283. Obsessed with Cholesterol

I have lost count of the number of people I have met who are convinced that they should be concerned about the cholesterol level in their blood. If it is considered to be “too high” then they are at serious risk of suffering from heart disease. Hence action has to be taken that will lower it in order to reduce the chances of having a heart attack.
There are enormous resources devoted to cholesterol-lowering by health care organisations in many countries. This is all based on the “lipid hypothesis”, which is the rationale that supports the widespread use of cholesterol-lowering drugs. In recent years, the main group has been statins. These are no longer the money-spinners for the pharmaceutical industry that they have been but a new generation is in the pipeline, which it is hoped will be very profitable for the companies.
Cholesterol-lowering does not work
However as I have repeatedly emphasised, the evidence which underpins this is fundamentally flawed. Here are some of the reasons why the lipid hypothesis has absolutely no credibility:
• The original concept that cholesterol is a crucial risk factor for heart disease was based on epidemiology. Subsequently it has been shown that the quality of this research was very poor. One critic described the Seven Countries Study conducted by Dr Ancel Keys and colleagues as follows:
“The dietary assessment methodology was highly inconsistent across cohorts and thoroughly suspect. In addition, careful examination of the death rates and associations between diet and death rates reveal a massive set of inconsistencies and contradictions…….
“It is almost inconceivable that The Seven Countries Study was performed with such scientific abandon. It is dumbfounding how the National Heart, Lung, and Blood Institute/American Heart Association alliance ignored such sloppiness in their many ‘rave reviews’ of the study…
“In summary, the diet-CHD relationship reported for The Seven Countries Study cannot be taken seriously by the objective and critical scientist’’(1).
• Any benefits are largely confined to a reduction in the morbidity and/or mortality related to heart disease. Even if there is some reduction in deaths from heart disease, there is usually an increase in the incidence of deaths from other causes. In particular, there have been increases in deaths due to violence such as murders and accidents. Although these results have been discounted, there are strong indications that low cholesterol per se does have an effect on behaviour. So in terms of all-cause mortality (ACM), it turns out that the benefits are virtually non-existent.
• In the early days it was accepted that further studies were needed and several very large trials were conducted, which were expected to provide confirmation but all of them failed to deliver.
• The ultimate test is to monitor cholesterol levels, follow the participants for the remainder of their lives and determine if the predictions have been accurate. The Hunt 2 study in Norway has done this. The results showed that those who comply with the recommended cholesterol guidelines actually had the highest ACM. Furthermore with women, those with the highest cholesterol had the greatest life expectancy (2).
If not cholesterol, then what?

The focus on cholesterol has been an absolute failure and a huge waste of money to boot. Essentially it has been one big scam that has been kept alive by the pharmaceutical industry so that it provides a justification for drugs, which are extremely profitable. This then raises the issue of finding an alternative marker that provides an accurate measure of a person’s health status. The good news is that this currently exists but is not normally available to vast majority of the population. It is called Coronary Artery Calcification (CAC). This refers to the build-up of calcification in the coronary arteries and extent of it can be measured by a CT scan. Various studies have been done to assess the accuracy of predictions based on this score. In this blog I do not intend to explain the background as my prime objective is to demonstrate the effectiveness of this approach. For more detail about CAC, I strongly recommend a visit to Ivor Cummins’ (The Fat Emperor) website (3).
Assessing risk
Here in the UK, your risk of developing cardiovascular disease is determined by using a complicated system referred to as QRISK, which includes the following factors:
ethnicity, age, sex, smoking status, systolic blood pressure, ratio of total serum cholesterol:HDL-cholesterol, body mass index, family history of coronary heart disease in first degree relatives under 60 years, Townsend deprivation score, treated hypertension, type 2 diabetes, renal disease, atrial fibrillation, and rheumatoid arthritis (4). One inevitable consequence is that the risk increases as you get older.
A similar approach is used in the US, which is based on data from the Framingham investigation (5).
However the reality is that the results obtained by these methods are essentially guesswork because many assessed as “high risk” never develop the disease while many “low risk” people do actually suffer and die from the disease.
A comparison with CAC scores is very revealing (Table 1).

Table 1. How the risk of developing heart disease varies with CAC scoreFramingham



                                                      CAC Score

Although the risks for those assessed at 10% by the Framingham method are somewhat higher than those assessed as 3%, the variation within each range is large. It is very clear that those with a CAC score of zero have a very low risk of developing heart disease. However at the other end of the extreme with CAC scores >600, the risks have been increased by a factor of almost 20. This is an absolutely huge difference. When translated into life expectancy terms this means many more years for those with low CAC scores.
The CAC score is a measure of how far the disease has actually progressed. There are no assumptions about the indirect impact of factors such as body weight or cholesterol. Anyone unfortunate enough to discover that their CAC is high should certainly be worried. The good news is that there are specific steps that can be taken, which will successfully reduce the CAC score and improve health.
The big issue is that in the UK and many other countries, it is not easy to have the CAC measured and there is certainly not widespread acceptance by the medical establishment. So anyone who wishes to obtain the value will have make the arrangements and will be required to pay. Unfortunately shedloads of money are committed to cholesterol-lowering and all that goes with it. Effectively much of this is being wasted and does not really provide the patient with information that would be helpful. It is a hard fact of life that the driving force is the pharmaceutical industry, which uses the focus on cholesterol to justify the prescription of statins and the next generation of cholesterol-lowering drugs that are in the pipeline.
If you wish to find out a lot more about CAC, this You Tube video of a talk by Ivor Cummins should be your next port of call (6).
1. R. L. Smith (1988). Diet, Blood, Cholesterol and Coronary Heart Disease. A Critical Review of the Literature Volume 2. Vector Enterprises
2. https://vernerwheelock.com/179-cholesterol-and-all-cause-mortality/
3. http://www.thefatemperor.com/
4. https://qrisk.org/2017/BMJ-QRISK2.pdf
5. http://circ.ahajournals.org/content/117/6/743
6. https://www.youtube.com/watch?v=kU0UNWEKhQo

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