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A Fat Problem with Heart Health Wisdom
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Comedian/documentarian Tom Naughton recently made a highly intriguing post about the “Spanish Paradox”; that is, the low rate of cardiovascular illness among Spaniards despite their apparently poor markers of heart health.

This post was made on the discussion site of Naughton’s 2009 documentary Fat Head. This movie (which I have yet to see, but plan to soon) criticizes the conventional wisdom on weight, fat intake, and health. Particularly, it was meant to be a response to Morgan Spurlock’s 2004 documentary Super Size Me, in which Spurlock went on an all McDonald’s diet for 30 days. Naughton found that the conventional wisdom about heart health and diet was deeply flawed, as he demonstrated in the film.

That conventional medical wisdom is highly suspect is not too surprising, as this is in line with John Ioannidis’s finding that most published research findings are false. This problem is particularly pervasive in the human sciences, especially medicine, (and of course, psychology, something with which regular readers are all too familiar).

In keeping with his theme critical of the exact role of diet and fat in health and cardiovascular illness, Naughton cited this chart from the American Heart Association on the incidence of cardiovascular illness and death in selected countries:


The first thing that jumped out at me was the very tight association of related groups. Roughly, we see a pattern that goes like this (in descending order of illness rates):

  1. Slavs and Eastern Europeans
  2. Celtic groups
  3. Germanic and Anglo groups
  4. Mediterraneans, tied with East Asians

Edit, 1/26/13: See this map of age-adjusted cardiovascular death rates across much of Europe, by region. This is of males, age 45-74, year 2000.

Europe Heart Death Men 2000

Notice the apparent Northeast to Southwest cline.

While there are some irregularities (i.e., China, Australia, and Greece), the general pattern is strong. This strongly suggests that genetic factors are involved. Indeed, Naughton brilliantly highlights the problems with the traditional markers of heart health:

Surveying a cross-section of Spanish adults, Dr Auxiliadora Graciani (Universidad Autonoma de Madrid, Spain) and colleagues measured “ideal cardiovascular health”–as described by the AHA–and found that only 0.2% of the 11, 408 subjects attained ideal values for all seven CVD health metrics: nonsmoker, body-mass index (BMI) <25 kg/m2, physical activity at goal, diet consistent with recommendations, untreated cholesterol <200 mg/dL, untreated BP <120/80 mm Hg, and untreated fasting glucose <100 mg/dL in the absence of clinical CVD and diabetes. Of those surveyed, 3.4% attained ideal values for at least six of the metrics and 15.4% for five, they note in their report published online January 8, 2013 in Circulation: Cardiovascular Quality and Outcomes.

Wow, that’s just awful. Barely one-fifth of one percent of the Spanish adults meet the American Heart Association’s ideal values for cardiovascular health. And I thought the people I saw falling down in Barcelona were just party animals who’d had too much sangria. Now I realize they were having heart attacks. In retrospect, I feel guilty for clapping.

“This is the first study to report information on cardiovascular health from Spain, a European country with low coronary heart disease mortality compared with many Western countries,” observe the authors. However, the level of cardiovascular health in Spain “is as low as in the United States, primarily due to poor lifestyles, especially lack of ideal diet,” they note.

Um … uh … but … did I read that correctly? The Spanish have a low level of cardiovascular health but also low coronary heart disease mortality? Isn’t that a bit like saying they’re in poor physical condition, but can run for miles and bench-press their own body weights? I don’t know about these researchers, but I define “good cardiovascular health” as “not dying from cardiovascular disease.”

Although the CHD mortality rate is low in Spain, recent research shows the prevalence of angina there is high, suggesting that atheromatous plaques are stable, the doctors say. Research is needed as to why these plaques do not rupture, translating into a high incidence of acute MI, as is seen in other countries, they state.

Oh, okay. Got it. The researchers are speculating that thanks to their stubborn refusal to adopt the American Heart Association’s definition of good health and a good diet, the Spanish actually do have lots of plaque buildup … but for some reason, plaques don’t rupture in Spain. Must be the weather. I’m surprised they didn’t say it’s because the Spanish drink wine.

This “paradox” of low CHD mortality and poor cardiovascular health in Spain could be explained by several things other than traditional CV risk factors, such as sedentary behavior, specific dietary components (eg, wine consumption and the Mediterranean diet), psychosocial factors (such as family support), and quality of medical care, among others, say Graciani et al.

Head. Bang. On. Desk.

I see. So the Spanish suffer from a “lack of ideal diet,” they have poor cardiovascular health because they don’t meet the American Heart Association’s criteria, but they don’t die from heart attacks because they eat a Mediterranean diet. They have a lousy diet, but their diet saves them from heart disease. Oh, and because they drink wine. And because of the quality of medical care. I guess that means they get treated for their high cholesterol.

And because lifestyles appear to contribute far more heavily than biological factors to poor cardiovascular health in Spain, there is a great need to strengthen the role of public-health efforts in the management of CVD there, they observe. Health services also need to improve, they add, noting that five out of every 10 people with elevated cholesterol are not being treated, and half of those with BP >140/90 mm Hg are unaware of this.

Head. Bang. On. Desk.

So, to sum up … The Spanish are in poor cardiovascular health because of their lifestyle and lack of an ideal diet, which means there’s a great need to strengthen government efforts in the management of cardiovascular disease. But they don’t die of heart attacks because of their diet and high-quality medical care.

I want to know how any researcher can make those arguments in a paper without reading what he wrote and thinking, “Wait a minute … I sound like a flippin’ moron here.”

Naughton continues, noticing that the connection between cholesterol levels and cardiovascular death rates do not seem to cross national lines:

A couple of years ago, I downloaded data from the World Health Organization’s MONICA study, which tracks cholesterol levels and cardiovascular death rates around the world. The average cholesterol level in Russia is 189. In France, it’s 210. Romania (near the top of the chart) and Spain (near the bottom) have the same average cholesterol level: 197. When I ran the correlation function in Excel on all the countries and their rates of cardiovascular deaths, the result was -0.25. In other words, there’s almost no correlation, and the slight correlation that exists points to cardiovascular deaths going up as cholesterol levels go down. (emphasis added)

But then, why should it? Cholesterol levels may be predictive within a group, but may mean nothing across groups. This is because (to quote the venerable HBD Chick) “different peoples is different.” What may be a perfectly acceptable level of cholesterol for individuals in one group may be highly detrimental to individuals in another (this is assuming that cholesterol levels matter at all). Indeed, failure to recognize this fact stymies research in this field.

Naughton continues in a newer post, this time looking at Norwegians:

…the researchers report on the results of applying them to data collected from several thousand Norwegians. Here’s what they found:

At age 40, 22.5% of women and 85.9% of men were at high risk of cardiovascular disease. Corresponding numbers at age 50 were 39.5% and 88.7%, and at age 65 were 84.0% and 91.6%. At age 40, one out of 10 women and no men would be classified at low risk for cardiovascular disease.

Hmmm … people in Norway must be dropping like flies from heart disease, at least according to the prevailing guidelines for estimating heart-disease risk … you know, cholesterol levels and all that stuff.

But as we see from the above post, they’re not.

So if heritable group differences are involved in heart health, what could those heritable factors be? One clue is digestive function itself. A Scientific American guest blog post by Rob Dunn, which discussed some of the complexities in measuring the effective calories delivered by food touched on one potential factor:

A Body is Not a Body—Amazingly, there are more ways in which a calorie is not a calorie. Even if two people were to somehow eat the same sweet potato cooked the same way they would not get the same number of calories. Carmody and colleagues studied a single strain of heavily inbred lab mice such that their mice were as similar to each other as possible. Yet the mice still varied in terms of how much they grew or shrank on a given diet, thanks presumably to subtle differences in their behavior or bodies. Humans vary in nearly all traits, whether height, skin color, or our guts. Back when it was the craze to measure such variety European scientists discovered that Russian intestines are about five feet longer than those of, say, Italians. This means that those Russians eating the same amount of food as the Italians likely get more out of it. Just why the Russians had (or have) longer intestines is an open question. Surely other peoples differ in their intestines too; intestines need more study, though I am not going to volunteer to do the dirty work. We also vary in terms of how much of particular enzymes we produce; the descendents of peoples who consumed lots of starchy food tend to produce more amylase, the enzyme that breaks down starch. Then there is the enzyme our bodies use to digest the lactose in milk, lactase. Many (some say most) adults are lactose deficient; they do not produce lactase and so do not break down the lactose in milk. As a result, even if they drink milk they receive far fewer calories from doing so than do individuals who produce lactase. Each of us gets a different number of calories out of identical foods because of who we are and who our ancestors were. (emphasis added)

It’s only too bad that the “craze” of measuring human differences went out of fashion, but regular readers know how that is.

Human bodies vary in both their efficiency in absorbing calories and nutrients as well as how well they metabolize them. This is to be expected, as recent evolutionary forces – particularly agriculture – have had a huge impact on human evolution, one of the most salient of these which is significant to diet is the distribution of lactose intolerance:


Additionally, there are heritable differences in how the body responds to certain chemical levels, such as cholesterol or fat levels, as Naughton notes about the Spanish and the Norwegians. (Indeed, as Greg Cochran and Henry Harpending note in The 10,000 Year Explosion, Africans are more retentive of salt, which is involved in the higher rates of hypertension among Blacks.)

But that’s not the only area where heredity could make a difference. Heritable behaviors could be at play (e.g., smoking or alcohol consumption), including societal structure (which may impact stress levels). Dietary preferences, which are clearly heritable between individuals within a group, likely plays a role in the preferred foods of each culture (not for the least reason that the same foods taste different to different people). The effects of heredity could range from the most direct (metabolism) to the most indirect (levels of societal stress).

My Twitter followers might have noticed a recent and somewhat heated discussion between myself and Naughton over a potential partial genetic explanation for the “French (and Spanish) Paradox”, particularly over the genetic distinctiveness between the English and the French. Of course, while there’s no question that the French and the English are genetically distinct today, to test the extent of the genetic contribution to the observed differences, we could look at some of the offshoots of said groups. To that end, I decided to take a look at the Québécois.

Here are the rates of “cardiovascular disease factors” across the various Canadian provinces:

Prevalence of risk factors for cardiovascular disease in Canadians ages 12 or over by province or territory
Province Current smoker (%) Hypertensive (%) Diabetic (%) Obesity (BMI ≥30) (%) Physically Inactive Low Income (%)
Canada 26.0 13.0 4.2 14.9 53.5 11.3
Newfoundland 29.0 15.4 5.8 19.8 59.6 18.4
Price Edward Island 27.9 14.0 5.0 18.5 56.4 13.0
Nova Scotia 28.2 16.2 5.2 20.8 55.3 15.0
New Brunswick 26.4 14.5 5.1 20.2 61.1 15.5
Quebec 29.5 12.6 4.1 12.7 58.5 13.4
Ontario 24.5 14.0 4.3 15.4 53.9 9.3
Manitoba 25.1 13.5 4.0 18.1 55.8 10.9
Saskatchewan 27.7 12.6 4.0 19.2 52.5 13.5
Alberta 27.7 10.5 3.4 16.3 48.0 9.3
British Columbia 20.6 11.4 3.9 13.3 43.7 11.4
Yukon Territory 33.7 8.5 3.2 18.2 36.0 8.8
Northwest Territories 46.6 8.1 2.8 22.8 55.4 16.3
Nunavut 56.8 6.2 1.9 25.5 52.4 38.7

And here are death rates from cardiovascular diseases in the various Canadian provinces:

Cardiovascular disease death rate per 100,000 population in Canada
Province Death Rate Province Death Rate
Newfoundland 290 Ontario 201
Prince Edward Island 264 Manitoba 257
Nova Scotia 261 Saskatchewan 289
New Brunswick 245 Alberta 183
Quebec 191 British Columbia 230
Canada 209

Quebec has significantly a significantly lower obesity rate that its fellow Canadian provinces. As well, it has a somewhat lower cardiovascular mortality rate, though the difference here isn’t as dramatic as the difference between France proper and the Anglosphere. While not extremely so, this is consistent with the genetic explanation. (However, it’s worth noting that the Québécois aren’t genetically representative of all French, having descended from about 2,600 colonists from a few specific regions of France. As well, the Québécois have undergone subsequent evolution).

As Naughton noted, there are outliers, such as Australia, indicating that genetics isn’t the whole story. Nonetheless, heredity must be a significant factor, as it is clear that both heart health and one’s lifespan are significantly heritable (also here and here).

Heredity clearly isn’t the sole explanation, but it’s obviously a significant part of it. If only research into human differences didn’t become taboo, we may have had these answers long ago.

(Republished from JayMan's Blog by permission of author or representative)
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  1. Thanks, this was a fascinating post. Definitely thought provoking. Will be visiting this blog more frequently.

  2. Staffan says: • Website

    It’s also a fact that the Eastern Europeans drink more and eat less fish than people with less heart disease, (like Australians for instance who seem to have better health than they should given their obesity).

  3. Anonymous • Disclaimer says:

    Like I said in fathead post : “Nice article JayMan but I still think LOW INCOME (%) is a better risk factor to predicted cardiovascular death. In Quebec medication Insurance are Mandatory since 1997 and that not the case in any other province. We pay less for medication more in taxes.

    If you got access to medication you are less likely to die from chronic disease. I think it is a simple as that.”

    • Replies: @JayMan
  4. JayMan says: • Website

    Low income is primarily the result of low IQ, low future-time orientation and other traits not conducive to success. It is associated with poor health not only because the low-income have less access to resources, as you note, but because low-IQ people take poorer care of themselves and are in genetically poorer health as well (having higher amounts of genetic load, for one).

  5. My general complaint about conventional diet discourse is that it’s so oriented toward finding the One True Diet that will work for everybody, when everybody, even within the same family, is a little different. For example, the Chinese nutritional supplement echinacea works well for me in helping me stave off colds, but it doesn’t do even my own kids any good.

    • Replies: @JayMan
  6. JayMan says: • Website
    @Steve Sailer

    Absolutely. Individual and group variation probably plays a big role in the results of diet.

    Along that line there was the study that showed exercise benefits Black girls less than it does White girls.

  7. Chuck says: • Website

    “Heredity clearly isn’t the sole explanation, but it’s obviously a significant part of it. If only research into human differences didn’t become taboo, we may have had these answers long ago.”

    Excellent post (again) Jayman! The way forward is to resolve the race-IQ controversy. Really. And I think it’s indeed resolvable. See here: To that end, I was thinking of doing a fuller investigation of the scores of Black African and West Indian immigrants –looking at PISA 2000, 2003, 2006, & 2009 scores by race by generation. Maybe it will turn out that Black 2nd gen immigrants are closing the gap. Did you ever read my post on the UK gaps?
    No one has been able to explain that. Makes you wonder. Unfortunately, I’m not super familiar with the UK testing system. So I can’t yet declare victory for racial environmentalism. That’s why I wanted to take a better look at the US. Wondering if you’d be interested in helping. You seem to be more familiar with the immigrant “people of color” community — you might have some ideas. Anyways, if you’re interested, shoot me an email. Later.

    • Replies: @Greying Wanderer
  8. “I define “good cardiovascular health” as “not dying from cardiovascular disease.” – See, that’s why you’re never going to make it in research. Or be an economist, of whom it is said “When he sees something working in practice he gets exceited and goes home to figure out if it also works in theory.”

    • Replies: @JayMan
  9. JayMan says: • Website
    @Assistant Village Idiot

    Thanks, but that was Naughton, not me. 🙂 The blockquote isn’t as conspicuous as I’d like it to be, but this was the best I could find out of the WordPress themes available.

  10. Anonymous • Disclaimer says:

    At least for the cholesterol aspect, there may be significant differences depending on the kind of cholesterol. If they are looking at total cholesterol, they lose sight of the fact that HDL is protective whereas LDL is (usually) risky for heart disease. And even within LDL the size and density of particles lead to different influences on heart disease.
    In short – two people with the same cholesterol level can have radically different heart disease outcomes if one gets his fats from olive oil / salmon and the other from margarine / beef.

    • Replies: @JayMan
  11. Anthony says:

    One can still see the rust of the Iron Curtain in your map of European cardiovascular death rates, especially in Germany. Looking purely geographically, Greece does not seem to be much of an outlier.

  12. @Chuck

    “No one has been able to explain that.”

    They closed the gap by dumbing everything down. If you have a high-jump where the bar is set at one foot high then almost everyone will pass and there will be no gap.

    It’s not complicated.

    In the UK’s case the original motivation was more about class than race but it’s the same blank slate nonsense where the true believers are desperate to prove IQ differences – if they believed in IQ which they don’t – are solely environmental.

    Anyone who knows anything about what happened to the British education system in the big urban centres – which is where all the black kids are – over the last 30 years knows this.

    If you knew what those schools were like you’d know how *utterly* nonsensical this claim is.

    It’s not even specifically related to race. Part of the same idealogical package as the blank slate was a belief that discipline was a bad thing. What happens in rough neighborhoods when you don’t have discipline in the schools? Answer, they turn into warzones where nobody learns anything. In the areas where most of the black kids are there’s a 30-40% functional illiteracy rate. What you’re saying is not just wrong – if you know the areas and schools involved it is *utterly* nonsensical.

  13. Very good stuff. Geography connects to past diet. It would be odd if people hadn’t become adapted to their local diet and if it was studied properly i think lactose tolerance would turn out to be one of hundreds.

    (This is the kind of thing my gut says will eventually revolutionize medicine – that the efficacy and side-effects of meds and foods will not only have racial differences but national and even regional ones also, based on adaptations to historic diet.)

    • Replies: @JayMan
  14. “Sure, but we’d have to wonder how the French are so genetically different from the Brits despite all the intermarrying.”

    “After Norman conquest, Brits and French were one kingdom, lots of intermarrying”

    Naughton’s twitters are inane. The Norman conquerors weren’t that numerous and weren’t particularly French to start with and there has never been anywhere remotely close to enough inter-marriage between the bulk of the two populations to create a homogenous whole. There isn’t even enough inter-marriage between the *regions* of countries to make the whole population completely homogenous unless they’re small enough (and flat enough) like Denmark.

    • Replies: @JayMan
  15. Pat Boyle says:

    We all know that medical science has been very wrong about many subjects in the past. There is every reason to believe that modern medical science is also wrong.

    Some examples.

    Booze is good for you. Your doctor won’t tell you but the research is old and solid. The studies have been done many times with thousands of subjects over long periods. There simply isn’t any room for doubt. Moderate drinkers have less heart problems than heavy drinkers or teetotalers. You doctor is afraid that you will slide from social drinking (good for you) into heavy drinking (very bad for you).

    Almost all diet advice is rubbish. The conventional wisdom is that you should exercise, eat lots of vegetables, cut down on the fat and eat complex carbohydrates. If you get overweight then you should diet – i.e. eat less of everything. We have been following this plan for a couple decades now and the result is that we have an obesity epidemic and those who can starve themselves down a couple pounds soon gain it back. Obviously there is something wrong with the advice. But know one will dare offer any other advice. Here’s mine. Eat only meat and green vegetables. No carbs at all. Don’t bother with exercise either. If you’re hungry eat as much as you wish, just no “comfort” food rich is carbs.

    If you want to avoid heart disease – i.e. atherosclerosis (fat deposits in your arteries), eat a lot of fat in your diet. If you want to be thin, eat fat. Sounds counter-intuitive doesn’t it? Since the so called intuitive suggestions are known to be wrong, just maybe these counter-intuitive ideas might be right.

    • Replies: @JayMan
    , @EvolutionistX
  16. JayMan says: • Website
    @Pat Boyle

    You’re probably right.

    But there’s one problem: the Atkins diet did fade away, and despite resurging in the form of “gluten free” and the “paleo” diets, it’s not clear that people can stick to low-carb diets long-term.

  17. JayMan says: • Website
    @Greying Wanderer

    I think you’re right.

    At the very least, can people stop comparing us to what other people are doing (different peoples is different)?

  18. JayMan says: • Website

    Is that true? I suspect that’s a bunch of hooey…

  19. @Pat Boyle

    If the US gov’t stopped subsidizing massive amounts of cheap, refined carbs, people would have a much easier time avoiding them. It is difficult when cheap, easy food is almost exclusively not good for you.

    • Replies: @JayMan
  20. JayMan says: • Website

    I’m not so sure refined carbs are causing people to be have heart trouble…

    Perhaps there may be something to it with the Spaniards. I want to see more experimental studies with more groups and large samples…

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