Last week I was going through some old files, and presentations, in a vague effort to clean up my computer. Whilst looking a one of many thousands of studies I had filed away I came across this paper: ‘Clarifying the direct relation between total cholesterol levels and death from coronary heart disease in older persons1.’
I read it, and immediately recalled why I kept it. For it came to the following, final, conclusion:
‘Elevated total cholesterol level is a risk factor for death from coronary heart disease in older adults.’
I remember when I first read this paper a few years ago. My initial thought was to doubt that it could be true. Most of the evidence I had seen strongly suggested that, in the elderly, a high cholesterol level was actually protective against Coronary Heart Disease (CHD).
However, when a bunch of investigators state unequivocally that elevated cholesterol is a risk factor for heart disease, I try to give them the benefit of the doubt. So I read the damned thing. Always a potentially dangerous waste of precious brainpower.
Now, I am not going to dissect all the data in detail here, but one sentence that jumped out of the paper was the following:
‘Persons (Over 65) with the lowest total cholesterol levels ≤4.15 mmol/L had the highest rate of death from coronary heart disease, whereas those with elevated total cholesterol levels ≥ or = 6.20 mmol/L seemed to have a lower risk for death from coronary heart disease. ‘
Now, I can hardly blame you if you struggled to fit those two quotes together. On one hand, the conclusion of the paper was that .. ‘Elevated total cholesterol level is a risk factor for death from coronary heart disease in older adults.’ On the other hand, the authors reported that those with the lowest total cholesterol levels had the highest rate of CHD; whilst those with the highest cholesterol levels had the lowest rate of CHD.
Taken at face value, this paper seems to be contradicting itself…. utterly. However, the key word here, as you may have already noted, is seemed. As in… those with elevated total cholesterol levels ≥ or = 6.20 mmol/L seemed to have a lower risk for death from coronary heart disease. ‘
Now you may think that this is a strange word to use in a scientific paper. Surely those with elevated total cholesterol levels either did, or did not, have a lower risk of death from CHD? Dying is not really something you can fake, and once a cause of death has been recorded it cannot be changed at a later date. So how can someone seem to die of something – yet not die of it?
The answer is that you take the bare statistics, then you stretch them and bend them until you get the answer you want. Firstly, you adjust your figures for established risk factors for coronary heart disease – which may be justified (or may not be). Then you adjust for markers of poor health – which most certainly is not justified – as you have no idea if you are looking at cause, effect, or association.
Then, when this doesn’t provide the answer you want, you exclude a whole bunch of deaths, for reasons that are complete nonsense. I quote:
‘After adjustment for established risk factors for coronary heart disease and markers of poor health and exclusion of 44 deaths from coronary heart disease that occurred within the first year, (my bold text) elevated total cholesterol levels predicted increased risk for death from coronary heart disease, and the risk for death from coronary heart disease decreased as cholesterol levels decreased.’
Why did they exclude 44 deaths within the first year? Well, they decided that having a low cholesterol levels was a marker for poor health, and so it was the poor health that killed them within the first year.
The reason why they believed they could do this is that, a number of years ago, a man called Iribarren decreed that the raised mortality always seen in those with low cholesterol levels is because people with low cholesterol have underlying diseases. And it is these underlying diseases that kill them. (What, even dying from CHD. And how, exactly does CHD cause a low cholesterol levels….one might ask).
In truth, there has never been a scrap of evidence to support Iribarren’s made-up ad-hoc hypothesis. [A bottle of champagne for anyone who can find any evidence]. However, it is now so widely believed to be true, that no-one questions it.
Anyway, without chasing down too many completely made-up ad-hoc hypotheses, the bottom line is that this paper stands a perfect example of how you can take a result you don’t like and turn it through one hundred and eighty degrees. At which point you have a conclusion that you do like.
Young researcher: (Bright and innocent) ‘Look, this is really interesting, elderly people with low cholesterol levels are at greater risk of dying of heart disease.’
Professor: (Smoothly threatening) ‘I think you will find…. if you were to look more carefully, that this is not what you actually found….. Is it? By the way, how is your latest grant application going?’
Young researcher: (Flushing red at realising his blunder) ‘Yes, by golly, how silly of me. I think I really found that elderly people with high cholesterol levels are at a greater risk of dying of heart disease.’
Professor: ‘Yes, excellent. Be a good lad, find a good statistician to make sure the figures make sense, and write it up.’
For those who wonder at my almost absolute cynicism with regard to the current state of Evidence Based Medicine, I offer this paper as a further example of the way that facts are beaten into submission until they fit with current medical scientific dogma.
As a final sign off I would advise that any paper that has the word ‘clarifying’ in its title, should be treated with the utmost suspicion. I think George Orwell would know exactly what the word clarifying means in this context. Facts do not need clarification.
1: Corti MC et al: Clarifying the direct relation between total cholesterol levels and death from coronary heart disease in older persons. Ann Intern Med. 1997 May 15;126(10):753-60
Dr. Malcolm Kendrick 
I despair. Having heard Jules Payne, Chief Executive of Heart UK describe cholesterol as “the silent killer” on Radio 4 news on Sunday morning, I looked up her charity, which describes itself as the major “cholesterol charity”. I wanted to put some alternative facts to her, but quickly realized she wouldn’t like them, as if she did she’d be out of a job.
Heart UK saves poor starving cholesterol molecules, and is funded almost entirely by the pharmaceutical and food industry. It is as much a charity as Barclays Bank.
Why doesn’t this surprise me?
I went to see my (lovely) GP this week. He was pleased to acknowledge that I am no longer hypertensive, (I stopped my medication in April, my blood pressure remains 115/75) nor do I need the Omeprazole as my GERD stopped, virtually the day I started the Atkins diet, but he just won’t accept that restricting Carbohydrates is anything to do with it! His stance is now that these things are only to do with the weight loss, nothing to do with Carb restriction. We had to agree 2 years ago that I’d stop having blood tests so that we’d stop arguing about Statins. There’s a long, long way to go in the UK! GPs don’t believe what’s right in front of their eyes, I’m afraid.
It would, perhaps be more accurate to say that GP cannot believe what’s right in front of their eyes. For, were they to do so, it would become very difficult to continue to believe in what they do.
That explains the “bum’s rush” given to my 94 year old friend, when she attempted to list her statin side effects to her charming (very young) doctor. Everything she listed was dismissed. This was followed by a detailed lecture about the need to continue with statins. Even my confirming the difference I’d seen in her was not believed.
It is all quite sad really. All side-effects dismissed, benefits plucked from thin air. Thank goodness we live in age of scientific enlightenment.
You think that’s bad? My dad went to see his GP last week. His total cholesterol went up. The ONLY reason it went up was that his HDL has risen since he’s been eating fewer junk carbs. In fact, his LDL number went down. But because the TOTAL went up, the GP suggested a statin.
Think about this for a minute: HDL up (good). LDL down (good, according to mainstream dogma). But because of the way maths works, HDL went up more than LDL went down, and thus the total went up. And according to the robotic mind of the GP, this meant STATIN TIME!
This is how the conversation went:
GP: Your total cholesterol has gone up. When we see cholesterol creeping up, we like to use statins to keep it in check
Dad: But isn’t it just HDL that’s gone up? My son said that this is a good marker?
GP: Yes, higher HDL is better. But we’re talking about your total cholesterol which we want to bring down. The statin will help with that.
Dad: But last time you did a blood test, you told me that my total cholesterol was ok, and no statin was needed. This time, the only reason the total has gone up is because my HDL is higher.
GP: The fact is, your total cholesterol is now above where we’re comfortable, so it’s best to bring it down just to be safe. A simple statin can help to do that with no down side.
Dad: I have been told about side-effects.
GP: Scare-mongerers. Those are the same sort of people who go on about the MMR and believe in conspiracy theories. Statins are perfectly safe.
So there you have it! The cream of the British medical establishment!
That’s a good one – people dying from poor health, so we’ll exclude them. Reading this, I honestly felt like laughing, except it’s too serious.
It’s like a bad film that’s so bad it’s funny. The analogy ends there, in the main bad films don’t ruin your health and ultimately kill you.
Broadening the debate as a teacher, such twisted manipulation of facts are exactly the examination material for A Level Critical Thinking Papers – indeed, I have used the cholesterol debate findings in my own practice Papers to help students see where statistics are used to mislead and misdirect. Is it any wonder, then, that this qualification is going to be phased out in the next 2 years in the UK. Almost fits a conspiracy theory but that would be too illogical, wouldn’t it?
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The appropriate word appears to be ‘total’ in my opinion. I’d have thought the authors of this work would have made a distinction between the good high-density lipoprotein cholesterol that hoovers the stuff out of your arteries, and the low-density lipoprotein stuff that does an excellent job of putting it back there. Presumably the healthy over-65s with high total cholesterol had a surfeit of HDL-cholesterol, and those with low total cholesterol had mainly LDL-cholesterol which contributed to their poor health, which as we all know eventually kills people. No mention of population size or selection criteria either, other than being ruled out for having the temerity to die of poor health!
The newly launched ‘NHS Health Check’ is still banging the same old drum. Cholesterol testing is on the list and use of statin therapies is promoted. This health check will no doubt end up like so many of the other screening-type services, something that many don’t want to participate in, especially as it is so keen to offer exit routes in the form of being added to various ‘registers’. Again this seems more about creating a system that focuses on targets and data gathering rather than helping individual human beings.
Dr Kendrick, your karma ran over their dogma! Thanks for bringing this to our attention. Fudging science like that will definitely shorten many lives if not worse.
I’ve recently had my annual meeting with my GP where he demands to know why I won’t take statins and I allude to my lovely cholesterol numbers, my beautiful angiogram piccies and the ‘orrible side-effects. We declare a truce and proceed.
Oh dear, oh dear.
http://cardiobrief.org/2013/07/31/european-heart-guidelines-based-on-disgraced-research-may-have-caused-thousands-of-deaths/
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Re; Iribarren, it is true that low cholesterol can be caused by underlying cancer, HCV infection, and so on, but how these diseases then translate to CHD deaths rather than deaths from cancers and liver failure is obscure to me.
It is also true that high cholesterol is protective against these diseases. Go figure.
The scientific evidence for astrology remains weak, but it’s still more convincing than the evidence for the lipid hypothesis.
Biggest threat to science are the bad “scientists”…
Your story reminds me of the sensation I felt after reading the paper “Human Atherosclerosis and the Diet” written by Ancel Keys in 1952. He describes the amount of dietary cholesterol required to induce atherosclerosis in experimental animals and said that a human would have to eat 10,000 to 15,000 mg of cholesterol a day to do the same, which is roughly 50 to 75 eggs a day. However, at the end of his paper, his last recommendation is to “disregard of cholesterol intake except, possibly, for a restriction to an intake less than 1 Gm. per week.” My head spun when I read that. His recommendation was arbitrary and conflicted with everything he presented in his paper.
This scandal makes me think that every scientific paper that uses statistics, should be signed off by a qualified statistician, who would take responsibility that the data processing was valid!
Sadly, I think this sort of misuse of statistics is rife – particularly where science and advocacy have become entangled. One particular case is that the evidence for “Global Warming” seems extraordinarily weak, but is bolstered by scientists with a campaigning agenda. Obviously this is not the place to discuss that issue, but you only have to type “The Hockey Stick Delusion” into GOOGLE to explore.
I think part of the problem nowadays is that there are far fewer science reporters with a decent science education to ask tricky questions.