Review takes issue with cholesterol guidelines

Generally speaking, doctors have almost unbridled enthusiasm for cholesterol-reducing drugs including statins. We doctors have generally been educated to believe that cholesterol at essentially normal levels causes heart disease, and bringing levels down is of paramount importance to health. Here in the UK, doctors are even remunerated by the Government to get their patients’ cholesterol levels below a specified cut-off. With Government endorsement, surely cholesterol reduction must be a good idea?

Well, it seems not everyone agrees.

Recently, I came across a Japanese review that takes exception to cholesterol guidelines (similar to those in the UK and US) on a number of grounds. [1] The paper itself is in Japanese, but we can learn a lot, I think, from the English translation of the abstract (summary).

The authors of the review, from the Faculty of Public Health at the University of Toyama in Japan, make reference to the fact that the Japan Atherosclerosis Society recommended that low-density lipoprotein (LDL) levels be kept below 3.6 mmol/L (140 mg/dl) in 2007. This corresponds to a total cholesterol value of around 5.7 mmol/L (220 mg/dl). The authors’ main criticisms of these guidelines appear to be:

1. That the Japan Atherosclerosis Society has not provided relevance evidence regarding the relationship between LDL levels and risk of heart attacks and death due to heart disease.

2. That the recommended cholesterol level is inappropriate seeing as lowest overall risk of death (known as ‘all-cause mortality’) in Japan corresponds with a cholesterol level of 6.2 – 6.7 mmol/L (240 – 260 mg/dl).

3. That there are big differences in heart disease rates between men and women, though these were not properly considered.

4. That conflicts of interest of the individuals who issued the guidelines has never been disclosed.

These all seem like valid issues to me. Of particular importance, I think, is the attempt here for attention to be drawn to the relationship between cholesterol and all-cause mortality. The fact is, while raised cholesterol levels can be associated with an enhanced risk of heart disease in some populations, low levels of cholesterol are associated with an increased risk of death from other conditions (notably cancer). It makes sense, then, that if cholesterol guidelines are going to be issued to the country as a whole, that these recommendations should reflect overall risk of death (not just risk of heart disease).

The issue of potential conflicts of interest is pertinent too, as past events suggest that guideline-setting might have something to do with politics and money. Back in 2004, there was a significant lowering of what are regarded as acceptable levels of cholesterol, as recommended by a group known as the National Cholesterol Education Program (NCEP) expert panel in the USA. No conflicts of interest were declared at the time. However, after this it emerged that 8 out of 9 members of the panel had financial links with drugs companies making statin drugs. You can read the (belated) disclosure here. The report’s publisher described the omission of these clear conflicts of interest as an ‘oversight’. I’ll say.

Subsequently, an independent review of the guidelines, published in the Annals of Internal Medicine stated: “In this review, we found no high-quality clinical evidence to support current treatment goals for [LDL] cholesterol”. They also went on to say that the recommended practice of adjusting statin dose to achieve recommended cholesterol levels was “not scientifically proven to be beneficial or safe” [2].

Personally, I think it’s a good thing that some researchers exhibit free-thinking and independence of mind. With more researchers like these, we may end up one day having cholesterol guidelines based purely on the evidence (not vested interest).


1. Inadera H, Hamazaki T.[Cholesterol controversy: cutoff point of low-density lipoprotein cholesterol level in Guidelines by Japan Atherosclerosis Society]. Nippon Eiseigaku Zasshi. 2010;65(4):506-15.

2. 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

7 Responses to Review takes issue with cholesterol guidelines

  1. FlatGreg 16 March 2011 at 9:43 pm #

    Thanks for the article. For years I’ve been skeptical of the need for medication that my mother takes to keep her cholesterol at 180. I’ve passed this info on to her.

  2. Millie 18 March 2011 at 1:25 pm #

    Another aspect of the Disease Mongering surrounding promotion of statins, is they were not tested on women prior to licensing!
    Statins cause muscle problems and depression in some people. This should be known by GPs but due to lack of pharmacology in medical training since 1993, few know how medicines side effects present.

    May I please paste your article on the APRIL charity web site ?

  3. Feona 18 March 2011 at 6:18 pm #

    I agree absolutely with your scepticism regarding cholesterol levels and the need for statins. Just one of these little pills (Lipitor)was enough to make me feel very ill indeed. I also had a friend who died of liver cancer and it was admitted that part of the problem was his very low cholesterol – an overall level of less than 3.0!
    I’m convinced that the obsession with statins is purely profit driven.

  4. Mrs M Given 19 March 2011 at 12:21 am #

    When will the medical profession wake up to the fact that cholesterol is the first building block of the immune system and every steriod hormone in the body. Together with the fact that it interferes with normal functioning of the pancreas and liver well documented on Pubmed.?
    We will see a huge spike in auto immune disease as a result of the overzealous prescribing of statins in totally inappropriate patients ie most of them. Its basic biochemistry which the medical profession continues to ignore. It not cost saving but cost increasing ie another drug for Big Pharma to supply to offset the damage statins have caused.

  5. kate 19 March 2011 at 7:29 am #

    The fact that the Japanese have lower rates of heart disease than U.S. populations and, I’m guessing, U.K. populations, does temper their stance toward LDL somewhat. It would be good to see current studies relating cholesterol and LDL levels to heart disease in the U.S. and the U.K.

    This is a little bit like the current mania for omega-3s, with all the benefits to heart health coming from fish and fish oil. Try to tell that to the Japanese, who already have omega-3s in their diet. But what about those Japanese who DO die from heart disease? Why, give them more fish! Consider the culture, consider the population.

  6. audrey wickham 19 March 2011 at 8:50 am #

    Something like thirty years ago I heard on the radio that reducing cholesterol quickly was likely to contribute to cancer. Is nothing new?


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