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Nutrition Past and Future

Norway, Women, and Cholesterol

Running a Cholesterol Confusionist Gauntlet, Part 7 – Norway and Risk Factors for Women

Apparently, Mr Colpo thinks I should have been totally familiar with all his writings, like this blog post he wrote in October, before I would have been justified in mentioning him in one of my videos. Yeah, he’s right. I didn’t put enough time into those 71 videos. That was a rush job. I should have added a video number 72 to include this blog and the paper he wrote about therein to give him the treatment he deserves. Sorry, Mr Colpo. But I’ll make it up to you. I’ll tell what I think of this study now.

Here’s the study he wants me to learn about. The authors say their aim is to test the validity of total cholesterol as a risk factor for mortality in a Norwegian population. This is a good one to look at after that Japanese study.

That one questioned cholesterol guidelines for a country at the low end of the cholesterol and heart disease spectrum. It’s as if they wanted to figure out whether the Japanese are just like everyone else. Maybe if you’re Japanese you get a pass on all this healthy diet stuff.

Now we move up the heart disease and cholesterol scale just a bit to see if maybe Norwegians can be exempted from all that healthy diet stuff, too. Sometimes when I’m talking diet with people I encounter some common rationalizations, like “Yeah, but you don’t understand. I need my meat!” Or “My relatives lived to be really old. I don’t need to worry about cholesterol!” It’s the same thing here but on a population level. It seems everyone wants an excuse to eat greasy, fatty foods. Let’s see if these researchers found a free pass for the Norwegians. You can see right away where their bias is. Do you see the second to last sentence? They put sarcastic quotes around the word “dangers”. No way could cholesterol be dangerous, right? Sarcastic quotes are a red flag for unserious scholarship. They want to pretend all the other scientists over the years have just been concerned about cholesterol for no reason, but they are so smart, they won’t fall for any myths.

That’s not the only occurrence of scare quotes in this paper. It is, quote, “common knowledge” that total cholesterol is a risk factor. They refer to a quote, “danger” limit for cholesterol. Scare quotes aren’t the only way they show bias. They say the idea of a link between cholesterol and heart disease is just “popularized”. Popularized with who? The biomedical research community? Then they raise the totally irrelevant issue of the money made by drug companies, just like Anthony Colpo does, and just like Anthony Colpo, they seem to be doing their best to ensure that there will be a market for statins well into the future by misinforming people about the harm of high cholesterol.

 Like the Japanese study, this study is not cross-cultural. They are testing a homogeneous population. Both the Japanese and the Norwegians were relatively affluent. Neither population has much racial or cultural variation. Studies like these are almost always less informative than cross-cultural comparisons. In a cross-cultural comparison like the Seven Countries Study, you have participants with clearly contrasting dietary practices. You can be sure that the Greek people in that study were eating differently than the Americans. When you study people in one place, especially in recent times, you might just be partially testing the honesty or memory of your participants as they report the foods they ate. Or you might be studying the effects of their statins. The real differences between participants may not be big enough to show clear results.

Here is the most obvious sign of researcher bias this in this paper. They say they have shown that according to treatment guidelines, 75% of the adult Norwegian population would be deemed at risk for cardiovascular disease. Consequently, they have questioned the theoretical basis of the guidelines. How incredible is that?! They see that their fellow citizens have high cholesterol. So what do they decide to do with that information? They try to redefine high cholesterol. This is sort of like saying that if too many medical students fail the medical board exams, then the solution is not to do a better job teaching medical students, the solution is to make it easier to become a doctor.

More scare quotes ahead. They say, “As cholesterol has become an essential part of lay-people’s basic understanding of their health, and the prevalence of slightly ‘elevated’ cholesterol levels is so high, we believe it is important to re-examine old assumptions regarding cholesterol as a risk factor.” Wait, I thought they were just complaining about the money the drug companies are making. Are they saying lay people are writing their own prescriptions for drugs? And if they are trying to help out the average Joe, why are they publishing in a medical journal? It’s really strange to see an article in a medical journal say that the purpose of a study is to correct public perception of a risk factor that the public can only learn about through their doctors anyway. People don’t give themselves lipid panels. This is pretty strange language in my opinion. And do they really think the lipid hypothesis is just an “old assumption” based on epidemiology? Is it an “old assumption” that Norwegians are the metabolically pretty much the same as other humans? What other “old assumptions” that have saved many lives are they interested in questioning?

Colpo says there is no way this study’s findings could reflect any reverse causation. If you read this quote of his, what he wrote is illogical, but I think that’s what he’s trying to say. He assures me he had no influence over any of these studies. This is about the most obvious statement he could possibly make. I won’t hold my breath to see if anyone lets this angry, ill-informed personal trainer design a serious study. Yes, I know, Mr. Colpo. Your influence is confined only to the uneducated among the lay public. I wasn’t worried about you having influence over a research project.

The oldest participants in this study were 84.

This makes me pretty skeptical of the claim that there was no reverse causation here.

The study authors say that other traditional risk factors did show a connection to mortality, just not high cholesterol. This sounds nice until you think about it a bit. Another risk factor would be smoking. They assessed smoking status by a simple yes or no. There were no gradations. Do you think the smokers in the study started smoking the week before the study began? Likely not. They probably had been smoking for a long time. Smoking really starts to hurt you after you’ve been doing it for a while. Because the people who answered “yes” for smoking had probably been smoking for a long time, a “yes” answer likely did reflect that someone’s health was compromised by long-term smoking. A “yes” or “no” for smoking is good enough. But what about cholesterol? If someone had low cholesterol, did that mean they had always had low cholesterol? The authors did not look into this. Cholesterol scores are not as simple to understand as smoking status. Are they saying that all those low fat dieters and vegetarians in Norway were the ones who were dropping dead? They would be the people with longtime low cholesterol scores, as opposed to those who had low cholesterol due to drugs or illness. There is no comment about time trends for individuals. Were the people who died experiencing rising or falling cholesterol over those ten years?

Problems like these can arise in within-population studies of homogeneous populations. Again, cross-cultural comparisons would illuminate the effects of diet better. These investigators didn’t ask the most important question: why? Maybe they think you won’t ask that either.

I’m skeptical of this statement at the bottom of the left column. Despite a lack of information about the very critical factor of the use of cholesterol-lowering drugs, they say that issue was not important here because drugs were not recommended for primary prevention of heart disease in Norway during the study period. It makes a great deal of difference to me to know how those with low cholesterol got their low cholesterol. If they took drugs to get low numbers, that means they had been judged to be at risk by their doctors. Also, the only medical conditions that got people excluded from this study were self-reported coronary heart disease or stroke at baseline. Reverse causation alert, yet again

During the time of this study, the Norwegians really took to cholesterol-lowering drugs. I highlighted their regression line in red. No country in this graph used them more. Are these authors really going to tell us that drugs were not a factor here? I don’t buy it. I’ll come back to this omission in a moment. It’s really important.

Here are the ages of the participants and how they were grouped. There in fact was a U-shaped association between cholesterol and cardiovascular disease mortality for men ages 40 to 79 indicating likely reverse causation. It’s just that this pattern was not there for women. Mr Colpo, women happen to be different than men.

The effects of cholesterol-lowering drugs and lipid levels are indeed different for women. Premenopausal women tend to have naturally better lipid profiles than men. After menopause things change.

But that delay in problematic lipid profiles gives women about a ten year advantage on men. Heart disease is still the number one killer of women, though. Unfortunately and amazingly, risk factors for women have not been studied nearly as well as in men.

 Total cholesterol and LDL levels do predict coronary heart disease mortality in women as well, although this association is not as strong for older women.

This very recent study which examined more than 21,000 subjects in Finland found a clear increasing trend for coronary heart disease with increasing LDL in both sexes. Mr Colpo, I have provided you with the results for women. Please understand what you are seeing here and realize that you are hardly looking out for the best interests of women with your denialist agenda. High LDL endangers women. Help me spread the word.

This study did find increased risk with very low LDL, but confusionists like you won’t be able to use this one. The researchers apparently knew what they were doing here because they looked for confounders that might be explanatory. They found them. Low LDL is very good in healthy people.

Here’s another reference for the 10-year advantage women have over men due to their later peak in cholesterol levels. For both sexes, cholesterol tends to rise with age before it falls off with elderly decrepitude in most industrialized nations. This happens in women, too, but it happens later. A greater risk factor than high cholesterol for cardiovascular disease in women is diabetes.

I spent some time in The Primitive Nutrition Series talking about how saturated fat potentiates insulin resistance and diabetes. Here is an important study looking at that issue.

Mr Colpo, only women can suffer from gestational diabetes, and if they were to listen to you and ignore the dangers of animal fats, they would be more likely to suffer from that. These researchers concluded that women would do well to replace animal fats in their diets with vegetable fats.

If you look at cross-cultural comparisons of death rates from heart disease up to the age of 74, you can see that the international distribution is similar for men and women, just at lower rates for women. They live longer so they will be less represented in these statistics. Still, this gradient lines up pretty well with saturated fat consumption, with Japan at the bottom and Ukraine at the top. Of course, the Japanese have historically eaten less saturated fat than people in most other countries. Are they eating a lot of saturated fat in Ukraine, where the rates of heart disease are atrocious?

Well, lots of factors contribute to heart disease, of course, but when you see a country with a big problem, you know they are eating a lot of saturated fat.  Only 5.9% of Ukrainians follow a low cholesterol diet.

They seem to eat more of everything there except for fruit, but undoubtedly their astronomical consumption of saturated fat is the most important problem. The lipid hypothesis is reaffirmed. 

On the topic of women Colpo proves that nothing is beneath him. He says I have misogynistic tendencies and he says I don’t think women matter. Again, how anyone reads this guy’s blog and thinks he is anything but a charlatan and a carnival barker, I have no idea. Here is a major study looking at dietary saturated fat and its association with coronary heart disease in women. Higher consumption of red meat and high-fat dairy products were associated with greater risk. Now how are you going to pretend you have women’s interests in mind, Mr Colpo?

I could just as easily call Mr Colpo a misogynist, and not just because he wants women to eat foods that raise their chances of heart disease. In this new study, fat from animal sources was linked to ovarian cancer.

This 2003 meta-analysis found that increased total fat, saturated fat, and meat intake all increased the chances of a women facing breast cancer.

Does Mr Colpo care that saturated fat is said here to have an independent role in the development of gestational glucose abnormalities? This is similar to a previous slide. I could go on but I won’t.

Here’s another example of the muddled thoughts of Colpo. He states that statins have shown no benefit to women for overall mortality.  He says this is evidence that women are getting royally shafted by the cholesterol mafia, whatever that means. But do you see the subtle dishonesty here? The purpose of statins is to lower cholesterol. The purpose of cholesterol lowering is to reduce cardiovascular events. But he just decided to talk about overall mortality instead. This is an example of a common tactic among the confusionists: when it becomes too difficult to argue with the lipid hypothesis because it is so obvious that high cholesterol does contribute to heart disease, change the subject to overall mortality. Play that reverse causation card again.

When any of these confusionist cranks raise this argument, show them the results of this brand new meta-analysis. Statins were here observed to reduce both cardiovascular events and all-cause mortality in women. Prior meta-analyses did not have as many women to study. Sorry, Mr Colpo. This particular tactic of yours just hit its expiration date.

Now back to this biased study. The authors say they have compensated for the effects of age by their statistical adjustments.

But look at what they say here. The U-shape was there for men ages 40 to 79. They say they decided to refrain from emphasizing these results. Why, because they do not want this evidence of reverse causation to be noticed? At a minimum, we can take their word for it and say their findings had limited statistical power. Again, Mr Colpo, this is weak.

Colpo thinks this is the study to show that there was no U-shaped or J-shaped curve signaling reverse causation. Notice amid his swagger, he narrows his claim to the women here. No mention of the men. That might introduce a little uncertainty for his blog and he can’t have that, can he? No, Colpo needs to keep it black and white. He also doesn’t mention all the many other high-quality studies that did show reverse causation. Mr Colpo, all those studies are why the medical community understands the phenomenon of reverse causation now. You’re a little behind the times.

Now back to the issue of cholesterol-lowering drugs. Over the age of 64, 38 percent of people in Norway use cholesterol-lowering drugs. Again, the fact that these researchers didn’t look at this invites my skepticism. Do you see how this official site says that many people in Norway have higher than recommended cholesterol levels? Look at the table at the top right. People there have indeed had high cholesterol. Fortunately, the numbers have been trending down, as have their deaths from heart attacks and ischemic heart disease. I don’t mind that drugs might be responsible for this. I’m just glad to see they are gradually getting their cholesterol down and living longer. Of course, I think they would be a whole lot smarter to eat a healthy diet to accomplish this, rather than rely on drugs with all their side effects.

What about the statement by these authors that cholesterol-lowering drugs were not recommended for primary prevention. Is that true? I am not in Norway. This is not what I do for a living. I should not have to be the one to correct them on this. Data was collected for this study between roughly 1997 and 2007.

During that time, there was considerable variation in the use of cholesterol-lowering drugs across Norway. Primary prevention was based upon a Framingham risk score of 20. You can see below that National Cholesterol Guidelines did indeed permit primary prevention drug treatment. Maybe the researchers for Colpo’s study were too biased to remember this.

Here is another reference for this. Patients who had not yet experienced a CVD event were eligible for medical intervention. That means they could receive drugs for primary prevention.

Because a consistent standard was not being applied across the country, the Norwegian health directorate put together new guidelines for 2009. For the decade before that, there were contradictory views regarding drug treatment. It turns out there is every reason to believe lipid-lowering drugs were being used in Norway at the time in question for this study for primary prevention.

So it looks like one of the key assumptions of the researchers was incorrect. They forgot to ask around, I guess. Mr Colpo’s study did not account for this at all. But all this overlooks the biggest red flag for this study. Its findings are not consistent with other studies relating heart disease to cholesterol, including those that studied Norwegians.

Here is a 2004 study that should balance out Colpo’s study. Over a roughly 30 year period, almost 31,000 fewer deaths occurred compared to what would have been expected. Most of the decline in the death rate was attributable to reduced saturated fat consumption which resulted in lower blood cholesterol levels. Most of the dietary changes were credited to reduced milk fat consumption.

Now, because of a faddish interest in low-carb, high-fat diets, butter consumption has risen sharply in Norway. If this fad takes root and lasts, I predict those death rates will go right back up again. That is, unless there is an equally strong surge in Lipitor sales.

Here’s an even more recent study from Norway. This didn’t cover just ten years but rather 12, 24, and 33 years. Cholesterol was a significant risk factor for coronary heart disease in each time span studied. The authors reaffirm that primary prevention in Norway should involve lowering cholesterol.

We should also recognize where Norway lines up in cross-cultural comparisons. Here in 1993 it was seen as fitting the pattern between saturated fat intake and coronary heart disease death.

The same was true in 1979. That does it for Norway. I’m not done though with my discussion of cholesterol in women yet, though.

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