Tag Archives: heart disease

How to kill a hypothesis

“Why do people insist on defending their ideas and opinions with such ferocity, as if defending honour itself? What could be easier to change than an idea?” J.G. Farrell.

When the orbit of Neptune was found to be irregular, and not to follow classical Newtonian physics, it was suggested that, perhaps, the laws of physics may break down in deep space. Others, rather more pragmatically, suggested that there was another planet out there, interfering with the orbit of Neptune. It was just too far out, and dim, to be seen.

That planet, no longer called a planet, was Pluto. Once observed, it accounted for the distortions in the orbit of Neptune.

When the orbit of Mercury was found to be irregular, and not to follow classical Newtonian physics, it was suggested that there was another invisible planet orbiting closer to the sun. This planet was named Vulcan.

Of course there was no planet Vulcan. The reason why classical Newtonian physics did not accurately predict the orbit of Mercury is because the mass of the sun bent time and space. Classical Newtonian physics had to be replaced by Einstein’s theory of relativity.

What does this tell us?

It tells us that it is very difficult to know if an apparently contradictory observation actually refutes a scientific theory. It also tells us that you can use ad-hoc hypotheses (there is another planet out there) to support a cherished central hypothesis, and that this is a valid scientific technique.

But at what point do you have to admit defeat? How many contradictory observations can you dismiss before you must accept that the game is up, and that your hypothesis is wrong?

I think about this a lot. Mainly with regard to the cholesterol hypothesis, or the diet-heart hypothesis, or whatever term is now current. I have seen evidence that directly refutes this hypothesis again and again and again and….indeed…again.

If anyone wishes to debate this issue with me, I can produce far more evidence contradicting it, than supporting it. Yet still it stands, untouched. In fact I would suggest more people believe in this hypothesis than at any time in human history. Billions of people also take statins to lower their cholesterol levels. As you can imagine, this is more than a little frustrating.

How can you convince people that this hypothesis is wrong? I have tried in many, many, different ways. As have other members of THINCS (The International Network of Cholesterol Skeptics).

Yes, I have helped to convince many thousands of people that cholesterol has nothing to do with heart disease, or cardiovascular disease, or atherosclerosis, or unstable atherosclerotic plaques…

Indeed, stepping sideways for a moment, one of the major difficulties in this area is that the terminology shifts and swirls in front of you, making it impossible even to pin down what you are talking about.

At one time the experts were quite happy to tell us that a raised cholesterol level caused heart disease. Now we have ‘good’ cholesterol and ‘bad’ cholesterol, and ‘light and fluffy’ bad cholesterol and ‘small and dense’ bad cholesterol (which really should be called ‘evil’ cholesterol, I suppose). We have the ratio of good to bad cholesterol, apob-100 levels, particle numbers, sub-fractions of good cholesterol, dyslipidaemia, LDL particle size, or number,  or…..the list goes on and on.

How can you argue against a scientific hypothesis when the damned thing will not stay still from day to day?

That, however, is a bit of a side-issue, although I have come to realise that this constant creation of new types of cholesterol, and sub-fractions, and ratios, is all part of the game that is played to protect the cholesterol hypothesis from refutation. How can you refute a hypothesis that can change into any shape it likes? Answer, you can’t.

Anyway, in my efforts to work out how to change ideas in the wider population I have spent a great deal of time looking at the history of scientific thought. I wanted to gain any insights I could into how people managed to kill off hypotheses in the past.

As part of my education I have tried not to get too depressed by fellow thinkers on the subject. Such as Max Plank, who said:

‘A scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die and a new generation grows up that is familiar with it.’

In short, his view is that you should forget trying to convince people. They will never, ever, change their minds. Max Plank, by the way, was the man who published Einstein’s special theory of relativity (against great opposition).

Another of my scientific heroes is Wilfred Trotter. A man you are unlikely to have come across. Unfortunately, however, he was not much help either:

‘The mind likes a strange idea as little as the body likes a strange protein and resists it with similar energy. It would not perhaps be too fanciful to say that a new idea is the most quickly acting antigen known to science. If we watch ourselves honestly we shall often find that we have begun to argue against a new idea even before it has been completely stated.’

I could fill hundreds of pages with quotes saying the same type of thing. Essentially, people love the ideas they have grown up with, and become deeply emotionally attached to them. Changing them is painful; they dislike and fear new ideas and, will bring forth all the powers of their intellect to do so.

Things are made all the more difficult when you try to convince people who have spent large amounts of their professional life studying a specific area. When someone has become an ‘expert’ in something, and their reputation, and position of authority, is inextricably linked to a certain hypothesis, you are not just attacking an idea, you are attacking them. As noted by Leo Tolstoy:

‘I know that most men, including those at ease with problems of the greatest complexity, can seldom accept even the simplest and most obvious truth, if it be such as would oblige them to admit the falsity of conclusions which they have delighted in explaining to colleagues, which they have proudly taught to others, and which they have woven, thread by thread, into the fabric of their lives.’ Leo Tolstoy

Despite all of this being rather depressing, it has all helped me to establish one clear rule. Do not bother trying to convince people who are ‘experts’ in heart disease that the cholesterol hypothesis is wrong. It is a complete waste of time and energy. The only people who can be convinced are inquisitive people who do not have too much invested in this particular hypothesis.

I have also worked out another rule. Facts are almost completely ineffective at convincing people of anything. Recently, I was reading an article on Daniel Kahneman, Nobel prize winner in economics. He was discussing the irrationality of the financial system. He made many interesting points. For example:

The way scientists try to convince people is hopeless because they present evidence, figures, tables, arguments, and so on. But that’s not how to convince people. People aren’t convinced by arguments, they don’t believe conclusions because they believe in the arguments that they read in favour of them. They’re convinced because they read or hear the conclusions from people they trust. You trust someone and you believe what they say. That’s how ideas are communicated. The arguments come later.’

Once again, if this is true, what can be done? How to change ideas…..

I leave you at this point with a small section of dialogue from the film Inception:

Dom Cobb: ‘What is the most resilient parasite? A bacteria? A virus? An intestinal worm?’

Arthur: ‘Uh, what Mr. Cobb is trying to…’

Dom Cobb: ‘An idea. Resilient, highly contagious. Once an idea has taken hold of the brain it’s almost impossible to eradicate. An idea that is fully formed, fully understood. That sticks, right in there somewhere.’

[he points to his head]

The cholesterol hypothesis is one of the most resilient parasites of all. How to kill it off? All suggestions welcome.

Sweden gets it right

I sometimes think that I should go and live in a Scandinavian country. They get so many things right about how to run healthy, equitable, societies. In addition, the people who live there seem more balanced and, well, frankly, more grown up. So it comes as no surprise to me that if a nation was to turn round and begin the process of rejecting the absolute nonsense that a high fat diet is bad for you, then it would be a country in Scandinavia.

That Scandinavian country is Sweden1.

Now, I have been aware that there has been a movement towards a high fat low carb diet (HFLC) going on in Sweden for some years. This has been led recently by the heroic Dr Annika Dahlqvist, a General Practitioner who had been advising her diabetic patients to eat a low carb high fat diet (LCHF).

She was, of course, attacked by the idiots…sorry experts:

‘In 2007, the controversy began when two dieticians pointed out to Sweden’s National Board of Health and Welfare that LCHF dietary advice recommended to diabetic patients by general practitioner Dr Annika Dahlqvist was not compatible with either scientific evidence or conventional practice. However, following a report by diabetologist Dr Christian Berne, Dahlqvist was cleared.’

Cleared of what, exactly? Advising diabetic patients not to eat sugar. The mere fact that anyone could be dragged in front of the authorities for advising this just shows had completely mad the world of dietary advice has become. How entrenched the idiotic anti-fat dogma now is. How utterly divorced from reality and science.

As I have pointed out many times on this blog, and elsewhere, carbohydrates, at least all the carbohydrates humans can digest, are converted to sugar(s) in the GI system. They must be, because all that carbohydrates consist of are different number of sugar molecules bonded together in different ways. When you break them to bits in the digestive system, they become simple sugars.

As we all know, people with diabetes have problems with high blood sugar levels. So, dum de dum….let me think. Should diabetics eat carbohydrates/sugar, or should they eat fats. Yes, you are right, they should eat fats. This is a complete no brainer.

But, of course, the argument goes that diabetics are more likely to die of cardiovascular disease and eating fat increases cholesterol levels, and this increases your risk of cardiovascular disease. Well, this could obviously be a problem if any part of that causal chain were true. But it is all nonsense. As the latest Swedish report from the SBU (Swedish Council on Health Technology Assessment) makes clear (after reviewing 13,000 studies), a low carb diet leads to the terrible dangers of

‘…a greater increase in HDL cholesterol (“the good cholesterol”) without having any adverse effects on LDL cholesterol (“the bad cholesterol”). This applies to both the moderate low-carbohydrate intake of less than 40 percent of the total energy intake, as well as to the stricter low-carbohydrate diet, where carbohydrate intake is less than 20 percent of the total energy intake. In addition, the stricter low-carbohydrate diet will lead to improved glucose levels for individuals with obesity and diabetes, and to marginally decreased levels of triglycerides.’2

In short, when they looked at all the evidence, they found that low carb/high fat diets raise HDL cholesterol (the so-called ‘good’ cholesterol). They have no effect on LDL levels; they also lower blood sugar levels and triglyceride (VLDL) levels. All good and healthy, and all of which bascially means that insulin resistance has been reduced – the underlying cause of diabetes.

In reality all that the Swedes really ‘discovered’ is the quite astonishing fact that eating a high carbohydrate diet is bad for you, and worse for you if you are a diabetic. Well, blow me down with a feather. They have found exactly what a working knowledge of human biology/physiology would tell you would happen.

But we live in a wold controlled by entrenched stupidity, dogma, and the financial interests of massive companies who are making billions selling tasteless low fat mush. These companies know that the only way you can make low fat food, e.g. low fat yoghurt, taste like anything half palatable is to stuff it with sugar. Cheap, nasty, and damaging to health – also driving the ever increasing weight gain and diabetes in the Western World.

Why is everyone in the Western World becoming obese? Because we are replacing fat with sugar in many foodstuffs. The obesity ‘epidemic’ started at exactly the same time as the idiots, sorry experts, decreed that a healthy diet was a diet full of carbs. Which was, and remains, the exact and complete opposite of the truth.

However, anyone who dares to stand up and state the truth, gets dragged in from of organisations such as the National Board of health and Welfare. Eventually, however, the truth does emerge, as it must. Because the truth never dies. It can be stomped on, squashed, concreted over and napalmed. However, it lives on, taunting those who do everything in their power to deny its existence.

The truth is that all of the dietary advice we have been bombarded with for the last forty years about the dangers of fat consumption has been utterly and completely and damagingly wrong. Of course there will be a backlash against the Swedish report – there always is. Various powerful idiots, sorry experts, will be pushed in front of cameras to make various denunciations of the Swedes and their damaging and dangerous conclusions. The strings of these idiots will be jerked in unison by faceless marketers in companies that promote low fat spreads, and the like. Yes, you know who you are.

And yes, this stuff does make me angry. It is killing people prematurely, millions of people, all around the world.

1: http://coconutoil.com/sweden-becomes-first-western-nation-to-reject-low-fat-diet-dogma-in-favor-of-low-carb-high-fat-nutrition/

2: http://www.dietdoctor.com/swedish-expert-committee-low-carb-diet-effective-weight-loss

P.S:

Question:            ‘What do you call five hundred dieticians lying at the bottom of the ocean?’
Answer:               ‘A good start.’

So much for scientific debate

I thank Ted Hutchinson for pointing me at this article in the Irish Independent. It appeared on the 5th of October, and I reprint it in full, here.

A LEADING vascular surgeon, whose research review concluded cholesterol-lowering medicines may do more harm than good for many otherwise healthy people, has been gagged by the Health Service Executive.

Sherif Sultan, a senior medic at University College Hospital, Galway, reviewed a range of studies of statins and found a lack of evidence to show they should be given as a means of prevention to healthy people with high cholesterol but no heart disease.

Mr Sultan and his surgeon colleague Niamh Hynes said lifestyle changes to reduce cholesterol were better because this allowed people to avoid the risk of statins’ side effects.

However, in a statement last night, Dr Pat Nash, a cardiologist and the group clinical director in University College Hospital said the recently published views of his colleagues were “not representative” of those in Galway or neighbouring hospitals.

“As group clinical director of the West/North West Hospitals Group, and a working cardiologist, I wish to reassure patients that statins are safe,” said Dr Nash.

“These are very important, well-validated drugs for the treatment of elevated cholesterol. We have extensive evidence to show their benefit and to show that they improve outcomes for patients with heart disease and stroke and that they have a role in preventing heart disease and stroke.

“As always, if patients have any concerns, they should not discontinue their medication without discussing with their GP or consultant.”

Asked to comment, Mr Sultan said: “I have received an official warning from the HSE and have been instructed not to liaise directly with the press in my capacity as a HSE consultant.” However, he said he could continue to comment as a consultant vascular surgeon at the Galway Clinic, where he has a private practice.

The HSE declined to comment on the reasons for ordering Mr Sultan not to speak as a public consultant. He said he stood by his analysis of the role of statins in otherwise healthy patients with high cholesterol. He pointed to another recently published review on exercise versus drug therapy in the management of pre-diabetes and cardiovascular disease.

“That ‘British Medical Journal’ analysis showed the superiority of exercise over drug therapy extends even to secondary prevention (where patients have developed disease)1.

This story has been rumbling on for a while. A report on the research paper can be found in the Irish Medical Times from a couple of weeks before.

The under-reporting of findings on major adverse effects of statin therapy and the way in which they had been withheld from the public, and even concealed, is a scientific farce, claims new Irish research.

Mr Sherif Sultan, Consultant Vascular and Endovascular Surgeon, and Niamh Hynes, Clinical Lecturer In Vascular and Endovascular Surgery, claimed their study, just published in the Journal of Endocrine and Metabolic Diseases (2013, 3, 179-185) highlights the major side-effects and dangers of statins.

They said there is a categorical lack of clinical evidence to support the use of statin therapy in primary prevention. They are both based in the Western Vascular Institute at University College Hospital Galway and the Galway Clinic. “Odds are greater than 100-to-1 that if you’re taking a statin, you don’t really need it2..

I was sent the original paper by Sherif Sultan a couple of months ago, and it is very scathing about statins….. very scathing indeed. It even suggests, perish the very thought, that pharmaceutical companies may have been trying to present statins in the best light possible. I find such a suggestion almost impossible to believe. Knowing how completely ethical these companies are.

Anyway, I suppose the key phrase in all of this sorry episode is the following:

The HSE declined to comment on the reasons for ordering Mr Sultan not to speak as a public consultant.”

If the Health Service Executive were to comment, what could they say to justify their actions?

The hell with scientific debate. He should just damned will shut up and say what we want him to say?”

“How dare anyone criticise the sainted statins which work in mysterious ways their wonders to perform.”

We expect utter loyalty from those who work in the glorious Irish Health Service. Those who do not support us can expect serious sanctions……”

On balance, declining to comment is probably the best policy for the HSE. Because if you start trying to justify why you are gagging a researcher for trying to tell the truth then, well, you will end up having to justify state censorship of scientific debate. Which never looks that good on the printed page, I find.

I feel I should sign off this blog with a quote from George Orwell, taken from 1984. “Being in a minority, even in a minority of one, did not make you mad. There was truth and there was untruth, and if you clung to the truth even against the whole world, you were not mad.”

1: http://www.independent.ie/irish-news/hse-gags-surgeon-after-cholesterol-drug-claims-29636095.html

2: http://www.imt.ie/news/latest-news/2013/09/study-claims-to-highlight-the-ugly-side-of-statins.html

What does cause heart disease?

(Part one of an occasional series)

So what does cause heart disease then, if it is not cholesterol?  This is question I am often asked – with varying degrees of accusation – by other doctors. Usually after I’ve given a talk dismissing raised cholesterol as a risk factor.

The simplest answer is that the most important causal factor of cardiovascular disease aka the development of plaques (thickenings) in the arteries, is stress (sorry about that rather clumsy form of words). However, as with many simple answers, explaining how stress causes ‘heart disease’ is a bit more complicated.

Which means, gentle reader, that we must go back to the beginning of the whole story, and weave a number of interconnected strands together.

The first strand here is to explain what ‘stress’ may be. I must admit that this is not easy, because few people have an agreed definition of stress. Many concepts are bandied about, and everyone has their own ideas on the subject, but most of them are rather too vague to be of any real use.

I define stress as a measurable dysfunction in the Hypothalamic-Pituitary-Adrenal axis (HPA-axis). But that may be jumping ahead rather too fast, and it requires many steps to get to this point. The first step is to attempt to break stress down into its component parts.

To do this, we have to start by accepting that stress has two basic components. There is the Stressor – the thing causing stress, and the Stressee – the individual affected by the stressor. Without making this important distinction, we will constantly mix up two concepts that need to be kept separate.

For example, many people talk about having a stressful day. I would immediately ask. Does this mean you were impacted on by lots of different stressors e.g. a traffic jam, a tight work deadline, your children getting ill. Or that you found yourself unable to cope with stressors that you would normally be able to cope with. Or both. [To be truthful I would rarely ask this, as I don’t want people shuffling away from me at the dinner table. But I might think it].

By looking at stress as having a cause, or causes, (the stressor), and then looking at their impact upon an individual (the stressee) we can start to disentangle the things that cause stress, from their actual impact.

In addition to this important distinction, there is also a need to accept that different stressors can create positive or negative effects, depending on how the person reacts to them.  Without getting too tangled in this issue, I will attempt put these first ideas into their simplest possible form

Stress has four distinct components:

  • Stressor – positive
  • Stressor – negative
  • Stressee reaction – positive
  • Stressee reaction –negative

Positive stressors could be:

  • Exercise
  • Winning the lottery
  • Giving a well-accepted speech
  • Watching your children perform on stage

Negative stressors could be:

  • Using cocaine
  • A close relative dying
  • Severe criticism at work/being bullied
  • Getting hit by a bus
  • Watching your army comrades being blown to bits by an IED

Some negative stressors are very short acting and, as such, the human psyche and physiology can cope and restore homeostasis (unless the trauma is gigantic). The problems start to arise when negative stressors act hour after hour, day after day, week after week. For example, being repeatedly physically or sexually abused as a child. Or being bullied day after day at work.

Problems created by a constant battering of negative stressors are also made significantly worse if your coping mechanisms are poor. Being bullied at work is not so bad if you have a good social life, a supportive partner, and a loving family. It also helps significantly if you are physically, fit and free from significant chronic disease.

If, however, you have no friends, no supportive family, and you have a chronic illness that weakens you, it does not take too much else to tip your system over the edge.

Unfortunately, early life trauma, and abuse, can leave people with very poor coping mechanisms. In addition, people who have suffered repeated negative stressors through their childhood often find themselves in a cycle of repeating negative behaviour. They are also likely to have poor coping skills, and difficulty with interpersonal relationships.

Effectively, therefore, the same ‘stressor’ can have very different effects on people, depending on their resilience. This resilience can be both psychologically and physically determined, and is hugely important. A ‘strong’ person can cope with stressors that might seriously damage a ‘weak’ person.

Some people say that stress can be simplified into the flight or fight response being constantly activated and eventually ‘burning’ out. Whilst it is true that a constantly stimulated flight or fight response is key to understanding the physiological damage that ‘stress’ causes, it is not the only factor in play.

A lack of social support is not the same thing as the flight or fight response. However, it can create significant problems with production of stress hormones. Depression is not the flight of fight response going wrong. Not having human contact, or touch, can damage your hormonal and autonomic/unconscious nervous systems just as much as being bullied.

In short, stress is not just determined by external factors, such as perceived – or real – threat. A vastly important aspect of stress lies within the individual, their responses to life events, and their resilience. As social animals, loneliness is just as damaging, if not more so, than someone threatening to fire you.

In my world, therefore, being depressed is a form of ‘stress’, and it causes exactly the same type of physiological damage as, say, post-traumatic  stress disorder. This is why you cannot look at an event in someone’s life e.g.  losing their job, or getting divorced, or suffering a car crash and loss of a limb, and score this from one to ten on how stressful this is.

  • Loss of job =2
  • Moving house = 3
  • Getting divorced = 4

For some people losing a job may be a blessed relief. For other a terrible humiliating shame. Others may just shrug their shoulders and move on.

For some of us, an apparently trivial event can be devastating e.g. a passing comment on our appearance.  Others will just laugh it off. Some years ago I was told by a doctor that stress couldn’t be a cause of heart disease because he had seen a well-off lady living in rose covered cottage in the country who had just had a heart attack.

I just replied ‘How do you know she wasn’t stressed?’ The externally idyllic existence may, in reality, be a battleground. Perhaps her smiling, smart, well-off, magistrate husband got home and beat the living daylights out of her every weekend. If so, it wouldn’t be the first time – and most certainly would not be the last.

In short, there is no point in guessing if someone is stressed. Often, there is no point asking them either. Most of us play complex internal games with regard to stress. Where it is considered a badge of honour to be ‘stressed’ and working incredibly hard – people will tell you how stressed they are. – even if they are not. Equally, if you have had a terrible upbringing, you may be so desensitised to stress that you cannot even recognise that you are suffering.

At this point I should probably attempt to bring together what makes up the concept of ‘stress’

Stress consists of stressors, and the stressee. Stressors can be positive, or negative. They can be psychological, or physical.

The same stressor can have a completely different impact on the stressee depending on their resilience.

Resilience can be damaged by such factors as:

  • Abuse in childhood
  • Long-term illness
  • A lock of supportive relationships, friends, family, church

Resilience will be improved by

  • A loving upbringing
  • Good health
  • Supportive relationships
  • Good interpersonal skills

There is no point in guessing is someone is suffering the physiological consequences of stress. Equally, there is no point in asking someone if they are stressed – they may well not know. The only way to know if someone is actually suffering from the consequences of repeated negative stressors is to measure their biochemistry and physiology.

Part two: How to measure if a person is ‘stressed’.