In my practice and through other work that I do I encounter a steady stream of men who are ‘concerned’ about their cholesterol. These men have turned up a ‘raised’ cholesterol on routine screening, Their doctor may have suggested that they swap cholesterol-reducing margarine for butter and cut back on cheese, eggs and red meat. However, if that doesn’t work (like it hardly ever does), the next step is to ‘go on a statin’.
I really have lost count of the number of men for whom ‘raised’ cholesterol is the only supposed abnormality in their blood markers of health as well as other measurements such as weight and blood pressure. Many of these men live what would generally be regarded as healthy lives: non-smoking with a decent diet and some physical activity thrown in for good measure. So, how can it be that so many people have so much evidence of good health throughout the body, yet quite consistently fail in this one measure (cholesterol)? What occurs to me when I see men like this is just how the ‘raised’ cholesterol sticks out like a sore thumb.
Well, one reason has to do with concept of what is termed ‘normal’? Usually, what is normal is determined by so-called ‘normal ranges’. Basically, the normal range is the range of levels of, say, sodium or thyroid hormones, seen in a ‘healthy’ population of people. The middle of the normal range normally corresponds to the average level of a substance in a population.
However, for cholesterol, normal ranges are not set in this way. The upper level of cholesterol is not represented by the upper end of the normal range in a population, but decided by panels of people who ‘weigh up the evidence’ and then set an arbitrary ‘upper limit’ of cholesterol over which, we are told, risk of heart disease is raised and efforts should be made to lower cholesterol.
Average cholesterol levels in the UK in men are about 5.5 mmol/l (213 mg/dl). The ‘recommended’ level of cholesterol is 5.0 mmol/l or lower (193 mg/dl). So, by definition, more than half of men are going to find themselves being diagnosed with a ‘raised’ cholesterol and at ‘increased risk of heart disease’, however healthy they are.
Even if one believes the conventional wisdom around ‘raised cholesterol causing heart disease’ (I don’t), then the real issue men like the ones I describe above are faced with is how much they stand to gain for taking advice to modify their cholesterol. It’s generally assumed that putting downward pressure on cholesterol is inherently good, but what does the evidence show?
Based on the best available evidence we know that taking dietary steps to reduce cholesterol by cutting back on saturated fat will not reduce the risk of heart disease, heart attack or overall risk of death, and there’s simply no evidence at all that eating cholesterol-reducing margarine benefits health. Turning our attention to pharmacological approaches we know that taking a statin (or any other drug, for that matter) will not extend the man’s life by a single day. And what of other benefits? Well, 50-100 men would need to be treated with a statin for 5 years to prevent one heart attack (in other words, only 1-2 per cent of men will benefit from treatment in terms of heart attack prevention). But let’s balance this with the facts that of these 50-100 men, one or more men will develop type 2 diabetes as a result of the statin treatment and about 20 per cent or even more of men will develop adverse symptoms such as muscle weakness, fatigue and memory loss. Others may go on to suffer from adverse effects such as liver or kidney damage.
Once we go through the numbers in this way, then most men come to the conclusion that their cholesterol level isn’t really ‘raised’ at all, and that doing something about their ‘raised’ cholesterol is very unlikely to benefit their health, and quite likely to harm it. Most determine that they can get on with their healthy lives as theY were before with no need to swallow drugs or highly-processed, chemicalised cholesterol-lowering ‘health’ foods like margarine.
Sometimes when talking to someone about their cholesterol, I ask them to ask me what my cholesterol is. Then I answer: “I have no idea, because I never have it checked.” That’s not because I take an ostrich-like stance on matters that relate to my health – it’s because the great likelihood is that knowing my cholesterol numbers would not lead to me having a different view on my health or have any bearing on how I live my life. End of.