Cholesterol Myths

[The SkepDoc]

Marshall E. Deutsch, a member of the International Network of Cholesterol Skeptics, wrote an article in Skeptic magazine and spoke at TAM4 on this topic. I wrote a rebuttal in the following issue of Skeptic. I am skeptical about cholesterol too, and I agree with some of Deutsch's points, but I think he has gotten some of his facts wrong and has misinterpreted others. I think he throws out the baby with the bath water.

I have engaged him in an e-mail discussion and have received his permission to copy our exchange to the forum.

Here's my initial e-mail to him:

Here's where I agree with you:
(1) Cholesterol has been demonized and is no where near as important as the general public thinks.

(2) Cholesterol by itself is not "the" cause of atherosclerosis in the sense
that the TB bacillus is the cause of tuberculosis.

(3) The data do not support testing the cholesterol levels of all young
children.

(4) The data do not support recommending a low fat, low cholesterol diet for
all young children.

(5) Dieting doesn't make much of an impact on cholesterol levels.

(6) Statins are overprescribed; they can cause harm, and they don't
accomplish as much good as doctors and patients would like to think they do.

Here are some areas where I think our apparent disagreement is more of a
miscommunication:

(1) There is a big difference between primary prevention (preventing heart
attacks in the first place) and secondary prevention (preventing heart
attacks in patients who already have heart disease. In every statement, we
need to make clear which group we are talking about.

(2) There is a big difference between making a statement about risk factor
statistics and making lifestyle change recommendations based on those
statistics. There is plenty of room for legitimate disagreement in this
area.

(3) Advice that may be good for an individual may be bad advice when applied to a whole society.

 

[The SkepDoc]

Deutsch's Answer (#1)

Thank you for your very agreeable letter. I would love to see some version of this in SKEPTIC magazine, but am aware of what is best expressed by a quotation from a recent book (Malignant Medical Myths) by Joel M. Kauffman: "More than ever, most individual medical providers, including mainstream ones, cannot use their own judgment or experience, because they can be threatened with lawsuits for malpractice if 'official' guidelines for diagnosis and treatment are not followed. Failure to follow procedures based on myths, or using an alternative treatment not sanctioned by the American Medical Association (AMA) can lead to ostracism by peer physicians or even de-licensing (Carter, 1992, xv ff) Some guidelines appear to have the sanction of the US government. One example is the 'New Cholesterol Guidelines' which appear to be promulgated by the National Heart, Lung and Blood Institute (NHLBI), a branch of the National Institutes of Health (NIH). These guidelines, which promote more and more aggressive use of cholesterol-lowering drugs, were prepared by drug experts, many involved with drug manufacturers with no government supervision or approval. Yet these guidelines are being promoted nationally as official guidelines of the NHLBI..." The Carter reference is to a book by James P. Carter.

 

[The SkepDoc]

The SkepDoc Answers - #2

I hope I have established the fact that I, too, am a cholesterol skeptic.
But my skepticism is firmly grounded in good science and cannot possibly be
considered malpractice or get me in trouble with my profession. As a matter
of fact, I essentially agree with the recommendations in American Family
Physician, the journal of the American Academy of Family Physicians (my
specialty). You may think this is incompatible with what I have said so
far, but I hope to persuade you that it isn't.

Having established a base of agreement, I'd like to go on to the points
where we disagree. There are many of these, and I'll start with just one.

Having established a base of agreement, I'd like to go on to the points
where we disagree. There are many of these, and I'll start with just one.

Where did you get the idea that there was no animal model where atherosclerosis could be produced by changing an animal’s diet? I queried PUBMED for “experimentally induced atherosclerosis” and it brought up over 130 citations. Atherosclerosis can be and has been experimentally induced. This is a minor point not worth arguing about, because it is irrelevant to the main question of whether lowering cholesterol lowers risk in humans. I only bring it up as an example of where you seem to have accepted "facts" that I cannot verify.

 

[RSLancastr]

SkepDoc, two things:

1) This would probably get the attention it deserves in another forum of the JREF board. Perhaps the General Skepticism one or the Science, Math Medicine and Technology one.

2) Do you have Deutch's permission to be posting the contents of his emails to you here?

Thanks for starting the debate with him It's an important one.

 

[The SkepDoc]

I'm new to the Forum and don't know about the different categories. If it would be better done elsewhere, perhaps you can help get it moved.

Yes, I have Deutsch's permission to post the contents of his e-mails both here and to the Quackwatch Healthfraud discussion list.

 

[RSLancastr]

I'm new to the Forum and don't know about the different categories. If it would be better done elsewhere, perhaps you can help get it moved.

Sure.

Moving the thread would require the help of a moderator or administrator.

Or, you could simply start the thread again yourself:

You can scroll through the forum index and select a category.

As I said before, the "Science, Technology, Medicine..." one would be a good place, as would the "General Skepticism" one.

Glad you have Deutch's permission. It might ease some worrywarts' minds if you stated "posted with permission of so-and-so" when you quote someone's email.

 

[kittynh]

also contact DArat (a moderator) and he can move it for you.

Good thread though!

 

[The SkepDoc]

Deutsch's Answer (#2)

Okay. Instead of saying that you "can't give a rabbit atherosclerosis by feeding it cholesterol unless you also give it an antithyroid drug" (I believe thiouracil was used.), I should have said "You can't give a rabbit atherosclerosis by feeding it as much cholesterol as an omnivore could possibly get in its diet unless you also administer an antithyroid drug." The experimenters using the rabbit model fed the rabbits 2% cholesterol. The food containing by far the highest cholesterol content is egg yolk which contains slightly less than 1.5% cholesterol. Note, also, that because the normal diet of herbivores has a low caloric density, they eat much larger volumes than do omnivores or carnivores.

Most of the papers turned up by PubMed do not actually discuss atherosclerosis, but discuss serum lipids and assume a relationship with atherosclerosis. Where an animal model is used it is usually the rabbit. To use mice, resort is made to apolipoprotein E- knockout mice (e.g. ref. 15933243), or to inducing plaque formation via vascular injury (11926895), in each case presumably because the simpler procedure of dietary manipulation doesn't work.

 

[The SkepDoc]

The SkepDoc answers Deutsch (#2)

The point here is that while nobody is going to get atherosclerosis just by overdosing on cholesterol, a high fat diet is definitely a contributing factor.

As I said, this is really irrelevant to what I want to know: whether lowering cholesterol reduces heart attacks. What does the evidence show?
You found plenty of articles to support your position, but there are always articles that support both sides of a controversy. When systematic surveys have been done of ALL the literature by large groups of independent experts following strict guidelines for assessing the quality of evidence, the conclusions are consistent:
a. Cholesterol is an independent risk factor for heart disease. This simply means that as a general rule, ALL OTHER THINGS BEING EQUAL, the higher your cholesterol the greater your risk of heart disease. There are all kinds of studies that have looked at this in different ways from different angles and in different populations of people, and they all essentially agree. This fact is so well established that no one can seriously question it.
b. For primary prevention, lowering a high cholesterol level reduces risk of heart attack, but probably not of death.
c. For secondary prevention (in those who already have been diagnosed with cardiovascular disease), lowering a high cholesterol level reduces the risk of a repeat heart attack and reduces the risk of death.

 

[geni]

Here's where I agree with you:
(1) Cholesterol has been demonized and is no where near as important as the general public thinks.

It is that important the first liquid crystals were cholesterol based.

 

[Chris Haynes]

..
(5) Dieting doesn't make much of an impact on cholesterol levels.

(6) Statins are overprescribed; they can cause harm, and they don't
accomplish as much good as doctors and patients would like to think they do.

....

I have changed my cholesterol levels through diet and exersize (I swim 2000 yards two to three times a week, it takes me an hour to do, but I do it). (I posted this on http://www.internationalskeptics.com/forums/showthread.php?t=48787 ... but is rapidly scrolling away). So I now know that it does help. Plus my doctor liked what I did enough to say I did not need medication. He only recommended that I take calcium and Vit D supplements because I am post-menapausal and need to limit how much cheese I eat.


So here goes my cholestoral happy dance:

Last year: Total= 255, Triglycerides=122, LDL=162, HDL=70

This year: Total=237, Triglycerides=130, LDL=137, HDL=74

The triglycerides is in the normal range (under 150), The total is supposed to be under 200, but my HDL really helps.

The bad stuff, LDL went down from "high" (160-188) to "borderline high" (130-159)...

AND the good stuff, HDL went up... anything above 40 is protective... which makes the LDL not so important.

Oh, and last year my blood pressure was 125/85 ... now it is 114/72 !

I just need to keep it up. I am also slowly losing weight, something on the order of about a pound per month.

By the way, Dr. H, I am a Healthfraud listserv lurker... I always enjoyed reading your posts. Though I am afraid I learned more than I ever wanted about animal husbandry during the past week.

 

[casebro]

I've often wondered about the linkage of statins to longevity. All you have to do is watch TV ads that say "xxxstatin has not been shown to...." While studies show that STATINS prevent heart attacks, thats not the same. My latest Googling says that statins cut the death rate by 1/2% per year. That means that treating 200 peolpe will prevent one heart attack death this year. Or take statins for 5 years, have a 97 1/2 % chance of them not doing anydamnthing. Some improvement, eh?

Likewise, I've lately found a site to compare statins and aspirin therapy. In this study aspirin cut the death rate by 40%, statins by 50%, both combined, about 60%. Makes me think that 80% of what statins do, are the same thing that aspirin does. Soooo, only 20% of whatever statins do, is related to cholesterol- or something else entirely?

My whole family seems to have mitochondrial issues, and statin myopathy has hit everyone of us that tried them. As, well I've met far too many folks who suffered muscle side effects to believe the drug studies claiming 1 in 1000 for that side effect.

So, I take a baby aspirin every day...... I wonder if there has been a study re: ASA or other NSAIDS, in foods, vs the heart attack rate? I know Hops, the beer ingredient, acts as a NSAID, maybe Parsley would explain the French paradox ?

 

[The SkepDoc]

Clarifying my position on diet and statins

Clarification: diet helps, it just doesn't help as much as most people think. Statins help, but they don't benefit everyone who takes them and they are sometimes used before or instead of the more important steps of smoking cessation and weight reduction.

Two factoids from my family practice journal:

"Dietary advice leads to an average 3 to 6 percent decrease in total cholesterol levels"

"A recent study of simvastatin in more than 20,000 compliant, high-risk, primary-prevention patients found a decreased risk of major coronary events, revascularizations, and stroke (risk decreased from 25 to 20 percent; NNT, 21)." NNT= number needed to treat.

There are two ways of looking at the NNT statistics. Some of us see a 1 in 21chance of preventing a heart attack; others see that 20 out of 21 people will be taking a drug they don't need. It becomes a question of whether you as an individual prefer to "buy insurance" or to take your chances that you are one of the 20 lucky ones.

 

[casebro]

Clarification: diet helps, it just doesn't help as much as most people think. Statins help, but they don't benefit everyone who takes them and they are sometimes used before or instead of the more important steps of smoking cessation and weight reduction.

Two factoids from my family practice journal:

"Dietary advice leads to an average 3 to 6 percent decrease in total cholesterol levels"

"A recent study of simvastatin in more than 20,000 compliant, high-risk, primary-prevention patients found a decreased risk of major coronary events, revascularizations, and stroke (risk decreased from 25 to 20 percent; NNT, 21)." NNT= number needed to treat.

There are two ways of looking at the NNT statistics. Some of us see a 1 in 21chance of preventing a heart attack; others see that 20 out of 21 people will be taking a drug they don't need. It becomes a question of whether you as an individual prefer to "buy insurance" or to take your chances that you are one of the 20 lucky ones.

On the average, insurance dooesn't pay. Otherwise, the insurance co's wouldn't be able to afford the biggest building in town.

I guess you are talking about the 4s study. (Swedish Simva-Statin Study) It is the longest term study to date at 10 years. Actually, it was 2 five year studies- at the five year mark, they put the controls on simavastatin too. Anyhow, 5% over ten years, is 1/2% per year. Asumming I start on simvastatin at age 55, at age 75 I would have a 90% chance of it not having done me any good. At a cost of $3 per day, thats $180,000 per life extended. (can the economy afford that?). In the meantime, on top of the 20% death rate from heart attack, you have a 60% chance of being dead from cancer, stroke, car accident, medical malpractice, bird flu,....

I think that if everybody in America took statins, we would each expect to live 2 months longer. I'll stick to aspirin.


ETA:

Here'a a little excercise for you, since I don't have a scanner or camera handy.

Make a graph, use any scale you find convenient.

Put 10 marks across the bottom, those are years. Put a mark up high on the right side, that is 95%.
Put another mark on the right side, 5% lower, that is 90%

Draw lines from zero on the left, through each of the two marks. Extend the line through the lower mark, until it
reachs the elevation of the upper mark. Draw in a hiorizontal line from the 95%
mark to the line extended through the 90% mark. Now measure the length of that horizontal line, and compare to the year scale
Now divide by ten, that will give the average life extension if everybody took statins. Pretty useless drug, if you ask me.

BUTT, if they did some genetic testing, they would tell me to stay away, it could kill me. They would tell 80% that it won't do any harm,
but it won't do any good either. But for 5%. it would be a life saver. Pharmacogentics, Line ONE!!!!

 

[The SkepDoc]

Casebro said, "Pretty useless drug, if you ask me."

Not to those who were saved from a heart attack! No one is recommending that the entire population take statins. The benefit is greatest for those at greatest risk.

Pharmacogenetics may eventually tell us which individuals will benefit, but it can't do that yet, and in the meantime we have to make clinical decisions based on incomplete information. I think it is reasonable to give a patient our best guess as to the NNT (number needed to treat) for his risk group and let him decide whether he wants the "insurance."

NNT's are a great way of looking at efficacy. It's interesting to compare the NNT for statins to the NNT for other commonly accepted treatments. You have to give 23 flu vaccinations to prevent one case of flu. The NNT for antibiotics after dog bites is 16; the NNT for freezing warts is 4.8. For preventing heart attacks with calcium channel blockers in patients with high blood pressure, the NNT is 35.

 

[casebro]

Skepdoc, what kind of trolling are you up to here? Didn't you start this thread as a skeptic, but now you are saying everybody ought to take them?

Looks like you have looked at all the studies, and come to the conclusion that their usefulness is overblown, but you'll still prescribe them? I guess you get paid to prescribe them, but you don't have to pay for them, or suffer the side effects. Was that the Hypocrits oath you took ?

 

[Amapola]

Skepdoc, what kind of trolling are you up to here? Didn't you start this thread as a skeptic, but now you are saying everybody ought to take them?

Looks like you have looked at all the studies, and come to the conclusion that their usefulness is overblown, but you'll still prescribe them? I guess you get paid to prescribe them, but you don't have to pay for them, or suffer the side effects. Was that the Hypocrits oath you took ?

Casebro, he did not say everyone should take them. He said,

I think it is reasonable to give a patient our best guess as to the NNT (number needed to treat) for his risk group and let him decide whether he wants the "insurance."

Being a skeptic does not mean never prescribing medication. It means asking questions, and then trying to do the best you can with the information that you have. I thought he made it quite clear in his post that though statins are not for everyone, there is as yet no perfect way to know exactly who will benefit the most from them. As a potential patient I would prefer to be given the option of taking a medication that could possibly save my life. I would of course consider the costs and possible side effects....... but I would want to the doctor to at least give me the option, and not dismiss a medication because it did not work in 100% of the population.

 

[HawkeyeMD]

Skepdoc, what kind of trolling are you up to here? Didn't you start this thread as a skeptic, but now you are saying everybody ought to take them?

This seems unnecessarily rude. It also seems like you didn't read what SkepDoc actually wrote.

Newsflash: all medications that can help you can also hurt you. That goes for aspirin, statins, antibiotics and everything else you can think of. It would be nice to think that we could know what the amount of help versus hurt is going to be in every single case, but we don't. The human body is an immensely complex set of systems, and we are generally tinkering with limited parts of it.

One of the continual cries of all of alternative medicine is that their therapies are "safe" because they're "all-natural" or "less toxic" or "gentler". The reason MDs have trouble countering this argument is that, since you mention Hippocrates, although we do take an oath to "do no harm", we also have to learn how to balance one harm against another, and we're required to acquaint patients with both the potential risks and benefits. Surgery is a clear 'harm', but it can save your life. Statins can cause side effects, but as SkepDoc said, they do help in many cases and particularly when the problem is especially severe. Doctors are not all-knowing, and if you have questions about why you're being prescribed something, you should ask and investigate. But SkepDoc has been very clear about *exactly* parts of "what everyone knows about cholesterol" that s/he considers sketchy and what parts of Deutch's paper were questionable.

Disclaimer on my own part: despite the moniker, I'm not yet an MD. Soon, though, if all goes well.

 

[Chris Haynes]

Skepdoc, what kind of trolling are you up to here? Didn't you start this thread as a skeptic, but now you are saying everybody ought to take them?...

Odd, I did not interpret her posts as trolling, nor in suggesting EVERYONE take the drugs.

I will repeat that even though my total cholesterol is over 200, that my family doctor has not prescribed drugs for me! It may because I have taken non-drugs steps to deal with my genetic tendency towards high-cholesterol.

 

[The SkepDoc]

I am not a troll. I am a card-carrying skeptic trying to sort out the truth from the hype in a complex issue. I think statins are overprescribed and not for everyone, but the evidence shows that they do benefit people, especially those at highest risk. I explained the NNT concept and said that the patient should be given the evidence and empowered to make his own decision.

For the record, I don't get paid to prescribe them. I'm retired. I never did get paid to prescribe anything - I practiced medicine in the USAF and got the same salary whether I gave the patient a prescription or not.

As for "paying for them," we all pay indirectly through insurance, Medicare, etc. It is in our best interests as a society to avoid overuse of medications while providing effective medications that will prevent health care expenditures later on.

As for "suffering the side effects," most people who take statins don't suffer from side effects, and if they do, they can stop taking them. With every medication, there is a risk/benefit ratio that must be taken into account.