Tag Archives: cholesterol

Losing Faith

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‘Moreover, for many current scientific fields, claimed research findings may often be simply accurate measures of the prevailing bias.’ J Ionnadis.

Recently, I have taken to looking at the headlines of various medical studies are groaning. You may have seen the hype surrounding a ‘low carb’ diet study in the BMJ. One headline, plucked from many, stated that ‘Heart disease linked to low-carb diets.’

Perhaps I should take such studies more seriously. After all, the BMJ is one of the most respected and highly ranked medical journals in the world. It is not the Fortean Times or the National Enquirer. So, one would hope that it prints things that should be serious and taken seriously.  I wish.

Instead, my first thought was. This is bollocks. I know that this is rubbish. But, frankly, can I be bothered to read the damn thing myself, to prove to myself it is rubbish. I immediately knew it was rubbish because I have been studying nutrition and health for nearly thirty years, and if there were anything inherently unhealthy about a low carb, high protein diet, I would know it. And I don’t.

I also know the context of such studies. Mainstream medical thinking has been high carb, low everything else for the past thirty years. It is unshakable dogma, maintained in the face of a relentless bombardment of evidence. When anyone, such as Atkins, dares to take on this established dogma, they are ruthlessly attacked, personal, professionally and scientifically.

On the other hand, when anyone produces a paper supporting the high carb, low everything else, dogma, it will be uncritically supported, waved through peer-review, then published. ‘See, we were right all along. Low carb diets kill you. Nyah, nyah, nyah…..you’re not singing any more etc.’ Such is the world of medical research today.

The decline of honesty in science

Anyone who has been a scientist for more than 20 years will realize that there has been a progressive decline in the honesty of communications between scientists, between scientists and their institutions, and between scientists and their institutions and the outside world.

Yet real science must be an arena where truth is the rule; or else the activity simply stops being science and becomes something else: Zombie science. Zombie science is a science that is dead, but is artificially kept moving by a continual infusion of funding. From a distance Zombie science look like the real thing, the surface features of a science are in place – white coats, laboratories, computer programming, PhDs, papers, conference, prizes, etc. But the Zombie is not interested in the pursuit of truth – its citations are externally-controlled and directed at non-scientific goals, and inside the Zombie everything is rotten…..

Scientists are usually too careful and clever to risk telling outright lies, but instead they push the envelope of exaggeration, selectivity and distortion as far as possible. And tolerance for this kind of untruthfulness has greatly increased over recent years. So it is now routine for scientists deliberately to ‘hype’ the significance of their status and performance and ‘spin’ the importance of their research.

Bruce Charlton: Professor of Theoretical Medicine

Getting back to the study, I did read it, it was rubbish. Luckily, others too read it, and there has pretty much been a barrage of criticism (none of which will ever reach the media, of course). Here is what  Dr Yoni Freehof had to say on the New England Journal of Medicine discussion forum. http://www.cardioexchange.org/voices/what-reading-that-low-carb-gives-you-heart-disease-paper-actually-told-me/

‘…..So, to review: The authors of this paper are  basing their 15-years-worth of conclusions off of a single, solitary — and clearly inaccurate — baseline food-frequency questionnaire; they didn’t control for clearly known smack-you-in-the-face dietary confounders; they found just a miniscule absolute increase in risk; and the diet they are reporting on can’t even be fairly referred to as a low-carbohydrate diet.

Useful?  Conclusive?  Press worthy?

It gets worse.

The BMJ didn’t just publish a completely useless paper, they gave this very clear, yet completely non-evidence-based, advice to clinicians in their accompanying editorial:

Despite the popularity of these diets, clinicians should probably advise against their use for long-term control of body weight.

Worse still, highly reputable, socially networked curators of medical information tweeted the resultant media stories as relevant, and even Physician’s First Watch — a news alert from Journal Watch and the publishers of the New England Journal of Medicine — reported it as valuable to scores of physician subscribers who trust JW to keep them abreast of the latest important journal studies.’

He didn’t like. I didn’t like it. No-one who knows anything about this area liked it. It was Zombie Science, to go along with an ever-increasing pile of Zombie Science. I am losing faith in medical research.

The UK Obesity Initiative (Failure guaranteed from the start)

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‘Insanity: doing the same thing over and over again and expecting different results.’ A. Einstein

Perhaps one should applaud the recent initiative by the UK Academy of Medical Royal Colleges (AOMRC), in their attempts to tackle the obesity epidemic. This is a very esteemed group indeed of the great and good. In their own words:

The Academy Obesity Steering Group has been established to carry out a project on tackling obesity on behalf of the medical Royal Colleges and Faculties.

Its main responsibilities are to:

  • Produce a strategy on the most effective and coherent way to tackle obesity
  • Produce a recommendation report to form part of a wider Obesity campaign by the last quarter of 2012.

They are looking for evidence from those with expertise in the area of obesity. They are asking various question, including:

  1. What do you believe are actions and/or strategy that actually work in preventing or reducing obesity?
  2. What is the evidence either from practical experience or relevant literature you have that these actions are effective?

My first response would be that anyone with ‘expertise’ in the area of obesity should be instantly dismissed from all discussions. Never have there been more ‘experts’ in weight loss and obesity than there are now. Never have more books been written on the subject. Never have there been more ‘celebrities’ getting in on the act. (Including Jamie Oliver who proudly claims never to have read a book.)

Never have there been more obese people than there are now.

Conclusion: none of the experts have the faintest idea what they are talking about, and whatever it is they have been doing has made the problem far worse. Ergo, get rid of them all.

Of course, this will not happen. All the experts know that that what people must do, to prevent obesity, is the following: Eat less, exercise, more and eat less fat – and junk food. This has been a pretty constant message over the last twenty years or so. We should all be very familiar with it by now; it gets repeated over and over, whilst people get fatter and fatter.

Rather than suggest the possibility that this message is utterly useless, and clearly not working, the Royal Colleges are doing what people usually do when their favoured strategy is not working. They redouble their efforts and do exactly the same thing, with extra added vigour.

I know they this is exactly what they are going to do, because I looked back to see what the main message of the Royal Colleges was likely to be in this area. Lo and behold, and to no great surprise, they have already been demanding the following:

The academy, an umbrella organisation for the medical royal colleges and their 200,000 members, demands:

  • A ban on firms such as McDonald’s and Coca-Cola from sponsoring major sports events such as the Olympics.
  • A safe area around schools where fast-food outlets are not allowed.
  • A prohibition on the use of celebrities or cartoon figures to sell unhealthy food and drink to children.
  • A legal obligation on all food and drink manufacturers to publish on their products clear guidelines about the amount of calories, sugar, fat and salt.
  • Consideration of “fat taxes” similar to those being implemented in Scandinavia, designed to penalise the buyers of food and drink high in salt, sugar and fat.

Stephenson said the academy was speaking out as it launched an investigation into what can be done to curb the rise in obesity. It will spend six months researching the causes and effects of obesity, and in the autumn will produce a report that will contain far-reaching recommendations for action.  http://www.guardian.co.uk/society/2012/apr/14/obesity-crisis-doctors-fastfood-deals-ban

As expected, although the Royal Colleges appear to be asking for advice and information, they have already pretty much stated exactly what it is they are going to propose. Banning, prohibiting, taxing, and introducing new laws. All the usual knee jerk responses that are employed by authoritarian figures over the years….. ‘Why won’t people just do what we damned well tell them to do? As they will not, we will make them.’ Sigh.

I have been involved in sending in a few different submissions to the AOMRC. They have all pointed out that the obesity epidemic started around the early nineteen eighties. At almost exactly the same time that that UK and US nutritional guidelines came out telling everyone that they must stop eating fat, and start eating carbohydrates. Advice which has been, mainly, followed.

Do you think it is a coincidence that the obesity epidemic took off at this time?

Prevention is better than cure – maybe

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[Part one- of many – probably]

The last few decades have seen medicine move inexorably towards the idea that its primary function is to prevent diseases from happening in the first place. Rather than trying to cure them after they have started. Which is a nice simple thought. It also seems an inarguably good thing. So presenting any case against preventative medicine can seem wilfully contrarian, and is often met with extreme anger….’do you want people to die!’

In truth, I do not want people to die – although I would have to add that we are all going to die anyway, whatever we do, so what would be your point exactly? No, what I want is for more people to understand that prevention is not a panacea. It can do more harm than good. Indeed, in certain cases, it can cause significant damage to health and general wellbeing.

It almost goes without saying that many preventative activities are a good thing. Clean water supply, surgeons washing their hands before operations, stopping smoking, taking exercise, and suchlike. But once you have got past such obviously useful activities, the benefit to harm ratio can rapidly become far less straightforward.

I spent some time recently reading a book by Peter Gotzsche called ‘Mammography Screening, Truth Lies and Controversy’. It helped to highlight many issues about cancer screening that have disturbed me for some time.

The first, and most important, is this. Many women have cancerous cells in their breasts. Around 40% of women in their forties, on autopsy, have detectable breast cancer(s). To balance this out, most men after forty, if you took out their prostate and sliced them open, would have detectable cancer cells present as well.

Although 40% of women have potentially detectable cancers, around 4% of women die of breast cancer.

This means that, the vast majority of breast cancers do not actually do anything very much. They sit there, and they sit there and…..presumably, many of them regress (shrink) back down to nothing at all. They cause no health problems, and a large proportion of women will die with, rather than of, breast cancer.

Increasingly, however, someone calls you in for mammography, and you have your scan, and they find a small suspicious lump. In an instant you turn from a happy healthy person, into someone with cancer – the deadly killer. At which point all hell breaks loose.

Now, if that cancer happened to be one that was going to grow and kill you, then all the crushing fear and despair, and biopsies, and operations, would be a small price to pay. But if that cancer was one of the 90% that was going to sit there doing nothing for the rest of your life, then you have paid an exceedingly heavy price indeed.

In addition to this downside, in many cases, the suspicious lump was not even cancerous at all. The mammography identified a possible cancer – and it wasn’t. In screening terms this is known as the false positive. In human terms it is known as, the most terrifying thing that has ever happened to me….. and you’re telling me it was a mistake!

There are those who take an absolutist position on this and say that ‘If even one life is saved, it is all worth it.’ Perhaps, but mammography exposes a women to a radiation dose that is around five hundred times that of a simple chest x-ray. Some estimates suggest that each mammography carries a one in two thousand risk of causing cancer.

If, over a lifetime of screening, you have ten mammograms, that represents  a one in two hundred chance that a procedure designed to pick up cancer, may actually cause it. Or maybe the risk is greater than is. Is the potential to cause cancer additive, or multiplicative? I can find no-one able to answer this particular question.

Then, of course, there is the risk that the mammogram is negative. You are reassured that you do not have cancer – but you do. So when you feel a lump you think. It’s OK, I’ve had a mammogram and I am clear. But you are not. You could have been treated, but you waited too long. This is known as the false negative.

I could go on into further downsides, but I hope to have made the general issue clear. Breast cancer screening sounds wonderful, it is presented as an absolute good, but it is not. There are significant. and not uncommon. harms. Yet such is the zealotry (I hesitated to use the word zealotry, but I can’t think of a better one) of those involved in breast cancer screening that no downsides at all are ever presented.

Screening is good, breast cancer screening is perfect….or not. Here is what Professor Michael Baum has to say on the matter:

‘After a systematic review of all websites on this subject, a recent paper in the British Medical Journal concluded that women are being coerced into screening by those organisations connected to the government or the screening industry. I am neither for nor against screening, but I am a passionate champion of informed choice for women. For an informed choice women should be treated as adults and provided with balanced information, not with propaganda.’ http://www.spiked-online.com/articles/0000000CA382.htm

Preventative medicine, and screening and scanning, has almost become a religion for those involved. Only the positives are ever mentioned, and those who dare criticise are subjected to ruthless attacks. As I will be for writing this.

Prevention is better than cure?

Sometimes. Maybe.

The Joy of Coronary Arteries (The body ain’t that simple)

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‘For every complex problem there is an answer that is clear, simple, and wrong.’ H.L Mencken

Of all the things that I find most frustrating about medicine, it is the power of the simple solution. Nothing, probably, does more damage than a fixed belief in a simple idea. The history of medicine is littered with examples. ‘You have a bad headache…..well then, let us relieve it by removing a large section of your skull.’

‘You have recurrent infection of the tonsils. Well, let us remove these two glands, designed to fight infection, and your problems with infection will be solved.’

‘You had a heart attack. Well, you must rest in bed and take all the strain off your heart for six weeks, at least.’ I have calculated that this action caused the premature death of more people than died in the first and second world wars, Stalin’s pogroms, and the holocaust, added together. No, this doesn’t happen anymore.

But many things still do.

One such thing is the obsession of the medical profession with attacking coronary arteries. The arteries that supply blood to the heart. In many people these arteries develop thickenings (plaques), which can gradually narrow the artery and reduce blood supply to the heart muscle.

This can lead to angina, and suchlike. People also believe this means that a sudden blood clot forming over a narrowing can completely block the blood supply and cause a myocardial infarction (heart attack). People think this, but it is not necessarily true. Arteries without narrowings can suddenly block too – and if they do, the outcomes are usually far worse. Oh yes, the counterintuitive world of human physiology.

Anyway. If you think that a narrow coronary artery is the equivalent of having a ticking time-bomb inside your chest, you will probably want to do something about it. In 1967, someone managed to do so:

 ‘In 1967, the Argentine surgeon Dr. René Favaloro, working at the Cleveland Clinic, successfully used a vein graft to bypass an obstructed coronary vessel. Like Edmund Hillary and Tenzig Norgay, the first climbers to reach the summit of Mount Everest, or Roger Bannister, the first to run a four-minute mile, Favaloro opened a terrain deemed beyond human reach. In coronary artery vascular surgery he sundered the barrier to the seemingly impossible. Within ten years 100,000 patients were subjected to coronary bypass operations in the U.S.; by 1990s the number had quadrupled.’ Essay by Bernard Lown.

I suppose everyone has heard of the Coronary Artery Bypass Graft (CABG), pronounced cabbage by most doctors. What a wonderful idea, you use a bit of vein (sometimes a bit of artery, if you can find one) to bypass the narrowing. Huzzah!

You would think that someone would have tried to find out if it did any good, or not. But no-one really wanted to know. This operation bypassed a narrow coronary artery, increasing blood supply to the heart. This is such a simple and straightforward idea that to question it was to question common sense itself.

Which is why we ended up with four hundred thousand people being operated on each year in the USA alone. Yet no-one had ever done a study to find out if it did any good.

The someone who did try mighty hard was Bernard Lown. He is a Nobel laureate, and he also invented the defibrillator. So he was not some unqualified nut case. However, he had become very worried about ever increasing number of interventions:

‘Dealing with the growing tide of interventions, most of which I regarded as unwarranted, was morally challenging. To remain silent was complicit. To speak out was to invite confrontation with a powerful and unforgiving establishment. One pressing question was, how could we identify the subset of coronary patients that did well without surgical treatment? To determine how to proceed entangled me in a welter of contradictory views and emotions. One thing was certain, something needed to be done.’

And so he set out to try and find out if CABGs did any good. This was very tricky as he found that the moment he did an angiogram (an x-ray test for looking at coronary arteries), anyone who had a narrowing wanted a CABG straight away. At first, could not recruit a single person into his ‘control’ arm.

Eventually, though, he did manage to study this area and he found that….

‘…we recruited 144 consecutive patients with advanced coronary artery disease. These were followed for an average period of nearly five years, during which time 11 patients died, for an annual rate of 1.4 percent. We referred only 9 patients for CABG (1.3 percent annually). These results were better than the best outcomes being reported for those undergoing CABG.’

These results were better than the best outcomes being reported for those undergoing CABG. Of course, the net effect of this was that the entire world applauded. Er, no

‘Our sense of achievement was short-lived. Leading medical journals refused to publish these findings.’

Of course, as is the way of such things, the world moved on. Instead of CABG, we now have angioplasty. This is a procedure where you open up the artery from the inside using a small balloon, or inserting a wire mesh (stent).

Angioplasty is now taking over from CABG as the intervention du jour and, guess what, it is less effective than CABG – which makes it less effective than doing something that is less effective than doing nothing. Which means that every day it grows in popularity.

Ah yes, the tyranny of the simple solution continues.

I am indebted to Paul Rosch for sending me the essay from Bernard Lown on this issue.

Does treating high blood pressure do any good?

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Although I am most interested in the medical madness surrounding cholesterol lowering and statins, I have long been interested in the parallel ‘Looking Glass’ world of blood pressure lowering. During a recent on-line discussion, someone recently sent me a link to study from two or three years ago which re-ignited my interest in this area.

‘A new review has found that lowering blood pressure below the “standard” target of 140/90 mm Hg is not beneficial in terms of reducing mortality or morbidity1.’ July 2009

It confirmed, or re-confirmed, what I have long believed to be true. Unless the blood pressure is very high, lowering it seems to be an exercise in ‘sweeping a symptom under the carpet,’ rather than doing anything remotely useful. However, before discussing the management of raised blood pressure in more detail, I need to establish a little context.

The average blood pressure of an adult is around 120/70mmHg. The 120 ‘systolic’ figure represents the highest pressure reached. This happens just after the heart has finished contracting. The 70 ‘diastolic’ figure represents the lowest pressure, occurring just before the heart contracts again (there is no time for it to drop all the way down to zero).

There is no doubt that, if the pressure is very high, say 200/120, that this is associated with a greatly increased risk of stroke, heart failure and other form of cardiovascular disease. No-one disagrees with this, not even me.

There is also no argument that lowering an extremely high blood pressure can be lifesaving. But, or perhaps there are many different buts here. Things are far less straightforward when it comes to a moderately raised blood pressure.

The first question to ask is. What exactly are we ‘treating’ when we lower it? A raised blood pressure is not a disease. It is not even symptom of a disease; because a raised blood pressure does not cause any symptoms unless it is extremely high. A raised blood pressure is simply a sign, or a measurement.

What is it a sign of? It is a sign that your heart is pumping so hard that the blood pressure is raised above the ‘normal’ level. Why would the heart pump too hard? It is statement of the obvious to say that it cannot just happen for no reason at all.

In some cases, an underlying cause can be found. If you have a narrow renal (kidney) artery, for example, this reduces blood supply to the kidney. The kidney therefore believes that the blood pressure must be too low, and it releases hormones designed to raise the blood pressure. Cause and effect.

In a case like this, you can do an operation to widen the renal artery, the blood flow to the kidney increases, and the blood pressure normalises. In around five per cent of cases of high blood pressure a cause, such a renal artery stenosis, can be found. In the other ninety five per cent there is no obvious reason.

At which point, something very strange happens. Instead of calling this ‘a raised blood pressure where no cause can be found,’ the medical profession decided to turn a clinical sign into a disease. This disease is Essential Hypertension, which literally means ‘a raised blood pressure where no cause can be found.’ But you have to admit that essential hypertension sounds rather more impressive.

Once it became a de-facto disease, it can be ‘treated.’ And so it came to pass that, over time, a whole series of drugs were developed. Some reduce the blood volume, some relax the blood vessels, some block the production of hormones designed to raise blood pressure, and others prevent the heart pumping too hard.

They come by names such as thiazide diuretics, beta-blockers, alpha-blockers, angiotensin converting enzyme inhibitors, angiotensinogen II inhibitors etc. etc. After statins, these are the most prescribed type of medications. Around the world, hundreds of millions of people take them each and every day.

This mass pharmacological assault happened before anyone had actually established that lowering blood pressure was actually beneficial. There had been a couple of short term studies on people with very high blood pressure. These did show benefit.

However, when it came to moderately raised blood pressure, there were absolutely no studies at all. Yes, you did read that right. No studies. It was not until the 1970s that anyone actually set out to answer this rather fundamental question by setting up a major study. The UK Medical Research Council (MRC) study.

Recruitment started in 1973. Seven hundred thousand people were contacted, and half a million people accepted an invitation to participate.  As is the way with such things, this enormous initial number was whittled down to just under eighteen thousand people who had a diastolic blood pressure between 90 – 109, and a systolic pressure below 200.

The eagerly awaited results were released in 1985. I remember the year well, as I was at a cardiovascular conference at the time. Everyone was convinced that that there would be major benefits.

And what were the results? Well, if you get down to the most important outcome of all, which is overall mortality, there were 248 deaths in the treated group and 253in the placebo group2. Or to put this another way: 248 out of 9000 died in the treatment arm died, and 253 out of 9000 died in the placebo arm:

Overall mortality: 248/9000 = 2.75% (treatment group)

Overall mortality: 253/9000 = 2.81% (placebo)

The total difference in deaths was seven. The absolute percentage difference in deaths was 0.06% over five years. There was no difference in the death rate from heart disease.

I remember thinking at the time. ‘Blimey that should throw the cat amongst the pigeons. We are going to have to re-think this area.’ How wrong could one man be? Because the result of the MRC study was that absolutely nothing changed. There was no re-think, no fundamental review, nothing.

‘Men occasionally stumble over the truth, but most of them pick themselves up and hurry off as if nothing ever happened.’ Sir Winston Churchill.

Actually, it is not entirely true to say that nothing happened. Within the world of anti-hypertensive therapy a subtle, but critically important, change did take place. Whilst there was no benefit on heart disease, or life expectancy, there was a small, but statistically significant, effect on stroke. One stroke delayed for around nine hundred years of treatment.

At this point, the research community started to combine stroke and heart disease under the heading ‘cardiovascular disease’. It was then reported that blood pressure treatment reduced total deaths from cardiovascular disease. Which is true. The fact that there was no impact on Coronary Heart Disease and/or overall mortality was gradually pushed into the background

Nowadays, when people report on blood pressure lowering, the discussion is almost entirely focussed on cardiovascular mortality (which basically means stroke).

In a parallel move, researchers started to move away from outcome data e.g. death from stroke and heart disease, and began to use a mathematical model (the log-linear model) to define the success of lowering blood pressure3.

Once you decide that the lower you get the blood pressure the better this is, you no longer need measure death from heart disease and stroke and suchlike. You just measure the blood pressure reduction, feed these data into the log-linear model, then you can establish the clinical benefit you must have had.

There is just one slight problem. This model doesn’t actually work in practice. Twenty years ago Ancel Keys – the man who created the diet-heart hypothesis – concluded that the linear model was useless. Twelve years ago, a group of medical statisticians re-analysed the original data which underpinned the log-linear model and they concluded the following:

‘Shockingly, we have found that the Framingham data in no way supported the current paradigm to which they gave birth. In fact…. The paradigm MUST be false4.’

They went on to make the following statement:

‘No randomised trial has ever demonstrated any reduction of risk either overall, or cardiovascular death by reducing systolic blood pressure to below 140mmHg.’

The effect of their analysis was, as you may expect, a deafening silence. This was despite the fact that these researchers had just proved that everything that everybody believed about lowering blood pressure was wrong. The log linear model rules, lowering blood pressure is beneficial.

Nine years later, another analysis appeared. The one mentioned at the start of this article. It exactly the same thing…. again:

‘A new review has found that lowering blood pressure below the “standard” target of 140/90 mm Hg is not beneficial in terms of reducing mortality or morbidity1.’ July 2009

During that twelve year period between these two studies, the thresholds for ‘treating’ blood pressure became lower and lower. For diabetics, essential hypertension has now fallen to a systolic of 115mmHg. This definition was created from combined end-point cardiovascular data, and the log-linear model. The one that has been proved ‘shockingly’ to be false. I wasn’t that shocked.

In fact, only one thing shocks me. It is fact that you cannot get anyone to change their minds in this area. A raised blood pressure is bad, and must be lowered, full stop. Whilst I would agree that a raised blood pressure is ‘bad’ in that it is associated with and increased risk of premature death. I cannot find evidence that lowering the blood pressure does any good, no matter what the level.

The simple fact is that when blood pressure is raised, it is raised for a reason. The reason is an underlying ‘disease’. And just because you cannot find it, does not mean that it doesn’t’ exist.

Lowering the blood pressure will certainly get rid of an annoyingly high measurement, but it cannot (unless by complete coincidence), have any impact on the underlying disease…… the thing causing you to die. So, unless it is startlingly high, what good can lowering blood pressure actually do?

The answer my friend, is not blowin in the wind. The answer is ‘no good at all.’

1: http://www.medscape.com/viewarticle/705670?src=mp&spon=2&uac=97302DZ

2: MRC trial of treatment of mild hypertension: principal results. Medical Research Council Working Party: BMJ 1985;291(6488):97

3: Stamler J. Blood pressure and high blood pressure, aspects of risk. Hypertension 1991; 18(Suppl I): I–95 – I – 107

4: Port S, Garfinkel A, Boyle N:  There is a non-linear relationship between mortality and blood pressure. EHJ (2000) 21 p 1635-1638

Do Low Cholesterol Levels Cause Cancer?

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We live in a world where a high cholesterol is now considered to be virtually the most terrible and dangerous thing known to man. Everything possible must be done to bring the level down, or else you are going to die of a stroke or heart attack.

The anti-cholesterol propaganda has been so successful that six million people in the UK now take statins each and every day to reduce their risk of heart disease. Something which, I strongly believe, future generations will look back on in amazement. ‘Did they not know that cholesterol is essential for human health….what on earth did they think they were doing?’

Can it really be true that a chemical compound, so important that the liver synthesises at least five times as much as you consume in food, can be disastrous to our health. All cell membranes need it, our brains need it, almost all of our hormones are made out of it, and it is used to make vitamin D in our skin. It has always seemed to me that having too little cholesterol is just as likely to be damaging as having too much – probably more so.

One area I have particular concerns about is cancer. For many years it has been noticed that people with low cholesterol levels are more likely to die of cancer. This has been a consistent finding, for many years, from studies done all around the world1-9.

The statin ‘zealots,’ as I shall call them, are well aware of the association between low cholesterol and cancer, and they have gone out of their way to dismiss the possibility that low cholesterol may cause cancer.

The primary argument they have used is known as reverse causality. This ‘reverse-causality’ hypothesis suggests that depressed LDL-cholesterol levels are the result of subclinical cancer (not the other way round). This idea has been put forward with absolutely no evidence to support it. Despite this, it has been accepted without question.

It is true that if you have advanced cancer, your cholesterol levels fall. This happens for a number of interconnected reasons, including the fact that large tumours use a lot of cholesterol to divide and grow.

However, the idea that a cancer so small, that it cannot not yet be detected, is using up so much cholesterol that it lowers the total cholesterol level throughout the body, is stretching the boundaries of possibility. I would say breaking the bounds of possibility.

The second argument put forward, which is not really an argument, is the ‘how can a low cholesterol level cause cancer anyway.’ It should always be remembered that a great deal of medical research consists of bumping into effects, without understanding how it could happen in the first place – see under penicillin. See more recently under aspirin protecting against cancer. A finding as yet, without any clearly defined mechanism of action.

In short, just because you can’t easily see a mechanism of action, does not mean that it doesn’t exist.  In fact, several possible ways that cholesterol, or to be more accurate lipoproteins, could protect against cancer have been researched in some detail10.

Anyway, as I have always known must happen, the ‘reverse causality’ hypothesis has finally been laid to rest.  A recent analysis of the longest running heart disease research project in the world (the Framingham Study) has shown that low cholesterol levels predate cancer diagnosis by many, many, years. And, to quote:

“Based on these data, it would suggest that lower cholesterol predated the development of cancer by quite a long time. Now, that doesn’t necessarily speak to [low cholesterol] causing the cancer; it could have been related to something else altogether, but it’s not supportive of the hypothesis that cancer caused the low levels of LDL cholesterol. We don’t know why it predates cancer, but it would be premature to attribute it to the cancer itself.” 11

In short, it must now be accepted that cancer doesn’t cause low cholesterol levels. Which leaves the possibility that low cholesterol levels might cause cancer. This, inevitably, leads to the next question. If low levels of cholesterol precede cancer, can statins cause cancer?

The evidence is not conclusive, and I would not claim that it was. But there have been some significant warning signs from statin studies. Just to mention three. In the CARE trial12, twelve women in the statin group had breast cancer at follow up, compared on only one in the placebo group. In the PROSPER study13 there were forty six more cases of cancer in the statin group than the placebo group.

Possibly the most worrying figures come from a Japanese study which looked at nearly fifty thousand people taking statins over six years. They found that the number of cancer deaths was more than three times higher in patients whose total cholesterol was less than 4.0mmol/l at follow-up, compared with those whose cholesterol was normal or high:

‘The patients with an exceptionally low TC (total cholesterol) concentration, the so-called ‘hyper-responders’ to simvastatin, had a higher relative risk of death from malignancy than in the other patient groups.’

The authors then went on to warn:

‘Malignancy was the most prevalent cause of death. The health of patients should be monitored closely when there is a remarkable decrease in TC (cholesterol) and LDL-C (Low Density Lipoprotein ‘bad cholesterol’) concentrations with low-dose statin.’14
This is not proof of causation, but these are warning signs. Armed with the Framingham data, I believe that the medical profession has to face up to the painful reality that low cholesterol levels could be a cause of cancer, and this needs to be properly researched. We must remember that it took Richard Peto more than thirty years to prove that smoking caused lung cancer, and no statin trial has lasted longer than six.

1. Williams RR, Sorlie PD, Feinleib M, McNamara PM, Kannel WB, Dawber TR. Cancer incidence by levels of cholesterol. JAMA 1981; 245:247–52.

2. Salmond CE, Beaglehole R, Prior IA. Are low cholesterol lvalues associated with excess mortality? BMJ 1985;290:422–4.

3. Schatzkin A, Hoover RN, Taylor PR, Ziegler RG, Carter CL,Larson DB, et al. Serum cholesterol and cancer inthe NHANES I epidemiologic followup study. NationalHealth and Nutrition Examination Survey. Lancet 1987;2:298–301.

4. To¨rnberg SA, Holm LE, Carstensen JM, Eklund GA. Cancer

incidence and cancer mortality in relation to serum cholesterol. J Natl Cancer Inst 1989; 81:1917–21.

5. Isles CG, Hole DJ, Gillis CR, Hawthorne VM, Lever AF.Plasma cholesterol, coronary heart disease, and cancer inthe Renfrew and Paisley survey. BMJ 1989; 298:920–4.

6. Kreger BE, Anderson KM, Schatzkin A, Splansky GL. Serum cholesterol level, body mass index, and the risk of coloncancer. The Framingham Study. Cancer 1992; 70:1038–43.

7. Schuit AJ, Van Dijk CE, Dekker JM, Schouten EG, Kok FJ.Inverse association between serum total cholesterol andcancer mortality in Dutch civil servants. Am J Epidemiol1993; 137:966–76.

8. Chang AK, Barrett-Connor E, Edelstein S. Low plasma cholesterol predicts an increased risk of lung cancer in elderlywomen. Prev Med 1995; 24:557–62.

9. Steenland K, Nowlin S, Palu S. Cancer incidencein the National Health and Nutrition Survey I. Follow-updata: diabetes, cholesterol, pulse and physical activity.Cancer Epidemiol Biomarkers Prev 1995; 4:807–11

10: http://qjmed.oxfordjournals.org/content/early/2011/12/08/qjmed.hcr243.full.pdf?keytype=ref&ijkey=kZGZxqVjYWEOtoc

11: http://www.theheart.org/article/1375049.do?utm_campaign=newsletter&utm_medium=email&utm_source=20120325_ACC_dimanche_2

12: Sacks FM, Pfeffer MA, Moye LA, Rouleau JL, Rutherford JD,Cole TG, et al. Effect of pravastatin on cardiovascular eventsin women after myocardial infarction: the cholesterol and recurrent events (CARE) trial. N Engl J Med 1996;335:1001–9

13: Shepherd J, Blauw GJ, Murphy MB, Bollen EL, Buckley BM,Cobbe SM, et al. Pravastatin in elderly individuals at risk ofvascular disease (PROSPER): a randomised controlled trial.Lancet 2002; 360:1623–30.

14: . Matsuzaki M, Kita T, Mabuchi H, Matsuzawa Y, Nakaya N,Oikawa S, et al. Japan Lipid Intervention Trial. Large scalecohort study of the relationship between serum cholesterol lconcentration and coronary events with low-dose simvastatin therapy in Japanese patients with hypercholesterolemia. Circ J 2002; 66:1087–95.

 

Association does not mean causation

6 Replies

Of all the things you should bear in mind when looking at health stories, this is probably the single most important. Association does not mean causation. The reason why this is so important is that studies that have only found associations make up the vast bulk of scare stories in the media:

Here is a typical recent headline, which you may have seen:

Eating red meat regularly ‘dramatically increases the risk of death from heart disease’

It is true that this newspaper headline does not actually state that eating red meat causes heart disease. Not quite, but very nearly, and you could be forgiven for thinking that it does. Read it again, and you will not see the word cause anywhere. It is just very implied very strongly

However, as you get into the article itself, any distinction between association and causation fades almost to nothing:

‘Senior author Professor Frank Hu, from Harvard School of Public Health in Boston, US, said: ‘This study provides clear evidence that regular consumption of red meat, especially processed meat, contributes substantially to premature death.

‘On the other hand, choosing more healthful sources of protein in place of red meat can confer significant health benefits by reducing chronic disease morbidity (illness) and mortality.’

The study found that cutting red meat out of the diet led to significant benefits. Replacing one serving of red meat with an equivalent serving of fish reduced mortality risk by 7 per cent.’

At this point we are heading into the territory of Bill Clinton in his impeachment trial where the meaning of words it being stretched to their very limit. ‘But what is, is?’

I defy anyone to read those paragraphs and not conclude the following:

1: These researchers proved that eating red meat causes premature death

2: The researchers further proved that cutting out red meat and replacing with fish reduced mortality risk by 7 per cent.

I don’t think you could be blamed for thinking these two things. Because that appears to be exactly what was said. Or was it? Were you just being fooled by a complex conjuring trick made up of carefully chosen words designed to bewilder.

Here are the actual conclusions of the paper:

‘Red meat consumption is associated with an increased risk of total, CVD, and cancer mortality.’

Note the word associated. Where is the word cause? It isn’t there, because this study could never, ever, prove causality. Why not? Because it was an observational study (actually it was a review of two other observational studies).

In an observational study you do not do anything active. You just study that things that people do, or eat, and see if any associations emerge. When you find an association the next question you have to ask is the following. Are you looking at yellow fingers, or smoking.

It is certainly true that yellow fingers are associated with a higher rate of heart disease Does it follow that yellow fingers cause heart disease? No, of course not, what it means is that people with yellow fingers are usually people who smoke. And smoking vastly increases the risk of dying of heart disease.

In this case the distinction between the cause and the association is blatantly obvious – or at it has become so after fifty years of research made it clear Indeed, if I were now to try and claim that having yellow fingers causes heart disease, you would look at me as though I were an idiot – and I would be.

Yet, when a study finds that eating red meat is associated with a higher risk of heart disease, we seem to rush headlong into the conclusion that eating red meat consumption almost certainly causes heart disease. But red meat could well just be the equivalent of yellow fingers.

You think not? In that case you are probably thinking that red meat contains saturated fat, and saturated fat raises cholesterol levels, and raised cholesterol levels cause heart disease. If you played this little causal chain in your mind, you would most certainly not be alone in doing so.

It is something that our brains seem hard-wired to do…

‘….our brains and nervous systems constitute a belief-generating machine, an engine that produces beliefs without any particular respect for what is real or true and what is not. This belief engine selects information from the environment, shapes it, combines it with information from memory, and produces beliefs that are generally consistent with beliefs already held. This system is as capable of generating fallacious beliefs as it is of generating beliefs that are in line with truth.’ http://www.csicop.org/SI/show/belief_engine/

We cannot seem to help ourselves from linking things together to create causal chains, or beliefs, that certain things cause other things to happen. This is emotional, it is exceedingly powerful, and deconstructing such beliefs is the work of Hercules.

In this particular case, though, you would be hard pressed to use this belief as an explanation. How do I know this? I know that because the Harvard team found that those who at the most red meat actually had the lowest cholesterol levels. This table (figures taken from the paper itself) divides people into five groups/quintiles. Those in quintile 1 ate the least red meat, those in quintile 5 the most.

Total Red Meat Intake Quintile, Servings per Day

 

Quintile

 

1

2

3

4

5

% with high

cholesterol

14.8

11.1

9.7

9.0

7.9

Pan A; Sun Qi;, ScD;  Bernstein A; et al: ‘Red Meat Consumption and Mortality:Results From 2 Prospective Cohort Studies.’ Arch Intern. Med.Published online March 12, 2012.doi:10.1001/archinternmed.2011.228

The authors chose not to make any comment at all on this finding. Although you might have thought it worth a quick mention. Had they found rising cholesterol levels with increased meat consumption you can be absolutely certain they would have presented this as a clear cut causal chain. So how did eating read meat cause an increase in the rate of heart disease? Because it just did….through some mechanism unknown to medical science? The evil power of redness.

What is far more relevant is that they also found that those who ate the most red meat also smoked the most, exercised the least, ate far more calories in total, and were more likely to have diabetes. But it was the red meat that killed them from heart disease….you think? Even if red med included pork, and unprocessed red meat included hamburgers.

This study demonstrated, as if any further demonstration were required, that a whole bunch of unhealthy lifestyle factors: smoking, taking no exercise, drinking, eating fast food are all linked together. But I think we knew this already.

To preventative medicine and beyond!

7 Replies

Preventative medicine has gone completely mad and it is only going to get worse. One of the most depressing articles I have read recently (and there was plenty of competition for this particular accolade) was in the Journal of Palliative medicine. It was entitled:

‘Statins in the last six months of life: A recognizable, life-limiting condition does not decrease their use.’

Statins, as you probably know, are used to reduce the risk of dying of heart disease, strokes and suchlike. Now, I am not exactly a fan of these drugs, to put it (very) mildly. But I thought that even the most fanatical ‘statinator’ might feel that if a patient is dying of terminal cancer, then there is little point in continuing with a drug designed to reduce the risk of heart disease.

Wrong. It seems that patients with terminal cancer are prescribed statins up until they draw their final breath on this Earth. What exactly are their doctors trying to prevent here? Well, at least they didn’t die of a heart attack first? Thank God for that.

I have had personal experience with this particular madness. I was visiting a lady of one hundred and one years old in a nursing home. The nursing staff asked me if I could change her statin from a tablet to a liquid form, as she was no longer able to swallow tablets. This lady was so severely demented that she could not speak, was unable to remotely recognise any of her relatives, and was lying immobile in her bed – doubly incontinent.

I felt that, in the circumstances, it was probably best just to stop the statin, especially as they are one hundred times more expensive in liquid than tablet form. So it all seemed like an expensive action in futility. For this action I was severely criticised by the nursing home, and another doctor involved in her care. I believe I was, at one point, accused of being ‘ageist.’ Well, I didn’t really know how to respond. I wondered where we drew the line with preventative medicine, and it appears we no longer draw the line, anywhere.

We carry on forever. We give drugs to the terminally ill, the extremely old and severely demented. Once started we never, ever, stop, no matter what, until the patient is dead. Perhaps at that point I should scatter statins on their ashes, just to make absolutely and completely certain that I am not missing a trick. After all, I would hate be thought of as ‘deadist’.