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Nutrition Past and Future

Drug-Fueled Delusions

Running a Cholesterol Confusionist Gauntlet, Part 10 – Drug-Fueled Delusions

Cholesterol confusionists comb the literature on the effects of drugs looking for anomalies that they can take out of context and blow out of proportion. Here’s an example of how this works.

On the left, you see an excerpt from Colpo’s journal article. He cites multiple references to support his statement that drug trials have shown no association between the degree of LDL lowering and heart disease mortality. One of his references for this statement is on the bottom left. This is the same reference that occupies the right of your screen. If you check up on Colpo’s reference, you’ll see it doesn’t support his beliefs very well. I’ll quote the authors. “We now report that the rate of coronary events was associated strongly with the plasma LDL cholesterol concentrations during treatment in the total cohort consisting of the patients treated with pravastatin or placebo. This is not an unexpected finding, considering that the HMG-CoAs were developed primarily to reduce LDL concentrations and that a close relationship between plasma total or LDL cholesterol and coronary events is well established.” Now how does Colpo rationalize using this reference? It seems to say the opposite of what he thinks it does. This is a running theme. The people who know the drugs best do not doubt the lipid hypothesis.

The various references used by confusionists about drugs are worthless for their argument, in my view. Who doesn’t know that drugs have side effects? Who doesn’t know that drugs reach the marketplace before their effects on humans are fully understood? Drugs are devised to target specific metabolic phenomena in an effort to short-circuit or alter them. This is a list of genes that have been shown to effect the development of atherosclerosis in mice. Each one is a potential target for a drug. But no drug will exactly duplicate the effects of a healthy diet in a holistic way. Instead, any drug focused on one small effect within the amazingly complex chemistry of the human body will cause distortions of other processes. In the mind of the confusionist, the workings of the human body are governed by simple cause and effect relationships between a handful of perfectly understood variables. Any unexpected finding is not seen by them as a window to understanding our biology in a more nuanced way. Instead, it’s new fodder for their one-sided debate.

Experts in drug therapies are generally up front about the shortcomings of drugs, and will usually remind us that lifestyle modification is preferable to drugs.

The cholesterol spin doctors usually rely on populist and conspiratorial rhetoric. This excerpt from a past article by Colpo is typical of his style.  He calls attention to a drug trial with disappointing results for aggressive LDL lowering, in this case the controversial ENHANCE trial.  He uses the apparent failure of this particular drug combination in this one trial, here a statin combined with a drug intended to inhibit an enzyme called Acyl-CoA cholesterol acyl transferase, to call into question our basic understanding of lipid metabolism.  According to Colpo, the results of this trial show us that big pharma is just out to make a buck as it spreads this big lie about cholesterol.  How’s that for a giant leap of logic? He takes the conclusion of one drug trial and uses that to impugn the drug makers. But, Mr Colpo, I thought you said these drugs had all kinds of benefits! But that’s not all. Here we have a study that showed an apparent failure of a drug combination.  Do you think the pharmaceutical industry wanted this study to fail?  Do you think they cleverly devised a trial to show how ineffective their products are?  How does that make any sense?  The makers of these drugs are Merck and Schering-Plough.  How did this trial result help their business?  Does this result not show instead that the approval process is not designed to maximize profits? If you think about it for a few seconds you’ll see that Colpo’s conclusion is totally backwards. And here’s my big question: What the heck does this have to do with eating foods that lower cholesterol? Does Colpo think simvastatin and ezetimibe are whole plant foods?

A rational and fair-minded person should learn a little something about these drugs before jumping to conclusions the way Colpo did. To give fair consideration to the drugs in question, one would have to consider issues such as those raised here by the US investigator in the ENHANCE trial, Dr Evan Stein.  He points out that participants in the study may not have had enough atherosclerosis to demonstrate the effects of the drugs.  He says the failure of this trial was due to patient selection and study design.  Do you think Colpo took these issues into consideration?  Dr Stein takes the opportunity to dismiss those like Colpo who question the so-called “LDL hypothesis”.

I’ll add that this trial did not look at hard clinical endpoints. It just looked at changes in carotid intima media thickness.  This trial did not investigate actual cardiac events and those are what matter. I already explained in my The Best Low Carb Research video number 53 that carotid intima media thickness may not be an accurate marker of risk.  Colpo probably did not see my video so he may not know this.

The ENHANCE trial results have fueled some controversy. I’ll take a moment to present two sides in the debate over the meaning of ENHANCE.  In this video, Dr Stein points out that the objective of drug therapies is to lower LDL. He says this objective is also met by diets that cut out cholesterol and saturated fat. Both approaches lower LDL and that is why they both work.  Dr Stein is a top expert in lipids and heart disease.

His opponent in the debate, Dr Allen Taylor, argues that ezetimibe did not show good results in ENHANCE because it has off-target effects on reverse cholesterol transport.  It inhibits cholesterol clearance, worsening atherosclerosis even though it lowers LDL, due to unintended side effects.  As if he thinks cranks like Colpo might be listening in on this debate, he says, “This is not about LDL. This is about a drug.”  Now shouldn’t that be obvious? The controversy is not about LDL.  It’s not about diet.  And only someone with an agenda like Colpo would try to make it seem that way. Do you see how much research I have to do to address each of Colpo’s phony arguments? This was one drug trial. Do you really think he has a clue what he’s talking about?

As I showed you in The Primitive Nutrition Series, evidence has come in since ENHANCE  that lower LDL than today’s targets is indeed better.  This is not the only study to indicate this. 

Here’s another.  This is considered evidence to medical professionals.  In a world where people insist on eating foods that cause heart disease, these drugs are necessary.  Someone like Anthony Colpo who encourages you to eat these foods is doing his best to make sure drugs like these generate big profits for the drug companies far into the future.  But don’t expect him to pay the bills for those drugs for you when the day comes that you need them.

Here is the closest thing I could find to a non-ideological argument against treating LDL. Dr Rodney Hayward of the University of Michigan questions whether there is good evidence to try to reach target numbers for LDL through drugs. He believes that statins prove to be beneficial for high risk patients regardless of their LDL number.

Here he went so far as to say LDL should be ignored altogether. Read this slide and you’ll see this was a highly provocative statement.

Recently he publicly urged the Adult Treatment Panel IV participants to abandon the idea of treating to LDL targets. He considers the belief in these target LDL levels to be dogmatic and lacking in evidence.

He believes that the success of statin drug trials has been due to their pleiotropic effects, the same argument used by Anthony Colpo. So would it be right to assume that this well-informed yet contrarian expert would be in agreement with Colpo that the lipid hypothesis is a failed idea? He seems to be on the same page as Colpo, doesn’t he?

Actually, he’s not. He and his co-author for this opinion, Dr Harlan Krumholz of Yale, also say that one does not need to impugn the cholesterol hypothesis. Their argument is that the negative side effects of some of the lipid-lowering drugs might be more important than their benefits from cholesterol lowering. They are not disputing those benefits. It is clear that he thinks it is desirable to have low cholesterol. He is just wary of the effects of some drugs.

Krumholz restates this opinion here as well.

Their concerns are about drug cost and safety. I don’t know about you but I’m glad to see medical experts having debates like this.

It’s time for me to ask you what you think of Anthony Colpo’s case against the mainstream understanding of cholesterol. Is he an isolated voice of honesty and reason protecting you from a massive con job? Or is it he who is trying to distract, confuse, bully and misdirect so that he can pull off a self-serving swindle. Now you have heard an opposing view to his. It’s up to you to decide whom to believe. As you have seen, like most confusionists, he lacks a coherent counterargument to the lipid hypothesis. He is against pharmaceuticals but he thinks they have a lot of benefits. He thinks the examples of the Tokelauans and the Masai damage the lipid hypothesis even though they had relatively low cholesterol. He believes antioxidant status is the most important factor in heart disease despite the lack of scientific support for this view. He desperately tosses out off-topic and unsupported claims about issues of overall mortality, cancer, and depression to change the subject from diet-heart. And worst of all, nearly all his arguments are based on obvious distortions or half-truths, and the few references he can find that clearly support his views are usually of questionable quality. I have no doubt Colpo will have a response to these videos but I am fine with letting him have the last word. I’ve done enough work to address this particular confusionist. If you decide to follow his advice, that’s your responsibility now. I’ve done my job.

Just because the denialist arguments are not being seriously considered anymore, that does not mean there isn’t an active debate today over cholesterol. To end this set of videos, let’s have a look at how today’s legitimate questions about cholesterol are framed. On the one side of this debate presented by the Wall Street Journal, you have a doctor who calls for the use of statins in patients who are not experiencing symptoms but who do have high LDL. He is talking about the prophylactic use of statins, using them for primary prevention. He expresses a typical sentiment: “Good habits like diet and exercise are the foundations of good health—but sometimes they're not enough.” As a whole food vegan, when I read a statement like this I think, “if the diet wasn’t enough, maybe it wasn’t enough of a diet.” I rarely see experts beside the occasional Caldwell Esselstyn or T Colin Campbell advocate diets that are actually likely to dramatically lower cholesterol.

I am not criticizing this doctor. As a responsible and prevention-minded physician, he doesn’t want people to experience a health crisis before their cholesterol problems are addressed. He knows your first symptom of heart trouble may be your last. He also understands the importance of diet. I just wish medical authorities like him spoke with clarity and specificity about high nutritional standards. If they did this persistently and without the usual deference to the sacred cow of moderation, one day the culture might be moved, and most heart disease might disappear with high safety and low cost.

Below you see a quote from this same doctor regarding nutrition. This is the sort of thinking that frustrates me. Why advocate the consumption of fatty fish when you know it raises LDL? Doesn’t he know LDL is already far higher than its physiologic need in most patients? Why not advocate cholesterol lowering foods instead? It is my expectation that when this instruction is put into practice by the typical patient, set in his ways, he will go to his usual restaurants, just order the fish and then feel good about that choice. It is just assumed by most doctors that it is too hard to adopt a new diet based on whole plant foods. It’s easier to get Americans (who believe they need a big hunk of meat and saturated fat on their plate to feel like they have been fed properly) to comply with recommendations if you ask them to just eat meats that are less bad. Recommendations like these are not about nutritional excellence, in my opinion. They are about our prevailing culture and simple human weakness. It seems to me only the ethical vegans, with their strongly counterculture nature, are able to leave behind cholesterol-raising foods with no regrets, and that is unfortunate.

I just have to shake my head when I read a statement like this. He sees statins as a better economic value than fruits and vegetables. Maybe it’s true but that’s still pretty sad. I know where he is coming from, though. He knows it is his responsibility to help his patients the best he can, and in his mind that means asking them to pop a pill. He can at least trust them to follow through most of the time when they are given that instruction.

The other side of this debate is represented by a doctor who believes diet and exercise are preferable to the prophylactic use of statins to prevent heart disease. She seems strong in her belief that fruits and vegetables are the real answer. Surely she is willing to take an unpopular stand for nutritional excellence, right?

Not really. Even this doctor feels it is necessary to advocate lean meats and fatty fish. She makes no mention of plant-based sources of protein. Now you might say I’m just reacting this way because I’m a vegan. That must be my kooky vegan ethics talking, right?

I disagree. In a comparison between tofu and lean meat, the tofu absolutely trounced the meat for its cardioprotective benefits. The tofu even retarded LDL oxidation. But you can’t ask people to eat tofu instead of meat, can you? No, we wouldn’t want to inform people of the actual best strategies we know of to stay healthy

This is why I’ve made these videos. I want people to at least have the information they need. Misinformation is everywhere, even from responsible and well-meaning health authorities who seem to be deceiving themselves. The cholesterol confusionists will never rest. They will always try to pander to those who want to feel good about their vices. I don’t expect any better from them. But I have been very disappointed by the failure of those in positions of responsibility to shoot down the fad diets, to strongly assert obvious conclusions based on real science, and to offer clear and effective strategies to help people not just be healthier but instead be as healthy as possible. But from where I stand, they are in pander-mode as well:

 “Sure, go ahead and eat your meat. But dry it out a bit first by draining off the fat. That won’t help you very much and it won’t taste very good and consequently you probably won’t even be consistent about it. If we can manage to get you to choose the fish at a restaurant, they will likely have cooked it in butter anyway. But don’t dare try to mature your palate so you can enjoy the foods that will actually make you healthier. Remember, we’re cardiologists. If everyone got radical about eating healthy, we might run out of patients one day.”

“We’ll pretend that fish does not have undesirable baggage like saturated fat. We’ll pretend there is no other way to get the nutrients in fish that we say are so beneficial. You have to eat fish.”

They don’t actually think like this, but they may as well. Their advice would be exactly the same either way. Until the meat eaters who populate the medical profession actually face their own research and follow it to its logical conclusion, it will be up to people like you and me to set the example.

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