Friday, December 10, 2021

Thoughts on Nick Hiebert's “A Comprehensive Rebuttal of Seed Oil Sophistry”

Introduction

Consider this a follow-up of sorts to my post and debate with Alan Flanagan (Goodrich, 2021a, 2021b), if you want some background.


Nick Hiebert (Hiebert, 2021a), whom I have been interacting with for several years on Twitter, thought he could do a better job than Alan did, and challenged me to a debate. After going through a little back-and-forth on format, it became clear that Nick wanted to debate me only if he could have a moderator that would take his side in his view of the facts and the logic. I proposed a standard Oxford-style debate, where such matters are handled by the debaters, and the moderator simply enforces the rules (time, taking turns, etc.).

Nick refused, and blocked me. And then apparently wrote this, “A Comprehensive Rebuttal of Seed Oil Sophistry” (Hiebert, 2021b). And then challenged me again to a debate (I’ve been told), which I couldn’t see, as he has continued to block me. Which is most amusing, but…

After several requests, I’ve decided to take a look at his post. I’m responding as I read it, as it’s 60-odd pages long*. I am doing this in the manner of an audit. I’m not going to go through the whole thing, but until I have a feeling that I can assess the quality of the argument to my satisfaction, and hopefully to that of the reader.

Off to a start, not a strong one

Sophistry — “The use of fallacious arguments, especially with the intention of deceiving.”

Nick starts with a short introduction, which ends:

“From what I can tell, almost all of the claims regarding the negative health effects of vegetable oils are essentially rooted in mechanistic research. Mechanistic research includes studies such as cell culture studies, animal studies, in-vitro studies, or even some short term human experiments. Despite the fact that it is absolutely true that this type of research can be incredibly valuable, it is also almost always extremely inappropriate to extrapolate from mechanistic research to population-level health effects. Especially if there is no population-level outcome data that actually agrees with the mechanistic speculation to begin with.”

Nick seems to be contrasting mechanistic research with epidemiological research, as he approvingly cites many epidemiological studies throughout the rest of his post, and epidemiology is the field of measuring “population-level health effects”.

There’s a vast literature of epidemiological research that has come to the conclusion that there are a class of diseases that are known collectively as Chronic Diseases, Non-Communicable Diseases, Western Diseases, Diseases of Civilization, and probably other names. These diseases are not caused by known pathogens or acute toxins, and typically are found in societies that have an advanced level of agriculture, and universally in countries that have adopted industrial methods of food production; but are absent in those that have primitive methods of agriculture, or depend on hunting and gathering (Bruhn & Wolf, 1970; Eaton, 2010; Lee et al., 1964; Lieberman, 2013; Lindeberg, 2009; Pontzer, 2021; Pontzer et al., 2018; Price, 1938; Stefansson, 1960; Taubes, 2008; Trowell & Burkitt, 1981; Wolf, 1977). The evidence that this phenomenon exists is massive, incontrovertible, and to my knowledge is nowhere disputed.

There are many hypotheses for why this phenomenon exists, many of which are covered in the works above, and the introduction of vegetable oils into the human diet is one hypothesis (Blasbalg et al., 2011; R. A. Brown, 2016; de Lorgeril et al., 1994; Lands, 2014; Lindeberg, 2009; Lindeberg et al., 1996; Okuyama et al., 1996; Price, 1938; Rosinger et al., 2013; Simopoulos, 2002). There are only a limited number of foods that are added to the diet when an industrial diet is adopted, and seed oils happen to be one of them.

So, Nick’s claim, “From what I can tell, almost all of the claims regarding the negative health effects of vegetable oils are essentially rooted in mechanistic research,” must reflect a lack of familiarity with the evidence.

As far as I am aware, there is not a single population that does not eat seed oils that suffers from the chronic diseases. That’s a rather notable bit of epidemiology, and it’s one that likely won’t be valid for much longer, as even the few remaining populations are being drawn into the modern food supply (Bethancourt et al., 2019).

The NIH defines a mechanistic study as, “…designed to understand a biological or behavioral process, the pathophysiology of a disease, or the mechanism of action of an intervention.” All toxicology and drug development research, for instance, depends on mechanistic studies. Epidemiology doesn’t even enter the picture until long after a drug is approved, for instance.

Nick’s claim, “...it is also almost always extremely inappropriate to extrapolate from mechanistic research to population-level health…” is absurd, as he describes the entire field of toxicology, since we don’t conduct toxicological experiments for new substances in humans. Every single new drug starts out with a mechanistic toxicology study before it is released to hopefully improve “population-level health.”

As far as existing foods go, the food mustard oil was banned in the United States and Europe entirely because of mechanistic studies done in animals (Imamura et al., 2013; Mustard Oil - Finally Edible Thanks to KTC, 2018; U.S. Food & Drug Administration, 2016), which also led to the development of Canola oil and other low-erucic rapeseed oils (which is what Canola is) in Europe. Epidemiological research can certainly also be used, if a food that was already in the market is determined to be harmful, as in the case of synthetic trans fats, but even there the case was made first decades earlier using mechanistic animal models (Kummerow, 2009; Mozaffarian et al., 2006). Mechanistic evidence alone is sufficient to prompt removal of food items from the food supply, under U.S. law (Food and Drug Administration, 2018).

That’s just Nick’s introduction.

Continue by demonstrating ignorance

He then goes into cardiovascular disease.

“The primary mechanism by which vegetable oils are suggested to increase the risk of cardiovascular disease (CVD) is through the oxidation of polyunsaturated fats (PUFA), particularly linoleic acid (LA), in low density lipoprotein (LDL) phospholipid membranes. In the literature, this hypothesis seems to be spearheaded by DiNicolantonio and O'Keefe (2018) [1].”

Oh dear. What’s he’s describing here is oxLDL.

From 2020: “Low-density lipoproteins cause atherosclerotic cardiovascular disease: pathophysiological, genetic, and therapeutic insights: a consensus statement from the European Atherosclerosis Society Consensus Panel” (Borén et al., 2020):

They illustrate what they describe in the section, “Low-density lipoprotein as the primary driver of atherogenesis”. The first step is the oxidation of LDL:

“Formation of macrophage-derived foam cells upon phagocytic uptake of aggregated LDL particles, or LDL in which lipid and/or protein components have undergone covalent modification, triggering uptake by scavenger receptors. Aggregation may occur by nonenzymatic or enzymatically induced mechanisms. Oxidation of lipids (phospholipids, cholesteryl esters, and cholesterol) or apoB100 can occur enzymatically (e.g. by myeloperoxidase) or non-enzymatically (e.g. by reactive oxygen species liberated by activated endothelial cells or macrophages).”

They bury the lede here, as both aggregated and covalently modified LDL are oxidized (Aviram et al., 1995), but of course that’s obvious.

We could therefore rename this section as “Oxidized low-density lipoprotein as the primary driver of atherogenesis”. Of course then we would also need to rename the paper, but such is life.

Thus a major medical society is endorsing (promoting?) this idea that oxidized LDL (oxLDL) is the major initiator of atherosclerosis.

Oddly, given what Nick has told us, neither DiNicolantonio nor O'Keefe are co-authors of this paper, their 2018 paper isn’t even cited, and neither one of their names appears anywhere in the document. So perhaps DiNicolantonio & O'Keefe aren’t “spearheading” this, after all?

Instead, the authors (Borén et al., 2020) cite a 1989 paper (Steinberg et al., 1989) which was also cited in a 1990 paper by Micheal Brown and Joseph Goldstein (M. S. Brown & Goldstein, 1990). Brown & Goldstein are worth mentioning since they won the 1985 Nobel Prize for their discovery of the LDL receptor. In their 1990 paper they note:

“The search for a physiological ligand for the scavenger receptor bore fruit when Steinberg and co-workers discovered that oxidized LDL competes for the binding of acetyl-LDL and delivers sufficient cholesterol to produce a foam cell (reviewed in ref. 5).” (M. S. Brown & Goldstein, 1990) their “ref. 5” is (Steinberg et al., 1989).

This was a major discovery, as Brown & Goldstein had attempted to create a foam cell using non-‘modified’ LDL, and failed (Goldstein et al., 1979). Steinberg’s discovery is the process described in (Borén et al., 2020). What caused the non-atherogenic LDL to turn into atherogenic oxLDL? “The unsaturated fatty acids of the phospholipids are highly susceptible to chemical oxidation…” (M. S. Brown & Goldstein, 1990). Steinberg and Witztum wrote a 1991 overview of their process of discovering oxLDL (Witztum & Steinberg, 1991):

“The nature of the substrate for lipid peroxidation, mainly the polyunsaturated fatty acids in lipid esters and cholesterol, is a dominant influence in determining susceptibility. As noted by Esterbauer et al. (52), there is a vast excess of polyunsaturated fatty acids in LDL, in relationship to the content of natural, endogenous antioxidants. The importance of the fatty acid composition was impressively demonstrated by our recent studies of rabbits fed a diet high in linoleic acid (18:2) or in oleic acid (18:1) for a period of 10 wk. LDL isolated from the animals on oleic acid-rich diet were greatly enriched in oleate and low in linoleate. This LDL was remarkably resistant to oxidative modification, measured either by direct parameters of lipid peroxidation (i.e., TBARS and conjugated dienes) or by the indirect criterion of uptake by macrophages (53).

And in humans:

“In a recent study, human volunteers were fed a similar oleic acid-rich diet. When their LDL was tested for susceptibility to oxidative modification, it was reduced albeit to a lesser degree than that noted in the rabbit studies (54). These studies demonstrate the feasibility of dietary modification of LDL fatty acid content in order to reduce its susceptibility to modification.”

They also don’t mention DiNicolantonio & O'Keefe, you’ll be surprised to hear, although given that DiNicolantonio was probably in grade school at the time, it’s hardly surprising—he got his PharmD in 2010, long after these papers had been written.

One of the authors of (Borén et al., 2020) is a scientist named Ronald Krauss. He also co-authored the previous 2017 consensus statement (Ference et al., 2017), and a 2010 paper looking at saturated fat and cardiovascular disease risk (Siri-Tarino et al., 2010). Once again, neither DiNicolantonio nor O'Keefe are mentioned. That paper concludes, “A meta-analysis of prospective epidemiologic studies showed that there is no significant evidence for concluding that dietary saturated fat is associated with an increased risk of CHD or CVD.” Krauss’ co-author for that paper was Frank Hu, who is one of the leading nutritional epidemiologists in the world, now the head of the department at Harvard (Harvard University, 2021a).

Krauss & Hu’s paper is notable because it is cited when we finally get to a paper co-authored by DiNicolantonio, “The Questionable Benefits of Exchanging Saturated Fat With Polyunsaturated Fat” (Ravnskov et al., 2014). His co-authors include the aforementioned Kummerow and Okuyama, esteemed senior scientists.

All of this recitation of evidence is necessary because none of it is mentioned by Nick. His claim, “In the literature, this hypothesis seems to be spearheaded by DiNicolantonio and O'Keefe (2018) [1],” is not even laughable, it’s absurd. The oxidized LDL hypothesis, as we have seen, is the consensus view of the scientific and medical establishment; there is no other explanation offered for how atherosclerosis progresses. Steinberg himself was key in statins being introduced:

“Merck was among the first companies to develop a statin program, but was on the verge of shutting it down based on rumors that statins caused cancer in dogs. Along with Mike Brown, Joe Goldstein, and a number of prominent clinicians, Dan convinced Merck to continue the program, leading to the introduction of the first clinical statin capable of significant reductions of cholesterol levels in humans.” (Glass & Witztum, 2015)

Steinberg’s eulogists further note the role of the oxLDL hypothesis:

“Over the next 30 years, Dan, J.W.L., and their colleagues provided compelling evidence in more than 100 manuscripts that LDL oxidation occurs in vivo and drives the atherogenic process. An important additional insight emerging from these studies was that oxidized LDL is proinflammatory and immunogenic, providing a mechanistic basis for inflammatory characteristics of atherosclerotic lesions and the presence of natural antibodies to oxidation-specific epitopes of oxidized LDL in the human circulation. More than 8,000 papers from hundreds of laboratories have been published on the topic of LDL oxidation, and the LDL oxidation hypothesis remains a central pillar of pathogenic mechanisms of atherosclerosis (Glass & Witztum, 2015).

But it is not just mechanistic research. The most famous epidemiological study of all was Ancel Keys’ Seven Countries Study, which largely launched the science of nutritional epidemiology. From the final paper of that project:

“It appears that reductions in serum total cholesterol levels are not likely to bring cultures with a high CHD risk, such as the United States and Northern Europe, back to a CHD mortality level characteristic for the Mediterranean and Japanese cultures unless other factors are also changed. The Mediterranean and Japanese diets, low in saturated fat and rich in antioxidants, may have beneficial effects both on the oxidizability of LDL particles and on thrombogenesis, apart from an effect on LDL levels per se.” (Verschuren et al., 1995)

It's hard to fathom why Nick would ignore all this evidence and claim that DiNicolantonio & O'Keefe are “spearheading” this hypothesis.

A saturated straw-man

Nick then states:

“The argument starts by proposing that saturated fat (SFA) is protective against LDL oxidation because SFA is not vulnerable to the same sort of oxidative damage to which PUFA is vulnerable, and that oxidized LA correlates with some measures of CVD.

It is therefore concluded that limiting one's intake of LA and increasing the intake of SFA protects LDL particles from oxidative damage and thus reduces the risk of CVD. However, does this simplistic mechanistic hypothesis regarding SFA and PUFA actually work this way in real life?”

He’s claiming this is DiNicolantonio & O'Keefe’s argument. Is it?

(DiNicolantonio & O’Keefe, 2018) discusses SFA, as many of the studies done are examining replacing SFA with n-6 PUFA. They note, for instance, an epidemiological study that concludes:

Polyunsaturated fat intake was positively associated with progression when replacing other fats (P 0.04) but not when replacing carbohydrate or protein…. In postmenopausal women with relatively low total fat intake, a greater saturated fat intake is associated with less progression of coronary atherosclerosis, whereas carbohydrate intake is associated with a greater progression.” (Mozaffarian et al., 2004)

Which they summarize:

“A study by Mozaffarian and colleagues found that postmenopausal women with a higher saturated fat intake had less coronary atherosclerosis progression (when measured as per cent stenosis as well as minimal coronary artery diameter), whereas polyunsaturated fatty acid (PUFA) intake was associated with worsening (a decline) in the diameter of the coronary artery.” (DiNicolantonio & O’Keefe, 2018)

But nowhere do they recommend increasing SFA.

“Thus, reducing the amount of dietary linoleic acid, mainly from industrial vegetable/seed oils, will reduce the amount of linoleic acid in LDL and likely reduce oxLDL as well as the risk for… coronary heart disease.” (DiNicolantonio & O’Keefe, 2018)

Nick is thus misrepresenting this paper in two ways. It doesn’t recommend increasing saturated fat intake (Nick is making a straw-man argument), and the argument they do make doesn’t depend solely on mechanistic data, but includes epidemiology from a leading researcher. Mozaffarian is a trained cardiologist and one of the most prominent nutritional epidemiologists (Tufts University, 2021), often co-authoring studies with the aforementioned Frank Hu.

So the answer to his question: “However, does this simplistic mechanistic hypothesis regarding SFA and PUFA actually work this way in real life?” is “yes”, at least according to the epidemiology Nick ignored in this paper.

Nick then goes into some mechanistic studies:

“As it turns out, we've thoroughly investigated the effects of altering the fatty acid composition of the diet on LDL oxidation rates in humans. For example, Mata et al. (1996) explored this question with one of the most rigorous studies of its kind. No statistically significant differences between the effects of high-SFA diets and high-PUFA diets on the lag time to LDL oxidation were observed [2].

(Nick never explains why lag time is important, so a quick explanation: since oxLDL drives atherosclerosis, and the quantity of omega-6 or omega-3 polyunsaturated fats (n-6 or n-3 PUFA) in LDL affects its susceptibility to oxidation, the idea is that LDL with less n-6 will take longer to oxidize in an in vitro model. This delay in oxidation is the lag time, and the idea is that a longer lag time will translate into less oxLDL in the body.)

Here we go again. I’m very partial to this study, as I tweeted about it way back in 2017.

“Read carefully”, I said.

Nick either didn’t read carefully, or is willfully misrepresenting the findings in this paper. Given that his reading of it supports his straw-man argument that people are recommending increasing SFA intake to protect LDL from oxidation, I suspect the latter. A careful reading undercuts his argument. I’ll also note that there were lots of similar studies that were done earlier, none of which are cited by Nick. I’ve mentioned the original ones (Witztum & Steinberg, 1991).

The authors explain:

“Consumption of the SFA diet resulted in slight but significant increases in C16:0 compared with the other three diets. Despite the low proportion of dietary C18:2 [linoleic acid] during the SFA period, this fatty acid accounted for 52.5% of the total fatty acids in LDL-CE. This proportion was greater than that observed during the MUFA diet (45.4%, P<.05). As expected, C18:1 was significantly increased during the MUFA diet compared with the other diets. C18:2 was significantly elevated during both PUFA diets compared with the SFA and MUFA diets. (Mata et al., 1996)”

Emphasis mine. C18:2 is linoleic acid (LA), the main n-6 fat found in seed oils, C18:1 is oleic acid (OA), found in olive oil and animal fats. C16:0 is palmitic acid (PA), a saturated fat found in animal and some plant fats, like the palm oil used here.

So the authors are noting that the SFA diet does not replace the LA in LDL, while the MUFA diet does, with OA.

This is important!

“TBARS values (expressed as nanomoles MDA per milligram LDL protein) were determined in freshly isolated LDL. Identical values were observed during the SFA (1.15±0.57) and MUFA (1.15±0.35) periods. These values were significantly lower than those obtained during the PUFA(n-6) (1.51±0.50) or PUFA(n-3) (1.69±0.48) periods.”

MDA is a toxic chemical, the presence of which defines oxLDL using the current tests (Witztum & Steinberg, 1991). OxLDL is itself toxic, of course (M. S. Brown & Goldstein, 1990; Yeang et al., 2019). MDA is only made from n-6 and n-3 fats. The degree of oxidation of LDL is a factor in its toxicity (Tsimikas, 2006), so a lower level is, on its own, a benefit. Since MDA is only made from n-6 and n-3, it’s not surprising that it’s lower in the two diets that have lower levels of those fats. This is a more important measure than lag time, as lag time simply measure the time to which MDA is produced, but ultimately it’s the amount of MDA that is a concern.

Nick doesn’t mention this, of course.

“The content of 18:1 in the PL [phospholipid] fraction of the isolated LDL was inversely correlated with the percent monocyte adhesion (r=−.5138, P=.0005), whereas the content of 18:2 in this same lipid fraction was positively associated with the percent monocyte adhesion (r=.3179, P=.04). (Mata et al., 1996)”

Measuring monocyte adhesion is an in vitro attempt to measure the early steps of atherosclerosis. More is worse. Here they’re quite clear that the degree of n-6 in the LDL is directly related to the poor outcome—the positive association is bad.

SFA in this model underperforms not because it is itself harmful, but because the fat chosen (palm oil with a high level of PA and a low level of OA) does not replace the actually harmful fat in the LDL (LA). As discussed in (DiNicolantonio & O’Keefe, 2018), SFAs such as PA don’t actually contribute to the oxidation of LDL, since they don’t oxidize in vivo, and OA is protective because it is also less susceptible to oxidation than the n-6 PUFAs.

Nick even seems to understand this, stating, “However, diets high in monounsaturated fat (MUFA) diets might actually be more protective than either SFA-rich or PUFA-rich diets.”

Protective against what? Well, the toxic effects of n-6 fats in LDL, of course! By making this statement, Nick cedes that n-6 is in fact harmful, and a causal factor in atherosclerosis.

“When comparing LDL that were enriched with PUFA to LDL that were enriched with MUFA, Kratz et al. (2002) observed a stepwise decrease in LDL lag time to oxidation with increasing PUFA, specifically linoleic acid (LA) [3].”

This is a neat paper, although I don’t understand why Nick includes it, I mean, we’re in the first section of his paper, on the third printed page, and he’s apparently abandoned his hypothesis. Even the chart that he includes from this paper shows that n-6 is harmful—remember, decreased lag time is a bad thing, as it leads to more toxic oxLDL!

But as a follow-up to the previous paper, it’s even more interesting. Since Nick doesn’t note anything other than that n-6 fats cause your LDL to oxidize more quickly, I’ll note a few points. (Kratz et al., 2002) cites (Mata et al., 1996) extensively, so it’s really building upon their findings. What do they add?

“Our study confirms previous reports that MUFA-rich diets lead to LDL that is less oxidizable than that found on a diet rich in PUFA. It is notable that this finding was consistent for all three parameters of LDL oxidizability, ie lag time, rate of propagation and maximum amount of conjugated dienes. This indicates that LDL do not only exert a lower tendency to become oxidized, but also that progression of the oxidation process once started is slower and that a lower amount of conjugated dienes are formed during oxidation after MUFA-rich diets compared to PUFA-rich diets.

“…In contrast to MUFA and PUFA, SFA were not incorporated into LDL to a degree commensurate with their presence in the diet.

“…Despite a more than two-fold variation in SFA intake (between 24.5 and 53.1% of dietary fatty acids), the SFA content of LDL was similar on all four diets (25.8 – 28.5% of LDL fatty acids). Thus, our SFA-rich wash-in diet did not result in the least oxidizable LDL.

“…Although the relative amount of dietary linoleic acid did not change during the SFA-rich wash-in phase compared to the habitual diet, the reduced relative amount of oleic acid in the diet may have provided scope for further enrichment of LDL in linoleic acid.” (Kratz et al., 2002)

So make sure you avoid those n-6 seed oils! Thanks, Nick!

So seed oils are bad, what do we do?

Sadly, having glimpsed the truth, Nick turns away and goes on a rather hilarious tangent.

“Don't get too excited, though. Despite the authors claiming that some studies show that supplemental vitamin E doesn't mask the effects of dietary fatty acids on LDL susceptibility to oxidation…”

What? I’m not sure quite what happened, but all of a sudden, having figured out there’s a problem, Nick goes into looking for a solution, and the solution around the time these papers were produced was anti-oxidants.

I’m going to spare you this section, as it’s a classic example of what Nick warned us about at the beginning: extrapolating a mechanistic effect to real-world effect without sufficient data. Having issued that warning, Nick promptly makes the same mistake. He reviews a bunch of these papers and then confidently states:

“Altogether this would seem to divulge that diet quality matters more than PUFA, or even LA, for LDL oxidation, because we've seen multiple times that low PUFA or low-LA diets can be outperformed by high-PUFA or high-LA diets of better overall quality. Little things add up, and the effect of diet is greater than that of MUFA alone, SFA alone, or even polyphenols alone. Perhaps not vitamin E alone, though.

We’ll take the bolded statement first, as it’s easiest to dismiss. Since he’s looking at old papers, and isn’t familiar with the subject (very apparent here) he’s obviously not familiar with the fact that this vitamin E antioxidant (chemically known as tocopherols) hypothesis has been extensively tested, both epidemiologically:

“Men with higher plasma levels of γ-tocopherol [gamma-tocopherol] tended to have an increased risk of MI (P for trend=0.01)

“These prospective data do not support an overall protective relation between plasma carotenoids or tocopherols and future MI risk among men without a history of prior cardiovascular disease” (Hak et al., 2003)

One of the authors of that paper was Walter Willett, at the time the head of nutritional epidemiology at Harvard (Harvard University, 2021b).

And mechanistically:

“Despite this, however, the overall outcome of studies investigating the benefit of supplementation of vitamin E on CVD has been disappointing, particularly the results of the large, randomized controlled studies (Table 4).

However, vitamin E also does not provide benefit in secondary interventions conducted with unhealthy subjects.” (Lönn et al., 2012)

And it’s thought this is because vitamin E can cause LDL to oxidize!

“However, subsequent studies revealed that a-tocopherol can promote peroxidation in isolated lipoproteins including LDL, via a process called tocopherol-mediated peroxidation in which the a-tocopheroxyl (rather than lipid peroxyl) radical acts as the chain-carrying radical.” (Lönn et al., 2012)

So Nick fell for the mechanistic trap he’s warning us to avoid.

His claim about some magical aspect of diet “quality,” also falls short. 75% of the studies he cites look at the Mediterranean diet (the fourth doesn’t support his claim), and the benefits in lag time cited in those studies are easily explained by the MUFA/PUFA balance of the diets, as discussed above:

“Total, monounsaturated, and polyunsaturated fat consumption was significantly reduced in the low-fat diet relative to both TMD interventions (Supplemental Tables 2-3).”(Hernáez et al., 2017—This is Nick’s reference 10.)

Yes indeed, the experimental diet with less PUFA does better.

Another volte-face

Nick’s right here:

“A marker like oxLDL can give us a better sense of just how many oxidized LDL are likely to form in the blood after a particular intervention or in a particular context. This is important because merely looking at the lag time to oxidation could give us an exaggerated sense of what is likely to happen in vivo.”,

Although his first sentence is a tautology; of course measuring something gives us an idea of how much of that something we have. That’s why we measure!

He then goes on to discuss a study that found, “Overall the butter diet resulted in higher LDL and higher oxLDL” (Palomäki et al., 2010—Nick’s reference 14)

Of course it did, it was using an invalid oxLDL measurement.

“Unlike the OxPL/apoB measure, the Mercodia OxLDL assay strongly correlated with LDL (r0.70) in multiple studies and may not be independent of LDL.” (van Tits et al., 2005)

Sadly, (Palomäki et al., 2010) don’t directly measure the fatty acids in the LDL, but as the oil used has far more OA than the butter they compare it to, it’s possible that it is protective, as we have already seen that SFAs don’t protect against harmful n-6 fats being taken up by LDL, while OA does (Kratz et al., 2002).

Nick: “Again, I speculate that this is likely the result of SFA being a poor source of antioxidants.” Oh boy.

(Note they were still using the Mercodia assay 5 years after the problem with it was noted. The Mercodia assay is still sold.)

Nick, “But, just for the sake of argument let's assume that high-PUFA diets do increase LDL oxidation relative to high-SFA diets.” We’re back to the straw-man.

Nick, “There are not many studies investigating this, so it's not clear at the moment.” (Lönn et al., 2012) is a review article looking at all these studies which investigate this, a body of work Nick should be familiar with.

…And statistics

So now we get to the gist of Nick’s argument here regarding OxLDL. “Lastly, oxLDL isn't actually a robust risk factor for CHD.”

We’re going to have to go through this, as Nick makes a rather involved argument here.

“Wu et al. (2006) discovered that the association between oxLDL and CHD does not survive adjustment for traditional risk factors like apolipoprotein (ApoB) or TC/high density lipoprotein cholesterol (HDL-C) [16].”

A little background. A risk factor is a thing that is associated with an outcome. It does not therefore mean that it is involved in causation of that outcome. One classic example is ice cream consumption being associated with shark attacks. Eating ice cream does not, obviously, cause sharks to attack you, but both are associated with hot weather, and people go swimming in hot weather, which does give sharks the opportunity to attack you. So ice cream is not a risk factor for shark attacks, but swimming is, but both may be highly associated with each other.

Simply looking at correlations (associations) tells you nothing about causation. This is why it is often said that correlation is not causation. Ice cream does not cause shark attacks. This is the difference between epidemiology, which looks at correlations, and mechanistic studies, which attempt to determine causation.

Nick’s statement that oxLDL “does not survive adjustment” is thus void of meaning for causation. It simply means that when we subtract the association of ApoB from that of oxLDL, there is no additional association for oxLDL remaining. These are simply adjustments in a statistical model.

He goes on: “Essentially this means that risk is more closely tracking ApoB or TC/HDL-C, and is not particularly likely to be tracking oxLDL at all.”

This is wrong. Risk is just as likely to be “closely tracking” oxLDL here as it is to be tracking ApoB. In this model, which is just statistics.

In order to determine the mechanisms behind this risk, in order to determine if this risk factor (a thing we think is a risk) is actually a risk, we must do an experiment. In this case, we would likely take an ApoB (also known as LDL), and we would attempt to induce CHD, or some part of CHD that we think is indicative of CHD progression, like atherosclerosis.

Here we go all the way back up our analysis, because, as mentioned, Nick doesn’t understand (or isn’t aware) of the existing evidence. (M. S. Brown & Goldstein, 1990) discuss how they performed exactly this experiment. They attempted to use ApoB (LDL) to induce macrophages to become foam cells, which was thought to be the first step in atherosclerosis, and thus CHD.

It failed.

OxLDL, however, succeeded (Steinberg et al., 1989). Which is why their paper is titled “Beyond cholesterol. Modifications of low-density lipoprotein (LDL) that increase its atherogenicity.” LDL, ApoB—what we often call ‘cholesterol’—doesn’t without oxidation induce atherosclerosis.

This is the ONLY explanation we have for this process now. Which is why in (Borén et al., 2020), a consensus report from a major medical society, the first step they describe is that one discovered in (Steinberg et al., 1989—reference 114 in (Borén et al., 2020)).

To claim, as Nick does, that ApoB and not oxLDL is the ‘risk’ here is to discard 40 years of research, a huge chunk of the cardiovascular literature, and as mentioned, thousands of papers and studies.

It is to claim that the Earth is flat while orbiting it in a spaceship.

Or to go back to our shark analogy, he’s claiming that since swimming “does not survive adjustment” by ice cream, it’s not a risk for shark attack.

It gets worse, however.

The title of (Wu et al., 2006) is “Is Plasma Oxidized Low-Density Lipoprotein, Measured With the Widely Used Antibody 4E6, an Independent Predictor of Coronary Heart Disease Among U.S. Men and Women?” Yes, the 4E6 test used is the same Mercodia test mentioned above.

“The oxLDL was measured by a sandwich ELISA kit with the monoclonal antibody 4E6 (Mercodia).”

“Because the antibody 4E6 is specific for oxidized apoB, it is important to determine whether this marker of oxidation is independent of and adds prognostic information beyond apoB itself” (Wu et al., 2006).

Nick then goes through a bit of hand-waving, frankly, to assure us that the Mercodia assay is OK.

But the real issue is that described in(Wu et al., 2006). Is it, in fact, a specific assay for oxLDL?

“In an effort to investigate the specificity of the assay used to determine OxLDL in plasma, we added two different amounts of either native LDL or OxLDL into five different plasma samples containing 88 ± 12 U/l OxLDL. We found that in plasma enriched with 5 or 15 ng of nonoxidized native LDL, the OxLDL levels determined with this assay were increased to 141 ± 21 or 399 ± 44 U/l, respectively. Similarly, enrichment of the plasma samples with 5 or 15 ng of OxLDL resulted in an increase of OxLDL levels to 175 ± 30 or 499 ± 63 U/l, respectively

“In this regard, we show that the present assay does not have a high specificity for OxLDL and that it also detects nonoxidized LDL in plasma.

“It is important that further studies be performed before a conclusion is drawn regarding the specificity of the methods used to detect OxLDL in plasma” (Tsouli et al., 2006)

The correlation between LDL and oxLDL is thus very high, as, to some extent, it’s measuring the same thing. In one test of the Mercodia assay, the correlation approached 1, in other words, they were identical (Feldman, 2019)

Nick cites this exchange, without including this quote, “Unlike the OxPL/apoB measure, the Mercodia OxLDL assay strongly correlated with LDL (r0.70) in multiple studies and may not be independent of LDL” (van Tits et al., 2005—Nick reference 17), but does not explore what it would mean, or note that the lack of specificity has been independently confirmed.

Nick, “Essentially, the 4E6 antibody assay makes a clear distinction between native LDL and oxLDL…” False.

Ignore the man behind the curtain

So the conclusion of (Wu et al., 2006) is correct, but the results are meaningless as to causation, as they are adjusting a measure of oxLDL by itself, effectively. Of course there is no additional correlation.

Nick then goes on to incorrectly state, “Because lipid peroxidation of the LDL particle's phospholipid membrane is not required for an LDL particle to oxidize…” This is just an absurd statement on the face of it. What oxidizes in the phospholipid membrane is the lipid. Both the Mercodia and the OxPL/ApoB test find malondialdehyde (MDA), which is produced by oxidizing lipids.

Oxidation of LDL is a free radical process in which the polyunsaturated fatty acids contained in the LDL are degraded by a lipid peroxidation process to a great variety of aldehydes (eg, malonaldehyde…” (Esterbauer et al., 1991—Nick’s reference 5)

And Nick continues, “…a measurement of oxPL could easily mistake a minimally oxidized LDL [mmLDL] particle as an oxLDL.”

This is in fact precisely why the OxPL/ApoB measure was constructed, to distinguish between mmLDL and oxLDL (Taleb et al., 2011).

Nick, “For this reason, it is likely that the 4E6 antibody assay is likely to better reflect the actual number of oxLDL [19].” Ignoring that his “reason” is incoherent and mistaken, let’s look at his reference 19. It’s an advertisement from Mercodia (Carlsson & Nikus, 2008—Nick’s reference 19).

Nick, “This is relevant because the immune cells that mediate the formation of atherosclerotic plaques only tend to take up maximally oxidized LDL particles, not minimally oxidized LDL particles [20][21].” 20 is an early reference from Steinberg, long before oxLDL was discovered, and does not support Nick’s claim (Henriksen et al., 1983), while the other one is an in-vitro experiment, and hardly supports this as being a fundamental mechanism (Meyer et al., 2014)

Then Nick gets into a discussion of OxPL/ApoB, premised on the above claim.

“If minimally oxidized LDL likely contribute as little to foam cell formation as native LDL, why favour measures of minimally oxidized LDL such as the E06 antibody assay over measures of maximally oxidized LDL such as the 4E6 antibody assay?”

First, E06 is not a assay of exclusively mmLDL. The OxPL/ApoB assay uses E06:

“The OxPL/ApoB assay was originally developed as an indicator of minimally oxidized LDL in plasma that might reflect the overall content of circulating OxLDL.

“The OxPL/ApoB assay is highly specific to the number of OxPL epitopes on individual apoB-100 particles, but does not measure the total amount of OxPL in plasma” (Taleb et al., 2011)

So what’s it’s telling you is how oxidized are the individual ApoB (LDL) particles.

Second, it’s not like mmLDL is harmless (Itabe et al., 2003; Miller et al., 2003), and at any rate, since 46E is not a specific antibody, it doesn’t do us much good. (Tsouli et al., 2006) note that 4E6 could be useful: “…although this method does not have a high specificity for OxLDL, it may give useful information for the OxLDL levels in plasma when they are expressed as a ratio to apoB-100 levels.” Which is of course what the OxPl/ApoB measure does.

Bull in a china shop

Nick charges along: “Unfortunately, so far no studies have attempted to explore the relationship between oxLDL, as measured by the E06 antibody assay, and CHD outcomes after adjustment for total ApoB. The closest we have is a single study by Tsimikas et al. (2006) that found no correlation between oxPL/ApoB and ApoB [22].”

More problems to unpack. First, he doesn’t seem to understand that finding a correlation between oxPl/abpoB and AboB wouldn’t’ really mean anything. We wouldn’t need the OxPl/ApoB measurement if it correlated to ApoB, since it would then be measuring the same thing, like the Mercodia assay does.

He’s also wrong that “no studies” have looked at OxPl/ApoB adjusted for ApoB (LDL) to see if there is any additional risk in a statistical model, as (Tsimikas et al., 2010) did exactly that, along with other risk factors.

And as for his silly comment about this being the closest, we have to the study above, “a single study by Tsimikas et al. (2006) that found no correlation between oxPL/ApoB and ApoB”, let’s review the title of that one, too:

“Oxidized Phospholipids Predict the Presence and Progression of Carotid and Femoral Atherosclerosis and Symptomatic Cardiovascular Disease: Five-Year Prospective Results From the Bruneck Study”

When you’re trying to determine causation, being able to predict an outcome is what you’re looking for. We’ll also observe that this paper did adjust for LDL.

Nick: “However, if ApoB and oxPL tend to vary in tandem, the oxPL/ApoB ratio might not be expected to change very much from subject to subject. If that is the case, then we would not expect oxPL/ApoB to correlate very well at all. It would be nice to see univariable and multivariable models presented that test for independent effects of these biomarkers.”

He really has no idea what he’s saying here, unfortunately. He doesn’t understand the basic process, or the papers that are showing very strong evidence that this is causative in atherosclerosis. Or he’s just trying to obfuscate this to make a point here.

His claim, “Lastly, oxLDL isn't actually a robust risk factor for CHD,” is the reverse of the science, the latest of which makes the claim that Lp(a) (the form of oxLDL detected by the OxPl/ApoB test), is the MOST robust risk factor for CHD:

“It shows if you mathematically remove Lp(a)-C from "LDL-C" to derive a corrected LDL-C, corrected LDL-C is NO LONGER predictive of events. It basically says the measure we call LDL-C is predictive only if it contains the Lp(a)-C in it” (Tsimikas, 2020; Willeit et al., 2020)

A few more thoughts

Nick cites (Hooper et al., 2020), “Reduction in saturated fat intake for cardiovascular disease”, to make his case that it’s a good thing:

“Additional exploratory meta-analyses by Hooper et al. (2020) also further divulge that SFA reduction lowers total CVD events (analysis 1.35), the best replacement for SFA is PUFA from vegetable oils (analysis 1.44), and the effect is likely via lowering TC (analysis 1.51). This evidence dovetails perfectly with the epidemiological evidence discussed above.

Nick has to dig deep to cherry-pick that study to support his case. Let’s look at their summaries:

“In this review, saturated fat reduction had little or no effect on all-cause or cardiovascular mortality but did appear to reduce the risk of cardiovascular events by 17%, although effects on MI and stroke individually were less clear.”

“There was little or no effect, regardless of what nutrients were used to replace the saturated fat removed, including replacement with PUFA, MUFA, CHO and/or protein (Analysis 1.9).”

“We found little or no effect of reducing saturated fat on all-cause mortality (RR 0.96; 95% CI 0.90 to 1.03; 11 trials, 55,858 participants) or cardiovascular mortality (RR 0.95; 95% CI 0.80 to 1.12, 10 trials, 53,421 participants), both with GRADE moderate-quality evidence.”

All these decades of research, and we’re left with “little or no effect”. That’s the best we can do?

He further discusses the Lyon Diet Heart Study—and notes, correctly, that (Hooper et al., 2020) incorrectly excluded it. If you want to see some more desperate attempts to bury evidence and some question-begging, read that bit. He claims “…and not replicated anywhere else in the literature, despite it being directly tested.” No, Nick, there aren’t any other tests of lowering LA for CVD risk improvement, none that I’m aware of; and since he doesn’t cite any, I’ll presume there are none.

From the evidence presented above, it should be obvious to any objective person why that trial worked.

It reduced the cause.

“The combined effect of hypercholesterolemia and being in the highest quartiles of the oxidized phospholipid:apo B-100 [OxPl/ApoB] ratio (odds ratio, 16.8; P<0.001) and Lp(a) levels (odds ratio, 14.2; P<0.001) significantly increased the probability of CAD among patients < 60 years of age” (Tsimikas et al., 2005). 

Conclusion

I’ve written ~9,334 words so far, over 17 pages, to critique ~2,671 word, over 7 pages. I’ve only gotten through one of his arguments. I’ve mostly restrained myself to fact-checking, as it’s such a rich target, and if you can’t get the facts correct in an area like this, you are in trouble. Nevertheless, it’s been hard to get through a sentence of Nick’s without having to make some correction or commentary, on an omission, misrepresentation, or just unsupported claim. And that’s with skimming over his ridiculous vitamin E discussion, in which he proposes that already debunked idea as a solution to a problem he can’t admit exists!

I’m certainly not going to waste more time on this. It’s clear he’s engaging in Google-fu to cherry-pick a few studies that (he thinks, when he actually reads them) support the argument he is trying to put together, and just make unsupported claims when that doesn’t work.

Nick’s put himself in the position of arguing against the scientific consensus on this topic. It’s quite clear after decades of research that what’s driving CVD is oxidized n-6 polyunsaturated fats. There’s not even another hypothesis proposed in the literature.

Opponents to that hypothesis are people like Nick, and, sadly, many of the cardiologists, who are unable to objectively look at the evidence. At least the cardiologists have the excuse that they are culpable, what I don’t understand is why folks like Nick get so incensed over this. Just follow the evidence.

There’s a very old principle in the law, dating back to Roman times:

Falsus in uno, falsus in omnibus” is a Latin term which means "false in one thing, false in everything." It in fact is a legal principle in common law that a witness who testifies falsely about one matter is not at all credible to testify about any other matter” (Bansal, 2018).

If you want to presume that Nick gets better in the rest of his document, I have a bridge to sell you.

Sophistry — “The use of fallacious arguments, especially with the intention of deceiving.”

It’s clearly Nick’s result, if not his intent. It’s entirely possible he’s fooling himself, first.





* I’m providing a link to a PDF version of the document produced by the “GoFullPage” screen grab extension for Google Chrome, in case he goes and updates it or deletes it (he’s already updated it after it was originally published), so that he can’t modify the content after my commentary.


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22 comments:

  1. Brilliant as usual; thanks for all the work you do on this. I've personally seen great results cutting out seed oils, inspired in large part by you.

    I wonder though how we can ever change the broader culture, where seed oils seem super-entrenched? I can't even convince my friends!

    I think 99% of people just believe whatever the official line is; they are uninterested in diving into the issues themselves, and assume whatever is official policy must be an accurate summary of the latest science.

    So maybe ultimately change needs to come from getting some influential in the establishment to take it seriously...

    ReplyDelete
    Replies
    1. "I wonder though how we can ever change the broader culture, where seed oils seem super-entrenched? I can't even convince my friends!"

      We're working on it. It's coming.

      Delete
  2. Excellent work, Tucker. It takes many times the effort to kill a lie or misunderstanding, as you show. If have anything left, there is short TPN section. He tries to show that it is not soy oil LA but plant sterol that destroys the liver. "To recap, the fatty liver observed in children receiving IVLEs while on TNP is likely a function of the direct intravenous administration of phytosterols, and it is unlikely that LA has any unique role to play here."

    So, it is plant cholesterol AND Pufa-6 that mess up with your liver and your innate cholesterol synthetis, ending up as oxidised membrane particle. Your advice on this, avoid like a plague, affects to both parts of this equation.

    Coconut oil, filled with stable fats, behaves a bit differently, and plant sterols may play a role together with shorter chain lengths? It remains as one of my favorites, though. Everything in moderation...
    RGDS JR

    ReplyDelete
    Replies
    1. The takeaway from my post is that Nick doesn't read studies, and misrepresents them.

      "Interestingly this study did not find ahepatotoxic effect of adding phytosterols to fish oil in enteral PN-induced liver injury. ...the composition of phytosterols added to fish oil approximated the types and amounts of phytosterols found in soybean oil."

      "Alpha-tocopherol in intravenous lipid emulsions imparts hepatic protection in a murine model of hepatosteatosis induced by the enteral administration of a parenteral nutrition solution"

      Delete
  3. A short continuation, if you please, on TPN.

    https://pubmed.ncbi.nlm.nih.gov/22796064/ (ref 123 is this)

    Soy oil vs fish oil. Both fed only pure is a bit problem. Thats why the developed a combi with soybean/MCT/olive/fish oil emulsion. This sounds like an emulation of a real fat! Note the inevitable phytosterols within soy and olives i guess.

    Nick: "When tested in humans at matched, eucaloric dosages, there are no clinically meaningful differences between SO-IVLEs and FO-IVLEs [122-123]. Across all of the markers investigated by Nehra et al. (2014), the only significant changes were increases in alkaline phosphatase, but they occurred in both groups."

    This is actually from the abstract (edited a bit):
    Mean concentrations of(ALT), (AST) and total bilirubin, ..., were significantly lower with soybean/MCT/olive/fish (SMOF) oil emulsion after the treatment period compared to control. Eicosapentaenoic acid, docosahexaenoic acid and n-3/n-6 fatty acid ratio increased in the SMOF group, while they remained unchanged in the control in plasma and RBC. Serum α-tocopherol concentrations significantly increased in the study group compared to control (p = 0.0004). IL-6 and sTNF-RII levels did not change during the study period. Grade 4 (serious) adverse events occurred in 2/34 SMOF patients and in 8/39 control patients (p = 0.03).

    So, "there are no clinically meaningful differences..."?

    wonder what those would be then?

    Falsus in omnibus
    JR

    ReplyDelete
  4. Good job Tucker. I appreciate your commitment on this issue and your thorough work. Look forward to your book.

    ReplyDelete
  5. Thank you Tucker for such a great rebuttal.
    What I found especially interesting was the SFA rich diet being unable to lower LA concentrations of the LDL lipid membrane. Only the MUFA rich diet was able to do that, although both diets were low in LA.
    Does that maybe mean that beyond eliminating seed oils from our diet, we should try to include foods that have higher MUFA content?

    ReplyDelete
    Replies
    1. Yes, when the body constructs fats (comprised of two or three fats in a triglyceride or diglyceride) it typically puts a SFA in one position and a UFA in another. So if you want to replace the UFA (say an omega-6 fat) you have to proved another UFA (like a MUFA).

      So if you are looking to reduce oxidizability, you have to restrict n-6 PUFA and provide MUFA (SFAs like stearic acid that quickly convert to MUFA might also do the trick, but I haven't seen a paper demonstrating that yet).

      Delete
  6. Most sources of animal fat have plenty of oleic acid. Butter has 32%, more than any other fatty acid in butter, for instance.

    If you are looking to recover from a high n-6 diet, then more oleic may be beneficial short term.

    ReplyDelete
    Replies
    1. Hi, Tucker.

      What would you suggest as a good formulation for a TPN product? SFA is stable and healthy, but TPN needs to be liquid (at least at body temperature, and probably at room temperature as well).

      Delete
  7. Hi, if kids are also eating the same omega 6 diet as adults, why do they not get the same health problems... Why does it take until middle age for most of the diseases of civilization to show up? I am wondering if it must include something about iron overload slowly developing over the years... the middle-aged adults have been accumulating the iron for a long time, and maybe that has a role, in addition to the omega 6 fats?

    ReplyDelete
    Replies
    1. There is something called "ferroptosis", which is the process by which iron oxidizes omega-6 fats into toxins. So it's certainly plausible that increasing iron could lead to health issues.

      We also have a phenomenon where we now have previously unknown diseases (ACL tears, non-alcoholic fatty liver disease), or diseases that were condsidered to be disease of old age (type 2 diabetes, some cancers, diverticulitis) becoming common in young people, which is likely due to increasing seed oil intake and the resultant damage to our bodies.

      Delete
  8. Excellent read, thank you 👍

    Something that puzzles me: how does oxidation increases LDL-C as measured by a conventional LDL assay? This question because a few in vivo studies in mice show that LDL, and not only Ox-LDL, skyrockets after oxidation. Why that?

    ReplyDelete
    Replies
    1. Oxidized LDL has a different clearance pathway than LDL. That could account for what you describe, although I haven't seen the results that you are describing. Could you post them here?

      Delete
    2. Here is a recent one with H2O2 induced oxidation:
      https://archrazi.areeo.ac.ir/article_124866.html
      I remember reading an old study where Cu2+ induced oxidation was used but I can't find it anymore.

      Delete
    3. Not sure why my reply didn't go through...

      Here is a recent article:
      https://pubmed.ncbi.nlm.nih.gov/35096330/
      with H2O2 used for oxidation. I remember older studies using Cu2+ instead but can't find them anymore.

      Delete
    4. It didn't go through because when you include a link, Blogger interprets it as spam (often correct) and puts it in the penalty box for my review.

      Delete
    5. Ok thank you. Would still appreciate to get your opinion on why LDL-C is also increased in oxidation studies. Or an artifact?

      Delete
    6. LDL is not increased in oxidation studies.

      "Total cholesterol decreased significantly in both study groups and LDL cholesterol decreased 24.5% in the linoleate group and 18.5% in the oleate group."

      "Effects of oleate-rich and linoleate-rich diets on the susceptibility of low density lipoprotein to oxidative modification in mildly hypercholesterolemic subjects."

      Delete
  9. "Since many potent peroxisome proliferators do not bind directly to the PPAR (Peroxisome Proliferator Activated Receptor), it seems probable that a natural ligand for the PPAR exists; in this regard it is interesting to note that natural fatty acids, and especially polyunsaturated fatty acids, activate PPAR as potently as does hypolipidaemic drug Wy-14643, the most effective activator known so far (Ref 1, Ref 2)."

    Excerpt Page 217
    Title: The peroxisome: a vital organelle
    Author: Colin Masters; Denis Crane
    Publisher: Cambridge, Mass. Cambridge University Press 1995

    Ref 1:
    Fatty acids activate a chimera of the clofibric acid-activated receptor and the glucocorticoid receptor.
    Author: M Göttlicher; E Widmark; Q Li; J A Gustafsson
    Publication: Proceedings of the National Academy of Sciences of the United States of America, v89 n10 (19920515): 4653-4657

    Ref 2:
    Fatty acids and retinoids control lipid metabolism through activation of peroxisome proliferator-activated receptor-retinoid X receptor heterodimers.
    Author: H Keller Affiliation: Institut de Biologie animale, Université de Lausanne, Switzerland.; C Dreyer; J Medin; A Mahfoudi; K Ozato;
    Publication: Proceedings of the National Academy of Sciences of the United States of America, v90 n6 (19930315): 2160-4

    ReplyDelete