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Butter nonsense: the rise of the cholesterol deniers
The Guardian, Tue 30 Oct 2018
Sarah Boseley

A group of scientists has been challenging everything we know about cholesterol, saying we should eat fat and stop taking statins. This is not just bad science – it will cost lives, say experts

Bosely leads with a snarky headline, and a tight set of assumptions presented as if fact. She chooses to call criticism of the cholesterol hypothesis “deniers” rather than “skeptics.” One by one:

  1. “Everything we know.” What do we know? Is popular opinion “what we know”? Are they challenging “everything we know,” or just some of it? New ideas in science are often presented as overturning “everything we know,” when they do no such thing. It is common that new ideas challenge, not what we know, but our ignorance, because “what we know” is necessarily incomplete. It may also incorporate errors, due to defective historical process that drew conclusions beyond what the data actually showed. The history of science is full of examples of this. Pointing this out is not an argument for any particular position, and my own expectation is that the mainstream is generally more right than wrong. But sometimes “mainstream errors” can be doozies with enormous human cost.
  2. “We should eat fat and stop taking statins.” Someone who says that is not functioning as a scientist, science does not tell us what to do. It gives us tested information on which we may base predictions of the possible or probable results of actions. Bosely is presenting an extremely shallow view. She is the Health Editor for the Guardian, and that is worrying me. I would expect better, but this is actually an editorial, not simple reporting, but presented as fact. What scientists allegedly are making this recommendation? Scientists and journalists also become book authors, and sell books, and that can create a conflict of interest. Bosely is an “award-winning” journalist. So is Gary Taubes. Who has done more research on diet, Bosely or Taubes? Who is taking a safe position and who is persisting in spite of flak?
  3. This is not just bad science. No, bad science is belief strong enough to suppress continued awareness of the possibility of error. Bad science can be”mainstream.” She is assuming that scientists are advocating conclusions, (what we “should” do) and she calls it “bad science,” because she obviously believes the conclusions she states are wrong.
  4. it will cost lives, say experts. So there are scientists, allegedly (I’m not saying she is incorrect and I will be looking for examples in the article), who are giving advice (which actually could qualify as bad science, because a scientist is not expert in what an individual should do), and then there are “experts” who think that advice will cost lives. That is not actually known. there are studies, and I have read some of them. It is speculative. Benefit from statins is generally found to be a risk reduction of death from a heart attack, but much less reduction in overall death rate, sometimes not significant.

In stating that, these experts are extrapolating from a presumed or studied risk factor, to outcomes, but human nutrition is complex, and so is our resp0nse to statins, and, further, even if some course of action might “cost lives,” — which may not be precisely defined, and which must mean increased risk — it might still be what people choose.

As an actual example, choosing not to take a statin might statistically increase risk of a heart attack by 1%, and so, one might imagine that in a treatment population, refusing the drug will increase death rates by 1%. but unless this is actually tried, in a real context, it may not be true and the real choice might even be life-saving. This depends on the alternative, which studies rarely cover.

Suppose that a population is given one of two sets of advice. first group, take a statin for ten years (and compliance is monitored). Second group, do an exercise program (which would also be monitored for ten years.) From what I have read, the exercise group could be expected to have a lower death rate, because exercise is far more effective at promoting heart health than statins. Further, someone taking statins may think that they are protected, when the reduction in death rate is only 1% (from 3% with placebo), and so may not take other measures (such as diet and exercise).

In my own history, what has shocked me is that I was prescribed statins, and, originally, years ago, there was no mention of an exercise program, i.e., disciplined, specific exercise. Yet it is common knowledge that an exercise program is a powerful response to cardiac risk (much more so than statins). To his credit, my cardiologist, more recently, recommending statins and an angiogram, also said “and I want to put you in cardiac rehab.” I did the rehab, set up a continuing program, and have put off the statins and the angiogram, pending better understanding. He actually understood and did not argue with me, and we continue communication over the issues.

Butter is back. Saturated fat is good for you. Cholesterol is not the cause of heart disease. Claims along these lines keep finding their way into newspapers and mainstream websites – even though they contradict decades of medical advice. There is a battle going on for our hearts and minds.

Boseley, I could claim, is a reality denialist. Let’s look at this.

  1. Butter is back. Is it? That is a description of a social condition. What is the history of the demonization of butter and saturated fats? Was it based on solid science? Or did studies, when actually done (guidelines predated the studies), show that butter consumption did not increase heart disease risk?
  2. Saturated fat is a natural food. Visiting Morocco, I saw how a local reacted to a package, maybe two pounds of sheep fat, aged in a traditional process. Our guide ate the whole thing with gusto. Craving fat is normal, it is a precious source not only of calories, because it is calorie-dense, but fat is also nutritionally essential (unlike carbohydrates). It is entirely possible that fat is good for you, but that needs more precise definition. In what context? For what goal? The studies that showed higher death rate from fat consumption were seriously flawed, study populations being cherry-picked. This is all well-known to the cholesterol skeptics, covered by Taubes in detail in GCBC and, I assume, other books. That studies were defective does not negate the conclusions, but . . . it does pull the rug out from under the argument that because some study found something, used to develop recommendations that were allowed to become dogma — which happened — therefore this is solid science, based on “scientific research.” Once the dogma was established, ongoing research became warped, in terms of what could obtain funding, what could be published in major journals, and publishing anything else was considered “dangerous,” just as Bosely and her “experts” are doing here. Again, that doesn’t mean they are wrong, but that something is off about the conversation.
  3. Cholesterol is not the cause of heart disease. Reality denialism. It is very obvious from the cholesterol and statin studies that cholesterol is “not the cause.” If it were the cause, major reductions in cholesterol would produce major reductions in disease incidence, and they do not. Rather, cholesterol levels are “associated” with disease incidence. They are “risk factors,” perhaps, which can be non-causal. It does not appear to me that causation has been established, and the true continued controversy over causation is a real issue. There is also controversy over how to translate cholesterol levels to estimated risk. It is fairly clear that total cholesterol is not so useful, and then there has been a continual series of refinements of this. Bosely glosses over all this, so far.
  4. Decades of medical advice is so much hot air, at least warmed at the time, not scientific evidence at all. Boseley is simply assuming that the advice was solidly based, when, if we go back and look at the actual advice, it was, at best, premature, and at worst, may have caused millions of premature deaths. Does she care? Those who do not study history are doomed to repeat it.
  5. There is a battle. Indeed. There is a battle between science, self-interest, and public interest, very complex, between real science and entrenched organizational positions, which almost always defend themselves to the bitter end, and this has been present for many years, and between questioning of authority and defense of it, and ego. Boseley, in her book, blames the marketers of “junk food.” In fact, much of what she says might find agreement with the “denialists.” Here is a review of the book by the publisher. Here are some Goodreads reviews. Boseley is not a deep thinker, I’m afraid. Her solution: calorie restriction, which is largely a failure as advice. Mixing up fat with sugar and highly processed carbs, she misses what does actually work, in the experience of many (and in studies, though studying diet is quite difficult).

According to a small group of dissident scientists, whose work usually first appears in minor medical journals, by far the greatest threat to our hearts and vascular systems comes from sugar, while saturated fat has been wrongly demonised.

Instead of informing us as to fact, like a good journalist, and letting us make our conclusions, she presents a pile of interpretations. It is not a specific group of scientists, and she does not name them, or provide sources for what they actually say. But it is a “small” group, and they are “dissidents,” and their work “usually” first appears in “minor medical journals.” She puts in “usually,” I assume because it is not always so, and most medical work appears first in minor journals. The point is to discredit, with an ad hominem argument, what they say, but what she first gives us is not particularly controversial. That is all well-established, if we review the literature instead of depending on a subset of experts.

There are many signs in the article that Boseley has an axe to grind. For example:

. . . Mainstream scientists usually keep their disquiet to themselves. But last week, some broke cover over what they see as one medical journal’s support for advocates of a high-fat diet. More than 170 academics signed a letter accusing the British Journal of Sports Medicine of bias, triggered by an opinion piece that it ran in April 2017 calling for changes to the public messaging on saturated fat and heart disease. Saturated fat “does not clog the arteries”, said the piece, which was not prompted by original research. “Coronary artery disease is a chronic inflammatory disease and it can be reduced effectively by walking 22 minutes a day and eating real food,” wrote the cardiologist Aseem Malhotra and colleagues. The BHF criticised the claims as “misleading and wrong”.

There are only 169 signatures to that letter, and 55 did not give an academic affiliation. The error is a piece of evidence that Bosely was looking for whatever she could say to strengthen the anti-denialist impression, and weaken the skeptical claims.

Saturated fat does not “clog the arteries.” Nobody with specific knowledge believes that. The argument has become that cholesterol somehow causes faster or more extensive buildup of plaque on the walls of arteries. This happens in the larger arteries, not in small ones, but the image has been promoted of fat building up in arteries. Fat never enters the blood. “Chronic inflammatory disease” is basic science, and, in fact, everyone agrees that exercise is the best treatment, and then there is controversy over what is the best food. So what was “wrong”?

The history of the cholesterol hypothesis is replete with confident recommendations by organizations like the British Heart Foundation that later turn out to be far from the mark. The history of diabetes involved political decisions that favored the use of insulin over reducing carbohydrates, insulin was sold on the basis that, with it, you could eat whatever you liked. No need to “deprive yourself.” No problem with sugar and refined carbs. And high-fat diets, eaten for millenia by some cultures, were demonized even for diabetics, on the basis that they had not been adequately tested. But the recommendations being made had also not been adequately tested? What was the difference?

And then we get into conspiracy theory territory. My own view is that no formal conspiracy is necessary, just a lot of actions that create social pressures to conform, to “go along to get along.”

In any case, the sports medicine journal article:

Saturated fat does not clog the arteries: coronary heart disease is a chronic inflammatory condition, the risk of which can be effectively reduced from healthy lifestyle interventions

The abstract:

Coronary artery disease pathogenesis and treatment urgently requires a paradigm shift. Despite popular belief among doctors and the public, the conceptual model of dietary saturated fat clogging a pipe is just plain wrong. A landmark systematic review and meta-analysis of observational studies showed no association between saturated fat consumption and (1) all-cause mortality, (2) coronary heart disease (CHD), (3) CHD mortality, (4) ischaemic stroke or (5) type 2 diabetes in healthy adults.1 (2015) Similarly in the secondary prevention of CHD there is no benefit from reduced fat, including saturated fat, on myocardial infarction, cardiovascular or all-cause mortality.2 (2014) It is instructive to note that in an angiographic study of postmenopausal women with CHD, greater intake of saturated fat was associated with less progression of atherosclerosis whereas carbohydrate and polyunsaturated fat intake were associated with greater progression.3 (2004)

I have linked to the sources cited and added the year of publication.

This is an editorial, hence it makes an overall judgment. As something challenging “popular belief,” it can be expected to arouse hostile response, it is rare that popular belief disappears from some single challenge! I find this article stunning. What was the response?

Implausible discussions in saturated fat ‘research’; definitive solutions won’t come from another million editorials (or a million views of one) August 2018

[response to] Open letter from academics, practitioners, students and members of the public to the British Medical Association, the British Medical Journal publishing group, and the British Association of Sports and Exercise Medicine regarding editorial governance of the British Journal of Sports Medicine October 2018

Guest Post: Does the BMJ publishing group turn a blind eye to anti-statin, anti-dietary guideline & low-carb promoting editorial bias? October 2018

The open letter. (read on 3/2/2019, archived)

My quick summary: the issues remain legitimately controversial. 

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