More on Women and Cholesterol

Running a Cholesterol Confusionist Gauntlet, Part 8 – More on Women (The WHI Trial), Framingham

Next up in our look at epidemiological studies is the Women’s Health Initiative dietary modification trial. Colpo uses this one as an example of what he is calling a controlled trial. Do you see how he references this study in the first paragraph and in the next he says, “In other words, controlled clinical trials show that following low-fat and low-saturate diets will either make no difference…”, etc.? He’s playing games again. This was not much of a controlled trial. And it did not address saturated fat. Let me show you how deceptive he is being.

Sure, they did have an intervention group and a control group. But look at how uncontrolled this was in other ways. People were randomly assigned. That’s a good thing, of course, but the downside to this in a study on diet is that there is no reason to think the women in the study were particularly motivated to stick to the experimental diet. We’ll see later, they did not really change their diets very much. Next, the intervention was counseling. No researcher carefully monitored what they actually ate. The participants self-reported their intakes. And, Mr Colpo, there was no formal intervention for saturated fat, cholesterol or other known atherogenic factors. Once again, Colpo needs his swagger and attitude to compensate for the weakness of his evidence.

So we shouldn’t make too much of the conclusion of the authors here that an intervention to improve the diets of these women did not show great results. Notice how they word this:
A “dietary intervention”. Remember, the intervention was just counseling. They recognized this weakness in study design and said that a more focused diet intervention would be needed to meaningfully improve outcomes. Don’t you think this strongly implies their intervention was not very focused?

Let’s just accept that the participants in this study reported their behaviors accurately and see what the data showed. First, let’s look at their polyunsaturated fat to saturated fat ratios at years one and six. This is an important measure since saturated fat raises cholesterol and polyunsaturated fat lowers it. Their ratios, as you can see, were essentially unchanged by the intervention. That’s some controlled trial, isn’t it, Mr Colpo? No difference! Next, let’s look at protein. This should give us an idea of how much the other damaging effects of animal foods were reduced. Again, almost no difference. What about their change in dietary fiber intake? Their fiber leapt up by a whole 2.4 grams, bringing them up to only 16.9 grams of fiber daily, still way short of the pathetically low standard set by the government. Realize this study was intended to increase whole grain consumption. Do you think they added a lot of whole grains now that you know how poorly they underachieved with fiber? Well, you can see the change for whole grains below dietary fiber. Again, basically no difference. Lastly, what about their consumption of plant-based cardioprotective foods like soy and nuts? Did they eat more of those? It turns out they ate no more soy and they actually ate fewer nuts. Really, Mr Colpo? This is supposed to be convincing?

Here is another way to show you how weak and ineffectual this intervention was. This gives me a chance to address some irrelevant hair-splitting that just a few have engaged in regarding my Anything But LDL videos. There are other good ways to assess the risks of dislipidemia and dislipoproteinemia beside an LDL score. There is no need to get technical here, but some might argue that a superior way of assessing heart disease risk is the measurement of non-HDL cholesterol. That accounts for LDL as well as other atherogenic lipoproteins.

It may be a better risk factor for women in particular.

Mr Colpo’s study did look at non-HDL cholesterol, or non-HDL-C. Here again, the intervention proved to be amazingly weak. There was only a three point drop in non-HDL-C over three years.

To understand what a miserable result that is, let’s see what other approaches can do for non-HDL-C. This should give you a frame of reference, Mr Colpo. At the top left, you see that neither a low carb nor a low fat diet did much for this important risk factor. I know you don’t advocate either of those. To the top right you can see that a supplement of a particular phytochemical did lower non-HDL-C. Maybe this explains some of the benefits of plant foods. Lastly, at the bottom, you can see that in 74 weeks, a low fat vegan diet dropped non-HDL-C by 21 points. Remember, it took the amazingly unmotivated women of the WHI trial three years to lower their scores only three points. The vegans did seven times better in less than half the time. So, Mr Colpo, are you a misogynist or will you recommend a plant-based diet for all those women out there?

As lame as it was, the trial did find that dietary fat reduction correlated to a reduced risk of invasive breast cancer.

When the dietary modification trial was put together, women who were ineligible or unwilling to participate took part in an observational trial. This one did not involve an intervention of counseling, counseling that could just be ignored. Instead, this project let the women do whatever they normally do and simply observed the effects.

The observational study came up with different results from the interventional study. Here, dietary patterns based on conventional nutritional guidelines were associated with a lower risk of cardiovascular disease. Did you see this one, Mr Colpo?

The authors of this one related some of the problems with the dietary modification trial. The nature of the fat consumed was not addressed, Mr Colpo. Interesting, right? You’re arguing with me about saturated fat, aren’t you? So that study did not have much chance of proving your point, did it? Notice, these authors also make reference to the delayed presence of risk factors for heart failure in women versus men. Do you remember how I said women have a ten-year advantage on men for heart disease risk?

The data for the observational study was put through two different models of statistical analysis and compared to two different dietary patterns. Notice model 1 accounted for cholesterol-lowering medications.

Using the Alternate Healthy Eating Index pattern, which is one of the two patterns they used, you can see that a very clear relationship emerged for risk based on similarity to the pattern. Actually, all the patterns and analytical models showed this trend, but this model proved especially valuable when paired with that pattern. So there you go, Mr Colpo. The lipid hypothesis is affirmed yet again.

Colpo mentioned a couple other studies. He talked about Framingham.

So did Donald Miller. I covered this in my The Confusionist Mind video.

Colpo says the authors of that Framingham paper observed that in older people, falling cholesterol levels associated with higher mortality. Colpo thinks we learned from this that low cholesterol is going to kill you. He tells us the authors commented that their observations were explained by reverse causation as illnesses resulted in lower cholesterol. I’ve explained why this happens ad nauseum by now. Colpo doesn’t buy it. He says there was a direct association between falling cholesterol levels over the first 14 years and mortality over the following 18 years

Have I shown you this slide enough to make my point? Look at that high cholesterol plummet. Does Colpo think the problem is not age and illness but rather inadequate butter consumption by old people? This is an incredibly dumb argument.

Colpo says the authors are engaged in unconvincing doublespeak but it is he who is not convincing. The study did not show that low cholesterol is the problem. The study showed that falling cholesterol is an indicator of a problem. Mr Colpo, do you understand the difference between low but stable cholesterol and falling cholesterol? Because if you do, it’s hard to tell. He thinks he is really onto something when he says that cardiovascular disease mortality increased with age. Does he not know that age is a separate risk factor for cardiovascular disease? Does he not know that atherosclerosis takes decades to build? Does he not know that it is plaque rupture that causes heart attacks and strokes, and these happen with increasing frequency in old age?

Plaques become less stable in old age. As I said in The Primitive Nutrition Series, our various parts start breaking down in old age, and plaques are no exception. The more loaded with cholesterol those plaques are, the less stable they are.

I’ll add that cholesterol under 160 in that paper was associated with a risk greater risk of cancer in smokers but not in nonsmokers. Colpo did not mention that. So if you are a nonsmoker, Mr Colpo’s concern about low cholesterol does not have much applicability to you. Mr Colpo, do you think smoking behavior made those old men any more likely to die of cardiovascular disease?

Colpo linked to one other epidemiological study.

This one’s easy. The authors themselves said a null result for a link between saturated fat and coronary heart disease was the result of unreliable data in cohort studies. They trust cross-cultural and metabolic ward studies more and the results of those are clear. Having seen the Women’s Health Initiative Trial, I think you can understand why they see it this way. Yet again, I’m not impressed by Colpo’s reference.

Anthony Colpo wants you to think low cholesterol will give you cancer and depression. I’ll show you why you shouldn’t believe him in the next video.