December 29, 2014

Book Review: The Big Fat Surprise

“It would be hard to imagine a greater set of unintended consequences than those resulting from the vast, uncontrolled experiment that the United States and the entire Western world have undergone by adopting a low-fat, high-carbohydrate diet over the past half-century.” (p.333)

“Measured just by death and disease, and not including the millions of lives derailed by excess weight and obesity, it’s very possible that the course of nutrition advice over the past sixty years has taken an unparalleled toll on human history.” (p.330)

“It now appears that since 1961, the entire American population has…been subjected to a mass experiment, and the results have clearly been a failure.” (p.330)

Since the earliest days of this blog (back when I had just three readers, as opposed to the five I have now), I have been talking about dietary fat. Specifically, I have been trying to shed some light on the chemistry of fats and oils, so that we, as buyers, home cooks, and maybe most important—eaters—of these things, can make informed choices.

More than just fats and oils overall, I have been trying to provide a little non-scary education regarding saturated fats, in particular, because while we have been generally advised to follow a diet that’s low in total fat from all sources, saturated fats, specifically, have been targeted as being especially detrimental to good health.

If you’re curious about why and how this demonization of fats overall, and saturated fat, in particular, came to be, The Big Fat Surprise will take you on a pleasantly readable journey through the political, economic, and social forces that shaped the nutrition science landscape beginning in the mid-twentieth century, and that largely continue to hold sway even today. (That is, even in the face of a large and growing-ever-larger body of scientific research suggesting that saturated fat is not, in fact, the dietary devil incarnate. Even if the research is not enough to put the final nail in the coffin of the “fat is not bad for you” thing [but personally, I believe it is], it’s enough that our most powerful and influential diet and health organizations should at least be questioning the long-held dogma they’ve been clinging to for decades.)

If something in the back of your mind is telling you I’ve discussed this book before, that something is right. When this book was released a few months ago, I offered a preview, quoting from reviews posted by medical doctors and nutrition researchers whose work I respect and admire. I’m happy to say that when I finally got around to reading the book, myself, I wasn’t disappointed. I do have a bone or two to pick, but they’re small, and on the whole, this book would find a comfortable home on the bookshelf of anyone concerned with their individual health, as well as health trends in the United States, and, by extrapolation, those of the entire industrialized world, which, often to its detriment, tends to follow guidelines espoused by the U.S. (The “to its detriment” might be exemplified nowhere more powerfully than in nutrition and the abandonment of ancestral foodways in favor of modern food processing technology.)

I’ve asked before: where do your fats come from: farms, or factories?

The Big Fat Surprise (TBFS) has often been compared to Good Calories, Bad Calories (GCBC) in its damning condemnation of the low-fat diet. And in fact, the two authors are personal friends and shared research findings during the writing of their respective books. To be honest, if you’ve read GCBC, there isn’t much in TBFS that’ll be new to you. TBFS focuses mostly on the relationship (or, rather, lack thereof) between saturated fat and heart disease, while GCBC runs the gamut: heart disease, dementia, cancer, obesity, hypertension, and more. And, of course, GCBC not only covers the wrongful accusations against dietary fat, but is mostly an ode to the detrimental role of a high-carbohydrate intake.

If someone in your life is concerned specifically about heart health, and less about body weight and other issues, TBFS might be a nice way to ease them into this philosophy, which runs so counter to what they’re likely accustomed to hearing—including from their own doctors. (Tell them not to be intimidated by the size of the book. The last 150 pages or so are notes and references.) Based on size alone, someone might be more inclined to read TBFS than they are to make their way through GCBC. (I’ll admit even I started and stopped GCBC three times before I hunkered down, put my big girl panties on, and plowed through it. And I love this stuff, so I can imagine the casual reader or layperson out there might have an even harder time. It is now one of my favorite books and I will sing its praises until the fatty cows come home. That doesn't mean reading it wasn't a labor of love)

One thing Teicholz shines a spotlight on, that Taubes didn’t, is the influence low-fat diets have had on women and children. If you know anything about human development, then you know fat is an absolutely critical, crucial building block for most of the structures in the body—including the central nervous system. (For you non-anatomy nerds out there, that includes the BRAIN.) It’s really no wonder we’re witnessing such stunning numbers of developmental delays and cognitive and behavioral issues in our children these days. When Mountain Dew and sugar-free Red Bull are easier to come by than whole, un-homogenized (not to mention unpasteurized) milk from grass-fed cows, there’s a problem. And when it’s easier for moms (and dads!) to call out for Chinese for dinner than to pop a nice, fatty pork loin in the slow cooker on top of some onions, carrots, celery, and cabbage before heading off to work, there’s a problem. (Note: this is not easier. It just seems easier. I swear, that pork loin process? It’s gonna take you less time than finding the take-out menu buried at the bottom of your kitchen junk drawer. Unless you’ve got a magnet holding it right to the front of your fridge, in which case you are probably not reading my blog anyway, but if you are, I want to come give you a hug. [And then take away your Chinese menu and buy you a slow cooker.])

Teicholz rolls out the all-too-familiar work of Ancel Keys, whose nutrition epidemiology studies during the 1950s and 1960s are a large part of what underpinned the recommendations for a diet lower in fat and higher in whole grains and vegetables. Believe me, I’m all for condemning Keys for sloppy science, but in my one big beef with this book (no pun intended), Teicholz lays what—in my opinion—is a disproportionate amount of blame/responsibility at Keys’ feet. Did he get the ball rolling? Yes. But who let it roll and roll and roll all over the country, until ultimately, millions of people who’d been thriving on beef tallow, lard, bacon, butter, and fresh, whole milk (with the creamline top!) came to think that, somehow, all of a sudden, these nourishing fats were harmful for health and should be abandoned in favor of the oils modern processing technology has managed to wrench from corn kernels, soybeans, and cottonseeds?

As Teicholz puts it, “That Americans came to see vegetable oil as the healthiest possible kind of fat was one of the more astonishing changes in our attitudes about diet in the twentieth century.” (p.82)

In fact, it’s pretty astounding that anyone thought it was the animal fats that were the problem, when it looks like consumption of those was actually declining, and what was rising (and in the case of soybean oil, in particular, skyrocketing) was intake of vegetable oils.

“The upward curve of vegetable oil consumption happened to coincide perfectly with the rising tide of heart disease in the first half of the twentieth century, but researchers and doctors at the time barely discussed this coincidence.” (p.75)

Trends in the estimated per capita consumption of major food commodities (A), major fat commodities (B), and vegetable and seed oils (C) between 1909 and 1999. kg/p/y, kilograms per person per year:

(Data from: Blasbalg, et al. Changes in consumption of omega-3 and omega-6 fatty acids in the United States during the 20th century. Am J Clin Nutr. 2011 May;93(5):950-62.)

By the way: see the beef tallow in the graph at the upper right? (The one labeled "B." Beef tallow is the dark brown line at the bottom.) Notice how it's pretty steady until the mid-1950s, then shoots up for a while before it drops down in the late 1980s. Wanna know why that happened? The social and nutritional history buffs among you might already know this, but the mid 1950s was when the fast food industry really got going. Paralleling the spread of the interstate highway system, fast food joints started popping up all over the place. Well, beef tallow was one of the preferred cooking fats in these places, because it's delicious and stable for high-heat cooking. (Not to mention that since they were slaughtering all those cows for hamburger meat, it only made sense to do something with all the fat as well.) This is why fries from back in the day were so yummy. But in the 1980s, vegetarian organizations convinced the big fast food chains to switch from frying in animal fats to vegetable oils, presumably so they could continue to consume fries free of both guilt and animal fat. So anyway, that's why we see the impressive increase in tallow use through most of the second half of the 20th century, and why we see a quick decrease at the tail end of the century.) This doesn't have much to do with the book; I just think it's nifty "gee-whiz" info and I can't help sharing it.

Sources of linoleic acid (LA) (A) and α-linolenic acid (ALA) (B) between 1909 and 1999. Fats included shortening, butter, lard, margarine, and beef tallow. Oils included cottonseed, corn, olive, coconut, canola, peanut, palm, safflower, sunflower, and sesame oils. Soybean oil was considered separately because of its disproportionate effect. Dairy included all milk, buttermilk, condensed milk, cream, sour cream, yogurt, cheese, and eggnog. Butter was not included in the dairy category to avoid double counting.
(Source: Ibid.)

So the name Ancel Keys makes me a little angry, but what really fans the flames is when I think of the thousands of researchers, doctors, government policy wonks, and maybe even moms and home cooks, who knew that some of this was flat-out crazy (or, at the very least, was not supported by sound science, not to mention visual observation). Researchers could see that data in their labs weren’t matching the conclusions we would “expect” if saturated fat were really so harmful. Doctors could see that record numbers of patients were continuing to present with heart disease and unexplained weight gain, despite eating just the way they were advised to. At a time when you had to work hard to find full-fat yogurt and real butter hiding among all the fat-free impostors and margarines, moms and home cooks could see what they were feeding their families, and they were sticking to those virtuous low-fat foods and vegetable oils, and yet dad and junior weren’t all that healthy. (Neither was mom, since the low-fat diet has proven disproportionately harmful to women.) Note: I am saying mom here since, at that time, it really was much more likely to be the mom at home cooking. It probably still is, but less so than it was about sixty years ago. (Hat tip to all you cooking dads!)

The policy people—the actuaries, the statisticians, the government geeks—could see that rates of chronic illness and obesity were rising. The more they talked about cutting the fat and eating more grain, the sicker and fatter everyone got.

But then again, I agree with Teicholz that we shouldn't really be looking to the government for nutrition advice, anyway: “With its massive bureaucracies and obedient chains of command, Washington is the very opposite of the kind of place where skepticism—so essential to good science—can survive.” (p.103)

It’s almost like as soon as they started telling us to cut back on fat and eat more carbohydrates, people started gaining weight. Correction: it’s not “almost like” that—it is exactly that! 

But nobody spoke up.

Or, rather the few—the very few—who did have the courage and scientific integrity to speak up were summarily dismissed. Denied grant money, denied speaking opportunities at conferences, and, in some cases, outright fired.

Funny thing is, here in 2014, it seems they were right.

“It’s clear that the original case against saturated fats was based on faulty evidence and has, over the last decade, fallen apart.” (p.330)

“Every plank in the case against saturated fat has, upon rigorous examination, crumbled away. It seems now that what sustains it is not so much science as generations of bias and habit.” (I have talked about this before.) A growing number of nutrition researchers has had their eyes opened to the notion that what we've been told to do for decades is, in many ways, the opposite of what we should be doing to return to and maintain good health. (Never mind weight. Weight is a separate issue, though somewhat related.) Nevertheless, the grain-based, low-fat, low saturated fat dogma continues, largely as a result of nothing but inertia. It is such a juggernaut at this point that turning it around is going to take a lot more time than has passed just yet, and a lot more surrendering of egos. And also institutional bias and protected reputations: there are a lot of people who stand to be completely humiliated and possibly even sued for malpractice on massive scales, should the public start educating themselves on these issues.

This makes me far angrier than anything Ancel Keys did. See, to me, he’s just one figure among many, all of whom deserve some of the blame and share some of the responsibility. He’s just one man, yet he’s come to symbolize what’s wrong with the entire low-fat dietary dogma. I don’t care how influential he was, or what a pompous windbag, and how good he was at strong-arming his “evidence” through various committees and review boards. How many other responsible scientists, researchers, and doctors, could have and should have spoken up? They could have presented mountains of contrary evidence, and the debate would have been far more robust, and all the evidence examined more rigorously. We likely wouldn’t have arrived at any nutritional blanket recommendations for everyone, across the board, let alone one that resembles a diet no group in human history has been known to thrive on for long periods of time.

Speaking of this—a diet to thrive on—perhaps where Teicholz shines best is in looking at the Mediterranean diet. This nutritional approach—typically touted as containing tons of fresh vegetables and fruit, whole grains and beans, fish, olive oil, nuts, and a little red wine, for kicks—is open to interpretation. Widely differing interpretation, in fact. What about feta cheese? What about tzatziki? (And I guarantee you the Greeks weren’t using fat-free yogurt for that in the 1950s.) What about a roast leg of lamb, dripping with delicious fat? What about a Tunisian chicken tagine--using chicken on the bone, and with skin? What about the cheeses Spain and Italy are known for? (Again, not low fat!!)

It turns out, a lot of what we think of as “the Mediterranean diet” was being eaten by Greeks in the 1950s because it was just after WWII, when the countryside had been destroyed, a portion of the population had been decimated [some of whom were likely livestock and dairy farmers, so imagine how much less meat and dairy were being produced than was the cultural and geographic norm], and people were broke. They weren’t living on beans and tomatoes because those were the most nutritious foods in the world, but because those were the foods they had available. And assessing people’s health after just a few short years of what amounts to deprivation and wild deviation from their normal diet confounds the protective role the normal diet might have had—the diet these people were raised on and consumed all their lives, with the exception of the blip in time caused by the war.

Would the real Mediterranean 
diet please stand up?
It's possible that prior to the war, people were consuming far more fat—especially animal fat, in the form of lamb, cured meats, cheese, yogurt, butter, eggs, and poultry. So what we now think of as “the Mediterranean diet” isn’t necessarily a true Mediterranean diet, or, at least, not a traditional one, which is the one that likely helped the Greeks Keys studied stay so healthy and robust through and after the war—not because of the low amount of animal fat in their diet, but despite it.

TBFS is worth reading for this deep-dive into these interesting issues regarding a truly “Mediterranean diet” alone. (It's also worth it for some good info on trans fats, and things that happen to polyunsaturated vegetable oils in restaurant deep fryers. Think spontaneous combustion.) I’m not suggesting that olive oil, fresh vegetables, and seafood aren’t good for health; I’m just playing devil’s advocate and wondering out loud how much animal fat Mediterranean people really ate back in the day, before even they had ever thought there was something magical about their diet. Seriously: fatty lamb. Chicken on the bone, with the skin. Probably also lamb sausages, made with the fat, stuffed in casings made from intestines. Not beans cooked in fat-free, low-sodium chicken broth, or boneless, skinless chicken breasts with cherry tomatoes and fat-free feta. This is wild speculation on my part, but when you think about it, kinda not that wild, right?

If you’re new here and are unfamiliar with the concept of saturated fat not being bad for us, I know it seems crazy. But I can assure you what I’m saying isn’t the deluded ramblings of a mentally ill patient being greased paid by the butter and red meat industries. There are people with some decent street cred (er…credentials), saying the same thing: 

I would be remiss if I didn’t address the low-fat elephant in the room. A few people have come out with less-than-glowing reviews of this book. They accuse Teicholz of the same data cherry-picking, biases, and blinders she accused Keys and his colleagues of. I admit here, in front of all, that I have my own biases. If you are new to my work, I’ll share my Twitter tagline with you: Low-carb/keto/Paleo/WAPF-friendly nutritionist. I am partial to low-carb and Paleo/Primal-type diets, but I’m not a zealot. I eat bread once in a while and have even been spotted with a cookie in my hand. (Oh. My. God.) But let it be known that I recognize reduced-carb diets aren’t ideal for everybody. That’s why I’m low-carb and Paleo friendly, but not exclusive. So even though I do have my own biases, I share the following links with you to show that I’m willing to consider (and share) other points of view: 
  • TBFS Critical Review, Part 1, by Seth Yoder of The Science of Nutrition
  • TBFS Critical Review, Part 2
  • There are a few more out there, but frankly, they were written by people I’d rather not link to from my blog. I have a strict policy of not feeding trolls, and especially not driving lots of traffic to their blogs. (If you’d like to check out some more contrary reviews, feel free to contact me privately and Ill send you links.)

Remember: Amy Berger, M.S., NTP, is not a physician and Tuit Nutrition, LLC, is not a medical practice. The information contained on this site is not intended to diagnose, treat, cure, or prevent any medical condition.


  1. Interesting, I'll have to check these ones out. The cover and general idea behind this book (shedding light on food history and focusing on US goverment guidelines/farm policy) reminds me of The Omnivores Dilemma. Have you read any of Pollan's books?

    1. Yes, I've read a few of Pollan's books. I'm a an extent. He gets a lot of things right when it comes to the economics & politics of food in the U.S., but he could use a good biochem & physiology refresher. ;-) He's still too down on saturated fat, red meat, and dietary cholesterol for me to champion his work. But he's a lot farther along to "real food" than many so-called "food writers."

  2. Just also wanted to add the bit about the real mediterranean diet... Its funny how obvious things seem once someone points them out, of course they ate so much more (animal) fat. I (and most people should) feel silly for not seeing it before.