by Malcom Kendrick M.D.
As a Scotsman of a certain age, I have always found heart disease fascinating. This is possibly because of the fact that, in my youth, Scotland had the highest rate of death from heart disease (by which I mean coronary artery disease/ atherosclerosis) in the world.
When I went to medical school I was told that the very high rate of heart disease in Scotland was caused by a diet containing far too much saturated fat. This raised our Scottish cholesterol levels. The excess cholesterol was, in turn, deposited in the artery walls, thus narrowing them to the point where they blocked up - causing angina, heart attacks and death.
The answer, therefore, to preventing heart disease was to eat less saturated fat, thus lowering cholesterol levels. Or, if you couldn't get people to eat less fat, then simply lower cholesterol level with drugs. It all seemed very simple and exceedingly straightfoward. Why look anywhere else, when the answer was clear.
For years I did not question this orthodoxy. Then, one day, I was on holiday in France. Whilst chewing on a fatty steak, dripping in butter, it suddenly struck me that the French ate rather a lot of saturated fat. As I peered through the smoke filled restaurant I also recognised that they smoked quite a bit too. However, their rate of heart disease was one tenth that of Scotland (age and sex-matched).
I then looked at the other classic ‘risk factors' for heart disease in France e.g. blood pressure, HDL ‘good cholesterol' levels, body mass index (BMI), amount of exercise taken. I found that, in comparison to the Scots, the French ate significantly more saturated fat, had the same cholesterol levels, the same blood pressure and the same HDL ‘good cholesterol' levels. They also had the same average BMI and took slightly less exercise (on average). They smoked considerably more. In short, much worse classical ‘risk factors,' one tenth the rate of heart disease.
I was not the only person to notice this. Another Scots doctor, Hugh Tunstall-Pedoe also noted that - according to their risk factors - the French ought to have significantly more heart disease than the Scots. Rather than the actual figure of ten times less. He termed this anomaly the ‘French paradox', and set out to explain it. Or, to be more accurate, he set out to explain it away. It is clear that he had no interest, whatsoever, in attacking the status quo. The world famous ‘experts' all knew what caused heart disease, and he wasn't going to rock the boat. No way. Professorships are not handed out to mavericks.
So, the soon to be Professor, Hugh Tunstall-Pedoe looked at the French, and their diet, and came to the conclusion that the French were protected against heart disease by their high consumption of garlic, red-wine and lightly cooked vegetables (full of anti-oxidants, don't you know). Very soon after this, it became a ‘fact' that these three factors were protective against heart disease.
One slight problem is that there never was, and still is not, the slightest evidence that any of these three factors provides any protection. I write this in the certain knowledge that many of you are absolutely convinced that garlic, red-wine and anti-oxidants truly are protective, and that many studies have proved it. To which I would say..... ‘show me the studies'. [Do not rely on such statements as ‘it is widely accepted that.' These statements mean nothing].
In fact, I have since discovered that the entire field of heart disease research is packed full of facts that do not (when you start looking properly) exist. Female sex hormones protect against heart disease. For many years this 'fact' was just known to be true. One slight problem. There never was any evidence to support it. Unlike most ‘facts' in heart disease, it was spectacularly disproved.
To give another example of facts that aren't true. Namely, that saturated fat intake raises cholesterol levels. The Framingham study, the longest lasting, most respected study into the causes of heart disease (started in 1948) reported that ‘In Framingham, Massachusetts, the more saturated fat one ate, the more cholesterol one ate, the more calories one ate, the lower people's serum cholesterol.' Dr William Castelli - director of the Framingham study at the time - 1992.
What was the effect of such a startling finding. Absolutely nothing at all. Complete silence. To quote Winston Churchill: 'Men occasionally stumble over the truth, but most of them pick themselves up and hurry off as if nothing had happened.' How true.
More recently, a major eight year long interventional study on fifty thousand women (the Woman's Health Intervention) found that a 25% reduction in saturated fat intake had no effect on LDL ‘bad cholesterol' levels, or heart disease rates. [One of many studies that have shown the same thing].
Commenting on this study, the director of the National Heart Lung and blood Institute stated that: ‘The results of this study do not change established recommendations. Women should work with their doctors to reduce their risks for heart disease including following a diet low in saturated fat, trans fat and cholesterol.' Never let the facts get in the way of a good recommendation, I say.
The cholesterol hypothesis is, perhaps, the greatest ever example of a medical hypothesis that has become too powerful to die. Too many vested interests are intertwined with it. World famous experts would look incredibly stupid if the hypothesis were to be accepted to be wrong. An entire industry of cholesterol lowering would fall apart. Hundreds of billions of dollars of statin sales are at stake. Worse, much worse, the medical profession would end up with a few million eggs on its face. Perish the thought. Much better that millions die, surely.
In fact, I have come to realize that there is, literally, no evidence that can dent the cholesterol hypothesis. Believe me, I have had a good go. For example, here is another quote from the Framingham study on the impact of cholesterol levels themselves. There is a direct association between falling cholesterol levels over the first 14 years of the study and mortality over the following 18 years. 11% overall and 14% CVD death rate increase per 1mg/dl per year drop in cholesterol levels
In short, once your cholesterol level starts to fall, you are much more likely to die from heart disease. A 150% increase in relative risk for every 10 % fall, approximately. Add this to another very big study of the elderly, published in the Lancet: Our data accord with previous findings of increased mortality in elderly people with low serum cholesterol levels, and show that long term persistence of low cholesterol concentration actually increases the risk of death. Thus, the earlier that patients start to have lower cholesterol concentrations the greater the risk of death.
The effect of this study on the cardiovascular research community was.....as you would expect...nothing at all. A deafening silence. Cholesterol continues to be demonised as the terror, killer substance. Statins are pushed more and more widely to lower cholesterol levels even further. When I tell people that the higher their cholesterol level they longer they will live, they look at me in a way that suggests they believe that my medication is clearly not working.
Now that I know that cholesterol has nothing to do with heart disease, and that lowering it with statins is a complete waste of time, I find myself in the position of the little boy who points out that the Emperor has no Clothes. With one rather important difference.
Even though the ‘experts' have been made aware of it many times, they care not that this particular emperor has no clothes. Or, to be more accurate, they cannot and will not allow themselves to accept that it might be true. For to accept this would be far too humiliating for the great and the good. Which, I suppose, is why people become so enraged when anyone dares to point out the truth.
It is a slight comfort to know that in fifty years (hopefully many fewer than this), people will look back at cholesterol lowering and say ‘You did WHAT?' Were you MAD? Don't you know that cholesterol is absolutely vital for human health? Didn't you realise that blocking cholesterol synthesis would directly lead to nerve cell damage, muscle destruction, liver obliteration and cancer?
‘My God, you presided over the greatest iatrogenic medical disaster ever.' I, of course, will probably be dead by then. But at least I will not have poisoned my metabolism with statins.
Malcolm Kendrick (MbChB MRCGP) M.D.
Dr. Kendrick has worked in family practice for almost twenty years.
He has specialized in heart disease and set up the on-line educational website for the European Society of Cardiology.
He is a peer-reviewer for the British Medical Journal. He is a member of the International Network of Cholesterol Skeptics (THINCS) as he does not believe that a high cholesterol level causes heart disease.