From NY Times:
February 7, 2006
Study Finds Low-Fat Diet Won't Stop Cancer or Heart Disease
By GINA KOLATA
The largest study ever to ask whether a low-fat diet keeps women from getting cancer or heart disease has found that the diet had no effect.
The $415 million federal study involved nearly 49,000 women aged 50 to 79 who were followed for eight years. In the end, those assigned to a low-fat diet had the same rates of breast cancer, colon cancer heart attack and stroke as those who ate whatever they pleased, researchers are reporting today.
"These are three totally negative studies," said Dr. David Freedman, a statistician at the University of California at Berkeley, who is not connected with the study but has written books on clinical trial design and analysis. And, he said, the results should be taken seriously for what they are — a rigorous attempt that failed to confirm a popular hypothesis that a low-fat diet can prevent three major diseases in women.
And the studies were so large and so expensive that they are "the Rolls Royce of studies," said Dr. Michael Thun, who directs epidemiological research for the American Cancer Society. As such, he said, they are likely to be the final word.
"We usually have only one shot at a very large scale trial on a particular issue," Dr. Thun said.
The studies were part of the Women's Health Initiative of the National Institutes of Health, the same program that showed that hormone therapy after menopause can have more risks than benefits. In this case, the diet studies addressed a tricky problem. For decades, many scientists have been saying, and many members of the public have been believing, that what you eat — the composition of the diet — determines how likely you are to get a chronic disease. But it has been hard to prove. Studies of dietary fiber and colon cancer failed to find that fiber was protective. Studies of vitamins thought to protect against cancer failed to show an effect.
Gradually, many cancer researchers began questioning the dietary fat-cancer hypothesis, but it has retained a hold on the public imagination.
"Nothing fascinates the American public so much as the notion that what you eat rather than how much you eat affects your health," said Dr. Peter Libby, a cardiologist and professor at Harvard Medical School.
But the new studies, reported in the Feb. 8 issue of the Journal of the American Medical Association, found that women who were randomly assigned to follow a low-fat diet ate significantly less fat over the next eight years. But they had just as much breast and colon cancer and just as much heart disease.
And, confounding many popular notions about fat in the diet, the different diets did not make much difference in anyone's weight. The common belief that carbohydrates in the diet lead to higher insulin levels, higher blood glucose levels and more diabetes was also not confirmed.
There was no such effect among the women eating low-fat diets.
As for heart disease risk factors, the only one affected was LDL cholesterol, which increases heart disease risk. The levels were slightly higher in women eating the higher fat diet, but not enough to make a noticeable difference in their risk of heart disease.
The studies follow a smaller one, reported last year, on low-fat diets for women who had breast cancer. That study hinted that eating less fat might help prevent a recurrence. But the current study, asking if a low-fat diet could protect women from breast cancer in the first place, had findings that fell short of statistical significance, meaning they could have occurred by chance. In essence, there was no solid evidence that a low-fat diet helped in prevention.
"These studies are revolutionary," said Dr. Jules Hirsch, physician in chief emeritus at Rockefeller University, who has spent a lifetime studying the effects of diets on weight and health. "They should put a stop to this era of thinking that we have all the information we need to change the whole national diet and make everybody healthy."
Although all the study participants were women, the colon cancer and heart disease results also should apply to men, said Dr. Jacques Rossouw, the project officer for the Women's Health Initiative. He explained that the observational studies that led to the colon cancer-dietary fat hypothesis included both men and women. As for heart disease, he said, researchers have consistently found that women and men respond in the same way to dietary fat.
The results, the study investigators agreed, do not justify recommending low-fat diets to the public to reduce their heart disease and cancer risk.
As for the cancer society, Dr. Thun said, with these results that he describes as "completely null over the eight-year follow-up for both cancers and heart disease," his group has no plans to suggest that low-fat diets are going to protect against cancer.
Dr. Rossouw, however, said he was still intrigued by the breast cancer data, even though it was not statistically significant. The women on low-fat diets had a 9 percent lower rate of breast cancer — the incidence was 42 per 1,000 per year in women in the low-fat diet group, as compared with 45 per 1,000 per year in women consuming their regular diet. That might mean that fat in the diet might have a small effect, Dr. Rossouw said, perhaps in some subgroups of women or over a longer period of time. He added that the study investigators would continue to follow the women to see if the effect became more pronounced.
Another of the study's investigators, Dr. Rowan Chlebowski, a medical oncologist at Harbor-U.C.L.A. Medical Center, shared Dr. Rossouw's hopes for a low-fat diet. "There will be different interpretations, but there's a reason for optimism," Dr. Chlebowski said.
While cancer researchers say they were disappointed by the results, heart disease researchers say they are not surprised that simply reducing total fat made had no effect.
"The problem is that this study was designed two decades ago when the fad was low fat," Dr. Libby said. Now, he said, he and others are persuaded that a so-called Mediterranean diet is best — not necessarily low in fat but low in saturated fats, like butter and cream cheese. That, with exercise, should help prevent heart disease, he says.
But, of course, that advice has never been tested in a large randomized clinical trial, Dr. Libby admits. And he says, "if they did a study like that and it was negative, then I'd have to give up my cherished hypotheses for data."
The low-fat diet was not easy, Dr. Chlebowski notes. Women were told to aim for a diet that had just 20 percent of its calories as fat. Most substantially cut their dietary fat, but most fell short of that 20 percent goal. The diet they were told to follow "is different than the way most people eat," Dr. Chlebowski said. It meant, for example, no butter on bread, no cream cheese on bagels, no oil in salad dressings.
"If a physician told a patient to eat less fat, that will do nothing," he said. "If you send someone to a dietician one time, that will do next to nothing." The women in the study had 18 sessions of meeting in small groups with a trained nutritionist in the first year and four sessions a year after that.
In the first year, the women on the low-fat diets reduced the percentage of fat in their diet to 24 percent of daily calories and by the end of the study their diets contained 29 percent of their calories as fat. In the first year, the women in the control group were eating 35 percent of their calories as fat and by the end of the study their dietary fat content was 37 percent.
Some medical specialists stressed that the study did not mean people should abandon low-fat diets.
"What we are saying is that a modest reduction of fat and a substitution with fruits and vegetables did not do anything for heart disease and stroke or breast cancer or colorectal cancer," said Dr. Nanette Wenger, a cardiologist and professor of medicine at Emory University Medical School. "It doesn't say that this diet is not beneficial," she added.
But the overall lesson, said Dr. Freedman, is clear.
"A lot of observational data show diet matters, but those studies have big flaws and that's why we have to do experiments," he said "We, the scientific community, tend to go off the deep end giving dietary advice based on pretty flimsy evidence."
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