LONDON — Every morning, British cardiologist Dr. Aseem Malhotra stirs one tablespoon of butter and one tablespoon of coconut oil into his coffee.
While it may not sound appetizing, the concoction — also known as “bulletproof coffee” — is popular among people who follow high-fat diets and modeled after yak-butter drinks consumed in Tibet for centuries. The combination, says Dr. Malhotra, gives him energy and “keeps me pretty full.”
There are not many cardiologists who embrace butter and coconut oil as health foods. But Dr. Malhotra rejects the decades-old mantra that eating foods rich in saturated fat causes heart disease, and he has been leading a campaign to change public opinion about fats, sugar and what constitutes a healthy diet.
“As part of a heart-healthy diet, I advise my cardiac patients to enjoy full-fat cheese, along with olive oil and vegetables,” says Dr. Malhotra, who regularly indulges in grass-fed meat and three-egg omelets, yolks included. “You should see the look on their faces when I tell them.”
Dr. Malhotra, who works with Britain’s National Health Service, is among a small but increasingly vocal group of doctors in the United States and Britain who are challenging the medical and nutritional orthodoxy around fat, carbohydrates and calories. He has been a fixture on social media and on television programs in Britain, thanks in part to a series of controversial papers he published in medical journals arguing that saturated fat, especially from dairy, can be protective against heart disease, that sugar is “public health enemy No. 1” in the Western diet, and that the dangers of high cholesterol are overstated.
In May, as a member of the National Obesity Forum, a nonprofit group, he helped write a widely publicized report that criticized the British government’s dietary advice to avoid saturated fat and eat low-fat foods. And in a country known for its sweet tooth, Dr. Malhotra is outspoken about the harms of excess sugar.
His critics – of which there are many – have pushed back. Public Health England, the agency that issues the country’s dietary guidelines, said the obesity forum report that Dr. Malhotra helped author was “irresponsible and misleads the public.”
Dr. Neil Poulter, a professor of preventive cardiovascular medicine at Imperial College in London, accused Dr. Malhotra of “cherry picking” data and misinterpreting research. And he said he was wrong to encourage people to consume saturated fat because it increases LDL cholesterol, which correlates with heart disease.
“Decades of studies are consistent in showing that LDL is pivotal and that by reducing LDL you reduce cardiovascular events,” Dr. Poulter said.
But Dr. Malhotra points to research like a major study published in the Annals of Internal Medicine in 2014 that found no link between saturated fat consumption and coronary heart disease. In January, a leading American cardiovascular expert, Dr. Steven E. Nissen, published an editorial criticizing the U.S. Dietary Guidelines for urging people to reduce their saturated fat and cholesterol intake without enough evidence from rigorous clinical trials.
While it is true that some established physicians and scientists are calling for more research on the effect of saturated fat, that doesn’t mean they endorse Dr. Malhotra’s promotion of high fat diets either.
“I do not think he has an established track record in the science of nutrition and heart disease,” said Dr. Nissen, who does not know Dr. Malhotra. “But I do wish we had more rigorous evidence to confirm or refute the claim that saturated fat and cholesterol are associated with heart disease, because I don’t think it’s clear.”
With a knack for controversy, Dr. Malhotra has pushed on. In the past year he has also taken aim at statins, the most widely prescribed drugs in the world, arguing in academic papers and on some of Britain’s leading news programs that the cholesterol-lowering medications are overused.
While the drugs can be lifesaving in people who have established heart disease, Dr. Malhotra says, people at low risk would be better off adopting a Mediterranean diet since the vast majority of cardiovascular disease is attributable to lifestyle factors like smoking and poor diet.
“I tell my heart patients that adopting a Mediterranean diet after suffering a heart attack is actually more powerful than aspirin, statins and even heart stents,” he says. “I’m not saying these treatments aren’t beneficial – they are. But the lifestyle changes are even more powerful, and without the side effects.”
As evidence, he often refers to a landmark clinical trial published in The New England Journal of Medicine in 2013, which found that heart attacks, strokes and deaths from heart disease plummeted in high risk patients assigned to follow a Mediterranean diet with large amounts of fat from nuts and olive oil.
To help spread his food-is-medicine message – a notion Hippocrates, the “father of western medicine,” first promoted centuries ago – Dr. Malhotra held a Kickstarter campaign to raise money for a documentary called “The Big Fat Fix,” which follows him as he visits the Campania region of Italy to explore the Mediterranean diet’s well-documented health benefits. He said he crowd-sourced the funding of the film to avoid conflicts of interest, and he and his co-star produced the film themselves and released it online.
Dr. Malhotra and his co-star, Donal O’Neill, a filmmaker and former professional athlete, argue in the film that the Mediterranean diet has been widely mischaracterized. While it features an abundance of plants, seafood, olive oil, nuts and red wine, it also includes plenty of red meat, cheese and other sources of saturated fat. Dr. Malhotra contends that the traditional diet is also very low in sugar, a fact that he says is often overlooked. “The locals there eat no processed food,” he said.
In the film, Dr. Malhotra also makes a case that the people of the region owe their remarkable longevity to a Mediterranean lifestyle, which prioritizes social engagement, stress reduction and proper sleep, movement and flexibility.
Dr. Rita Redberg, a cardiologist and professor at the University of California, San Francisco, medical school, said she applauded Dr. Malhotra and his film’s emphasis on prioritizing lifestyle before medicine. She said that too often people rely on pills as an antidote to poor diet and other unhealthy behaviors.
“I think a lot of people feel that they can eat whatever they want and just take a statin and not have to worry about exercise,” she said.
Dr. Malhotra said that although his work challenging the conventional wisdom has been controversial, he intends to do more of it. He repeats a quote from the South African surgeon Dr. Christiaan Barnard, who performed the world’s first heart transplant procedure and later became a champion for heart disease prevention through proper nutrition and lifestyle changes.
“If I had first concentrated on heart disease prevention,” Dr. Barnard once said, “rather than saving the lives of 150 people, I could have saved the lives of 150 million.”