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Nutrition Past and Future

TPNS 36-39: The Infamous Ancel Keys

Primitive Nutrition 36:
The Infamous Ancel Keys? Part I


In order to demonstrate the reliability of the information and the quality of the reasoning you will find among the cholesterol confusionsists, I'd like to focus on a favorite whipping boy of theirs, the great Ancel Keys. 

Ancel Keys was one of the most famous public health researchers of the twentieth century.

He pioneered several modern techniques in health and biology...

including detailed comparisons of whole populations to determine the effects of different lifestyle factors on health.  It was out of this research that he more than anyone else established the connection between saturated fat and coronary heart disease.

This has made him persona non grata among the lovers of saturated fat.  Google his name and after a Wiki entry and a biography page from the school where he worked, you will see a series of attacks on him from the confusionsist blogosphere. 

One source of noise in that echo chamber is Mark Sisson, who turned his primal analytical skills to Keys and to saturated fat in this "definitive guide."  Calling it "definitive" would lead one to believe he is quite confident about the quality of his research.

In targeting Keys, Sisson has a distinct advantage in this debate because he has chosen an adversary who is dead.  Before taking him on, he attempts to demonstrate how woefully misguided the world is about saturated fat by simply reporting the number of hits a Google search turned up for the phrase "artery-clogging saturated fat."  He got 4,490 results.  We are to take this to mean the internet is abuzz about how saturated fat clogs your arteries.  Of all the research strategies one might choose, counting hits on Google has to be the laziest.  Therefore, I'll give it a try, too...

My search for the false statement "saturated fat is good for you" turned up 129,000 hits, or nearly 29 times as many as Sisson's search.  Feeling better about the internet's collective wisdom now, Mr Sisson?  I'm not. 

Notice the way he expresses himself in this blog.  "Doctors toe the company line," "the public ... laps it up from birth."  This is a rather contemptuous tone for science writing but this is just how broscientists think.  Apparently Mark Sisson fancies himself to be an extraordinarily intelligent man.  That must be quite a cross to bear.

He goes on: "It all started, of course, with the infamous Ancel Keys and his Seven Countries Study."  What does “it” refer to?  If he means suspicions that saturated fat contributes heart disease, and I do think that is what he means, he is definitively wrong.  That did not start with the Seven Countries Study.

A link between fat and heart disease was suspected in the 1930's.  These concerns planted the seed for Keys' work years later.

Here is another source for this history.

Keys first turned his attention to cholesterol and heart disease in 1948.  He was not convinced there was a connection.

He first made public his suspicion of the American high fat diet in 1952.  Notice he was not concerned about dietary cholesterol.

The following year he delivered a landmark speech blaming dietary fat for its contribution to heart disease, yet he did not believe it deserved full blame.  This 1953 address and the paper associated with it are what Sisson is actually criticizing in his article, although he apparently doesn’t understand that.

The Seven Countries Study was begun five years later in 1958 to investigate Keys' concerns. 

In 1961 Keys first makes the distinction that it is specifically saturated fat, and not dietary fat in general, that increases blood cholesterol. 

By 1964 it was a common belief that saturated fats contributed to heart disease.

In 1968 it was shown that reducing saturated fat in the diet could lower risk factors for heart disease.

And it is in 1970 that the Seven Countries Study was first presented.

So in his so-called definitive guide, Sisson doesn’t even know which paper he is talking about.  He thinks the Seven Countries Study was named incorrectly because Keys didn’t use information for 22 countries, but he doesn’t understand that that data about 22 countries relates to his 1953 paper, not the Seven Countries Study.  When he says it all started with the Seven Countries Study, he is off by somewhere between 17 and 35 years or so, depending on which events you think he has in mind.  And he fails to present the cautious and gradual development of Keys' ideas leading to his concerns over saturated fat.  All this while he has the temerity to call him infamous, and present the medical world, in other words, people with proper training, as towing the company line.  This is the shoddy arrogant broscience of a shirtless supplement salesman and fad diet promoter.  I'll show you how even this data on the 22 countries on this graph is being abused, but first, let's take a moment to remember the man Sisson calls "infamous".

This was the man who created the K rations that fed American soldiers in World War II.

He also lead a one-of-a-kind starvation experiment using healthy volunteers so that Allied forces could better understand and manage the undernourished victims of the war once they liberated them.

Keys also introduced the idea of a "Mediterranean diet" to America, a nutritional model that has contributed far more to good health than any fad diet based on cavemen.

Regrettably, the Mediterranean diet is falling out of favor today in its native lands, with meat-consumption increasing and waistlines following suit.

Did you notice on this slide that Keys lived to 100?  Even this accomplishment has been derided by the most small-minded of the low carb fringe.

Here's a blog post entitled "Jack LaLanne vs Ancel Keys" by fat and meat apologist Michael Eades.  In his mind there is something to be gained by casting a fitness legend and a science legend as opponents.  At 93, LaLanne looked fantastic...

And at 100, Keys looked, well, 100.  Eades wants us to choose who we would rather look like in old age.  You stay classy, Dr Eades.

I guess when you're the physical specimen Dr Eades is, you have a right to judge the appearance of centenarians.  I wonder if Eades ever his shared fitness tips with LaLanne.

Keys' longevity is annoying to Eades.  Read this slide and you'll see Mark Sisson isn't the only one saying Ancel Keys cast a 40-year-long Jedi mind trick on the medical establishment. 

Eades wants to associate himself with Jack LaLanne.  Since their connection isn't immediately obvious, he provides a link to an old video of LaLanne talking diet.

The video is mostly about sugar, but at the end LaLanne does say you should try to eat a lot of protein for breakfast, lunch and dinner.  Eades likes this advice about protein, of course.

He will be disappointed to learn that LaLanne did not maintain a special focus on protein for the rest of his life.

LaLanne spent years as a strict vegetarian.  His protein fixation in the video was nothing more than the product of the conventional wisdom of the time.  While he did eat fish and egg whites, he abstained from other meats and dairy throughout his later years.  He made up the difference with lots and lots of fruits and vegetables.  This, along with his fitness regimen, explains his great health into old age.  If the esteemed Dr Eades did not limit his research to watching a single YouTube video he might have learned that he did not share a lot with LaLanne...

and he would have found that Keys himself was hardly a radical.  Keys only advocated eating less meat, eggs and dairy, and encouraged the consumption of other animal products. He considered fruits and vegetables to be merely supplemental.  Consequently, his cholesterol score of 209 would be considered borderline-high today.  It seems to me Dr Eades has more in common with Keys than LaLanne.

Back to the broscientist Sisson.  After his mangling of history, he next repeats a critique of Keys that you will find all over the internet.  He references "original evidence“ about 22 countries that would have "demolished" the substance of Key’s paper, which again is based on his speech in 1953, not the Seven Countries Study.  His additional red dots on the graph’s right side represent some primitive populations, two of which I have already addressed in the Primitive Nutrition series.  You know the real story on those cultures now.  Do you think he bothered to research those?  You will notice Sisson has shifted from saturated fat to fat in general.  Did he notice himself just do that?

Sisson dares us in his swaggering brosciency style to draw a line through the points in this irrelevant graph.  He then makes the trite observation that an epidemiological study demonstrates correlation and not causation.

No one says correlation equals causation, much less that a single epidemiological study can make an airtight case for causation, including the Seven Countries Study, which again, is not what Sisson is referring to.  Realize the Seven Countries Study was the first of its kind so it was not as refined as similar studies that followed.  It was flawed enough that it couldn't even turn up a connection between smoking and heart disease.  But back to Sisson’s graph…

Really, he’s just parroting a bogus critique that you’ll see all over the internet from confused confusionists.

As best I can tell this material originates from Dr Uffe Ravnskov.  He also develops this critique further than Sisson, so I will our shift attention now to his book, The Cholesterol Myths 

Like all cholesterol skeptics, Ravnskov comes across as quite old-fashioned. He seems to think atherosclerosis just happens to arteries with age after a lifetime of stressful bloodflow.  For unknown reasons, he unhelpfully informs us, some people are unlucky enough to develop irregular plaques.

To me this sounds a lot like this text from 1908 attributing heart disease to mysterious variations in "vital rubber”.  I also included some material here about moderate smoking being safe to emphasize the obsolescence of this publication.

On this page you can see why I'm more interested in Ravnskov's writing than Sisson's.  He at least manages to get a date right and seems to be aware of the Mediterranean diet idea.

But he, too, relies on inflammatory language.  His odd phrase in the third line from the bottom, "the Americans are inferior to other countries," suggests he is fumbling for an emotional hot button in his readers to press.

Look at this sentence: "He considered a defeatist attitude about coronary heart disease to be despicable."  This language is inappropriate and does not reflect Keys‘ measured tone at all.  The Swedish Dr Ravnskov then engages in some armchair social psychology about the "proud" American people for whom the word "aggressive" is a word of honor.  That’s pretty funny, doctor.

Back to the content.  This seems to be the point of origin for the the notion that Keys should have used data for 22 so-called "original" countries.  There may have been data, but that doesn't mean it was in any way usable, as we will see. The reference to 22 countries seems to have come from an article by Yerushalmy and Hilleboe in 1957, before the Seven Countries Study even began.  Ravnskov knows this, so he is not claiming he is criticizing the Seven Countries Study here.  Mark Sisson did not even understand what Ravnskov wrote about Keys, much less bother to understand Keys’ work for himself.

Yerushalmi and Hilleboe were writing in response to that landmark address Keys gave in 1953 and it’s corresponding paper.  Keys was affected by their critique.  It helped to eventually guide him to the real culprit, saturated fat.  This took time.

The first report from the Seven Countries Study was published in 1970.  Keys had refined his understanding of the effects of different fats by then.

So when someone like Gary Taubes writes about how Keys was shown to be wrong about dietary fat by Yerushalmy and Hilleboe, he is not accounting for Keys' process of understanding the unique harmful effects of saturated fats.  Science progressed, and Keys' views did as well.  You see here Taubes is another one who can't resist repeating the tired truism that correlation is not causation.  I guess it takes the science writer Gary Taubes to inform the medical world that one of their major modes of research is basically useless.  Either that or Taubes simply doesn't understand the value of epidemiology. 

Correlation is not the same thing as causation, but correlation can certainly help in the search for causation. Epidemiology helped show us how bad smoking is for us, for example.  Undue skepticism of this important type of research can cost lives.

In Part II, I'll look at these 22 countries and what Yerushalmy and Hilleboe had to say about that so-called original data.  This will not be good for the low carbers.


Primitive Nutrition 37:
The Infamous Ancel Keys? Part II


At the end of Part I, I showed you that much of the criticism of Keys is based on a rebuttal to a paper of his from 1953 by two researchers named Yerusalmy and Hilleboe.

Epidemiology as an Investigative Method for the Study of Human Atherosclerosis JEREMIAH STAMLER, M.D JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION MAY, 1958

Here is the graphic Yerushalmy and Hilleboe presented in that rebuttal, and it should look familiar.  Ravnskov, Sisson, and all the other Keys-bashers use it.

I do not have access to the text of their paper, but from these excerpts, it is clear it was intended to be, and was received as, a rebuke by Keys. 

It provoked him to sort out what he called "puzzling discrepancies" in his observations of fat by conducting controlled experiments.  Through these, he found that saturated fatty acids with greater than 12 carbons were those that harmed health.  These are called long-chain and very-long-chain fatty acids which have higher melting temperatures than unsaturated fats and are associated with animal foods.

The paper by Yerushalmy and Hilleboe struck a general tone of skepticism about both the diet-heart relationship and about epidemiology in general.  These views now seem antiquated.  Once again, everyone knows correlation does not equal causation, yet saying so never seems to get old.  In fairness, it was probably a fresher idea in 1957, though.

Let's focus on four of these countries first.  They are showing high fat intake in 1950 but low mortality from heart disease.  Anyone familiar with the history of cholesterol and fat research should immediately know what is happening here.

This is a famous study often used to implicate animal products in heart disease.  Mortality from heart disease went down in Finland, Norway and Sweden *following the Second World War because their fatty animal foods were less available *during the war.  This is not apparent in that graph. Yet we know it takes time for heart disease to develop, so if diet does matter, then changes in diet will take time to show any effects.

This lag time between that food supply disruption and its effects on the health of the people who experienced it is actually supportive of the argument that saturated fats induce heart disease.

Let's look at each country appearing in both this study and the Yerushalmy and Hilleboe graph individually.

Finland was mentioned as well, but I didn't circle it.  As number 7 on this graph, it is not an outlier in connecting fat to heart disease.  We'll look at Finland more later.  First is Denmark.

Denmark was occupied by the Germans.  Their consumption of animal foods fell dramatically during the war, especially eggs.

The Netherlands is next.

They had been in the grips of the nightmare of the Dutch Famine imposed by the Nazis in 1944 and 1945, so that can be explained by the war as well.

That brings us to Norway and then Sweden.

Norway experienced a reduction in fat consumption during the war.

And so did Sweden.

Removing those countries would clean up our graph a bit.  Mexico, number 14 at the bottom stands out, doesn't it?  I'll get back to that, I promise.

So the so-called "original evidence" is not looking so compelling for this argument made by Taubes and Ravnskov.  For someone who pretends to have looked under every stone to do real research into fat, Gary Taubes steps in a curious contradiction when he mentions this paper by Yerushalmy and Hilleboe, as does practically everyone else who mentions it.  They do not seem to have actually looked at their paper.

If they did, they would see this table.  Here are the statistical correlations for mortality they found within these countries. Calories from fat did correlate to mortality, but other factors correlated better.  Animal fat correlated to deaths better than fat in general.  Vegetable fat did not correlate well.  Percentage of calories from animal fats correlated well with deaths, but the percentage of calories from carbohydrate did not correlate at all.  Are you listening, Gary Taubes?  Which factor had the best correlation?  Calories from animal protein was best.  This was their correction of Keys.  Animal protein had been overlooked.  Isn't it interesting that Gary Taubes and Uffe Ravnskov fail to mention this?

As far as I can tell, Yerushalmy and Hilleboe took their data for these 22 countries from work done by the Food and Agriculture Organization of the United Nations.  These data, when looked at in detail, point to dietary patterns that had high correlations with heart disease, including total calories, saturated fat and cholesterol.  So the so-called "original evidence" actually reinforces Ancel Keys' belief in the diet-heart idea, as well as our present understanding of it.  Do you think Mark Sisson realizes this when brings up this so-called “original evidence”?

You can see that in textbooks written by people without the agenda of Taubes or Ravnskov, that paper by Yerushalmy and Hilleboe is indeed seen as a rebuttal to Keys.

However, these textbooks include the point they were trying to make:  Animal protein seemed to be more damaging.

Here is another textbook mention of this. 

And here is another.  They pointed to animal protein.

Here we can see what Hilleboe thought in his own words.  The association between cardiac death and diet is stronger for animal protein.  Now he does go on to say that noncardiac death is inversely related to animal protein, but this is explained by the difference between diseases of poverty and diseases of affluence.  I’ll talk about this in Playing Games with your Heart.  Hilleboe’s overall point here was simply that the definition and causes of heart disease were hard to nail down, which may have been true in 1957 but is far less true now.

By 1960 it was beginning to be understood that the separate and conflicting associations of fat and animal protein were best reconciled by separating out saturated fat from animal foods.

And as I said earlier, Keys understood this in 1961 as well.

Hilleboe had previously drawn attention to animal protein in 1952.  Yerushalmy and Hilleboe found an inverse correlation with vegetable protein, meaning people were less likely to die the more vegetable protein they ate.  Here is another graph Mark Sisson might like. If you dared him, he could draw a decent line to demonstrate animal protein's risks.

It was not outlandish then to believe animal protein is more damaging than animal fat.

Here is a textbook from 1920 on heart disease.

Red meat was called undoubtedly harmful in excess.  The purine-producing proteins of meat were thought to be the problem.  Fats were seen as innocent.

Fast forward to 1979 and you can see that animal protein was still thought by some to be the real culprit.

Here is the work of a researcher named Kritchevsky who was mentioned in the previous slide.  In 1995 he summarized the case against animal protein, believing it was more important than animal fat.

Animal protein is still treated as a suspect today.

This abuse of the work of Yerushalmy and Hilleboe has been repeated by many other apologists for dangerous low carb diets.  Here is prominent fad diet promoter Jeff Volek also mentioning this paper and totally missing the point.  He mentions Ravnskov's The Cholesterol Myths as a reputable source, which should tell you plenty about his biases.

Evidently low carb promoter Richard Feinman also stepped in this.  He brings up Yerushalmy and Hilleboe to support his fringe ideas in a Power Point presentation, as you see here.  This guy argues that protein has a metabolic advantage, yet he references these two authors who tied animal protein to heart disease.  This is what passes for good scholarship among the low carbers.

I'm not done with Yerushalmy and Hilleboe, and I'm far from through with Dr Ravnskov.  I'll meet you in Part II for more.


Primitive Nutrition 38:
The Infamous Ancel Keys? Part III


Picking up where we left off ...

Here's another problem with using that data for 22 countries to argue against the Seven Countries Study, if that’s really what the confusionists insist on doing.  As I said, that data came from a statistical compilation by the FAO.  That was not data used in the Seven Countries Study.  The Seven Countries Study was a prospective cohort study. Researchers were dispatched within the seven countries to collect their own data using uniform standards.  Individuals were studied prospectively, or over time, so they were considered cohorts.  This study was not created by merely crunching someone else’s data, which is what Yerushalmy and Hilleboe did.  Keys was working with far better and more useful data than those two.  I'll give you an example of a problem with their data...

And bring us back to Ravnskov and Mexico, as promised.  Ravnskov says, "at that time information was available for 22 countries."  You can now see how that careless sentence has lead to so much misinformation today.  He goes on to contrast Mexico with Finland. 

Here they are on the graph.  You can see why he picked them - similar fat consumption but very different death rates.  Ravnskov should know the explanation for this.

He knows how much standards for the recording of deaths can vary by country.  He doesn't seem to be aware how this undercuts his own argument, however.

Mexico had not even developed a death certificate system when that data was collected.  I think that might go a long way toward explaining their low reported mortality rates, don’t you?

Moreover, when they were recorded, the accuracy of the cause of death was notoriously unreliable there.

In 1958, it was known that these factors made the determination of rates of mortality from heart disease very difficult there.  Keys didn’t have such enormous problems with his data, but Yerushalmy and Hilleboe did.

Here’s another issue.  This is a passage Jeff Voleck liked but I doubt he fact-checked it.  Ravnskov states that heart disease is five times more common in eastern Finland than in western Finland.  Ravnskov thinks this disproves the diet-heart hypothesis because he assumes they ate the same food in both places.

First, Ravnskov doesn't seem aware of the importance of statistical power in epidemiology.  He feels he has disproven this hypothesis based on a difference in heart attack deaths of only 12 individuals.  It is well understood in population studies that such small samples are not meaningful.  This sort of data is statistically insignificant, and it’s certainly nothing that threatens the diet-heart idea.  Ravnskov is just grasping at straws now.

It's interesting he would choose to bring up Finland.  Here is a map of Finland.

And here are the cities that represent east and west Finland in this data.

There actually was a difference in saturated and overall fat consumption between the two places.  East Finland ate more saturated fats and had more heart attacks, even in that small sample.

I wouldn't call that no correlation, as Ravnskov does here.  It correlates in the expected direction, with the region with more saturated fat and total fat suffering more cardiovascular events.

The area so afflicted by heart disease, North Karelia from eastern Finland, became the focus of a huge effort to lower its heart disease mortality.  The campaign against cholesterol and saturated fat was successful in saving lives in North Karelia.

Ravnskov knows this and decides to takes it on.  He says the decrease in heart mortality started before the program did.  He even says the program increased heart disease in its first three years.  Ravnskov really should know better than to say this. He published this book in 2000, so he could easily have looked beyond just the first three years.  But first, notice he then mentions Jukka Salonen as agreeing with him that the project could not be said to have had a beneficial effect.  He is mischaracterizing Salonen’s views.

Here is the paper of Salonen from 1987 to which Ravnskov refers.  I do not have access to its contents.  I can show you what he thought, anyway.

Salonen clearly thought they were on the right track with this program in 1983.

And in 1985 Salonen was clearly convinced that serum cholesterol was an important risk factor for heart disease. 

In 1989, two years after the paper to which Ravnskov refers, Salonen was troubled to see a flattening of the decline in heart disease deaths.  He linked this to a lack of progress on blood cholesterol and blood pressure.

And in 1991, four years after the paper Ravnskov references, he wrote that saturated fat consumption was associated with high blood pressure.

That Ravnskov leaves all this out in a book published in 2000 should tell you a lot about his credibility.

What about Ravnskov's claim that cardiovascular mortality increased after the project but had been decreasing before it?

Look at the left at all he had to ignore to say that.  He is only focusing on that little blip up in mortality around 1975, the first little upturn to the left.  Again, he wrote this book in 2000.  He knew about the bigger trend going way, way down.  Yet he decided to give you the opposite impression based on that little blip.

But what of the statement that a downward trend had already begun before the campaign?  Maybe that was because saturated fat consumption had already been declining.  Butter consumption started falling steeply back in 1965, as you see on the right.  Ravnskov did not tell you that, either.

Here we can see the effect of the campaign in the two communities with which Ravnskov is so concerned, North Karelia and Turku.  Both saw fewer deaths because this public health campaign helped the whole country.  This looks like a good news story to me, but not to Ravnskov.  Let’s not lose sight of something here.  These are not just lines on graphs.  These are the deaths of ordinary people, every one a tragedy for a loved one.  Lines moving down like that mean more people got to spend more years together with the ones they loved.  I don’t understand how Ravnskov can make these manipulative arguments.  Does he not want to save lives?

So far, I've talked a little about the Seven Countries Study but I've only shown you Yerushalmy and Hilleboe's tables and graphs in response to that 1953 address and paper from Keys.  Isn’t it about time we look at the graphs that appeared in the Seven Countries Study now?  They can be found in Steinberg's excellent historical accounts.

Here they are.  The graph on the left is for the relationship between blood cholesterol and deaths and the one on the right is for saturated fat and deaths.  You can see why the cholesterol apologists don't like the Seven Countries Study.  There are definite patterns in his data.  It is clear that as cholesterol and saturated fat rise, so do cardiovascular deaths.

There are some other graphs freely available from Keys' work during the fifties.  I have not seen the cholesterol skeptics address these.  The graph on the left show us blood cholesterol levels among people of Japanese descent from different socioeconomic backgrounds and regions plotted with calories from fat.  Although this is one shows calories from fat in general, and so it was created before he came to understand saturated fat, the correlation between fat and cholesterol is strong.  Similarly, you can see on the right how rates of heart disease compared between Japanese individuals living in Japan versus ethnic Japanese in Hawaii, and how that relates to fat consumption.  Living in Hawaii provided these people more saturated fat, so they suffered more heart disease.  Pretty impressive visuals, aren’t they?

Here is a later pair of graphs created by Osmo Turpeinen in 1979 that looked a lot like Keys‘ graphs.  The graph on the right is for dairy fat.  That he found similar patterns suggests to me that Keys was onto something.

The effect on coronary heart disease of saturated fat consumption has been observed in many other studies.  Keys was merely the first to do large scale epidemiology on this.

It is worth pointing out that the Seven Countries Study continued to be useful after 1970.  The cohorts continued to be followed.  Here is a paper checking in with the participants at 25 years.

This caught up with the Finnish cohort at 35 years.  This investigated the relationship between height and heart disease.

This is a follow up at 40 years.  Cholesterol levels are still looking important in this one.  Research into the diet-heart hypothesis did not stand still after Keys' involvement ended.

Which brings me back to Mark Sisson for one last comment.  He wants you to believe that forty years ago the whole medical profession was hoodwinked by Ancel Keys, a man he presents as either dishonest or stupid, and they have all marched in lock step ever since.  Does that make any sense to you?  Or does it make more sense that Keys, after recognizing the unique effects of saturated fat, was right and has been proven right over and over ever since?  To think like Sisson does, you need to think you are a lot smarter than top research scientists all over the world over a period of decades. 

Alright, enough about Sisson.  In Part IV I want to talk more about Ravnskov.


Primitive Nutrition 39:
The Infamous Ancel Keys? Part IV


I have a few more words on this first chapter of Ravnskov's book.  This is a really interesting statement of belief from Dr Ravnskov. 

"Thus, although a risk factor changes in parallel to the death rate, that still does not mean that the risk factor is necessarily the cause.  But if the risk factor is the cause, its rise and fall must be reflected, with no exceptions, in the rise and fall in the death rate from the disease."

Ravnskov wants to present the world in simple binary terms, with no tolerance for the messiness and complexity of real life. This is not a reasonable expectation for any epidemiological study.  It is totally inappropriate with regard to heart disease as well.  There are many risk factors for heart disease, some of which are likely unknown at this moment.  That in no way detracts from the importance of the ones we do know.  We all know of stories of smokers living past 80 but does that mean that smoking does not lead to heart and lung disease?  Of course not.  There is too much science that says otherwise.

Ravnskov gets so silly in his opening chapter, he even argues that the ownership of televisions is a risk factor for heart disease because that correlates along a gradient for income, just like heart disease.  Does he have a point?  Does owning a television hurt your heart somehow?

Epidemiologists know any observations of practical importance will need to be biologically plausible.  There is an enormous amount of research stretching back over 100 years behind the idea that cholesterol has a causal role in heart disease.  Can the same be said about televisions?  How would that work on a mechanistic level?

Here you can see that medical science does not say that high cholesterol is the only contributor to heart disease.  Others include age, gender, heredity, smoking history, high blood pressure, exercise history, BMI, and diabetes, among others. The are many more risk factors of interest as well.  No one expects them to not interact in complicated ways.  Ravnskov knows this of course, but he is more invested in clinging to his beliefs and selling contrarian books than he is in protecting public health.

The television argument and all the other poorly researched and reasoned nonsense I've brought up so far only gets us part way into the first chapter.  It's at this point that I start to look longingly at all the much more promising books around me that I'd rather be reading.  Ravnskov hasn't put enough thought and work into The Cholesterol Myths to be worth a full read, much less a full length review by me here.  The responsibility for fact checking really is on him and his publisher.  And who is his publisher?  The Weston A Price Foundation and Sally Fallon, of course.  This is the sort of quality information I've come to expect from them.

Before giving up on this book, I wanted to see Ravnskov's take on Dean Ornish's famous study.

Ornish was able to prove that heart disease can actually be reversed through a low fat, whole plant based diet.  How could Ravnskov argue with this?

Here is his answer.  Vegetarians don't have less heart disease so diet was not responsible for the success Ornish had.  He says we should look at page 107 to see his evidence for this statement.  I would have to reproduce that whole page here to show you it contains no such evidence.

I, on the other hand, will show you evidence to the contrary now.

"Death rates were lower in non-meat-eaters than in meat eaters for each of the mortality endpoints studied."  That included ischemic heart disease, which is the restriction of blood flow to the heart due to plaque build-up.

Ischemic heart disease was "much less frequent among strict vegetarians for both sexes."

"Vegetarianism seems to confer some protection against ischemic heart disease."

Five different studies were combined here to show a 26% reduction in death from ischemic heart disease for vegans.  You see the that some groups did better than vegans, but unfortunately I think it is likely that people eating fish but not meat are generally more health conscious than vegans.  Vegans typically chose their diet for ethical reasons.  The high percentage of them not supplementing with B12 is proof of their collective cluelessness about nutrition. A recent study using the EPIC-Oxford cohort found, and I quote, "Fifty-two percent of vegans, 7% of vegetarians and one omnivore were classified as vitamin B12 deficient"  Vegans, stop being foolish and take your B12.

We can look at Ravnskov's unreferenced claim another way.  Meat consumption is positively correlated to ischemic heart disease in this study.

Ravnskov is an interesting doctor. Here you see he doesn't seem to believe in prevention or the precautionary principle in the interest of saving lives.  He says, "why inflict a diet that only rabbits may find tolerable on millions of people?"  Does this sound scientific and reasonable to you?  Who is doing the inflicting?  Do rabbits eat tempeh or nutritional yeast or oatmeal or mangoes?  And why does this medical doctor think this is an appropriate reaction to a landmark study showing an effective strategy against our top killer?

Like most apologists for disastrous diets, Ravnskov is too captive to his idea of pleasure to accept the mountain of evidence before him.

This order of priorities is stark in his writing here.  He would like you to believe diet cannot effect your cholesterol levels much.  Clearly, that is not true and even he must admit that.  However, palatability is a higher priority to this particular physician.  He should ask a few vegans if they like what they eat.

Dietary cholesterol does in fact affect blood cholesterol.  Some confusion over this has occurred because once you've eaten up to a certain amount of cholesterol, eating more doesn't do much additonal harm.

A strategy of prevention was appreciated as appropriate by the medical establishment long ago.  Fortunately, most doctors think prevention is worth some effort, unlike Ravnskov.

Ravnskov is the founder of The International Network of Cholesterol Skeptics, which forms the acronym, "THINCS".  I like this name.  It's funny to me that he should pair a drawing of Rodin's "The Thinker" with an acronym that spells "thinks" wrong.  It also gives the impression these folks are the only ones who are really thinking about cholesterol.  It's quite a select bunch.  Only 88 people in the whole world.  Two of whom are dead.  Ravnskov must have offered lifetime memberships and afterlife memberships for anyone willing to support his ridiculous site.

Compare those 86 living members of THINCS to the number of prescribing doctors there must be who accept the lipid hypothesis.  There were 29.7 million people using 174 million prescriptions for statins in 2005.

Ravnskov has made some other argumens I can't ignore here.  I listened to this podcast.  He repeats a common canard, saying scientists perpetuate a belief in cholesterol's role in heart disease because they want to continue to receive research funding.  This ignores how scientific research works.  Science is competitive.  Anyone who could find a more successful treatment strategy would be assured enhanced stature, and pharmaceutical companies would gladly produce new drugs to sell based on this research.

He also floats another half-baked conjecture about the cause of heart disease. He says atherosclerosis is an infectious disease but he doesn't name a particular pathogen that causes it.  No, this is the first infectious disease caused by stress or carbs.  It's an infectious disease that begins as fatty streaks in childhood and advances throughout life.  It's an infectious disease that afflicts populations with the lowest burdens of infectious disease.  This is a major advance in germ theory if it's true.

One of his proposed solutions to heart disease, based on his lifetime of serious research I presume, is vitamin D, a vitamin he admits here he hasn't really studied.

Amazingly, with these insights he thinks he is on firm enough ground to accuse the rest of the medical world of lying about what causes our top killer.

"I'm not a specialist in this area so I don't know exactly what to do, but I think we should look for other causes of heart disease..."

He also makes some other amazing assertions.  People with familial hypercholesterolemia don't die from heart disease sooner because of their cholesterol.  No, it's because of their blood coagulants.  Yet you can see here that cholesterol is believed to increase coagulation, and that plant foods and low fat diets can lessen it.  So if this is his belief, shouldn’t he at least recommend a vegan diet for people with inherited high cholesterol?

Almost everything I've heard him say is totally irresponsible, but his comments about familial hypercholesterolemia are especially terrible.  He has actually suggested that people with this genetic defect live longer.  He is basing this crazy claim on studies of the ancestors of people with this trait.

Here's the study he is talking about.  Indeed, fewer people who carried this trait died in the old days than now.  But the question is why.  The authors themselves say high consumption of fat in modern times may be at least partly explanatory. 

That wasn't the only study to look back in time at people with this phenotype.  Heterozygotes were suffering deaths from heart disease at only 45 years old.  Their ancestors had lived to old age, though.  Why? Lifestyle factors, of course.  In this study, one patient dropped his cholesterol from 426 to 248 with a low fat diet.  Do you see why Ravnskov cited the other one and not this one?

Familial hypercholesterolemia is a serious matter with which Ravnskov should not play around.  Children with FH are far more likely to lose a parent to heart disease when their lipids profiles are poor.

Something we should keep in mind when we see comments like Ravnskov's about people with FH is that there are no modern studies on people with this phenotype because it would be unethical to give such individuals a placebo instead of the treatment they need to survive.

An alternative treatment was ethical in this study of children with FH because they were too young to be at risk for heart disease.  Soy protein was shown to lower their cholesterol, unlike animal protein. 

I love this published response to Ravnskov by Martijn Katan.  He points out the absurdity of Ravnskov's insistence that health risks that take years to manifest in disease be proven in short trials or in the lab.   If that standard were similarly applied to other health hazards, the implications would be unacceptable.  We wouldn't be able to say cigarettes are harmful or that you should wear safety belts...

or that asbestos causes mesothelioma.

Katan then does something very funny.  Look at that top right line.  He says Ravnskov has published 58 letters to the editor repeating the same faulty arguments.  Dozens of scientists have patiently responded to him.  He then provides citations for all 58 letter!

That's what they look like together.  How ridiculous!

Here's a quote from Ravnskov in that podcast.

"I have sent a large number of letters to various journals pointing out that there's ... serious error ... They couldn't find a space for my ten or twenty lines of criticism.  This has happened again and again and again."

I hope with my work here you can see why he has trouble getting published these days.

I find it very interesting that those who flail about like Ravnskov in every possible direction to find an alternative cause of heart disease feel diet and cholesterol have been conclusively exonerated. Of course, heart disease is a result of a complex process.  That process involves diet and cholesterol, and those are modifiable risk factors. You can do something about them.

Ravnskov is just like others who claim censorship in science due to their fringe beliefs.  Climate change deniers have the same complaints.

9/11 Truthers feel the same.

The same goes for those who cannot accept the fact of evolution.

And of course the anti-vaccine people see conspiracies around them as well.

THINCS will always have trouble getting published in scientific journals because of their bad science.  We should think of them in the same way as all those other fringe groups claiming scientific censorship.

Ravnskov and Sisson aren't the only ones out there making mischief with the serious matter of heart health.  I'll show you some examples of the games the confusionists play in the next video.

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