Are we soon to see a relaxing in cholesterol guidelines?

What is deemed a desirable cholesterol level in the mind of many health professionals has a lot to do with the opinion of panels of ‘experts’ who, essentially, tell doctors what to think and how to manage their patients. One such endeavour in the US is known as the Adult Treatment Protocol (ATP), which itself is part of the National Heart, Lung and Blood Institute. The ATP has seen three versions, the last of which (ATP III) was published in 2002 and updated in 2004. The message from ATP III was loud and clear – individuals should strive to lower their cholesterol levels to reduce their risk of cardiovascular disease.

ATP IV is due later this year. According to this report in the journal Nature, there may be relaxing of the rules on cholesterol management. The piece draws attention to some key deficiencies in current cholesterol policy.

Firstly, the idea that ‘lower is better’ has not been formally tested. It’s actually based on assumptions. And these assumptions come from studies that were never able to determine whether getting cholesterol levels down to a certain level is better for patients than other levels. In fact, it’s been previously noted in the scientific literature that the idea of treating people according to predetermined cholesterol levels is not founded in science at all [1].

The greatest assumption of all made in the current recommendations is that reducing LDL-cholesterol (supposedly ‘unhealthy’ cholesterol) levels translates into a reduction in risk of cardiovascular disease. However, just plain logic dictates that just because something reduces cholesterol levels does not mean it must be beneficial for health. Eating coal or swigging back arsenic might, for all we know, be wonderful cholesterol-reducing strategies, but it’s obvious they would unlikely bring us better health.

In the piece we learn of research which found that more aggressive drug treatment for diabetes brought worse outcomes for patients. It’s worth bearing in mind we have seem similar things with cholesterol, where drugs that ‘improve’ blood fat levels (such as torcetrapib) have been found to increase the risk of heart attacks and death. We also continue as doctors to prescribe cholesterol-modifying drugs such as ezetimibe even though no evidence to date has found it brings benefits for health, and some evidence links it with an increased risk of cancer.

The news piece quotes Yale University cardiologist Harlan Krumholz, who says: “We can’t just assume that modifying the risk factor is modifying risk,” Professor Krumholz believes that LDL-cholesterol targets should be abandoned, because they have never been test properly tested. And he’s not the only one who is skeptical. Here’s an excerpt from the article:

Jay Cohn, a cardiologist at the University of Minnesota Medical School in Minneapolis, also worries that the focus on LDL levels offers up the wrong patients for statin therapy. Most of those who have a heart attack do not have high LDL, he notes. Cohn advocates treating patients with statins based on the state of health of their arteries, as revealed by noninvasive tests such as ultrasound. “If your arteries and heart are healthy, I don’t care what your LDL or blood pressure is,” he says.

Against these opinions, though, we have the might of the pharmaceutical industry. We know from experience that this business has a history of grooming and paying ‘key opinion leaders’ to work on their behalf. No doubt, I think, there will be some such influence on the ATP panel.

However, what is heartening is that this issue is being discussed at all. Against the relentless tide of information which persuades us of the merit of cholesterol reduction, its good to see at least some doctors think for themselves and with a clear head.

References:

1. Hayward RA, et al. Narrative review: lack of evidence for recommended low-density lipoprotein treatment targets: a solvable problem. Ann Int Med 2006;145:520-530

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15 Responses to Are we soon to see a relaxing in cholesterol guidelines?

  1. Christopher Palmer 1 March 2013 at 1:02 pm #

    Cholesterol has been the ‘sterol’ of choice for creatures that have some awareness of their surroundings and that generally seem to show some ability to navigate their surroundings to good advantage and what’s more that demonstrably been the case for considerable swathe of evolutionary time. In marked contrast plants make biological use of sterols of various formulations but not the particular formulation that is cholesterol. This long established biological precedent would suggest cholesterol has a constructive part to play in animal physiology and especially so perhaps in mammals like ourselves.

    The target setting for cholesterol isn’t really a target for cholesterol at all, it is, as ostensibly discussed here, a target for a lipoprotein; low-density-lipoprotein (LDL) in particular. Lipoproteins and cholesterol are not the same thing albeit lipoproteins are the ingenious natural arrangement mostly responsible for transporting cholesterol and other things. Crucially there are other things going on in relation to lipoproteins besides carrying cholesterol. The blurring of the distinction between cholesterol and lipoproteins hasn’t simply confused the public it has muddled the mind of many a conscientious practitioner. Really there is no such thing as LDL-cholesterol and no such distinction as ‘good’ or ‘bad’ cholesterol since cholesterol can only come in one formulation and with one set of properties. But cholesterol does ride in proteins of varying size to which we attribute (realtively speaking) terms that are more arbitrary than they appear.

    The medical establishment has fallen for a pup in taking up with the cholesterol hypothesis and I know you are in little doubt of this Dr Briffa, but aggressive down-management of supposed bad cholesterol achieved via prescription of the weapon of choice, the statin drug, is fast proving the Achilles heal of the policy, for by all accounts unpleasant side-effects are not uncommon and people are getting better at matching their experience with these (mostly) unnecessary drugs.

    I feel better for having had my attention drawn to this report in Nature for at least I sense an injustice is being challenged. We have achieved a great systemic failing in having arrived at a circumstance whereby the ambition to sell a treatment for patients triumphs over concern for their well-being or for curiosity for the real causal associations that might genuinely have a bearing upon incidence and promotion of heart disease.

  2. Dan 1 March 2013 at 4:19 pm #

    This is encouraging news that people are actually looking objectively at the science. Still, I suspect the outcome will depend on the success of lobbying efforts of big pharma.

  3. Eddie Mitchell 1 March 2013 at 6:44 pm #

    Hi John, another great post, thank you.

    As a lowcarber this has made my weekend. “Most of those who have a heart attack do not have high LDL” Almost all lowcarbers see a rise in HDL the so called good cholesterol, they also see trig numbers plummet, < 1 being the norm. According to Dr. Malcolm Kendrick who has studied heart disease and cholesterol for a long time, tells us, cholesterol numbers and heart disease has no correlation. I am old enough to remember a time when a total cholesterol number of 6 was regarded as fine in the UK. A population that has high total cholesterol, the Swiss, have around one third of the heart disease as the UK.

    The solution for good health is do not base your meals on sugar and starch, eat less and move more. If you feel good, you probably are good. The average person does not have to lose sleep worrying about cholesterol. The solution is not more drugs, the answer is spinach, ok it turn’s out that crap will kill ya, but you know what I mean. (Apologies to Bill Maher)

    http://www.youtube.com/watch?v=rHXXTCc-IVg

    Kind regards Eddie

  4. Judy Barnes Baker 1 March 2013 at 7:11 pm #

    Do you think the recent study from Spain that showed that those who ate lots of fat in the form of olive oil and nuts had 30% fewer heart attacks than those on a low-fat diet will have any impact on the guidelines for statins? Statins have only been tested in combination with a low-fat, low-cholesterol diet and the inserts that come with statin prescriptions tell patients to eat a low-fat/low-cholesterol diet.

  5. Anne 1 March 2013 at 11:27 pm #

    I’m not sure there will be much change in attitudes to statins though, following the most recent Cochrane review which supported the use of statins for primary prevention of cardiovascular disease in ‘people without evidence of cardiovascular disease’. This was a complete turnaround from their previous review in 2007, with only 4 more studies added and their previous reservations (such as all the studies were drug-industry funded, over one third selectively reported and almost half didn’t report adverse outcomes) no longer seemed to be an issue. Three of the studies were stopped early (sometimes only half way through) because the results were so good – call me cynical, but I wonder if the results would have been as good if they had carried on to the bitter end. With this sort of data coming out, doctors have the green light to treat you with statins, regardless of cholesterol levels, or even any evidence of cardiovascular disease.

  6. William L. Wilson, M.D. 2 March 2013 at 1:13 am #

    As a practicing physician, I am well aware of the fact that drug companies often call the shots when it comes to guidelines and the standard of care. The issue of fat and cholesterol is complex. When you combine saturated fat with sugar, high glycemic carbohydrates and salt, you are likely going to clog your arteries and fry your brain. If you consume saturated fat as part of a healthy diet of whole foods, it likely won’t be much of a problem.

    I just finished the book by Michael Moss titled “Sugar, Salt, Fat—How Food Giants Hooked Us”. He does a remarkable job of showing how the fast food industry has rolled over any health concerns about the products they foist on the public. The message is fairly simple. If you want to stay healthy, stay away from processed foods.

  7. Hilda Glickman 2 March 2013 at 2:53 pm #

    The cause of heart disease has nothing to do with cholesterol. See DVD on Youtube by Sally Fallon. It is caused by processed vegetable oils. The heart disease rate increased dramatically after these oils were introduced. Rapeseed oil is in every processed food.It is not a food at all but almost plastic. Few people really understand fats, least of all GPs (not Dr Briffa of course).. Cholesterol is needed in so many functions of the body. Breast milk is high in sat fat See the Cholesterol Myth by S Sinatra , cardiologist.

  8. Hilda Glickman 2 March 2013 at 2:58 pm #

    PS

    Also see Sally FAllon on how Ancel Keyes manipulated his data to make it seem that countries with high fat diets had higher rates of heart disease. He left out all the countries that did not fit his ideas! In fact there was no correlation at all. However this theory has caused all the modern ideas of sat fat being the cause of heart disease.
    I also agree with the MD above who said that sat fat plus sugar is not a good idea!.
    Hilda Glickman nutritionist

  9. William L. Wilson, M.D. 2 March 2013 at 7:27 pm #

    Hilda:

    I totally agree with you. Barry Sears lives near me in Boston and he has been saying this for decades. Omega 6 fatty acids are toxic, yet they are the most common fat in our modern diet. And let’s not forget about sugar. My friend Robert Lustig just published a landmark population study showing that sugar intake is directly associated with the development of type II diabetes and of course diabetes is a gateway to heart disease:

    http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0057873

    The solution is simple. Eat a Paleo style diet that eliminates these toxic elements.

  10. tony kerstein 2 March 2013 at 7:34 pm #

    What is needed is a class action lawsuit against big pharma by people who have been adversly affected by the side effects of statins, If nothing else it will bring the whole issue into the public domain and force the medical and scientific establishment and the general public to take a good hard look at the cholesterol mythology.

  11. Chris 3 March 2013 at 10:01 am #

    William, as a practising physician you have no doubt studied a great deal and gained immense experience from years of practice, but practice surely presents you with a great many issues about which you must know something, and surely makes great demands of your time. These are things to be respected.

    When pickings are rich and food is readily available I gain weight. The same is true and evident in the animal kingdom. There is evidently some evolutionary advantage for creatures (many mammals certainly) to be able to sequester energy reserves as an insurance against harder times. It tends to be the creatures that suffer seasonal variations in the availability of their chosen type or source of food that do this and the characteristic is not uncommon amongst herbivores. Fats are a diverse group running to several hundred (perhaps thousands) in number that exhibit a range of properties and opportunities in nature. When I gain weight my body lays down reserves of saturated fats and mono-unsaturated fats in the main. Other mammals do much the same. Fats make for a good way to sequester energy because of the density of energy for their weight. If nature dictated creatures sequestered energy as protein or carb then to store the same energy would take roughly double the amount of additional mass.

    When pickings are lean the mammals that sequester energy reserves as fats (mostly in the categories of saturated and mono-saturated fats) begin to utilise these fats as fuel. We don’t sequester fat reserves as polyunsaturated fats because polyunsaturated fats don’t ‘burn’ well, or ‘cleanly’; they do not make for good fuel but they do make for good communication molecules and several of them go on to become the foundations for hormones and eicosanoids. This arrangement of laying down fats and then drawing down upon them has been in place for some considerable wadge of evolutionary time, so long that it seems reasonable to think the arrangement is a virtuous one and not ‘vicious’. In other words, for the fats that are found the tissues of otherwise healthy mammals to be toxic, in the main, to mammals is counter-intuitive.

    The ubiquitous involvement of relationships of cause and effect generally infer effects will be witnessed in some proximity to their causes. For outcomes to favour certain times and places then it is reasonable to consider that their causes will also favour those times and places. Plus, if you have a virtuous arrangement as decreed by nature and evolution and then interfere with with by introducing something novel in its place you greatly increase the prospects of a maladaptive response. In the physiology of mammals an indication of a maladaptive arrangement can be indicated by something that doesn’t receive the airtime it deserves,’inflammation’.

    For these reasons, and for having read two books that read in conjunction amount to far more than the sum of their separate parts I’d say that many a health condition that troubles us today arises as a result of maladaptive arrangements and inflammation. I’d include heart disease in this category. And because the lipid hypothesis (or cholesterol hypothesis) incorporated a series of errors into the supposed ‘science’ that was then compounded by an outright deception or ‘lie’ then I have no reason to subscribe to the dogma that saturated fat or cholesterol has any causal involvement in the advance of heart disease. I am also aware that many a delusion can still be profitable.

    I respect your view, appreciate your C-A-R-B syndrome project, concur with a probable causal association involving sugar and fast cabs, but disagree on a technicality.

    When you combine saturated fat with sugar, high glycemic carbohydrates and salt, you are likely going to clog your arteries and fry your brain.

    Insulin has a bearing upon eicosanoid production. Levels of insulin circulating in our body can act like a ‘switch’ when certain polyunsaturated fats are converted into messenger molecules. High insulin can result in a shift in balance to more pro-inflammatory eicosanoids. Plus a surfeit of polyunsaturates in the diet likely invokes greater prospects of lipid oxidation and stress, or oxidative stress. Attributing causal involvement to saturated fat is likely assisting the free passage of a lie, I feel.

    There are synergies to be found between to books of entirely different approach. ‘Trick & Treat’ (Barry Groves) and ‘Earthing’ (Ober Sinatra & Zucker). If you take up with them you might consider my direction imperfect but not groundless. Barry was a long time researching his book; ten years in fact, but he probably tell you he was at for ten years at least before he actually embarked upon the enterprise. ‘Earthing’ does greatly endorse his directions I feel.

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