Are Public Health Experts Wrong About Cholesterol, Too?

DrRich | May 30th, 2011 - 7:24 am

Podcast:

Q: What’s the difference between a public health expert and an ax murderer?

A: Actually, there are two differences. The public health expert usually means well. And the public health expert has only metaphorical blood on his hands.

In a prior post DrRich related how public health experts, displaying every ounce of the overblown self-confidence traditionally enjoyed by the expert class operating within our Progressive institutions, have wreaked all manner of harm upon our society with their premature promotion of Low-Fat Diets, an action which, DrRich argued, is at least partly responsible for triggering our current epidemic of obesity (and therefore, according to some respected experts, global warming).

As if causing the rotundity of the American populace (and again, with less certainty, the impending destruction of our planet) was not enough, it is now beginning to appear as if another major public health initiative, an initiative with which we have all been pummeled mercilessly for over two decades, also may be based upon a faulty premise.

DrRich speaks, of course, of the long crusade which the experts have preached, and which we among the faithful have doggedly waged, against cholesterol. While nobody is talking about it, it is beginning to appear (to DrRich, at least) as if the fundamental hypothesis underlying our long war on cholesterol is far less solid than we have been assured.

DrRich is moved to describe his uneasiness with the cholesterol hypothesis at this time because, last week, yet another nail was driven into its coffin.

The Cholesterol Hypothesis

Our war on cholesterol is based on the cholesterol hypothesis, which states that an elevated cholesterol blood level is a major cause of atherosclerosis, and therefore of heart attacks, strokes and peripheral artery disease. The hypothesis goes on to describe two major species of blood cholesterol – LDL cholesterol, or “bad” cholesterol, which increases cardiovascular risk; and HDL cholesterol, or “good” cholesterol, which reduces cardiovascular risk.

According to the cholesterol hypothesis, the LDL cholesterol molecules deliver excess cholesterol to the lining of the arteries, where it gradually accumulates, leading to the buildup of the plaques that obstruct blood flow. HDL cholesterol represents cholesterol that has been removed from those plaques (so the higher the HDL level, the more cholesterol is being removed)

Therefore, it behooves every American to work assiduously to reduce our LDL cholesterol levels and increase our HDL cholesterol levels.

This, of course, has become more than merely a suggestion or recommendation. Under our new incipient universal healthcare paradigm, in which your suboptimal health habits directly affect the healthcare services which will be available to me, your failure to control your cholesterol and your subsequent utilization of precious healthcare resources amounts to attempted murder, and is therefore a grave crime against humanity.

The cholesterol hypothesis is based upon two observations gleaned from clinical research. First, that high LDL cholesterol levels are significantly associated with the risk of heart attack, &c. (and that high HDL cholesterol levels are associated with reduced risk); and second, that lowering LDL cholesterol levels (or increasing HDL cholesterol levels) with drug therapy lowers that risk.

It was this second observation that “clinched” the cholesterol hypothesis for the public health experts (and most doctors).  And this second observation is based virtually entirely on the statin drugs. Until the statin drugs were first developed – drugs that powerfully and reliably reduce cholesterol levels – it had never been convincingly demonstrated that lowering cholesterol levels actually did any good.

And so, according to the cholesterol hypothesis, every American is obligated to work to maintain “healthy” cholesterol levels. In general, we are urged to begin with diet and exercise, and if that does not work (and depending on the level of our cardiovascular risk) we are likely expected to begin on drug therapy.

But DrRich suggests (reluctantly, since by doing so he undoubtedly invites even more personal attacks against his intellect, honesty, personal appearance, parentage, &c.), that the cholesterol hypothesis may not be correct.

Evidence Against the Cholesterol Hypothesis

1) Despite several clinical trials showing that the kinds of lifestyle modifications which are officially  recommended for the reduction of cholesterol can in fact reduce LDL cholesterol levels, it has not been shown that such lifestyle-induced cholesterol reductions lead to improved clinical outcomes.

2) Early (pre-statin) cholesterol-lowering trials (using clofibrate, cholestyramine, and gemfibrozil) were unable to demonstrate that an improvement in cardiovascular mortality accompanies a reduction in cholesterol levels, and indeed, each of these studies showed an unexpected increase in non-cardiovascular mortality with the cholesterol-lowering drugs.

3) More recently, studies showed that adding the powerful non-statin cholesterol-lowering drug ezetimibe  to a statin drug not only failed to improve outcomes, but also (unexpectedly) may have led to more plaque growth than was seen with the statin alone. (Ezetimibe is marketed as Vytorin in those god-awful commercials comparing your Aunt Helen to a strawberry cheesecake.)

4) Just last week, the NIH prematurely halted a high-profile study (the AIM-HIGH trial) comparing statin to statin + niacin in patients with cardiovascular disease and low HDL levels. (This study was designed to show that increasing HDL levels with niacin would improve outcomes.)  The study was stopped 18 months ahead of schedule not only because it was determined to be extremely unlikely that the increase in HDL produced by niacin would improve outcomes, but also because of an unexpected increase in strokes among the patients receiving niacin.

5) Numerous trials using statin drugs have demonstrated that these drugs can reduce cardiovascular events and improve cardiovascular mortality – without an increase in non-cardiovascular mortality – in patients who have known heart disease or who are at increased risk for heart disease. However, the mechanism by which statins provide these benefits may have little or nothing to do with their cholesterol-lowering effects. (Statins have several mechanisms of action under which they can improve cardiovascular outcomes, including stabilizing plaques, improving endothelial function, reducing intravascular blood clotting, and reducing inflammation. Each of these mechanisms can directly and immediately reduce the risk of heart attack and stroke – more directly and immediately, one must concede, than by merely reducing cholesterol levels.) So, for instance, when statins are administered during acute coronary syndromes, their benefits are seen immediately – an effect not explained by the cholesterol hypothesis.  Further, the JUPITER trial showed convincingly that statins can improve outcomes even in patients with “normal” cholesterol levels, which is also not explained by the cholesterol hypothesis.

In summary, lowering cholesterol by any method other than statins has not been shown to significantly improve outcomes.  And evidence indicates that the chief benefit of statins may be imparted by the drugs’ non-cholesterol-lowering mechanisms.

These observations suggest an alternate hypothesis.

The Bear Shit Hypothesis

If you are walking in the woods and you see bear droppings, your chances of being eaten by a bear are much higher than if there were no bear droppings. But if you take out your (legally registered) firearm and shoot the bear droppings, you have not improved your risk at all.

DrRich maintains that the totality of the data regarding cholesterol, as it exists today, is entirely consistent with the bear droppings hypothesis.  That is, elevated cholesterol levels may (and certainly do) indicate a higher risk of cardiovascular disease, but may not themselves be a causative factor.

Indeed, the bear shit hypothesis can explain the facts as we know them much better than the traditional cholesterol hypothesis. The bear droppings hypothesis can explain why treating cholesterol with any of several methods (aside from statins) fails to improve risk.  (While cholesterol is associated with atherosclerosis, it may not be a critical cause of atherosclerosis.)  Since discharging one’s firearm at bear droppings might awaken a sleeping bear, the bear droppings theory is also consistent with the fact that reducing cholesterol with virtually any drug save one of the statins may actually worsen outcomes (by creating sundry “unexpected” medical problems of one variety or another).

That is, unless you are using statins (which have several important therapeutic effects unrelated to reducing cholesterol, and which in high risk patients far outweigh – statistically speaking – any side effects these drugs have), treating cholesterol levels with drugs may turn out to be a bad idea.

The Bear Shit Hypothesis, being merely an hypothesis, may not be correct, either. But it seems to fit the existing clinical evidence at least as well as – and DrRich suggests, better than – the cholesterol hypothesis. And at least DrRich admits his hypothesis may not hold up at the end of the day, and does not insist that all his fellow citizens drop what they are doing and rearrange their entire lives to comport with its implications.

Where Does This Leave Public Health Experts?

For over 20 years, the cholesterol hypothesis has been presented to the public, with all the evangelical fervor employed by the global warming experts, as settled science.  There is clearly some muttering going on these days amongst the experts – in their private conclaves – about certain “anomalies” that have appeared in the clinical database over the past decade or so, anomalies which have muddied the nice, clear cholesterol hypothesis they have so forcefully promulgated for so many years. They are desperately trying to explain away these anomalies by subdividing LDL and HDL cholesterol into more and more complex “subspecies” that have “counter-intuitive” behaviors. (This latter effort has the benefit of being so mind-numbingly complex that nobody can follow it – which means that it is difficult to assert with any authority that it’s all folderal.)

In the meantime, because statins are effective at reducing cardiovascular mortality and morbidity, and because statins also (quite possibly as an unrelated side-effect) reduce cholesterol levels, the experts can continue to trumpet their cholesterol hypothesis to an unsuspecting public, with the caveat that statins ought to be the drug therapy which one should try first. They have not yet reached the point where they are willing to say that if statins are not tolerated, one should probably not attempt to reduce cholesterol levels with any of the non-statin drugs (i.e., with drugs that merely reduce cholesterol).

And so, for the second time we see that a massive public health campaign that has been whipped up by the expert class is likely to turn out to be a wrong-headed “experiment,” one which so far has been conducted on the entire population for more than two decades.  This time (and in distinction to the low-fat diet “experiment”) it appears that little widespread harm has been done. But this result is fortuitous, and is most likely related to the fact that statin drugs turn out to help prevent the rupture of atherosclerotic plaques by means apparently unrelated to their cholesterol-lowering abilities.

What will the experts do if the cholesterol hypothesis finally is proved to be mistaken? It is easy to predict. They will stick tenaciously to their cholesterol hypothesis until the last possible minute, then if and when they at last find it to be utterly unsupportable, they will simply move on to the next hypothesis as if the old one never existed.

For one thing we know with certainty about the expert class is that they are never chastened. Their low-fat diet dogma simply and smoothly elides into a Mediterranean diet mantra (a diet, as it happens, with plenty of fats). Their demands that “safe” trans fats be substituted for saturated fats in processed foods simply transforms, 10 years later,  into indignant demands that the trans fats be removed when it is discovered they are worse than saturated fats. The phrase “global warming” is simply dropped in favor of “climate change” when it is discovered that the planet actually has been cooling since the 1990s.  In no case is there an acknowledgement that their prior expert pronouncements have been both arbitrary and wrong, and much less is there ever an apology. Being experts, and thus by definition correct, they never, ever have anything to apologize for. They simply abandon the old dogma as needed, and seamlessly adopt the new one.

For when you’re an expert within our multiplicity of institutions for public improvement, history will always have begun 10 minutes ago.

13 Responses to “Are Public Health Experts Wrong About Cholesterol, Too?”

  1. Chris FOM says:

    We have always been at war with Eastasia.

    Over the course of my residency I’ve been getting increasingly skeptical about the cholesterol hypothesis myself. Is LDL a risk factor or a risk marker? The scary thing is, soon such possible errors will have the force of the government behind them, since such dogmas will be incorporated into the Guidelines, which must be followed without deviation or recourse. It’s fine to be wrong, many discoveries are based on making a hypothesis that appears correct and eventually findings that the mistakes still lead you closer to the truth, but when those mistakes or held to be dogma and enforced with the full weight of the powers that be, the possibility of being forced to actively hurt people becomes frighteningly real.

  2. Jan Krouwer says:

    “If you are walking in the woods and you see bear droppings, your chances of being eaten by a bear are much higher than if there were no bear droppings. But if you take out your (legally registered) firearm and shoot the bear droppings, you have not improved your risk at all.”

    But bears may run away when they hear gunfire, so risk may nevertheless be improved.

  3. [...] publicized reversals and much public confusion, Dr. Rich of the Covert Rationing Blog wonders if public health experts might not be wrong about cholesterol, too. “For over 20 years, the cholesterol hypothesis has been presented to the public, with all [...]

  4. sb says:

    Cholesterol plays a role in predicting heart attacks and statins play a pretty consistent role in preventing them. Non-statin cholesterol medications have been disappointing.

    If the public health apparatus has lead to greater use of statins for high-risk patients then it was likely very helpful, though very inefficient.

  5. Mark Spohr says:

    Thank you very much for this enlightening discussion. I think this does a good job of summarizing the current state of evidence in this field.
    My only objection is to your attitude. I do understand that it can be frustrating when dealing with scientific evidence and expert interpretation. However, you seem to make it very hard on these people who are doing their best to interpret the evidence and give public health recommendations. Yes it is true that the evidence changes as more studies are done and that the advice changes in response. It may not change as quickly as necessary but there is danger in changing advice frequently in response to every study.
    The danger of your cynicism is that people will ignore all advice and label it “folderol”, thus throwing out the baby with the bath water.

    • DrRich says:

      Mark,

      Thanks for your comment. You object to my attitude, and say, “You seem to make it very hard on these people who are doing their best to interpret the evidence and give public health recommendations.”

      I hope so. Public health experts, once they leave the arena of advising people to put the outhouses below the water supply and drain the swamps, have all too often demanded sweeping but inappropriate changes for the entire population, based on insufficient evidence. This is especially true when they advise us about what to eat and not eat. They did it with their low-fat diet recommendations, and in demanding that trans-fats be substituted for saturated fats – and now they’re doing it with salt restriction (which by no means has been proven to be helpful when applied across the whole population – and there’s already evidence it may be harmful).

      So, yes, I think the people should and must question the policy initiatives that are instituted by “experts,” especially now that panels of experts are going to be determining who gets what, when and how, for all of healthcare. And if I can do my bit to urge people in that direction, and in so doing give pause to some of the all-knowing experts, I will consider my mission to have been successful. I am gratified by your statement that I may actually be having such an effect.

      Rich

  6. [...] publicized reversals and much public confusion, Dr. Rich of the Covert Rationing Blog wonders if public health experts might not be wrong about cholesterol, too. “For over 20 years, the cholesterol hypothesis has been presented to the public, with all [...]

  7. [...] highly publicized reversals and muchpublic confusion, Dr. Rich of the Covert Rationing Blog wondersif public health experts might not be wrong about cholesterol, too. “Forover 20 years, the cholesterol hypothesis has been presented to the public,with all the [...]

  8. Pavlov says:

    Current cholesterol guidelines are flawed beyond belief !

    It is indeed obvious, as you point out with your usual eloquence, that statins have pleiotropic effects thats surely cannont be measured by mere variation of LDL. Jupiter proves this beyond any reasonable doubt. (I don’t buy the hs-CRP measurement hype either.)

    In Canada, statin therapy is goal-driven to arbitrarly fixed thresholds, which are not supported by any evidence whatsoever, and never make sense to anyone outside of the medical zombies that most of us have become.

    For instance, a medium-risk patient (Framingham 10 to 20%) will not be treated if his LDL is under 3.5. That same individual has to be lowered to an LDL less than 2.0 if he has the bad luck of being at 3.6 to begin with. Sorry, but I don’t see how this can make any sense.

    And what to say of the lithany of reviews (I don’t know if you have this same proselytism in the States) urging doctors to give the lowest dose possible, because the maximum effect on LDL occurs at these doses. I see high risk diabetes patients on Lipitor 10 every day + Ezetrol, with “perfect” LDL levels indeed … but will they reap any vascular benefits ? Their doctors don’t seem to even ask themselves the question. And I am not even speaking of immediate post-MI patients on Zocor 20.

    Pavlov

  9. Plas says:

    From your blog, it looks like you can combine 2 different set of statistics, and come up with the following conclusions:

    “CO2 emissions have increased in the last hundred years”

    “Global warming, er, climate change, has been occurring during the last hundred years”

    “The rate of heart disease has been increasing during the last hundred years”

    “CO2 emissions therefore can cause heart attacks”

    “Statins decrease the risk of heart attacks”

    “Therefore”, by some convoluted logic, “increased use of statins will reduce climate change by modifying the CO2 levels”

    As an amateur climate guy, I’m always amused at some of the logic used to “prove” mankind induced AGW.

    Ain’t statistics fun? Kind of reminds me of a headline in a local paper a few years ago “Murder Rate Doubles in XYZ County”. Scary stuff, huh, until you read the article. Last year there was one murder – this year there were two, 10 months apart. Statistically accurate, but absolutely meaningless.

    Keep up the great blogs.

  10. Plas says:

    Actually, it proves that theorom. As I have lost 60 pounds in my quest for forgiveness, the world has had no noticeable warming (actually some cooling) recently.

    http://icecap.us/

    I KNEW it was all my fault as the climte warmed for years while I gained that weight, now I’ve PROVED it by losing it.

  11. winifred says:

    So what would you recommend instead? If your cholesterol is elevated at a young age (23) and you’re wary of (ie too cheap for) going on regular medication, what are the valid options?

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