5th August 2020

This article was first published on RT.com on the 4^th of August, and it can be seen here

In the midst of the COVID-19 epidemic almost every other medical condition has been shoved onto the side-lines. However, in the UK last year, heart attacks and strokes (CVD) killed well over one hundred thousand people – at least twice as many as have died from COVID-19.

CVD will kill just as many this year. Which makes it significantly more important than COVID-19, even if no-one is paying much attention to it right now. So, it is good to see that research goes on, and papers are still being published.

One of the most significant, and of great interest to me personally, was a critical examination of the benefits of lowering cholesterol. This was published on the fourth of August. The paper was called ‘Hit or miss: the new cholesterol targets,’ and it came out in Evidence Based Medicine, one of the key titles that sits under the umbrella of British Medical Journal publishing

It was carefully worded, as all clinical papers are, but a key section of the press release was as follows: “Setting targets for ‘bad’ (LDL) cholesterol levels to ward off heart disease and death in those at risk might seem intuitive, but decades of research have failed to show any consistent benefit for this approach, reveals an analysis of the available data, published online in BMJ Evidence Based Medicine.”

 What is being said here is the following. Everyone thinks that lowering LDL, a.k.a. ‘bad cholesterol is considered the single most important way to reduce the risk of heart disease and strokes. However, “decades of research have failed to show any consistent benefit for this approach.”

Surely this flies in the face of almost all the advice we have been bombarded with for the last fifty years, or so? Cholesterol – by which we really mean low density lipoprotein (LDL) – is a killer and must be lowered. This is the whole point of statins, the single most widely prescribed type of drug in the history of medicine. Drugs that have racked up sales of nearly one trillion dollars since their launch.

Now, newer, and far more expensive LDL lowering medications are available, riding on the success of statins. They are injectable, rather than a tablet, and the cost is far higher. In the US, you are looking at around $5,000 per year. In the UK, one of these drugs Repatha, costs the NHS just over £4,000 per year. These drugs are known as PCSK9-inhibitors.

These are eye-watering costs. It is estimated that around seven million people in the UK take statins currently. If everyone converted to a PCSK9-inhibitor, this would cost the NHS twenty-eight billion pounds a year. Not far off the entire defence budget.

But do these drugs work, does lowering LDL work? Surely it does, surely it must. The answer is, not necessarily. Yes, statins have been found to reduce the risk of cardiovascular disease, not by a massive amount, but the effect exists. At least in some studies, if not all.

However, many other drugs also reduce the risk of cardiovascular disease without having any
effect on LDL levels, e.g. aspirin. A number of researchers have long argued that the benefits of statins are mainly due to “off-target” effects. By which they mean that, yes, statins lower LDL, but they also have effects on many other things and it is the “other things” that provide the benefit.

For example, statins have been found to have quite strong anti-coagulant (anti blood clotting) effects. Same as aspirin, as highlighted in the 2013 paper, ‘Anticoagulant effects of statins and their clinical implications.’ It states: “There is evidence indicating that statins… may produce several cholesterol-independent antithrombotic [anti-coagulant] effects.”

So, it has always remained possible that the main benefit of statins was NOT due to their impact on lowering LDL BUT because of something else that they do.

In this recent study, the authors decided to examine this possibility. So they gathered together all the LDL lowering trials – at least those big enough, and long enough to count – and try to establish whether the amount that the LDL was lowered, matched the reduction, if any, in cardiovascular disease. The technical term for this is “dose-response”.

Or, to put this another way, if the LDL hypothesis is correct, the greater the LDL lowering, the greater the benefit on CVD should be. What did they find? Here are the key findings – from the press release:

“Their analysis showed that over three quarters of all the trials reported no positive impact on the risk of death and nearly half reported no positive impact on risk of future cardiovascular disease.

And the amount of LDL cholesterol reduction achieved didn’t correspond to the size of the resulting benefits, with even very small changes in LDL cholesterol sometimes associated with larger reductions in risk of death or cardiovascular ‘events,’ and vice versa.

“Thirteen of the clinical trials met the LDL cholesterol reduction target, but only one reported a positive impact on risk of death…

“Considering that dozens of [randomised controlled trials] of LDL-cholesterol reduction have failed to demonstrate a consistent benefit, we should question the validity of this theory.”

And they conclude: “In most fields of science the existence of contradictory evidence usually leads to a paradigm shift or modification of the theory in question, but in this case the contradictory evidence has been largely ignored, simply because it doesn’t fit the prevailing paradigm.”

In short, what they found was that there was absolutely no correlation between the amount that LDL was lowered and the resulting benefit on CVD. In fact, the benefit was inverse i.e. the less the LDL was lowered, the greater the benefit.

This is a hugely important finding that really ought to be shouted from the rooftops. I admit I have a horse in the race, having long argued that LDL has nothing to do with heart disease (and being roundly condemned for doing so). So, it is nice to have my thoughts so powerfully supported in a peer-reviewed, high impact journal.

For the average person on this street, what this research means is that you should stop worrying about your LDL levels, and obsessively trying to get them down with drugs or diet. Tucked away in the paper was this significant finding:

“Moreover, consider that the Minnesota Coronary Experiment, a 4-year long RCT [randomised controlled trial] of a low-fat diet involving 9423 subjects, actually reported an increase in mortality and cardiovascular events despite a 13% reduction in total cholesterol.”

Cholesterol (LDL) went down, CVD went up. We really are wasting a colossal amount of money. And causing avoidable death?

17th February 2019

[Adherence to placebo saves lives]

To an extent I am cursing myself for doing what I am about to do. I have been dragged, yet again, into reviewing a paper that has made headlines round the world which proved, yes proved, that adherence to statins saves lives. I am doing this review because a lot of people have asked for my opinion on the paper.

I do feel like saying. ‘Look, I wrote the book Doctoring Data so that you could read papers like this and work out why they are complete nonsense for yourselves’. Clearly, not enough people have read my book, and I would therefore heartily encourage another million or so people to do so. [Conflict of Interest statement – I will get lots of money if this happens, which I think of as “win, win”].

The paper, in this case was called ‘Association of statin adherence with mortality in patients with atherosclerotic cardiovascular disease.’ It was published in the New England Journal of Medicine (NEJM) a couple of days ago.

The main finding was:

‘Using a national sample of Veterans Affairs patients with ASCVD (atherosclerotic cardiovascular disease), we found that a low adherence to statin therapy was associated with a greater risk of dying. Women, minorities, younger adults, and older adults were less likely to adhere to statins. Our findings underscore the importance of finding methods to improve adherence.’ ¹

First thing to say is that this was an observational study. So, it cannot be used to prove causality, especially as the improvement in outcomes that they observed was an increased mortality risk of 1.3 (HR) in those who were least adherent – compared to those who were most adherent.

As many people know… sorry I shall rephrase that… as many geeks like myself know, if the hazard ratio is less than two, in an observational study, the best thing to do with said paper is to crumple it up and throw it in the bin. Because it is almost certainly meaningless. To quote Sir Richard Doll and Richard Peto, two of the fathers of medical research and epidemiology:

“when relative risk lies between 1 and 2 … problems of interpretation may become acute, and it may be extremely difficult to disentangle the various contributions of biased information, confounding of two or more factors, and cause and effect.”²

Observational studies with relative risks between one and two, are the type of studies which find that drinking five cups of coffee protect against CVD – or would that be increase the risk of dying of CVD.  Or maybe it is tea, not coffee? [I apologise for mixing up odds ratios, hazard ratios and relative risk. For ease of understanding, think of them as the same thing].

For example, I was looking at this paper:

‘Tea and coffee consumption and cardiovascular morbidity and mortality’.

Where they found that drinking between three and six cups of coffee reduced CV mortality by 45%:

 ‘A U-shaped association between tea and CHD mortality was observed, with an HR of 0.55 for 3.1 to 6.0 cups per day.’³

That is a far better result than adhering to statins. After all it is a 45% reduction vs. 30% reduction. My advice therefore would be to stop the statins and have nice cup of tea instead. Life would be so much better, and you would live longer as well. Sorry, but I don’t know what sort of tea. English breakfast, Earl Grey, Darjeeling… So many questions. So many stupid studies to read. So much crumpling. So many bins to empty.

Leaving behind the nonsenses they are – the observational studies with a minute difference in hazard ratio – let us move on to the major confounder of this latest crumple, bin, paper. Which is that people who adhere to medications do far better than those who do not – even if that medication is a placebo.

This was first noted, with regard to cholesterol lowering medications, nearly forty years ago in another paper, coincidentally published in the NEJM. It was called:

Influence of adherence to treatment and response of cholesterol on mortality in the coronary drug project.

I have copied the abstract in full. In part because it is written in something akin to understandable English. Most unusual in any medical journal. In this study the researchers were looking at drugs used to lower cholesterol levels, prior to the invasion of the statins.

‘The Coronary Drug Project was carried out to evaluate the efficacy and safety of several lipid-influencing drugs in the long-term treatment of coronary heart disease.  Good adherers to clofibrate, i.e., patients who took 80 per cent or more of the protocol prescription during the five-year follow-up period, had a substantially lower five-year mortality than did poor adherers to clofibrate (15.0 vs. 24.6 per cent; P = 0.00011).

However, similar findings were noted in the placebo group, i.e., 15.1 per cent mortality for good adherers and 28.3 per cent for poor adherers (P = 4.7×10-16). These findings and various other analyses of mortality in the clofibrate and placebo groups of the project show the serious difficulty, if not impossibility, of evaluating treatment efficacy in subgroups determined by patient responses (e.g., adherence or cholesterol change) to the treatment protocol after randomization.’ ⁴

I think it is worth highlighting the main findings again.

Those who adhered to taking clofibrate               =          15% mortality

Those who had poor adherence to clofibrate     =          24.6% mortality

Those who adhered to taking placebo                 =          15.1% mortality

Those who had poor adherence to placebo        =          28.3% mortality

From this is can be established that it was worse for you to not take placebo regularly than it was to not take clofibrate regularly.

If we move forward in time, others have looked at adherence to taking statins. The first thing they noted was people who take their medication regularly are different in many, many, ways to those who have poor adherence.

The paper is called: ‘Statin adherence and risk of accidents, a cautionary tale.’ Published in the American Heart Association journal Circulation.

As they say in the introduction:

‘Bias in studies of preventive medications can occur when healthier patients are more likely to initiate and adhere to therapy than less healthy patients. We sought evidence of this bias by examining associations between statin exposure and various outcomes that should not be causally affected by statin exposure, such as workplace and motor vehicle accidents.’

As they conclude:

‘Our study contributes compelling evidence that patients who adhere to statins are systematically more health seeking than comparable patients who do not remain adherent. Caution is warranted when interpreting analyses that attribute surprising protective effects to preventive medications.’ ⁵

This takes us back to Hill and Peto:

“when relative risk lies between 1 and 2 … problems of interpretation may become acute, and it may be extremely difficult to disentangle the various contributions of biased information, confounding of two or more factors, and cause and effect”

In the case of this latest ‘nonsense’ paper on statins, it is not actually difficult to disentangle the various contributions of biased information.

We already know that people who take tablets regularly, and placebo regularly, are more health seeking than those who do not. We already know that if you take a placebo regularly, this almost halves your (absolute) mortality rate. These are both enormous confounders in the latest NEJM study.

In fact, the confounder effect unearthed in previous studies is far larger than the effect they found. Which, if you are going to be ruthlessly logical, would suggest you would be far better off regularly taking a placebo than regularly taking a statin. If you choose to do so, you could entitle their paper “Proof that statins have no beneficial effect”.

You sure as hell cannot use such data to suggest that adhering to statins is beneficial. Yet, the authors of this study have done so. I give their paper a mark of D-Fail, please try again.

Or else, I would say, please inform yourselves of the previous research done in this area before writing a paper. This will avoid wasting everyone’s precious time.

1: https://jamanetwork.com/journals/jamacardiology/article-abstract/2724695?fbclid=IwAR20HUGfxI9Cq8KVAgW0GY8Mu0MmK5goqGkqmErIb-hl5QZbcy_zahgNEvc

2: Richard Doll & Richard Peto, The Causes of Cancer 1219 (Oxford Univ. Press 1981).

3: https://www.ncbi.nlm.nih.gov/pubmed/20562351

4: https://www.ncbi.nlm.nih.gov/pubmed/6999345

5: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2744446/

3rd July 2018

“Explanations exist; they have existed for all time; there is always a well-known solution to every human problem — neat, plausible, and wrong.’ H.L. Mencken.

Of all the flaws of the human mind, the number one must be the overwhelming desire to find simple, easy to understand answers – to everything. I think this is why my favourite film of all time is Twelve Angry Men. It was a stage play first.

A black youth is accused of killing his father. The evidence that is presented by the prosecution seems utterly overwhelming. A unique knife is used for the murder, one that the youth was known to carry. He was seen leaving the apartment after shouting ‘I’ll kill you’ and suchlike. Most importantly, however, he was a young black youth, and young black youths are widely considered to be the sort of person who do such things.

In the film, prejudice presses down heavily on most of the jurors. Some of them, it is hinted, would have found him guilty no matter if there had been any evidence, or not. Here we have all the worst aspects of human decision making on show. Confirmation bias, prejudice, gathering together only the evidence that supports a case, the desire to ‘get on with it’ and not hang about listening to people who just want to make things complicated.

In my mind, for many years, I have changed ‘black youth’, into the word ‘cholesterol’ as I watch the ‘heart disease jurors’ in action. A suspect was found, fitted up, put on trial and found guilty by people who were just desperate to get on with it. At the very first congressional meetings on dietary guidelines, any attempts to wait until there was sufficient evidence, were railroaded.

‘When the US government introduced “Dietary Goals for the United States”, they did not have unanimous support. The guidelines, which urged the public to cut saturated fat from their diet, were challenged by a number of scientists in a Congressional hearing. The findings were not based on sufficient evidence, they argued.

They were ignored. Dr. Robert Olson recounts an exchange he had with Senator George McGovern, in which he said: “I plead in my report and will plead again orally here for more research on the problem before we make announcements to the American public.” McGovern replied: “Senators don’t have the luxury that the research scientist does of waiting until every last shred of evidence is in.’¹

Senator McGovern might as well have said. ‘Listen son, we know that saturated fat raises cholesterol and causes heart disease, we don’t need any damned evidence.’ Of course, they didn’t have any evidence at all. None. But they still managed to find saturated fat and cholesterol guilty. Some people would call this proper leadership. Make a decision and go with it.

I would call it monumental stupidity.

As you can see I am stepping back in this blog to look at saturated fat – again. Because I am going to share some thinking with you, which I have not really shared before. Some of you will know that I am a ‘first principles’ kind of guy. I take very little at face value, and I am certainly highly critical of accepted wisdom: I usually translate it, in my mind, into accepted stupidity.

So, I am going to try and explain to you that saturated fat cannot raise blood cholesterol levels. By which I mean low density lipoprotein levels (LDLs) as this is the substance which someone or another ended up calling ‘bad’ cholesterol. It is the lipoprotein that is thought to cause CVD.

However, LDL is not cholesterol, it never was. We do not have a blood cholesterol level – but we are seemingly stuck with this hopelessly inaccurate terminology for all time.

Anyway, the idea that saturated fat raised cholesterol was driven by Ancel Keys in the late nineteen forties. The first point to make here is that, when Keys first started his anti-fat crusade, no-one knew that there was such a thing as LDL. You took a blood test, gathered together all the lipoproteins you could find (good, bad, and indifferent) and measured them all. Quite what they were measuring is a good question.

Despite this rather important gap in his knowledge, Ancel Keys was able to create an equation to exactly predict the effect of saturated and polyunsaturated fatty acids in the diet on serum cholesterol levels.

Change in serum cholesterol concentration (mmol/l) = 0.031(2Dsf − Dpuf) + 1.5√Dch

[Where Dsf is the change in percentage of dietary energy from saturated fats, Dpuf is the change in percentage of dietary energy from polyunsaturated fats, and Dch is the change in intake of dietary cholesterol].

This became the accepted wisdom. You could believe, given the apparent precision of this equation, that he did some proper research to prove it was true. Frankly, it seems bloody unlikely, as the equation contains the ‘change in dietary cholesterol’ as a key factor in raised blood cholesterol levels. It is now accepted that cholesterol in the diet has no significant impact on blood cholesterol levels. Keys even knew this himself.

To quote him from a paper in 1956:

‘In the adult man the serum cholesterol level is essentially independent of the cholesterol intake over the whole range of human diets.’

In 1997 Keys wrote this:

“There’s no connection whatsoever between cholesterol in food and cholesterol in blood. And we’ve known that all along. Cholesterol in the diet doesn’t matter at all unless you happen to be a chicken or a rabbit.” Ancel Keys, Ph.D., professor emeritus at the University of Minnesota 1997.

More recently, the fact that cholesterol in the diet has no impact on ‘cholesterol levels’ or CVD was reaffirmed. In 2015, the Dietary Guidelines Advisory Committee in the US, having reviewed all the evidence made this statement:

“Cholesterol is not considered a nutrient of concern for overconsumption.” ²

This was even supported by the likes of Walter Willet and Steven Nissen:

‘Nutrition experts like Dr. Walter C. Willett, chair of the Department of Nutrition at Harvard School of Public Health, called the plan a reasonable move. Dr. Steven Nissen, chair of cardiovascular medicine at the Cleveland Clinic, told USA Today “It’s the right decision. We got the dietary guidelines wrong.’³

Anyway, Keys had started out with a hypothesis that cholesterol in the diet raised cholesterol levels in the blood but discarded it after feeding eggs to volunteers (eggs contain more cholesterol than any other food) and finding that their cholesterol level remained stubbornly unchanged.

Undaunted, he did what no scientist should ever do. He simply changed the hypothesis. The nutrient of concern was no longer cholesterol, it was saturated fat. So, what is it about saturated fat that can raise LDL? I wanted to know the exact, proven, mechanism.

We start with the certain knowledge that the body is exceptionally good at keeping all substances in the blood under strict control. If the level of something rises too high, mechanisms are triggered to bring them back under down, and vice-versa. The entire system is known as homeostasis.

Thus, if saturated fat intake really does cause LDL levels to reach damaging levels, it must be overcoming homeostasis, and breaking metabolic and physiological systems. How does it do this?

To try to answer this question we should look at what happens to saturated fat when we eat it. The first step is that it binds to bile salts in the bowel. Bile salts are a form of mildly adapted cholesterol, synthesized in the liver and released from the gall bladder. Without bile, fat cannot be absorbed well, if at all, and simply passes through the guts and out the other end.

The absorbed saturated fat is then packed into a very large lipoprotein (known as a chylomicron). Once a chylomicron is formed it travels up a special tube, called the thoracic duct, and is released directly into the blood stream. It does not, and this is important, pass through the liver.

Chylomicrons then travel around the body and are stripped of their fat, shrinking down until they become about the size of an LDL. At which point they are called chylomicron remnants. These are absorbed back into the liver – using LDL receptors – and are then broken down into their constituent parts

Therefore, a small amount of fat that you eat will end up in the liver. However, the vast, vast, majority will go straight from the guts to fat cells (adipose tissue). Whereupon they are stored away for later use.

In fact, this is the fate of all types of fat: saturated, polyunsaturated, or monounsaturated. There is nothing unique about saturated fat in the way that it is absorbed and transported around the body. Anyway, as you may have noticed, none of this has anything to do with LDL whatsoever. Nothing. Ergo the consumption of saturated fat, or any fat, can have no direct impact on LDL levels.

I suppose the next question to ask is simple. Where does LDL come from? LDL is created when VLDLs (very low-density lipoproteins) shrink down in size. VLDLs are the type of lipoproteins that are synthesized in the liver, then released into the bloodstream. They contain fat and cholesterol and, as they travel around the body, they lose fat and become smaller and smaller, until they become an LDL -which contains proportionately more cholesterol.

Almost all LDL molecules are removed from the circulation by LDL receptors in the liver. They are then broken down and the contents used again. Some LDL continues to circulate in the blood, and cells that need more cholesterol synthesize an LDL receptor to bind to LDL molecules and bring the entire LDL/LDL receptor complex into the cells.

Just to re-cap. Saturated fat (any fat) is absorbed from the gut and packed into chylomicrons. These travel around the body, losing fat, and shrink down to a chylomicron remnant – which is then absorbed by the liver. There is no connection between chylomicrons and LDL.

Instead LDL comes from VLDL. VLDLs are made in the liver, they contain fat and cholesterol. VLDLs leave the liver, travel around the body and lose fat, shrinking down to become an LDL.

As the only source of LDL is VLDL, this leads to the next obvious question. What makes VLDL levels rise? Well, it sure as hell isn’t fat in the diet. What causes VLDL levels to rise is eating carbohydrates. The next quote is a bit jargon heavy but worth including.

‘De novo lipogenesis is the biological process by which the precursors of acetyl-CoA are synthesized into fatty acids [fats]. In human subjects consuming diets higher in fat (> 30 % energy), lipogenesis is down regulated and extremely low; typically < 10 % of the fatty acids secreted by the liver. This percentage will increase when dietary fat is reduced and replaced by carbohydrate.’⁴

To simplify this as much as possible. If you eat more carbohydrates than your body needs, or can store, the liver converts the excess (primarily fructose and glucose) into fat in the liver. This process is called de novo lipogenesis (DNL) The fats that are synthesized are saturated fats, and only saturated fats. Once synthesized they are then packed into VLDLs and sent out of the liver.

In short, if you eat fat, the VLDL level falls. If you eat carbohydrates the VLDL level rises. Which is pretty much what you would expect to see.

Moving the discussion on, as VLDLs are the only source of LDL. you now have a conundrum to solve. How can you connect saturated fat intake to a rise in LDL levels, when saturated fat consumption reduces VLDL synthesis? What is the mechanism? The mechanism does not exist!

You could counter by saying, what of the many studies that have shown a fall in LDL when saturated fats are replaced by polyunsaturated fats? Well, this seems to have been shown often enough for me to believe it may even be true.

The explanation for this finding is most likely the fact that, in these studies, saturated fats were replaced by polyunsaturated fats, from plant oils. Plant oils contains stanols (the plant equivalent of cholesterol).

Stanols are known to lower LDL levels, see under Benecol and other suchlike ‘low fat’ spreads. Because stanols compete with cholesterol for absorption there is an impact on the ‘measured’ LDL levels. What this means, in turn, is that the studies that demonstrate a lower LDL, with a reduction in saturated fat consumption, fall foul of the two variables problem.

Namely, if you change two variables in an experiment at the same time, you cannot say which of the variables was responsible for the effect you have seen. Was it the reduction in saturated fats, or the increase in plant stanols, that lowers LDL?

This is all tacitly accepted in this Medscape article – again heavy on jargon: ‘Saturated Fat and Coronary Artery Disease (CAD): It’s Complicated.’

‘In a meta-analysis of over 60 trials, higher intakes of saturated fat were associated with increases in both LDL-C and high-density lipoprotein cholesterol (HDL-C) and decreases in triglyceride levels [VLDL}, for a net neutral effect on the ratio of total cholesterol to HDL cholesterol.

Although saturated fats increase LDL-C, they reduce the LDL particle number. Total LDL particle number quantifies the concentration of LDL particles in various lipid subfractions and is considered a stronger indicator of CV risk than traditional lipoprotein measures.

As for stearic acid, the allegedly non-cholesterol-raising fat, while it appears to lower LDL-C relative to other SFAs, one analysis concluded that it raised LDL-C, lowered HDL-C, and increased the ratio of total to HDL cholesterol in comparison with unsaturated fatty acids. And this is one of the confounders of much nutrition research—observations about a given nutrient are highly dependent on what you compare it to.’⁵

Which is a long-winded way of saying that everything we have been told about saturated fat, its impact on LDL, and its impact on CVD is – frankly – complete bollocks. And if it is complete bollocks, the Keys equation – which has driven all research in this area for seventy years – is also bollocks.

In truth, all possible combinations of LDL going up, down, and staying the same have been found in dietary studies. But I would like to focus on the most recent study. It formed the basis of an episode of a programme called ‘Trust me I’m a doctor’, on the BBC. Researchers studied the impact of different types of saturated fat on LDL and HDL levels.

‘For the experiment, the team recruited nearly one hundred volunteers, all aged over fifty. They were split into three groups and every day for four weeks each ate fifty grams of coconut oil (about two tablespoons), or fifty grams of olive oil – an unsaturated fat already known to lower bad LDL cholesterol – of fifty grams of butter.

This amount of coconut oil contains more than forty grams of saturated fat, twice the maximum recommended daily amount for women, according to Public Health England, but is the level previous research has revealed is necessary to show measurable changes in blood cholesterol over a four-week period.

Before the experiment, all the volunteers had their bad LDL and good HDL cholesterol measured, as well as their height, waist, blood pressure, weight and body fat percentage. Four weeks later, these tests were repeated.

The group who ate butter saw their bad LDL levels rise by about ten per cent, as expected. But the olive oil and coconut oil saw no rise in bad LDL – despite coconut oil having more saturated fat than butter.’

Even more surprisingly, while butter and olive oil both raised good HDL cholesterol by five per cent, coconut oil raised it by a staggering fifteen percent, meaning that it seemed to have a more positive effect on cholesterol related health than olive oil.’ 6

It is worth pointing out that this was the largest study of the kind ever to have been done. This may surprise you, but in many nutritional studies the number of subjects is often in single digits. In case you are thinking we can simply ignore a study done by the BBC, it was carried out to high standards, and has since been published in the BMJ. Equally I can see no reason why the BBC would have any desire to bias the conclusions in any direction.⁷

What they found was that coconut oil, containing the highest percentage of saturated fat, had absolutely no impact on LDL. But it did raise HDL (so-called ‘good’ cholesterol) by 15%. Which is no surprise. If VLDL goes down, HDL goes up. And in this experiment they kept everything else the same, but just added saturated fat. A single variable.

Anyway, the thing that interests me most, and the reason for writing this particular blog is that I have come to the realisation that the best way to find the answer to a scientific question is to immerse yourself in the science. I would like to believe the published research, because it would be lovely if you could look at a study and believe it to be correct/true/unbiased. But that is no longer possible, most especially in the connected fields of heart disease, and nutrition.

‘It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgement of trusted physicians or authoritative medical guidelines.” Marcia Angell – long-time editor of the NEJM.

‘The case against science is straightforward: much of the scientific literature, perhaps half, may simply be untrue…science has taken a turn towards darkness.’ Richard Horton – editor of The Lancet.

‘The poor quality of medical research is widely acknowledged, yet disturbingly the leaders of the medical profession seem only minimally concerned about the problems and make no apparent efforts to find a solution.’ Richard Smith – long time editor of the BMJ.

It is always, of course, risky to base your thinking and conclusions on what is known about the basic science. New facts can come along to upend your thinking at any time. However, with mainstream medical research in such a corrupt mess, I do not know how else to do it. The basic research tells us that there is no mechanism whereby saturated fat can raise LDL levels, and the research, such as it can be disentangled, appears to fully support this.

I looked at this blog again, and again, and I thought: Why did I write it…for sure? I wrote it because I wanted to make you aware of three things. First, how powerful a thought can be. Saturated fat raises the LDL level, and how difficult this is to shift. The power of a simple idea.

Secondly, so that you can see that the truth is out there. It is not to be found amongst the experts in the field. It cannot be found by reading the research, or the guidelines. But it is out there, if you look hard enough.

Third, the mainstream just will not change its mind. A recent conference in Switzerland, organised by the BMJ, and others, tried to discuss the dietary guidelines and the role of Saturated fat. I was invited, but did not go, as I was working. Zoe Harcombe went, and wrote a blog about it.⁸  As she wrote about the conclusion of the conference:

‘At the recent Swiss Re/The BMJ Food for Thought conference, the closing speakers tried to find some agreement on dietary fat guidelines…

Fiona (Fiona Godlee, editor of the BMJ) started with: “The point about saturated fat is: the evidence is now looking pretty good, but the guidance hasn’t shifted… there doesn’t seem to have been an enormous ‘mea culpa’ from the scientific community that we got it so wrong. That does surprise me.”

Salim replied: “We got brainwashed by a very questionable study, called The Seven Countries Study, many years ago and it was ingrained in our DNA and generations of us were brought up with that… Somebody said that you need to wait for guidelines committees to die before you can change the guidelines committees”!

Fiona then said: “Maybe one outcome of this meeting would be for this meeting to say ‘that’s gone now’, the science has changed. Am I right Salim? Am I right Dariush? It seems to be that should be an outcome of some sort from this meeting.”

Alas, the UK guidelines committee shows no signs of such change, let alone the ‘mea culpa’ that Fiona suggests might be in order.’

1: https://www.diabetes.co.uk/in-depth/every-last-shred-evidence-low-fat-dietary-guidelines-never-introduced/

2: http://time.com/3705734/cholesterol-dietary-guidelines/

3: https://www.health.harvard.edu/blog/panel-suggests-stop-warning-about-cholesterol-in-food-201502127713

4: https://www.ncbi.nlm.nih.gov/pubmed/12133211

5: https://www.medscape.com/viewarticle/839360

6: https://www.pressreader.com/uk/daily-mail/20180109/282643212945759

7: http://bmjopen.bmj.com/content/8/3/e020167

8: http://www.zoeharcombe.com/2018/07/saturated-fat-consultation-sacn-my-response/

12th May 2018

[A classic black swan]

If your hypothesis is that all swans are white, the discovery of one black swan refutes your hypothesis. That is how science works. Or at least that is how science should work. In the real world, scientists are highly adept at explaining away contradictions to their favoured hypotheses. They will use phrases such as, it’s a paradox. Or, inform you that you didn’t measure the correct things, or there are many other confounding factors – and suchlike.

Anyway, accepting that the finding of someone with a very high LDL level, and no detectable atherosclerosis, will always be dismissed – in one way or another – I am still going to introduce you to a ‘case history’ of a seventy-two-year-old man with familial hypercholesterolaemia, who has been studied for many, many, years. Try as they might, the researchers have been unable to discover any evidence for cardiovascular disease (CVD) – of any sort.

In the past, I have spoken to many people with very high LDL and/or total cholesterol levels who are CVD free, even in very old age. The mother of a friend of mine has a total cholesterol of level of 12.5mmol/l (483mg/dl). She is eighty-five, continues to play golf and has not suffered from any cardiovascular problems.

However, none of these people had been studied in any detail. Which means that they can, and are, dismissed as irrelevant ‘anecdotes’. Yes, the widely used and highly exasperating phrase that I often encounter is that ‘the plural of anecdote is not data’. This, of course, is completely untrue, or at least it is untrue if you start dismissing detailed individual cases as anecdote.

Whilst an anecdote may simply be a story, often second hand, a case history represents a painstaking medical history, including biochemical and physiological data. In reality, the plural of case histories is data. That is how medicine began, and how most medical breakthroughs have been made. We look at what happens to real people, over time, we study them, and from this we can create our hypotheses as to how diseases may be caused and may then be cured.

So, a single case is NOT an anecdote, and cannot be lightly dismissed with a wave of the hand and a supercilious smirk.

In fact, the man who is the subject of this case history has written to me on a few occasions, to tell me his story. I have not written anything about him before, as I knew his case was going to be published, and I did not want to stand on anyone’s toes. With that in mind, here we go.

The paper was called ‘A 72-Year-Old Patient with Longstanding, Untreated Familial Hypercholesterolemia but no Coronary Artery Calcification: A Case Report.’ ¹

The subject has a longstanding history of hypercholesterolemia. He was initially diagnosed while in his first or second year as a college student after presenting with corneal arcus and LDL-C levels above 300 mg/dL [7.7mmol/l]

He reports that pharmacologic therapy with statins was largely ineffective at reducing his LDL-C levels, with the majority of lab results reporting results above 300 mg/dL and a single lowest value of 260 mg/dL while on combination atorvastatin and niacin. In addition to FH-directed therapy, our subject reports occasionally using baby aspirin (81 mg) and over-the-counter Vitamin D supplements and multivitamins.

In the early 1990s, our patient underwent electron beam computed tomography (EBCT) imaging for CAC following a series of elevated lipid panels. Presence of CAC (coronary artery calcification) was assessed in the left main, left anterior descending, left circumflex, and right coronary arteries and scored using the Agatston score.

His initial score was 0.0, implying a greater than 95% chance of absence of coronary artery disease. Because of this surprising finding, he subsequently undertook four additional EBCT tests from 2006 to 2014 resulting in Agatston scores of 1.6, 2.1, 0.0, and 0.0, suggesting a nearly complete absence of any coronary artery calcification. In February of 2018, he underwent multi-slice CT which revealed a complete absence of coronary artery calcification.

So, here we have a man who has an LDL consistently three to four times above ‘average’. He had tried various LDL lowering agents over the years. None of which had done anything much to lower LDL. Therefore, his average LDL level over a twenty-year period has been 486mg/dl (12.6mmol/l.

Despite this he has absolutely no signs of atherosclerotic plaque, in any artery, no symptoms of CVD and is – to all intents and purposes – CVD free. What of his relatives? If he has FH, so will many others in his family.

‘He has one sister three years his senior who also has FH and a history of high lipid levels. She also has no history of myocardial infarction, angina, or other symptoms of coronary artery disease. His mother had FH, although she died of pancreatic cancer at age 77. She and her three siblings were never treated for, and had no history of, cardiovascular disease. The patient reports that his father had one high cholesterol score (290s), but was never diagnosed with FH, had no history of cardiovascular disease and died in his 80s during surgery for hernia repair.’

What to make of this? Well, I know that the ‘experts’ in cardiology will simply ignore this finding. They prefer to use the ‘one swallow does not a summer make’ approach to cases like this. For myself I prefer the black swan approach to science. If your hypothesis is that a raised LDL causes CVD, then finding someone with extremely high LDL, and no CVD, refutes your hypothesis.

Unfortunately, but predictably, the authors of the paper have not questioned the LDL approach. Instead, they fully accept that LDL does cause CVD. So, this this man must represent ‘a paradox’. They have phrased it thus:

‘Further efforts are underway to interrogate why our patient has escaped the damaging consequences of familial hypercholesterolemia and could inform future efforts in drug discovery and therapy development.’

To rephrase their statement. We know that high LDL causes CVD. This man has extremely high LDL, with no CVD, so something must be protecting him. I have an alternative, and much simpler explanation: LDL does not cause CVD. My explanation has the advantage that it fits the facts of this case perfectly, with no need to start looking for any alternative explanation.

And just in case you believe this is a single outlier, something never seen before or since. Let me introduce you to the Simon Broome registry, set up in the UK many years ago to study what happens to individuals diagnosed with familial hypercholesterolaemia (FH). It is the longest, if not the largest, study on FH in the world.

It has mainly been used as one of the pillars in support of the cholesterol hypothesis. However, when you start to look closely at it – fascinating things emerge. One of the most interesting is that people with FH have a lower than expected overall mortality rate – in comparison to the ‘normal’ population. Or, to put this another way. If you have FH, you live longer than the average person.

Even if we look at death from heart disease (those with FH have never been found to have an increased rate of stroke) we find that in the older population, the rate of death from Coronary Heart Disease (CHD) was actually lower than the surrounding population in some age groups.

For instance, in the male population aged 60 – 79 (who were CHD free on entry to the study) the rate of death from heart attacks was lower than the surrounding population. Not significantly, but it certainly was not higher.

In fact, in the total male population aged 20 – 79 with FH, the rate of death from CHD was virtually identical to the surrounding population. Over a period of 13,717 years of observation, the expected number of fatal heart attacks was calculated to be 46. The actual observed number was 50.

In women, the expected number of heart attacks in the population aged 20 – 79 was 40, the actual number of observed fatal heart attacks was 40. Which means that FH was not found to be a risk factor for CHD in those enrolled in the study – who had no diagnosed heart disease prior to enrolment².

Which represents, I suggest, another fully grown black swan. There you go. Two in one day.

1: https://www.cureus.com/articles/11752-a-72-year-old-patient-with-longstanding-untreated-familial-hypercholesterolemia-but-no-coronary-artery-calcification-a-case-report

2: https://academic.oup.com/eurheartj/article/29/21/2625/530400

Fat and Cholesterol Don’t Cause Heart Attacks

There is a group of doctors, scientists and researchers called the International Network of Cholesterol Skeptics (THINCS) www.thincs.org. I am a member, and recently a number of us have contributed chapters to a new book called Fat and Cholesterol Don’t Cause Heart Attacks And Statins are Not the Solution.

This was written in honour of the founder of THINCS, Uffe Ravnskov, a Swedish doctor and researcher who has been arguing against the current die-heart/cholesterol hypothesis for many years. He has written several books, many, many, research papers, and had the dubious honour of having one of his book burned, live, on television. [Finland 1992, the book was The Cholesterol Myths]. He has also been ruthlessly attacked, both professionally and personally. Yet he has never given up.

Ravnskov, like all of us in THINCS, started looking at heart disease, or cardiovascular disease (CVD) and recognised that the widely accepted views were simply wrong. Something recognised by many people over the years, including Professor George Mann (who helped to start up and run the Framingham study).

‘Saturated fat and cholesterol in the diet are not the cause of coronary heart disease. That myth is the greatest scientific deception of this century, perhaps of any century.’

George Mann, like many others was silenced. Kilmer McCully, who discovered the role of homocysteine in CVD, and suggested that it could be more important that cholesterol was also attacked. Funding for his research disappeared, leading to the loss of his laboratory. His hospital director told him to leave and ‘never come back’. His Harvard affiliation and tenure were terminated.

Another contributor to this book, Professor Michel De Logeril, set up and ran the seminal Lyon Heart Health Study. Possibly the seminal work on the ‘Mediterranean Diet.’ Yet he is a trenchant critic of the diet-heart hypothesis, and believes that statins do more harm than good. He is, again, attacked ruthlessly.

Yes, there is a pattern here. Dare to criticise the current dogma that saturated fat in the diet raises cholesterol, which then goes on to cause CVD, and your chances of progression in the research world are, precisely, zero. Your chances of getting anything published are, pretty close to zero. You will be attacked both personally and professionally. You will be accused of killing thousands of people by putting them of taking statins – and suchlike.

However, those in THINCS have never given up in their efforts to get the ‘truth out there’ and never will. This book is a further way to help inform the public about the true facts. There are chapters on competing hypotheses as to the cause(s) of CVD, there are chapters outlining the flaws in the current ideas. Some chapters are technical, others not.

Everything is held together by Paul Rosch, a brilliant researcher, writer and editor, clinical professor of Medicine and Psychiatry and New York Medical College, Chairman of the Board of the American Institute of Stress, and a great, deep thinker, on many subjects. Would that there were more like him.

You can get a copy direct from the Publishers here…

Or if you prefer to support Amazon, it’s on Amazon UK here and Amazon USA here

Amazon.co.uk
Amazon.com

Yes, if anyone is interested, I enjoyed my holiday. Mountains, snow, skiing, food, France. What more could you ask for?

Whilst away I kept an eyes on a whole series of stories on cholesterol and statins and adverse effects of statins, and suchlike, unfold across various newspapers. Many of you were kind enough to send me said various articles and stories. Some of which were easy to follow. One, in particular, was completely incomprehensible.

HOPE-3, was a study done by Astra Zeneca looking at the use of rosuvastatin vs. placebo. Actually, it was a study done using rosuvastatin alone vs. antihypertensive medication vs. rosuvastatin and antihypertensive medicine vs. double placebo (a term I have never come across before). Double placebo has twice the power of a single placebo? Yes, its ‘Double Placeboman’ playing at a cinema near you.

I have read the HOPE-3 article, and given up several times. I just cannot understand it. Professor Michel de Lorgeril (who ran the Lyon heart health study) also had a go at making it easier to understand. Below is part of his simplification which (I am afraid) is not terribly simple. But it may give you some gist. There is a prize for anyone who gets to his final point:

1. No effect on all-cause mortality.

2. No effect on cardiovascular mortality.

3. As cardiovascular disease is a serial killer, we could conclude that rosuvastatin is shown useless in that trial (as in the previous trials). We could stop the analysis at this point.

4. Since the authors do suggest that rosuvastatin was protective, it means that these patients are as “deaths cured”’ or “death prevented”, which is probably not what they expected when taking the pills.

5. All this despite the LDL reduction that was close to 30%.

6. HOPE 3 investigators curiously examine the effects of rosuvastatin on two “combined primary endpoints” (called “first and second co-primary outcome” as shown on Table 2, below) suggesting that there were two primary hypotheses. This is not “in line” with basic Methods in clinical trial sciences [one trial, one primary hypothesis]. That strange and novel strategy should have been presented long before starting the trial. In any case, the probability of a difference between rosuvastatin and placebo for the first co-primary outcome [the only one to be considered] should have been adapted, a kind of Bonferroni correction; p should have been much lower than 0.05 to be significant; which is not “clinical significance”.

7. HOPE 3 investigators present the comparison of rosuvastatin with placebo (Table 2, below) as if there were only two randomized groups. In fact, there were 4 groups as there was a second randomization to test an antihypertensive treatment; and also the combination of cholesterol lowering and blood pressure lowering. In summary, these investigators tested many more than two primary hypotheses. They say that they can pool the data from all the patients taking rosuvastatin (plus antihypertensive) to make the comparison with all the patients taking a placebo, including those taking antihypertensive; thus comparing two groups of about 6300 patients rather than 4 groups of about 3100 patients each) because there was no interaction between treatments. This is not exactly true as we see a clear interaction between treatments for at least two components (myocardial infarction and stroke) of the two co-primary outcomes (see Table S20 in the supplementary materials, below). It would have been therefore imperative to present data and full statistics for the 4 groups together to examine the effects of rosuvastatin vs. placebo. It is a mistake not to do that. 6- HOPE 3 investigator also say that there were fewer heart attacks; but after almost 6 years and with about 13,000 patients randomized, there were only 114 heart attacks (45 vs 69 in a simplistic analysis of 2 groups only, Table 2 below).

8. In fact, things are not so clear when looking at Table 2: they report for the first co-primary outcome (CV deaths + myocardial infarction + stroke) 304 events in the placebo group and 235 in the rosuvastatin group, thus numbers different from the sum of 171+69+99 (total 339, placebo group) Michel de Lorgeril 2016 and 154+45+70 (total 269, rosuvastatin) according to the numbers given in Table 2. This means that they do not use the same numbers in the Table and in the statistics. This is a way of misleading the readers.

Ahem. Perhaps not as simple as you may expect, but I hope you get the general drift. All I did, rather than Lorgeril, was attempt to pull out the figures of greatest interest, to me. Which should be the figures of greatest interest to everyone taking rosuvastatin. The absolute difference in number of deaths between those taking rosuvastatin and double placebo.

• After five years of treatment, in 3,181 people taking rosuvastatin, there were 171 deaths (of all causes)
• After five years of taking double strength placebo, in 3,168 people, there were 178 deaths (of all causes)

This represents a difference of 7 deaths over 15,905 years of treatment. Or, one death delayed for every 2,272 years of treatment. This is both statistically, and clinically, insignificant. It is well within the limits of a chance finding. It is a difference that can simply be ignored.

Of course, it was hailed as a triumph, and further proof of the cholesterol hypothesis.

Of more interest, in many ways, and coming out at almost exactly the same time as HOPE-3 was the ACCELERATE trial. Which looked at the use of evacetrapib on lowering LDL (‘bad’ cholesterol), and raising HDL (‘good cholesterol) on the risk of CVD. It was reported thus…

‘Cleveland Clinic researchers studying evacetrapib have shown that despite reducing levels of low-density lipoprotein (LDL, or “bad” cholesterol) by 37 percent and raising levels of high-density lipoprotein (HDL, or “good” cholesterol) by 130 percent, the drug failed to reduce rates of major cardiovascular events, including heart attack, stroke, angina or cardiovascular death.

The phase 3, multi-center clinical trial was discontinued in October 2015, on the recommendation of the independent Data Monitoring Committee after preliminary data suggested the study would not meet its primary endpoint of a reduction in major cardiovascular events. The research is being presented at the American College of Cardiology’s 65th Annual Scientific Session

“Here we have a paradox. The drug more than doubled HDL and lowered LDL levels by as much as many statins, but had no effect on cardiac events,” said Steve Nissen, M.D., chairman of Cardiovascular Medicine at Cleveland Clinic. “These findings illustrate the importance of performing large, high-quality outcome trials. Just looking at the effects a therapy has on cholesterol levels doesn’t always translate into clinical benefits.”

The ACCELERATE trial involved more than 12,000 patients at more than 540 sites who were at high risk for serious cardiovascular problems. They were randomized to receive either 130 milligrams of evacetrapib or a placebo daily, along with standard medical therapy throughout the trial. Study participants either had an acute coronary syndrome 30 days to one year before enrolling, had cerebrovascular atherosclerotic disease, had peripheral vascular disease, or had both diabetes and coronary artery disease.’

In HOPE3, LDL was lowered 30%, had some (very slight) impact on CVD, and was hailed as a triumph for cholesterol lowering. In ACCELERATE LDL was lowered 37%, HDL raised 130%, with no effect whatsoever on CVD. Aha, but, there is an answer…

The ACCELERATE trials was, you’ve guessed it. A paradox. [Question, how many paradoxes can a hypothesis sustain before it collapses in a smoking ruin?]

Karl Popper would call such a thing a black swan. Which is a refutation of your hypothesis. Karl Popper, as we all – ahem – know ‘proposed falsification as a solution to the problem of induction. Popper noticed that although a singular existential statement such as ‘there is a white swan’ cannot be used to affirm a universal statement, it can be used to show that one is false: the singular existential observation of a black swan serves to show that the universal statement ‘all swans are white’ is false—in logic this is called modus tollens. ‘There is a black swan’ implies ‘there is a non-white swan,’ which, in turn, implies ‘there is something that is a swan and that is not white’, hence ‘all swans are white’ is false, because that is the same as ‘there is nothing that is a swan and that is not white’.

One notices a white swan. From this one can conclude:

At least one swan is white.

From this, one may wish to conjecture:

All swans are white.

It is impractical to observe all the swans in the world to verify that they are all white.

Even so, the statement all swans are white is testable by being falsifiable. For, if in testing many swans, the researcher finds a single black swan, then the statement all swans are white would be falsified by the counterexample of the single black swan.’²

Here is another ‘white swan’ hypothesis

Researchers, looking at those living in Framingham, in the US, found that younger men with high cholesterol levels were more likely to die from CVD. From this they concluded. Raised cholesterol causes CVD. ACCELERATE clearly falsifies their simplistic hypothesis. It is a black swan. Thank you, and goodnight.

Next, part XII as to what causes heart disease.

References:
1: http://www.dddmag.com/news/2016/04/evacetrapib-impacts-cholesterol-doesnt-reduce-cardiovascular-events

2: https://en.wikipedia.org/wiki/Falsifiability