Prudent Diet: Were The French Right About Fat?

by Research Insights

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Remember back in the 1970s when, in the US, UK and Australia, fat became the dietary enemy? The thing we had to a eradicate from our diets and replace with healthy margarine and vegetable oils? Meanwhile, the French were piling their plates with full fat brie and pâté de foie gras. So, who was right?

Saturated fat and cholesterol in the diet are not the causes of coronary heart disease. That myth is the greatest scientific deception of this century, perhaps of any century.’

Dr George V. Mann, Associate Director, Framingham Heart Study

Main Points

  • The theory that eating fatty foods cause heart disease arose in 1950s;
  • ‘The French Paradox’ showed an inverse relationship in the 1990s;
  • The ‘Mediterranean’ diet showed more impact on heart disease than any other;
  • Lowering cholesterol does not equate to lowering heart disease risk;
  • Boomers need more cholesterol, not less, as we age.

(If you’d like to skip directly to the way of eating that applies the health benefits of the Mediterranean Diet to satisfying, gourmet foods that help you lose weight, read more about the MMM! Anti-diet.)

The 7 Countries Study

American Physiologist, Dr Ancel Keys

It all began back in the 1950s, when American physiologist Ancel Keys promoted the new idea that eating saturated fat raised blood cholesterol levels which caused heart disease. Keys devised the famous ‘Seven Countries Study‘ which was widely accepted as proof of this hypothesis.

Interestingly, Keys study didn’t include countries like France, Spain, Belgium or Switzerland, which had – and still have – the lowest rates of heart disease in Europe and the highest rates of fat consumption. (More on this later.) At the time, Keys argued that neither exercise nor smoking played a role in heart disease; this has since been updated. Incredibly, physicians and dieticians bought this story.

By the time Britain’s foremost nutritionist John Yudkin’s book about sugar called Pure, White and Deadly saw the light in 1972, Keys’ cholesterol hypothesis had already become doctrine, fat was the enemy and Yudkin was declared a heretic.

The Bad News

In the 1980s, the US National Institutes of Health (USA) launched the Lipid Research Clinics Coronary Primary Prevention Trial (LRC-CPPT), which enrolled 3,800 American men recorded to have high cholesterol. The trial gave half of them cholestyramene, a foul-tasting bile acid sequestrant to sprinkle over their breakfast cereal.

There was no placebo group, and all participants were encouraged to reduce their saturated fat and cholesterol intake at the same time. In other words, there was more than one variable; clearly this was not a gold-standard trial.

The triumphant trial leaders reported a risk reduction of heart attack of 19% (which was relative) even though the absolute risk was just 1.1%. (More on the 4 numbers you need to know and how they’re calculated, here.) The broadcast take-home message was simple: a 1% reduction in cholesterol reduces the risk of a heart attack by 2%.

Once it was accepted that high cholesterol caused heart disease and low cholesterol was the goal, it wasn’t long before a faster solution than diet was found: cholesterol-lowering drugs. The ‘statin’ class of drug emerged in the 1980s and it achieved its objective – lowering cholesterol – with brutal efficiency. The question was, did lower cholesterol translate to lower levels of heart disease?

Paradoxes by the Numbers

In the early 1990s, a research paper stunned the medical world by showing that the French ate their way through mountains of triple cream brie, pâté de foie gras and duck cooked its own fat – yet, they had half the rate of heart disease compared to Americans, Britons and Australians, and lived two years longer.

The AHA Diet or Prudent Diet with the fat base of starch

Given this news and the millions of lives lost to heart disease every year, you might have expected cardiologists and nutritionists to jump on the next flight to France to find out what they were doing.

No such luck; instead they coined a new term to explain this called the ‘The French Paradox’. They tried to explain it in all manner of ways: that French doctors routinely under-reported heart disease, or that is was the spermadine in Roquefrort cheese, or that the whole story was concocted to avoid affecting sales of French wine.

The real paradox was that, just like the French, the Spaniards, Italians, Belgians and Swiss were also eating diets high in saturated fats (think about all that cheese, butter and mayonnaise), and they all had lower levels of heart disease than people in the UK, US and Australia. Another paradox was the poor correlation between blood cholesterol levels and mortality. The Swiss had the highest cholesterol levels in Europe (6.4) yet among the lowest rate of heart disease; and their obesity rate was just over 10%.

The French paradox is the observation of low coronary heart disease (CHD) death rates despite high intake of dietary cholesterol and saturated fat.

National Institutes of Heath (USA)

More paradoxes emerged: the French had normal cholesterol levels, yet consumed more butter than any country on earth. Belgium’s cholesterol levels weren’t far behind Switzerland’s, yet its rate of heart disease was in the lowest. Russia had very low cholesterol readings, yet heart disease was out of control which, surprisingly, was mirrored Down Under in First Nations people. What on earth was going on?

The French Fight Back

Maybe miffed because France wasn’t included in the Seven Countries Study, French researchers set up the Lyon Diet Heart Study to track the effect of diet on people who had suffered at least one heart attack.   The research group comprised 300 participants which were were split into two groups, each following one of these diets over four years: 

1. Mediterranean Diet (MD) high fat, low carb, supplemented with linoleic acid, or

2. American Heart Association (AHA) Diet, the ‘Prudent Diet’, low-fat, high-carb.

Published in 1999, results were stark: a 50-70% absolute reduction in heart attacks, strokes and deaths for group 1 (Mediterranean Diet) compared to group 2 (AHA the control group).

Worse for the AHA group, the trial was cut short after 27 months due to excessive morbidity and mortality in this group.

Then, a follow-up of the Mediterranean group at the 46-month mark showed ‘the protective effect’ of the diet had been maintained for the full period. Ouch.

...subjects following the Mediterranean-style diet had a 50% to 70% lower risk of recurrent heart disease…’

Lyon Diet Heart Study 2001

More Drugs to The Rescue

Not learning much from this, a decade or so later, patents on statin drugs were running out. As a result, their makers were busily testing promising replacements called Cholesteryl Ester Transfer Protein (CETP) Inhibitors, with several concurrent trials underway by different companies.

Eli Lilly was the first to pull the pin in 2015, announcing the termination of its Phase III trial with its CETP Inhibitor evacetrapib. The trial had enrolled 12,000 patients in 37 countries and had only been running for two years. It had two more to go, so why stop?

In early trials, CETP inhibitors had lowered LDL levels by 40% and more than doubled HDL levels. Yet, when the trial leaders checked the interim results, the number of deaths in the drug group was the same as in the placebo group. It was the same story with heart attacks and strokes. They checked the records of participants, to see if the drug had failed to work.

The drug had worked brilliantly: it had reduced LDL readings by 37%, and increased HDL readings by 125%. In other words, the drugs were even more effective at moderating good and bad cholesterol than statins had been, but this had no effect on the number of heart attacks. Ooops.

Pfizer and Roche also abandoned trials of their new CETP inhibitors. When reporters asked the experts what had gone wrong, Steven Nissen from the famous Cleveland Clinic made a memorable statement; he said that it wasn’t just a matter of lowering LDL, it was how the lowering was done that was the critical factor. (I can’t help thinking that, if my grandson gave an answer like that in his science class, the teacher would suggest he might be more suited to the arts.)

Boomers Need More Cholesterol

Moving along, a recent meta-analysis of studies involving more than 68,000 participants over 60 years of age found that older people with high levels of low-density lipoprotein (LDL-C or ‘bad cholesterol’) live as long, and often longer, than their peers with low levels of it.

A number of studies have shown similar results. This is hardly surprising given that cholesterol is essential for repairing damage to our boomer bodies caused by wear and tear. It’s the glue and the putty.

It turns out that Cholesterol is absolutely essential to our health and survival, even more so as we get older. Cholesterol plays a key role in building cell membranes, nerve conduction, synthesis and intra-cellular transport of fat‐soluble vitamins (A, D, E, and K), and as a precursor for sex and steroid hormones.

25% of the cholesterol produced by our livers goes to our brains; the myelin sheath surrounding our nerves is next in line. We couldn’t function without cholesterol, so why did it get such a bad wrap?

It can all be traced back to the selection of the seven countries for Ancel Keys’ study and that fact that cardiologists in the US, UK and Australia swallowed the ‘cholesterol causes heart disease’ mantra hook, line and sinker and then defended it against all the contrary evidence. Meanwhile, the French and other Europeans were sipping their wine, smothering their meat in butter and savouring their full-fat soft cheeses, all the while watching their heart disease rates drop relative to the Americans.

I don’t know about you but, if high cholesterol doesn’t cause heart disease, the buttery, satisfying, mouth-filling diet of the Europeans looks a whole lot more attractive to me than the margarine-filled, low-fat, high-starch diet of the Americans. The French have always known a lot more about good food than the Yanks, in my book.

If you like good food as much as I do, find out how to eat more of it AND lose weight (as well as shrugging off the heart diseases myth) in our ebook: MMM! Lose Weight The Food Lover’s Way.

Lose Weight


Discover The Muscles & Marbles Mediterranean Anti-diet


Lack of an association or an inverse association between low-density-lipoprotein cholesterol and mortality in the elderly, British Medical Journal

Cholesterol goes up heart disease goes down, Malcolm Kendrick

The Highs and Lows of Cholesterol: A Paradox of Healthy Aging?, American Geriatrics Society

Kim Brebach

Kim Brebach

Hi, I’m Kim Brebach, boomer, information researcher, technical writer and Joiner of Dots at M&M. In my spare time, I review wines and love to cook.

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