New cholesterol guidelines
for converting healthy people into patients
By Uffe Ravnskov, M.D., Ph.D.
Source: http://www.ravnskov.nu/ncep_guidelines.htm In the May 16 issue (2001) of the Journal of the American Medical
Association an expert panel from the National Cholesterol Education
Program has published new guidelines for "the detection, evaluation,
and treatment of high blood cholesterol" (read the paper). Their
writing seems to be an attempt to put most of mankind on cholesterol-lowering
diets and drugs. To do that, they have increased the number of risk
factors that demands preventive measures, and expanded the limits
for the previous ones.
But not only does the panel exaggerate the risk of coronary disease
and the relevance of high cholesterol, it also ignores a wealth of
contradictory evidence. The panel statements reveal that its members
have little clinical experience and lack basic knowledge of the medical
literature, or worse, they ignore or misquote all studies that are
contrary to their view.
Here come a few examples of the panel’s false statements.
As an argument for using cholesterol-lowering drugs the panel claims
that twenty percent of patients with coronary heart disease have a
new heart attack after ten years. But to reach that number any minor
symptom without clinical significance is included.
Most people survive even a major heart attack, many with few or no
symptoms after recovery. What matters is how many die and this is
much less than twenty percent.
The panel also recommends cholesterol-lowering drugs to all diabetics
above 20, and to people with the metabolic syndrome. If you have at
least three of the "risk factors" mentioned below, you are
suffering from the metabolic syndrome:
Risk factor - Limits according to the NCEP expert panel
Abdominal obesity
Waist circumference above 88 cm in women; above 102 in men.
Some male "patients" can develop many risk factors with
a waist circumference of only 94 cm
High triglycerides
150 mg/dl or more
Low HDL
Men less than 40 mg/dl
Women less than 50 mg/dl
High blood pressure
130/85 or higher
High fasting blood sugar
110 mg/dl or higher
Test yourself and your family! I guess that using these limits, most
of you "suffer" from the metabolic syndrome. And this new
combination of risk factors, says the panel, conveys a similar risk
for future heart disease as for people who already have coronary heart
disease.
Luckily, it is not true.
It is not true either, that cholesterol has a strong power to predict
the risk of a heart attack in men above 65. In the 30 year follow-up
of the Framingham population for instance, high cholesterol was not
predictive at all after the age of forty-seven, and those whose cholesterol
went down had the highest risk of having a heart attack! To cite the
Framingham authors: ”For each 1 mg/dl drop of cholesterol there
was an 11 % increase in coronary and total mortality (115).”
It is not true either, that high cholesterol is a strong, independent
predictor for other individuals.
In most studies of women and of patients who already have had a heart
attack, high cholesterol has little predictive power, if any at all.
In a large study of Canadian men high cholesterol did not predict
a heart attack, not even after 12 years, and in Russia, low, not high
cholesterol level, is associated with future heart attacks (read
summary of paper)
Most studies have shown that high cholesterol is a very weak risk
factor or no risk factor at all for old people; see for instance the
paper by Schatz et al., but there are many more. Considering that
more than 90% of all cardiovascular deaths occur in people above 60,
this fact should have stopped the cholesterol campaign years ago.
Also interesting is the fact, that in some families with the highest
cholesterol levels ever seen in human beings, so-called familial hypercholesterolemia,
the individuals do not get a heart attack more often than ordinary
people, and they live just as long (read
the paper and my comment).
Taken together such observations strongly suggest that high cholesterol
is only a risk marker, a factor that is secondary to the real cause
of coronary heart disease. It is just as logical to lower cholesterol
to prevent a heart attack, as to lower an elevated body temperature
to combat an underlying infection or cancer.
It has also escaped the panel’s attention that the effect of
the new cholesterol-lowering drugs, the statins, goes beyond a lowering
of cholesterol. The question is whether their cholesterol-lowering
effect has any importance at all because the statins exert their effect
whether cholesterol goes down a little or whether it goes down very
much.
No doubt, the statins lower the risk of dying from a heart attack,
at least in patients who already have had one, but the size of the
effect is unimpressive. In one of the experiments for instance, the
CARE trial, the odds of escaping death from a heart attack in five
years for a patient with manifest heart disease was 94.3 %, which
improved to 95.4 % with statin treatment
For healthy people with high cholesterol the effect is even smaller.
The WOSCOPS trial studied that category of people and here the figures
were 98.4 % and 98.8 %, respectively.
In the scientific papers and in the drug advertisements these small
effects are translated to relative effect. In the mentioned WOSCOPS
trial for instance, it is said that the mortality was lowered by 25
%, because the difference between a mortality of 1.6 % in the control
group and 1.2 % in the treatment group is 25 %.
When presented with accurate statistics on the value of statins,
almost all my patients have rejected such treatment. To claim that
the statins dramatically reduce a persons risk for CHD, as was stated
in the press by Claude Lenfant, the director of the National Heart,
Lung and Blood Institute, is a misuse of the English language.
The figures above do not take into account possible side effects
of the treatment. In most animal experiments the statins, as well
as most other cholesterol-lowering drugs, produce cancer (see
reference 90), and they may do it in human beings also.
In one of the statin trials there were 13 cases of breast cancer
in the group treated vid pravastatin (Pravachol®), but only one
case in the untreated control group, a scaring fact that is never
mentioned in the advertisements or the guidelines.
It is also an alarming fact that in one of the largest experiments,
the EXCEL trial, total mortality after just one year's treatment with
lovastatin (Mevacor®) was significantly higher among those receiving
statin treatment. Unfortunately (or happily?) the trial was stopped
before further observations could be made.
In human beings the effects of cancer-producing chemicals are not
seen before the passage of decades. If the statins produce cancer
in human beings, their small positive effect may eventually be transformed
to a much larger negative one, because side effects usually appear
in much higher percentages than the small positive ones noted in the
trials.
Whereas possible serious side effects of the statins are hypothetical,
those from the previous cholesterol-lowering drugs, still recommended
by the panel, are real. Taking all experiments together, mortality
from heart disease after treatment with these drugs was unchanged
and total mortality increased, a fact that has given researchers outside
the National Cholesterol Education Program and the American Heart
Association much reason for concern.
The panel’s dietary recommendations represent the seventh major
change since 1961. For instance, the original advice from the American
Heart Association to eat as much polyunsaturated fat as possible has
been reduced successively to the present “up to ten per cent”.
But why this limit? Seven years ago the main author of the new guidelines,
Professor Scott Grundy, suggested an upper limit of only seven per
cent, because, as he argued, an excess of polyunsaturated fat is toxic
to the immune system and stimulates cancer growth in experimental
animals and may also provoke gall stones in human beings. These warnings
have never reached the public.
Furthermore, the panel ignores that a recent systematic review of
all studies concerning the link between dietary fat and heart disease
found no evidence that a manipulation of dietary fat has any effect
on the development of atherosclerosis or cardiovascular disease (read
summary of the paper -this paper won the Skrabanek Award 1998).
For instance, in a large number of studies, including the incredible
number of more than 150,000 individuals, none of them found the predicted
pattern of dietary fats in patients with heart disease.
No supportive association has been found either between the fat consumption
pattern and the degree of atherosclerosis (arteriosclerosis) after
death.
Most important, the mortality from heart disease and from all causes
was unchanged in nine trials with more radical changes of dietary
fat than ever suggested by the National Cholesterol Education Program,
a result that was confirmed recently in another review (read
the paper and my
comment).
To suggest that diabetic patients should obtain more than 50 percent
of their caloric intake from carbohydrates seems unusually bad advice.
Many carbohydrates are quickly transformed into sugar inducing rapid
changes in blood sugar and insulin levels and thus stimulating a rapid
conversion of blood sugar to depot fat and chronic feelings of hunger.
Diabetic patients should eat more fat.
Is it a coincidence that the Americans’ decreasing intake of
fat during the last decade has been followed by a steady increase
of their mean body weight and an epidemic increase of diabetes?
Instead of preventing cardiovascular disease the new guidelines may
increase the mortality of other diseases, transform healthy individuals
into unhappy hypochondriacs obsessed with the chemical composition
of their food and their blood, reduce the income of producers of animal
fat, undermine the art of cuisine, destroy the joy of eating, and
divert health care money from the sick and the poor to the rich and
the healthy. The only winners are the drug and imitation food industry
and the researchers that they support.
Uffe Ravnskov
MD, PhD, independent researcher
Spokesman for THINCS, The International Network of Cholesterol Skeptics
A short edition of the above was sent to the editor of JAMA. Read
his answer.
If you lack the scientific evidence of something written above you
will find it in The Cholesterol Myths Feel free to publish this site
anywhere, but don't forget to tell from where it comes
Published June
2, 2001; latest revision Oct 31, 2003
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