävalko: "ON my morning walk I suddenly got a feeling that, I don’t dare take another step. My thighs were completely rigid…”