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Saturated fat and cardiovascular disease

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Whether saturated fat is a risk factor for cardiovascular disease is a question with numerous controversial views.[1] Medical, scientific, heart-health, governmental and intergovernmental, and professional authorities, such as the World Health Organization,[2] the American Dietetic Association,[3] the Dietitians of Canada,[3] the British Dietetic Association,[4] American Heart Association,[5] the British Heart Foundation,[6] the World Heart Federation,[7] the British National Health Service,[8] the United States Food and Drug Administration,[9] and the European Food Safety Authority[10] advise that saturated fat is a risk factor for cardiovascular disease, and recommend dietary limits on saturated fats as one means of reducing that risk. A 2015 systematic review presented a contrary position.[11]

History

Cholesterol and cardiovascular disease

The initial connection between arteriosclerosis and cholesterol was made by the Russian pathologist Nikolay Anichkov, prior to World War I.[12] Another significant contribution to the debate was made by the Dutch physician (internist) Cornelis de Langen, who noticed the correlation between nutritional cholesterol intake and incidence of gallstones (and soon after, arteriosclerosis and other "Western diseases") in the Javanese population in 1916.[13][14] De Langen reported on his findings at the conference of the International Society of Geographic Pathology in 1935. These observations were made on patients admitted to the municipal hospital in Jakarta. Consequently, he studied this phenomenon in defined populations outside the hospital. He showed that the traditional Javanese diet, very poor in cholesterol and other lipids, was associated with a low level of blood cholesterol as well as a low incidence of cardiovascular disease (CVD), while the prevalence of CVD in Europeans in Java, living on the Western diet, was significantly higher.[13] De Langen's colleague, Isidor Snapper, made a similar observation in North China in 1940. Since de Langen published his results only in Dutch, his work remained unknown to most of the international scientific community.[13]

Saturated fat and cardiovascular disease

The notion that saturated fat has a detrimental effect on human health gained wider intternational attention for the first time in the 1950s.[15] It was promoted by Ancel Keys, a US nutritional scientist. Keys postulated a correlation between cholesterol levels and cardiovascular disease, and initiated a study of Minnesota businessmen (the first prospective study of CVD).[16] At a 1955 expert meeting of the World Health Organization in Geneva, Keys presented his diet-lipid-heart disease hypothesis.[17] At that time in the USA, the incidence of heart disease was rapidly increasing, with no apparent cause.[15] Keys reaped severe criticism at the conference. Consequently, he set out to develop the yearslong Seven Countries Study.[18]

Systematic reviews

Summary table

Systematic review Relationship between cardiovascular disease and saturated fatty acids (SFA)
American Heart Association: Presidential Advisory on Dietary Fats and Cardiovascular Disease[5] "Randomized controlled trials that lowered intake of dietary saturated fat and replaced it with polyunsaturated vegetable oil reduced cardiovascular disease by about 30%, similar to the reduction achieved by statin treatment."
Hooper, 2016[19] "The findings are suggestive of a small but potentially important reduction in cardiovascular risk on modification of dietary fat, but not reduction of total fat, in longer trials. Lifestyle advice to all those at risk of cardiovascular disease and to lower risk population groups, should continue to include permanent reduction of dietary saturated fat and partial replacement by unsaturates."
Ramsden, 2016[20] "Available evidence from randomized controlled trials shows that replacement of saturated fat with linoleic acid effectively lowers serum cholesterol but does not support the hypothesis that this translates to a lower risk of death from coronary heart disease or all causes."
de Souza, 2015[11] "Saturated fats are not associated with all cause mortality, CVD, CHD, ischemic stroke, or type 2 diabetes, but the evidence is heterogeneous with methodological limitations."
Schwab, 2014[21] "there was convincing evidence that partial replacement of SFA [saturated fat] with PUFA [polyunsaturated fat] decreases the risk of CVD, especially in men."
Chowdhury, 2014[22] "Current evidence does not clearly support cardiovascular guidelines that encourage high consumption of polyunsaturated fatty acids and low consumption of total saturated fats."
Farvid, 2014[23] "In prospective observational studies, dietary LA [linolenic acid] intake is inversely associated with CHD [coronary heart disease] risk in a dose-response manner. These data provide support for current recommendations to replace saturated fat with polyunsaturated fat for primary prevention of CHD."

Review details

A 2017 systematic review by the American Heart Association recommended that decreasing saturated fat intake and increasing consumption of monounsaturated fats and polyunsaturated fats could lower risk of cardiovascular disease by about 30%.[5] A 2015 systematic review of randomized control trials by the Cochrane Library found that reducing saturated fat intake resulted in a 17% reduction in cardiovascular events, and that replacing saturated fats with cis unsaturated fats in particular is beneficial. It concluded: "Lifestyle advice to all those at risk of cardiovascular disease and to lower risk population groups should continue to include permanent reduction of dietary saturated fat and partial replacement by unsaturated fats."[24]

A 2017 systematic review on randomized controlled trials concluded that replacing saturated fats with mostly n-6 polyunsaturated fats is unlikely to reduce coronary heart disease (CHD) events, CHD mortality or total mortality. The 2017 review showed that inadequately controlled trials (e.g., failing to control for other lifestyle factors) that were included in earlier meta-analyses explain the prior results.[25] A 2015 systematic review found no association between saturated fat consumption and risk of heart disease, stroke, diabetes, or death.[26]

A 2014 systematic review looking at observational studies of dietary intake of fatty acids, observational studies of measured fatty acid levels in the blood, and intervention studies of polyunsaturated fat supplementation concluded that the findings ″do not support cardiovascular guidelines that promote high consumption of long-chain omega-3 and omega-6 and polyunsaturated fatty acids and suggest reduced consumption of total saturated fatty acids.″[27] Researchers acknowledged that despite their results, further research is necessary, especially in people who are initially healthy. Until the picture becomes clearer, experts recommend people stick to the current guidelines on fat consumption.[28] Indeed, Dr Nita Forouhi, one of the coauthors of the meta-analysis, stated to the BBC that headlines proclaiming that "butter is back" "is an oversimplification, we never said that" and noted that the study was not able to distinguish between the differing effects of reducing saturated fat intake depending on what foods were used in substitute. "While that research is going on I don't think we should just go changing everything. It's too premature to give the public the impression that they have a licence, based on this preliminary research, which is exciting but not yet definitive, to say butter is back."[29]

Moreover, Dr. Walter Willett of Harvard Medical School warned that the conclusions of the meta-analysis are seriously misleading, contains major errors and omissions, and should be retracted.[30] In response to the Chowdhury review, Dr. Walter C. Willett and coauthors Frank Sacks, and Meir J. Stampfer commented that:

″The meta-analysis of dietary fatty acids and risk of coronary heart disease by Chowdhury et al. contains multiple errors and omissions, and the conclusions are seriously misleading, particularly the lack of association with N-6 polyunsaturated fat. For example, two of the six studies included in the analysis of N-6 polyunsaturated fat were wrong. The relative risks for Nurses’ Health Study (NHS) and Kuopio Ischemic Heart Disease Study (KIHD) were retrieved incorrectly and said to be above 1.0. However, in the 20-year follow-up of the NHS the relative risk for highest vs lowest quintile was 0.77 (95 percent CI: 0.62, 0.95); ptrend = 0.01 (the authors seem to have used the RR for N-3 alpha-linolenic acid from a paper on sudden cardiac death), and in the KIHD the relative risk was 0.39; 95% confidence interval [CI], 0.21-0.71) (the origin of the number used in the meta-analysis is unclear). Also, relevant data from other studies were not included.
Further, the authors did not mention a pooled analysis of the primary data from prospective studies, in which a significant inverse association between intake of polyunsaturated fat (the large majority being the N-6 linoleic acid) and risk of CHD was found. Also, in this analysis, substitution of polyunsaturated fat for saturated fat was associated with lower risk of CHD. Chowdhury et al. also failed to point out that most of the monounsaturated fat consumed in their studies was from red meat and dairy sources, and the findings do not necessarily apply to consumption in the form of nuts, olive oil, and other plant sources. Thus, the conclusions of Chowdhury et al. regarding the type of fat being unimportant are seriously misleading and should be disregarded.″

Views

Mainstream authorities

Specialist/professional textbooks

The 2009 European Society of Cardiology Textbook of Cardiovascular Medicine states that, in cohort studies, the positive relationship between fat intake and CVDs was linked to their saturated fatty acid content.[31]

2007's Cardiovascular Prevention and Rehabilitation states that large epidemiological studies have shown consistent associations between the intake of saturated fatty acids and CHD mortality.[32]

According to the 2007 Critical Pathways in Cardiovascular Medicine, substituting unsaturated fat for saturated fat may lower LDL cholesterol without simultaneously lowering HDL cholesterol. This dietary principle partly underlies the Mediterranean style of diet, which has been associated with reduced cardiovascular event rates in two randomized controlled trials.[33]

The 2003 second edition of Evidence-based Cardiology in 'PartII: Prevention of cardiovascular diseases' recommends a low intake of SFA, less than 7% of daily calories, and intake of foods rich in myristic and palmitic acids should be especially reduced. The recommendation was evaluated to be supported by the best grade of available evidence.[34]

Position statements and guidelines of major health organizations

Medical establishments

In 2003 a World Health Organization (WHO) and Food and Agricultural Organization (FAO) expert consultation report concluded that "intake of saturated fatty acids is directly related to cardiovascular risk. The traditional target is to restrict the intake of saturated fatty acids to less than 10%, of daily energy intake and less than 7% for high-risk groups. If populations are consuming less than 10%, they should not increase that level of intake. Within these limits, intake of foods rich in myristic and palmitic acids should be replaced by fats with a lower content of these particular fatty acids. In developing countries, however, where energy intake for some population groups may be inadequate, energy expenditure is high and body fat stores are low (BMI <18.5 kg/m2). The amount and quality of fat supply has to be considered keeping in mind the need to meet energy requirements. Specific sources of saturated fat, such as coconut and palm oil, provide low-cost energy and may be an important source of energy for the poor."[35]

In its 2007 guidelines, the European Society of Cardiology states that there are strong, consistent, and graded relationships between saturated fat intake, blood cholesterol levels, and the mass occurrence of cardiovascular disease. The relationships are accepted as causal.[36]

The Mayo Clinic considers saturated fats potentially harmful and monounsaturated and polyunsaturated fats potentially helpful. It references the Dietary Guidelines for Americans, 2010 and recommends reducing foods rich in saturated fat and emphasizing options with more monounsaturated and polyunsaturated fats.[37]

The British Dietetic Association guidelines found good evidence in systematic reviews of randomized controlled trials that reducing saturated fat reduces morbidity in patients with CVD.[38]

The 2007 position statement of the American Dietetic Association and the Dieticians of Canada holds that epidemiological studies have shown a positive association between the intake of saturated fatty acid and the incidence of coronary heart disease.[3]

The Harvard School of Public Health holds that saturated fats should be replaced with cis monounsaturated and polyunsaturated fats, but that they should not be replaced with refined carbohydrates.[39]

Heart-health organizations

Consumption of saturated fat is a risk factor for cardiovascular disease in the view of the Canadian Heart and Stroke Foundation,[40] the American Heart Association,[5] the British Heart Foundation,[6] the National Heart Foundation of Australia,[41] the National Heart Foundation of New Zealand [42] and the World Heart Federation.[7] The Irish Heart Foundation states that saturated fats can raise LDL cholesterol and increase the chance of developing heart disease.[43]

Governmental guidelines

The Dietary Guidelines for Americans, 2010 produced by the U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services says the human body makes more than enough saturated fats to meet its needs and does not require more from dietary sources. It says higher levels of saturated fats are associated with higher levels of total cholesterol and low-density lipoprotein "bad" cholesterol and recommends reduced saturated fat intake.[44] The guidelines are based on the recommendations of the Dietary Guidelines Advisory Committee (DGAC) report that incorporated the results of the review of 12 studies from 2004 to 2009 conducted by the Nutrition Evidence Library (NEL) part of the Evidence Analysis Library Division of the USDA's Center for Nutrition Policy and Promotion. The NEL concluded that there was "strong" evidence that dietary saturated fats increased serum total cholesterol and LDL cholesterol and increased risk of cardiovascular disease.[45][46]

Editorial, commentary and conference findings

Recommendations for lower intake of saturated fat

A 2010 debate at the Academy of Nutrition and Dietetics's 93rd conference stated: "Regarding saturated fat, the key point agreed upon by the panel and scientific community at large was that researchers agree that replacing saturated fat with healthy polyunsaturated fats is beneficial for health and cardiovascular disease." Recommendations for dieticians emphasized using mono- and polyunsaturated fats whenever possible, avoiding trans fats. Further, "The evidence against saturated fat may not be as strong as dietary guidelines have interpreted [it is clear] that PUFAs (especially) and MUFAs are healthy fats", and that while there is room for saturated fats within the diet, but "[they] should not be viewed as good for you".[47]

A 2010 review found that the risk of coronary heart disease is reduced when saturated fatty acids are replaced with polyunsaturated fatty acids, but there was no clear benefit in replacing saturated fatty acids with carbohydrates or monounsaturated fatty acids.[48]

A 2009 review found that the best evidence showed reduced intake of saturated fat decreased the risk for coronary heart disease.[49]

Another 2009 review found that epidemiological evidence suggested a negative influence on vascular function from saturated fat, but that the experimental evidence did not support this convincingly.[50]

Opposition to reduced intake

A opinion critique of dietary guidelines which recommended lower intake of saturated fat summarized systematic reviews and meta-analyses that found insignificant effects on the incidence of cardiovascular diseases by reducing intake of saturated fat.[51]

The 2010 U.S. Dietary Guidelines Advisory Committee report was criticized for the "use of an incomplete body of relevant science; inaccurately representing, interpreting, or summarizing the literature; and drawing conclusions and/or making recommendations that do not reflect the limitations or controversies in the science" stating rather that the evidence associating dietary saturated fat with increased risk of cardiovascular disease is inconclusive.[52]

A 2010 meta-analysis concluded that no evidence exists that dietary saturated fat is associated with increased risk of cardiovascular diseases,[1] but this conclusion was disputed,[53] and the authors of the meta-analysis themselves later noted that "A critical question is what macronutrient should be used to replace saturated fat. ... Epidemiologic studies and randomized clinical trials have provided consistent evidence that replacing saturated fat with polyunsaturated fat, but not carbohydrates, is beneficial for coronary heart disease."[54]

A 2009 scientific conference reported that despite the contribution of dairy products to the saturated fatty acid intake of the diet, there was no clear evidence that dairy food consumption is consistently associated with a higher risk of cardiovascular disease.[55]

The Dairy Farmers of Canada published an opinion that summarized findings of a meta-analysis,[1] stating: "In light of new scientific data, it appears that saturated fat is not associated with an increased risk of cardiovascular disease."[56]

See also

References

  1. ^ a b c Siri-Tarino PW, Sun Q, Hu FB, Krauss RM; Sun; Hu; Krauss (March 2010). "Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease". The American Journal of Clinical Nutrition. 91 (3): 535–46. doi:10.3945/ajcn.2009.27725. PMC 2824152. PMID 20071648.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  2. ^ Joint WHO/FAO Expert Consultation (2003). Diet, Nutrition and the Prevention of Chronic Diseases (WHO technical report series 916) (PDF). World Health Organization. pp. 81–94. ISBN 92-4-120916-X. Retrieved 2011-03-11.
  3. ^ a b c Kris-Etherton, PM; Innis, S; American Dietetic, Association; Dietitians Of, Canada (September 2007). "Position of the American Dietetic Association and Dietitians of Canada: Dietary Fatty Acids" (PDF). Journal of the American Dietetic Association. 107 (9): 1599–1611 [1603]. doi:10.1016/j.jada.2007.07.024. PMID 17936958. Retrieved 2011-03-18.
  4. ^ "Food Fact Sheet - Cholesterol" (PDF). British Dietetic Association. Archived from the original (PDF) on February 1, 2012. Retrieved 3 May 2012. {{cite web}}: Unknown parameter |deadurl= ignored (|url-status= suggested) (help)
  5. ^ a b c d Sacks, Frank M.; Lichtenstein, Alice H.; Wu, Jason H.Y.; Appel, Lawrence J.; Creager, Mark A.; Kris-Etherton, Penny M.; Miller, Michael; Rimm, Eric B.; Rudel, Lawrence L.; Robinson, Jennifer G.; Stone, Neil J.; Van Horn, Linda V. (15 June 2017). "Dietary Fats and Cardiovascular Disease: A Presidential Advisory From the American Heart Association" (PDF). Circulation: CIR.0000000000000510. doi:10.1161/CIR.0000000000000510.
  6. ^ a b "Fats explained". Retrieved 2012-05-03.
  7. ^ a b "Cardiovascular Disease Risk Factors". Retrieved 2012-05-03.
  8. ^ "Eat less saturated fat". National Health Service. Retrieved 2012-05-03.
  9. ^ "Nutrition Facts at a Glance - Nutrients: Saturated Fat". Food and Drug Administration. 2009-12-22. Archived from the original on September 17, 2011. Retrieved 2012-05-03. {{cite web}}: Unknown parameter |deadurl= ignored (|url-status= suggested) (help)
  10. ^ "Scientific Opinion on Dietary Reference Values for fats, including saturated fatty acids, polyunsaturated fatty acids, monounsaturated fatty acids, trans fatty acids, and cholesterol". European Food Safety Authority. Retrieved 3 May 2012.
  11. ^ a b De Souza, R. J.; Mente, A; Maroleanu, A; Cozma, A. I.; Ha, V; Kishibe, T; Uleryk, E; Budylowski, P; Schünemann, H; Beyene, J; Anand, S. S. (2015). "Intake of saturated and trans unsaturated fatty acids and risk of all cause mortality, cardiovascular disease, and type 2 diabetes: Systematic review and meta-analysis of observational studies". BMJ. 351: h3978. doi:10.1136/bmj.h3978. PMC 4532752. PMID 26268692.
  12. ^ Steinberg, D. (2004). "Thematic review series: The Pathogenesis of Atherosclerosis. An interpretive history of the cholesterol controversy: Part I". The Journal of Lipid Research. 45 (9): 1583–1593. doi:10.1194/jlr.R400003-JLR200. PMID 15102877.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  13. ^ a b c Blackburn, H. (2012). "20th-Century "Medical Marco Polos" in the Origins of Preventive Cardiology and Cardiovascular Disease Epidemiology". The American Journal of Cardiology. 109 (5): 756–767. doi:10.1016/j.amjcard.2011.10.038.
  14. ^ de Langen, Cornelis (1916). "Cholesterine-stofwisseling en rassenpathologie". Geneeskundig Tijdschrift voor Nederlandsch-Indie (in Dutch). 56: 1–34.
  15. ^ a b Teicholz, Nina (6 May 2014). "The Questionable Link Between Saturated Fat and Heart Disease". Wall Street Journal. Retrieved 9 May 2015.
  16. ^ Keys A, Taylor HL, Blackburn H, Brozek J, Anderson JT, Simonson E (1 September 1963). "Coronary heart disease among Minnesota business and professional men followed 15 years". Circulation. 28 (3): 381–95. doi:10.1161/01.cir.28.3.381. PMID 14059458.
  17. ^ Famous Polemics on Diet-Heart Theory. Henry Blackburn, School of Public Health, University of Minnesota. http://www.epi.umn.edu/cvdepi/essay.asp?id=33 accessed 18th March 2014
  18. ^ Keys, Ancel (1980). Seven Countries: A Multivariate Analysis of Death and Coronary Heart Disease. Harvard University Press. ISBN 0-674-80237-3.
  19. ^ Hooper; et al. (Apr 2016). "Reduced or modified dietary fat for preventing cardiovascular disease". Sao Paulo Med J. 134 (2): 182–3. doi:10.1590/1516-3180.20161342T1. PMID 27224282. {{cite journal}}: Explicit use of et al. in: |author= (help)
  20. ^ Ramsden, Christopher E; Zamora, Daisy; Majchrzak-Hong, Sharon; Faurot, Keturah R; Broste, Steven K; Frantz, Robert P; Davis, John M; Ringel, Amit; Suchindran, Chirayath M; Hibbeln, Joseph R (12 April 2016). "Re-evaluation of the traditional diet-heart hypothesis: analysis of recovered data from Minnesota Coronary Experiment (1968-73)". BMJ. 353: i1246. doi:10.1136/bmj.i1246. PMC 4836695. PMID 27071971.
  21. ^ Schwab, Ursula; Lauritzen, Lotte; Tholstrup, Tine; Haldorssoni, Thorhallur; Riserus, Ulf; Uusitupa, Matti; Becker, Wulf (10 July 2014). "Effect of the amount and type of dietary fat on cardiometabolic risk factors and risk of developing type 2 diabetes, cardiovascular diseases, and cancer: a systematic review". Food & Nutrition Research. 58: 25145. doi:10.3402/fnr.v58.25145. PMC 4095759. PMID 25045347.
  22. ^ Chowdhury, Rajiv; et al. (March 18, 2014). "Association of Dietary, Circulating, and Supplement Fatty Acids With Coronary Risk: A Systematic Review and Meta-analysis". Ann Intern Med.
  23. ^ Farvid, Maryam S.; Ding, Ming; Pan, An; Sun, Qi; Chiuve, Stephanie E.; Steffen, Lyn M.; Willett, Walter C.; Hu, Frank B. (28 October 2014). "Dietary Linoleic Acid and Risk of Coronary Heart Disease: A Systematic Review and Meta-Analysis of Prospective Cohort StudiesCLINICAL PERSPECTIVE" (PDF). Circulation. 130 (18): 1568–1578. doi:10.1161/CIRCULATIONAHA.114.010236.
  24. ^ "Reduction in saturated fat intake for cardiovascular disease". Cochrane Database Syst Rev. Jun 10 (6): CD011737. 2015. doi:10.1002/14651858.CD011737. PMID 26068959. {{cite journal}}: Cite uses deprecated parameter |authors= (help)
  25. ^ Hamley, S (May 2017). "The effect of replacing saturated fat with mostly n-6 polyunsaturated fat on coronary heart disease: a meta-analysis of randomised controlled trials". Nutrition Journal. 16 (1): 30. doi:10.1186/s12937-017-0254-5. PMID 28526025.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  26. ^ de Souza RJ, Mente A, Maroleanu A, Cozma AI, Ha V, Kishibe T, Uleryk E, Budylowski P, Schünemann H, Beyene J, Anand SS (Aug 12, 2015). "Intake of saturated and trans unsaturated fatty acids and risk of all cause mortality, cardiovascular disease, and type 2 diabetes: systematic review and meta-analysis of observational studies". BMJ. 351 (h3978). doi:10.1136/bmj.h3978. PMC 4532752. PMID 26268692.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  27. ^ Chowdhury R, Warnakula S, Kunutsor S, Crowe F, Ward HA, Johnson L, Franco OH, Butterworth AS, Forouhi NG, Thompson SG, Khaw KT, Mozaffarian D, Danesh J, Di Angelantonio E (2014). "Association of dietary, circulating, and supplement fatty acids with coronary risk: a systematic review and meta-analysis". Ann. Intern. Med. 160 (6): 398–406. doi:10.7326/M13-1788. PMID 24723079.
  28. ^ "Saturated fats and heart disease link 'unproven'". NHI Choices. March 18, 2014.
  29. ^ Gallagher, James (6 January 2016). "Diet debate: Is butter back and is sat fat good?". BBC. Retrieved 17 July 2017.
  30. ^ "Dietary fat and heart disease study is seriously misleading". Harvard University School of Public Health. March 19, 2014.
  31. ^ Camm, John; Luscher, Thomas; Serruys, Patrick (2009). The European Society of Cardiology Textbook of Cardiovascular Medicine. Blackwell Publishing. p. 257. ISBN 978-0-19-957285-4.
  32. ^ Perk, J (2007). Cardiovascular Prevention and Rehabilitation. Springer-Verlag London Limited. p. 184. ISBN 978-1-84628-462-5. {{cite book}}: Unknown parameter |displayauthors= ignored (|display-authors= suggested) (help)
  33. ^ Cannon, Christopher; O'Gara, Patrick (2007). Critical Pathways in Cardiovascular Medicine, 2nd Edition. Lippincott Williams & Wilkins. p. 243.
  34. ^ Yusuf, S (2003). Evidence-based Cardiology, Second edition. BMJ Books. p. 320. ISBN 0-7279-1699-8. {{cite book}}: Unknown parameter |displayauthors= ignored (|display-authors= suggested) (help)
  35. ^ Joint WHO/FAO Expert Consultation (2003). Diet, Nutrition and the Prevention of Chronic Diseases (WHO technical report series 916) (PDF). World Health Organization. pp. 81–94. ISBN 92-4-120916-X. Retrieved 2011-03-11.
  36. ^ European Society of Cardiology; Atar; Borch-Johnsen; Boysen; Burell; Cifkova; Dallongeville; De Backer; Ebrahim; Gjelsvik; Herrmann-Lingen; Hoes; Humphries; Knapton; Perk; Priori; Pyorala; Reiner; Ruilope; Sans-Menendez; Scholte Op Reimer; Weissberg; Wood; Yarnell; Zamorano; Walma; Fitzgerald; Cooney; Dudina; European Society of Cardiology (ESC) Committee for Practice Guidelines (CPG) (2007). "European guidelines on cardiovascular disease prevention in clinical practice: executive summary" (PDF). European Heart Journal. 28 (19): 2375–2414. doi:10.1093/eurheartj/ehm316. PMID 17726041.
  37. ^ Dietary fats: Know which types to choose Mayo Clinic website
  38. ^ Mead, A (December 2006). "Dietetic guidelines on food and nutrition in the secondary prevention of cardiovascular disease – evidence from systematic reviews of randomized controlled trials (second update, January 2006)". Journal of Human Nutrition and Dietetics. 19 (6): 401–419. doi:10.1111/j.1365-277X.2006.00726.x. PMID 17105538. {{cite journal}}: Unknown parameter |displayauthors= ignored (|display-authors= suggested) (help)
  39. ^ "Fats and Cholesterol", Harvard School of Public Health. Retrieved 02-11-16.
  40. ^ "Dietary fats, oils and cholesterol". Heart and Stroke Foundation of Canada. Retrieved 2010-12-22.
  41. ^ "'Reduce saturated fat' urges Heart Foundation after major review" (PDF). National Heart Foundation of Australia. Retrieved 2014-12-24.
  42. ^ Seddon MB. ChB. MPH., M (March 1999). "Dietary Fats: An Evidence-Based Nutrition Statement from the National Heart Foundation of New Zealand's Nutrition Advisory Committee" (PDF). Retrieved 2016-04-11.
  43. ^ "Cholesterol". Irish Heart Foundation. Retrieved 2014-07-08.
  44. ^ U.S. Department of Agriculture and U.S. Department of Health and Human Services. (December 2010). Dietary Guidelines for Americans, 2010 (7th Edition). Washington, DC: U.S. Government Printing Office.
  45. ^ USDA Nutrition Evidence Library. (2010). What is the effect of saturated fat intake on increased risk of cardiovascular disease or type 2 diabetes?. Retrieved March 13, 2011.
  46. ^ Dietary Guidelines Advisory Committee. (June 14, 2010). Part D. Section 3: Fatty Acids and Cholesterol. Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans.
  47. ^ Zelman, K. (2011). "The Great Fat Debate: A Closer Look at the Controversy—Questioning the Validity of Age-Old Dietary Guidance" (PDF). Journal of the American Dietetic Association. 111 (5): 655–658. doi:10.1016/j.jada.2011.03.026. PMID 21515106.
  48. ^ Astrup, A; Dyerberg, J.; Elwood, P.; Hermansen, K.; Hu, F. B.; Jakobsen, M. U.; Kok, F. J.; Krauss, R. M.; Lecerf, J. M.; et al. (January 2011). "The role of reducing intakes of saturated fat in the prevention of cardiovascular disease: where does the evidence stand in 2010?". American Journal of Clinical Nutrition. 93 (4): 684–688. doi:10.3945/ajcn.110.004622. PMC 3138219. PMID 21270379.
  49. ^ Lottenberg AMP (July 2009). "Importance of the dietary fat on the prevention and control of metabolic disturbances and cardiovascular disease". Arquivos Brasileiros de Endocrinologia e Metabologia. 53 (5): 595–607. doi:10.1590/S0004-27302009000500012. ISSN 0004-2730. PMID 19768250.
  50. ^ Hall WL (June 2009). "Dietary saturated and unsaturated fats as determinants of blood pressure and vascular function". Nutrition Research Reviews. 22 (1): 18–38. doi:10.1017/S095442240925846X. PMID 19243668.
  51. ^ Teicholz N (2015). "The scientific report guiding the US dietary guidelines: Is it scientific?". BMJ (Clinical Research Ed.). 355: i6061. doi:10.1136/bmj.i6061. PMID 27913380.
  52. ^ Hite Adele H.; Richard; Feinman David; Guzman Gabriel E. (October 2010). "In the face of contradictory evidence: Report of the Dietary Guidelines for Americans Committee". Nutrition. 26 (10): 915–924. doi:10.1016/j.nut.2010.08.012. PMID 20888548. {{cite journal}}: Unknown parameter |displayauthors= ignored (|display-authors= suggested) (help)
  53. ^ Stamler J (February 2010). "Diet-heart: a problematic revisit". The American Journal of Clinical Nutrition. 91 (3): 497–99. doi:10.3945/ajcn.2010.29216. PMID 20130097. The authors are inaccurate in concluding that 'there are few epidemiologic or clinical trial data to support a benefit of replacing saturated fat with carbohydrate
  54. ^ Siri-Tarino PW, Sun Q, Hu FB, Krauss RM (November 2010). "Saturated fatty acids and risk of coronary heart disease: modulation by replacement nutrients". Curr Atheroscler Rep. 12 (6): 384–90. doi:10.1007/s11883-010-0131-6. PMC 2943062. PMID 20711693. Retrieved 17 July 2017.
  55. ^ German JB; Gibson RA; Krauss RM (June 2009). "A reappraisal of the impact of dairy foods and milk fat on cardiovascular disease risk". European Journal of Nutrition. 48 (4): 191–203. doi:10.1007/s00394-009-0002-5. PMC 2695872. PMID 19259609. {{cite journal}}: Unknown parameter |displayauthors= ignored (|display-authors= suggested) (help)
  56. ^ Mente A. "New evidence reveals that saturated fat does not increase the risk of cardiovascular disease". Dairy Farmers of Canada. Retrieved 2011-03-18.
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