Science and Medicine

I’ve been spending quite a bit of time lately reading about fat in the diet, cholesterol, atherosclerosis, and statins. Some story:

Sometime around 1990 or so, I was diagnosed with hypercholesterolemia and a low-fat diet was prescribed. It’s difficult for an individual to assign cause and effect, but that diet coincided with a period of increase in my weight, and something else happened. Sometime around 2007 I was diagnosed with prostate cancer. Both of these may be connected with “low fat diet,” but the state of research on this is poor.

By the middle of the first decade of this century, my wife went on an Atkins diet. My physician, noting my high cholesterol, recommended the South Beach Diet, which could be called Atkins Light. I read up on them, and it appears to me that Atkins had more science behind it. (Both Atkins and Agatston were cardiologists). It was called a “fad diet,” but was actually quite old — my physician pointed to a Diabetes textbook from the 1920s that considered a “low-starch diet” an effective treatment for type 2 diabetes.

Eliminating most fat from a diet will predictably lead to replacing it with something, and unless one goes high-protein, it will be carbs. In the 1990s, it was pasta, I had never eaten much pasta before, but it became a staple.

On Atkins, not only did I lose weight rather efficiently, but I was now eating my favorite foods. When I was a kid, they would say to me, “Have some bread with your butter.” My favorite food, besides steak, was baked potato with butter and sour cream, emphasis on the last two.

Eventually, I came across Taubes’ Good Calories, Bad Calories, and read the story of how it came to pass that low-fat diets were recommended, and, as well, that cholesterol came be be considered dangerous in food, and cholesterol levels “risk factors” for heart disease.

And then that one could prevent heart disease using statins.

It’s a horrifying story, where the scientific method was not followed, where poor studies were used to create a drastic change in diet, and it is possible that this cost millions of premature deaths.

Or not.

What’s the truth? How would we know? Under this page, I intend to collect individual studies. Is this related to cold fusion? Well, peripherally. Before Taubes wrote GCBC, he wrote Bad Science, about cold fusion. As a science journalist, he had occasion to look at the idea that salt in the diet was dangerous, and found himself looking at developing beliefs that were not adequately tested, that turned into standard medical advice without balanced consideration. And then he did the same with fat in the diet.

There are parallel issues with cold fusion. Widespread “scientific opinion” developed through information cascades and with diet, weak associational or epidemiological studies, rather than solid science. Wihen it was proposed that fat in the diet was causing heart disease, it came to be seen as a health emergency, and considered it would be foolish to wait for more solid science, because waiting, people would (it was believed) continue to die unnecessarily, and (it was also believed), removing fat from the diet could not possibly do harm. After all, weren’t we too fat? And aren’t we what we eat?

I’m not going into all the details here, but the original fat/cholesterol hypotheses was far, far from reality. Study after study failed to confirm it, but there was always an excuse and the cholesterol hypothesis was a moving target.

At first it was believed that eggs were dangerous foods, to be avoided, because they have high cholesterol content. Eventually, those recommendations almost entirely disappeared. Cholesterol in the diet does not cause blood cholesterol.

Originally, as to fat, it was all fats, then it moved to saturated fats (such as butter). When it was found that butter consumption did not correlate with heart disease, it got more and more complex, various kinds of fat, etc.

The cholesterol hypothesis (relating to blood levels) started out as all cholesterol. Even though total cholesterol continues to be used by many, within the last decade or so, fractionating the cholesterol came into fashion, so we ended up with “good cholesterol” (HDL) and “bad cholesterol” (LDL) and a consideration of the ratio, and then it got even more complex.

I was told by my physician that cholesterol was actually a relatively poor measure as to risk. I had familial high cholesterol, my mother had high cholesterol, and died in her mid-nineties from congestive heart failure, not from atherosclerosis. My doctor wanted me to see a cardiologist and told me that he would not be able to find one who would not want to put me on statins. I did see a cardiologist, had a stress test (no problems), and continued to monitor my blood lipids. I also generally had C-reactive protein measured, which is apparently a better predictor, and, when insurance would not cover a calcium score CAT scan, I paid for it. My Agatston score was in the 26th percentile for men my age. So 74% of men had more calcification than I. I was not worried.

Fast forward about ten years. In my seventies now, I flew to my son’s wedding, and as I was getting ready to fly, I had a strange sensation in my chest. I would have gone to the hospital, but I would have missed the flight and my son’s wedding, very important to me. So I flew, and when I got back, went immediately to my primary care physician and he sent me back to the cardiologist for another stress test. Some abnormalities (minor, actually) showed up, so they immediately scheduled a nuclear stress test, I think it was the next day.

Result: major blockage, showing up under stress only. So I was able to get into cardiac rehab, and started an exercise program. I’m still doing that. No heart attack yet, I carry a pulse oximeter and  nitroglycerin just in case. I have never used it.

The cardiologist, of course, recommended two things: an angiogram and a statin. I declined the angiogram until I could become better informed. He understood and actually appreciated that. I obtained the statin prescription and on something like the first day, I accidentally took a double dose and felt miserable. It was a high dose. That’s meaningless, except that I realized I simply did not want to take the drug.

Statins function to lower cholesterol, primarily. There is a substantial rate of complications (and that is controversial and I am not convinced it has been adequately studied). However, statins are sold on the idea of a 30% reduction in risk. What is not said is that for people who have not had a heart attack, this may be a 1% absolute risk reduction (from 3% to 2%), and it appears that, at least in many studies, there is no reduction in death rate, which would imply that statins might be reducing heart attacks, all right, but participants were dying from something else instead.

I also looked into angiograms and the placement of stents. Having the procedure (which is quite invasive — and expensive!) apparently, for a relatively normal population, not having had a heart attack, does not improve survival rates. The procedure (angiogram with possible stent placement) can be life-saving if one is in critical condition, but may be overkill when one is merely at some level of risk from age and some level of arteriosclerosis.

I’ve mentioned some “facts” above. Are they facts? What do the studies actually show? I’ve been reading off and on about this for years, but have never done an organized study. That’s what I’m starting here. I’ve been following the blog of Dr. Malcolm Kendrick, a Scottish physician and very good writer, calling himself a sceptic. The pseudoskeptic trolls I’ve been following have attacked him, which is how I found him.

He encourages open discussion and criticism on his blog. The other day, there was a link placed to the Science Based Medicine blog, The Cholesterol Controversy, by Christopher Labos. It’s a recent post, February 15, 2019.

The subhead:

Why is cholesterol so much more controversial than the other cardiac risk factors? A review of cholesterol’s troubled and contentious history might help us understand where many of the cholesterol controversies originated… and why it’s time to let them pass into
history.

He seems to be more willing to actually discuss the issues than many I’ve seen, which just assume the “consensus.” So I’m staring here.

Subpage studies

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