Intended for healthcare professionals

Rapid response to:


Frequency of eating and concentrations of serum cholesterol in the Norfolk population of the European prospective investigation into cancer (EPIC-Norfolk): cross sectional study

BMJ 2001; 323 doi: (Published 01 December 2001) Cite this as: BMJ 2001;323:1286

Rapid Response:

Non-dietary factors explain the lower cholesterol concentration associated with frequent eating

Dr. Titan and her co-workers’ suggestion that frequent eating lowers
cholesterol may be right, but their data allow other explanations to their
findings (1). From table 2 it appears that intake of energy increased in a
continuous relation with eating frequency. Indeed, those who ate six times
daily or more often, consumed almost 30 percent more kilojoules per day
than those who only ate once or twice although their body mass was almost
the same. The only valid explanation is that their physical activity has
been underestimated. Furthermore, smoking decreased, also in a continuous
relation with eating frequency. Meta-analyses have found that exercise
results in small but significant decreases of low-density-lipoprotein- and
total cholesterol (2), and that smoking is associated with a small, but
significant higher concentration of these lipids (3). The habit of eating
once or twice a day also reflects a stressful life with little control of
one’s daily activities, and many studies have shown that mental stress may
rise the cholesterol concentration considerably (4).

Therefore, the advice
to eat more often to prevent cardiovascular disease is not backed up by
this study. Even if the habit of eating frequently, or exercising
regularly, or abstaining from smoking, or living a non-stressed life may
lower the cholesterol concentration, there is no evidence either that this
effect may influence the risk of cardiovascular disease by itself. A high
physical activity may lower the risk by improving endothelial function (5)
or the formation of collateral vessels (6); non-smoking by lowering the
burden of oxidant exposure; and freedom from mental stress by beneficial
influences on adrenal hormone secretion. The higher cholesterol
concentration of the physically inactive, smoking and stressed individual
may just be an innocent bystander telling that something is wrong.

1. Silvia M O Titan, Sheila Bingham, Ailsa Welch, Robert Luben, Suzy
Oakes, Nicholas Day, and Kay-Tee Khaw. Frequency of eating and
concentrations of serum cholesterol in the Norfolk population of the
European prospective investigation into cancer (EPIC-Norfolk): cross
sectional study. BMJ 2001; 323: 1286-90.

2. Halbert JA, Silagy CA, Finucane P, Withers RT, Hamdorf PA.Exercise
training and blood lipids in hyperlipidemic and normolipidemic adults: a
meta-analysis of randomized, controlled trials. Eur J Clin Nutr 1999; 53:

3. Hambrecht R, Wolf A, Gielen S, et al. Effect of exercise on coronary
endothelial function in patients with coronary artery disease. N Engl J
Med 2000; 342: 454-60

4. Belardinelli R, Georgiou D, Ginzton L, Cianci G, Purcaro A. Effects of
moderate exercise training on thallium uptake and contractile response to
low-dose dobutamine of dysfunctional myocardium in patients with ischemic
cardiomyopathy. Circulation 1998; 97: 553-61

5. Craig WY, Palomaki GE, Haddow JE. Cigarette smoking and serum lipid and
lipoprotein concentrations: an analysis of published data. BMJ.

6. Ravnskov U. The Cholesterol Myths. Washington DC: New Trends
Publishing, 2000

I have no competing interests

Competing interests: No competing interests

18 January 2002
Uffe Ravnskov
Independent researcher
Magle Stora Kyrkogata 9, S-22350, Lund, Sweden