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FRANCISCO LOPEZ-JIMENEZ: Hello. And welcome back to the Mayo Clinic Medscape video series. I am Francisco Lopez-Jimenez, cardiologist and professor of medicine at the Mayo Clinic. Today, we will be discussing no harm in red meat after all. I'm joined by my colleague Dr. Stephen Kopecky, consultant and professor of medicine and expert in this area. Welcome Dr. Kopecky.

STEPHEN L. KOPECKY: Thank you, Francisco.

FRANCISCO LOPEZ-JIMENEZ: The US has some of the highest red meat consumption per capita in any country of the world. The controversial 2019 Annals of Internal Medicine article encouraged red meat consumption and came to the conclusion that we do not need to cut down. Could you briefly tell us the key points of this study?

STEPHEN L. KOPECKY: Yes. That's a very interesting study in that it was a systematic analysis, and it was an analysis of systematic analysis. So it had multiple studies in it. And the conclusions were we don't need to cut down on our red meat. Well, if you read the study, it actually showed that eating red meat increased cardiovascular events and increased cardiovascular death. That was their conclusions.

But their overriding conclusion was that it wasn't a very big increase. And people like to eat red meat. So we really shouldn't change our red meat eating habits. Now, that was very controversial. There were some issues about conflict of interest and other things that came out later. But it did generate much interest and a lot of [INAUDIBLE].

FRANCISCO LOPEZ-JIMENEZ: Good. Do you think all red meat is the same in terms of health effects?

STEPHEN L. KOPECKY: Well, that's a very important question. And it is very clear that red meat can be divided into two groups, unprocessed and processed. So unprocessed is the whole meat, the whole organ, the whole muscle. Processed, though, includes a lot of other things. We classically think of processed-- in fact, the top five processed foods, meats eaten in this country, are lunch meat, sausage, hot dogs, ham, and bacon.

Now, what's a processed meat? If it's cured, if it's smoked, if it's fermented, if it has salt added and/or chemical preservatives, it's a processed meat. And it's very clear that processed meat, for every 50 grams you eat, which is about two bites, it increases your risk of coronary heart disease by about 40% over a few years. And that's per daily intake. So if you look at the data, about two thirds of that increase risk seems to be related to the sodium in the processed meats, because it's very heavily added sodium to, because it's a preservative.

So what we end up doing is having to divide them up into processed and unprocessed. Now, the unprocessed meat is not as bad, by any means, in terms of causing coronary heart disease. But it doesn't really mean we can eat it ad lib either. People think, well, it's OK. So I'll have a big 18 ounce steak. And it really should be considerably less red meat that we eat daily.

FRANCISCO LOPEZ-JIMENEZ: Good. Now, this paper showed results all over the place. I mean it was not really a unified result in all of these studies. So why is it so difficult to do a study on red meat intake and effects on health?

STEPHEN L. KOPECKY: Yeah. Good question. What we standardly do in medicine is we like to do a randomized, placebo controlled, double blind trial. You can't do that with red meat. You can't double blind it. And you can't say you eat-- this group of patients, you eat red meat, this group of patients, not eat red meat, because you would be including vegans or vegetarians. And that would be a whole different subset of people. So it's impossible to do a randomized trial, almost. Even the Mediterranean diet trial, the PREDIMED study, was basically a cohort that was followed. So we just can't really do a standard trial.

And there's a lot of crossover. So a lot of people that are eating red meat a little bit will eat more. They'll have a family reunion, or Fourth of July picnic, or something. And it's basically the studies that are done are done from recall. And they do not recall every day. They have a recall questionnaire every couple of years, and say, how much red meat do you eat every day? Well, as humans, we tend to forget how much we actually eat or misremember it. And so it's very, very difficult to know the dose of the red meat that people eat.

Plus the final thing is what accompanies the red meat. If you're eating red meat with a lot of fats on it, mayonnaise, and processed foods, and et cetera, it really confounds things quite a bit. And it's just almost impossible to separate those things out.

FRANCISCO LOPEZ-JIMENEZ: The other question is what the other people that are not meat eaters are eating that might not be very healthy either. So if they eat a lot of sugar or low fat things might be also affecting. Thank you. So moving on, the next question. So red meat has been linked to saturated fats, because, obviously, red meat has a considerable amount of saturated fat. And this has been linked since the Seven Nations Study published about 50 years ago. What have we learned that is still true regarding saturated fat right now?

STEPHEN L. KOPECKY: Well, the saturated fat story from the Seven Nations Study is very interesting. If you go back and look at these studies-- and there are minutes, there are notes of their meetings and such that I've reviewed. And many of the Mediterranean countries that were involved around the Mediterranean ocean sea, they said to the principal investigator, gee, you're focusing a lot on red meat and saturated fat. And maybe what we really do more here is we use more monounsaturated fat like olive oil for our primary source of--

And the principal investigator, Ancel Keys-- who was really a leader in this field and many of the things he said are exactly correct-- but he said, I really think it's more red meat, and that's where the saturated fat came from. Well, subsequent studies have been done. One of our colleagues, Bob [INAUDIBLE] father, was one of Ancel Keys investigators with him. And some data has come out showing that it really wasn't that important to worry about saturated fat. That instead, try to have more olive oil in the diet and limit saturated fat to a certain degree.

The other thing is, what do you eat instead of saturated fat? Well, you tend to eat, at least when those studies were done, a lot of carbohydrates and a lot of trans fats, which have now been outlawed, and a lot of carbohydrates that contain trans fats and were highly processed. Again, it's very difficult to separate out individual macronutrients in a diet. And I think the best way to handle this is to help us all understand in our patients what to eat in terms of things they understand, like eat red meat, or eat a blueberry, or eat an apple, or things like that.

FRANCISCO LOPEZ-JIMENEZ: Sure. No. Thank you. Now, going back to the red meat consumption. So based on the [INAUDIBLE] study that showed a modest but significant increase in risk but only in the group that had a very high intake of red meat, will it be safe to say that modest amounts of meat will not be necessarily harmful compared to being vegetarian? Any thoughts on that?

STEPHEN L. KOPECKY: Yeah. That's a good question, Francisco. If you look at what our bodies have eaten for the past tens of thousands of years and millennia, we've had red meat. We've eaten red meat. But we didn't eat a lot every day. We couldn't go out and kill a deer for breakfast. We would use meat for celebratory purposes, a new wedding, or a new king or queen, or a new birth, or a celebration of some sort. So small amounts of red meat, we've been using, we've been eating forever.

But again, emphasize the small amounts. If you look at some of the tribes in the world like the Bolivian jungle, Amazonian jungle, the [INAUDIBLE] Indians, they eat a few ounces of red meat on average a day. And if you look at the PREDIMED study, the Mediterranean diet study, they allowed up to 3 ounces of red meat a day. Now, I ask my patients to eat 3 ounces of red meat, and I show them it's a deck of cards. And they say, oh, my god. That's like two bites doctor. What am I going to do?

And so we have to encourage our patients to slowly change their habits. And I do emphasize the slow, one bite at a time, because you cannot change quickly. But take one bite. Put it on the side. And fill something else in there that may be a little better or healthier for you.

So the bottom line is processed meats are the ones to avoid. The whole meat is OK to have a little bit. But be careful, because it's small amounts. And it gets away from us very quickly. And finally, though, even the whole red meat, while it doesn't seem to increase our risk much-- although, it does increase the risk for diabetes-- it doesn't seem to lower our risk any at all, like some of the other things we eat, like fruits, vegetables, legumes, olive oil.

FRANCISCO LOPEZ-JIMENEZ: Now, the Mediterranean diet has been shown to be beneficial for cardiovascular disease event reduction. Do these dietary patterns allow red meat? And if so, how much?

STEPHEN L. KOPECKY: Yeah. Well, Mediterranean, they suggested this 3 ounces of meat at day, and not to go over that. It wasn't required. But don't go over it, and then really avoid the processed meats like we talked earlier. They're the ones that are full of sodium, raise our blood pressure, have a lot of chemical additives. And that's what we really have to be careful with. And the issue there, of course, is when we're in times like now with the pandemic, we tend to eat a lot more premade foods. And that would include processed meats, luncheon meats, which is the number one processed meat that we eat in this country.

FRANCISCO LOPEZ-JIMENEZ: Good. Well, excellent. Thank you, Dr. Kopecky. Those were very important points. Thank you for joining us on theheart.org, Medscape Cardiology. Thank you.

STEPHEN L. KOPECKY: Thank you.

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