TPNS 43-45: Anything But LDL

Primitive Nutrition 43:
Anything but LDL, Part I

Here's a quick disclaimer to start this video.  My Anything but LDL presentation might get a bit tedious for some of you.  If you want to skip it I'll understand.  The point of this section is that you shouldn't be impressed with all the biomarkers low carbers name to make it seem like their diet strategy is healthy.  Levels of total cholesterol and LDL bad cholesterol are probably the best risk factors for heart disease out there.  Doctors know this, and they also know how to interpret all the other biomarkers to treat their patients properly.  Stay focused on lowering your total and LDL cholesterol numbers, listen to your doctor, and eat a prudent diet high in whole plant foods and you won't ever need to contemplate the alphabet soup of other biomarkers.

And now on to the content.

As you might be able to tell, I've been observing the low carb world with interest recently.  I've noticed that some low carbers say cholesterol is good for you while others claim their diet is great because it can lower cholesterol.  They can't seem to get there story straight on this molecule.

Those who want you to just ignore the whole issue of cholesterol almost always start their pitch by informing you that your body needs cholesterol.  Here Mark Sisson, in one of his articles he immodestly calls definitive, follows this formula.  He wants you to think of cholesterol in simple caveman terms: cholesterol good!

As if the scientists who have advised us to keep our cholesterol low have no idea what it actually does.

It also seems that some believe certain biomarkers, or measurable substances in the blood, are better for assessing heart health than cholesterol.  Let's take a look at a few of these and see if they're really any better than good old LDL bad cholesterol.  But first, it must be understood that all that really matters is the clinical endpoint.  In heart disease, that means something like a heart attack or heart failure.  Doctors use biomarkers because they are considered the best indicators of risk in situations where they can't observe a problem directly.  Biomarkers are just surrogates and they shouldn't be thought of as substitutes for the real endpoints.

For example, vegetables were here shown to be able to turn back heart disease in mice despite biomarkers that wouldn't have suggested this was happening.  Biomarkers aren't perfect.

Doctors sometimes use formulas based on risk factors to calculate heart health.  They aren't necessarily any more reliable for uncovering heart disease.

Let's look at some of these other biomarkers.  Uffe Ravnskov is a believer in coagulants in the blood like fibrinogen.  I guess the logic is that atherosclerotic plaque is ok as long as when pieces of it come loose they don't form a clot.  He might be heartened to know that low fat diets and hempseed can reduce coagulant activity.

Fruits and vegetables are good for that, too.  So plants are good for this issue.  Did you see that coming?  Get used to it.

Ravnskov's hypothesis about fibrinogen may not be worth much.  Experiments on genetically altered mice don't really validate the importance of fibrinogen.

Low carbers say triglycerides are a problem caused by carbs. 

However, triglycerides don't seem to predict clinical endpoints better than cholesterol.

It seems triglycerides are adversely affected by junk food carbs. 

But healthy complex carbs don't seem to cause much of an increase.

Any elevation in triglycerides seen after eating healthy carbs on a low-fat diet doesn't represent the same metabolic conditions as in high fat diets.

If keeping your triglycerides in check is your aim, then a healthy, fiber-rich vegan diet is a good option.  Plants are great for this, too.

What about the idea that it's more important that your HDL, or good cholesterol, be kept high?  This is a big one for the low carbers.

This is an idea lacking in support right now.

You may have heard about the big clinical trial that was stopped by the NIH looking into niacin and statin interventions to raise HDL.  HDL went up and triglycerides went down, but it wasn't helping these patients. I've heard this study used to argue that high-HDL is not protective.  However, often overlooked is the fact that all participants  in this trial were on aggressive drug treatments to lower their LDL.  The study may just mean that if LDL is low, you don't need high HDL.

LDL seems to be a much more useful biomarker than HDL for cardiovascular disease.

It's been known for a while that healthy low-fat diets reduce HDL by changes in the clearance rate of cholesterol from the blood, so again, we have a biomarker that means different things in different contexts.

It is understood now that the HDL idea needs some refining.

This important study also showed that a healthy high-fiber diet changes the nature of the HDL from pro- to anti-inflammatory, meaning the HDL could offer better protection.  Plants win again.

Low carbers are very invested in the idea that they are safe with higher LDL scores because their LDL particles are larger, which is somehow better.

They should know that all LDLs are atherogenic.  You see here that the large ones do indeed correspond with people eating high saturated fat diets.  Those particles hold more cholesterol. 

LDL particle size measurements may only be useful in patients with borderline-high total LDL.

It's been shown that when calories are kept constant, switching from high-fat to lower-fat diets lowers the levels of the small, dense LDLs the low carbers say they are trying to avoid.

If you want to reduce your small, dense LDLs, eat healthy plant foods, which reduce them along with total cholesterol.

You may have heard there is a so-called ultra-bad LDL that occurs when LDL is glycated, or attached to a sugar molecule. 

It is especially associated with diabetes.  A molecule called methylglyoxal causes the glycation. Forgive me for a little speculation here.  I want to play connect the dots.

For what it's worth, in this study, aminoacetone increased methylglyoxal more than sugars.

This study in rats showed that aminoacetone caused iron in the blood to damage mitochondria.  Iron overload and aminoacetone may play an important role in diabetes.  You know a bit about iron by now from my Protein Choices video.

For now, notice that the most important sources of threonine, which is needed to produce aminoacetone, are meats, unless for some reason you are eating a ton of watercresss or seaweed.

I hope you're not getting sick of biomarkers already.  There's much more in Part II!

Primitive Nutrition 44:
Anything but LDL, Part II

Low carbers also talk a lot about the issue of oxidized LDL.

Measurements of oxidized LDL may not be a reliable indicator of risk.  What is being detected may just be oxidized LDL fluxing out of arterial plaque, which is a good thing.  This is why it sometimes goes up on healthy low-fat diets.

Increases in oxidized lipids occur when damaged arteries are healing.

Oxidized LDL may be beneficial in certain contexts.  Some think it doesn't really lend itself to targeted therapy.

This may be why clinical trials of isolated antioxidants have been disappointing.  Oxidized lipids don't seem to be very good biomarkers.

Internet cholesterol confusionist Chris Masterjohn puts a lot of faith in the oxidative modification hypothesis.  He is concerned about what this stuff does to damage the layer of endothelial cells that line our arteries.  That would interfere with the production of nitric oxide, something your arteries need to stay healthy.

Caldwell Esselstyn of the Cleveland Clinic is concerned about this as well, which is why he recommends a plant-based diet, unlike Masterjohn.  He explains his reasoning in this book.

Daniel Steinberg has been one of the leading researchers in the study of oxidative stress on LDL.  He wants better drugs to control this.  Surely Masterjohn would not disagree on this subject with an authority of the stature of Steinberg, who shares his interest in oxidative modification.

I wouldn't disagree with him, either.  I agree with other comments he has made as well: High LDL is sufficient to cause heart disease.  Adopting dietary strategies to lower LDL is advisable.  LDL levels should be as low as possible.  I couldn’t agree more.  But Masterjohn would disagree with these statements. 

They both know the effect of diet on the integrity of the LDL particle.  However, only one has a personal investment in dangerous low-carb diets.  And only one is an undisputed leader in lipid research.  Guess who is who.

Masterjohn knows compounds found in plants fight this oxidation.  He mentions polyphenols.

And he is right about that.  They are found in plants and known to improve the health of the endothelium.

Fruits and vegetables are known to generally fight inflammation and oxidation.

And they help your lipoproteins this way as well.

Meanwhile, dietary cholesterol has been shown to promote LDL oxidation. 

The pharmaceutical industry is only too happy to find drugs to treat oxidation and inflammation.  But realize we are no longer talking about *preventing plaque buildup with this approach, and we are no longer talking about food.

The endothelial cells use nitric oxide to dilate vessels to allow greater blood flow.  This was shown to be adversely affected by low carb diets in this study...

and in this study.

Maybe it's because the saturated fat in those diets impairs endothelial function.

On the other hand, a vegan diet decreased oxidized LDL and total LDL in this study.  So why doesn't Masterjohn advocate a diet with lots of fruits and vegetables and minimal saturated fat and cholesterol if he thinks this is an important issue?

Loren Cordain.  meandmydiabetes.com

Let's talk about inflammation.  Another primitive idea is that plaque doesn't matter.  What matters is the inflammation.  Here is Loren Cordain saying that arterial plaque is fine as long as it doesn't break off and give you a heart attack.  I'm not sure why it wouldn't be better to not have that plaque there in the first place.  Cordain is making the argument that inflammation is the real problem.  If you have low inflammation, you have nothing to worry about.

This is an odd stance for him of all people because the relationship between inflammation and heart disease doesn't seem to exist in hunter gatherers.  This is an inconvenient study for him, I imagine.  These hunter gatherers had high levels of inflammation, but hardly any heart disease.  By the way, they did have parasites.

Of course, pharmaceutical companies welcome the prospect of treating inflammation in heart disease.  New drugs await discovery.  And they will probably help.

It should be noted, though, that it has been demonstrated that everyone's favorite biomarker of inflammation, C-reactive protein, or CRP, has been shown to arise from reverse causation in the context of heart disease.

Inflammatory biomarkers don't seem to be responsible for increasing atherosclerosis.

And they don't seem to cause vascular events after a stroke.

And they don't cause atrial fibrillation.

Or heart failure.

Or coronary heart disease in general. 

One of the common canards with the cholesterol confusionists is the claim that diet doesn't effect blood cholesterol that much.  As I've shown you already, this is only really true in diets that are already high in cholesterol.

CRP is like cholesterol in that if you already are inflamed or have high cholesterol, a diet that increases inflammation or cholesterol won't effect you much.  It should be noted that cholesterol itself increases inflammation.  Calorie restriction seems to help inflammation like it helps so many other metabolic problems, which is why some calorie restricted low carb studies seem to improve this biomarker.

Dietary choices can affect markers of inflammation.  Loren Cordain should know that red meat is specifically associated with C-reactive protein.

A low fat, vegan diet, however, dramatically lowers it.

It is true inflammation is important in heart disease, but this does not change the story on cholesterol.  High cholesterol and inflammation are partners in crime.

This leads me to a bigger issue, which I'll discuss in Part III.

Primitive Nutrition 45:
Anything but LDL, Part III

In my view, this argument that cholesterol levels are somehow less important than inflammatory markers raises a larger point.

This is an outstanding paper on the role of inflammation in atherosclerosis.  It is not appropriate to review it in a detailed way here.  These researchers are well aware that inflammation is important in the process of atherogenesis.  They show that our detailed understanding of atherosclerosis enabled by genetic research has illuminated the importance of inflammation as well as cholesterol.

Two of these researchers have written separately about the inflammatory process in atherosclerosis.  I just want use their graphics to illustrate how well atherosclerosis is understood now.

You can see that their description of the chain of events in its development is highly nuanced.

Here's the caption for that graphic.  Pause the video and read through it if you dare.  I find it comical that there are Crossfit trainers and exercise physiologists out there who think they understand the development of heart disease better than today's brilliant medical researchers.

Their narrative of how these plaques develop reflects our contemporary understanding. 

Read these few sentences and you can imagine all the research that has been done on cholesterol.  We're really getting into fine-grained detail.  These people are not misguided fools as Mark Sisson would you like to believe.

Here, for example, is a recent paper that has demonstrated in new detail how dietary cholesterol creates plaques.

New research into dietary cholesterol just makes it seem more and more guilty of hurting our health.

This knowledge has been facilitated by the exploding use of genetically altered lab animals, particularly mice and rats. 

Here you see that in rodents over 100 genes have been studied that influence the development of plaques.  Notice one of the researchers is Gregg Fonarow, the author of that paper about those first time heart attack sufferers, the one I talked about in Playing Games with Your Heart.  Maybe he knows what he's talking about a little better than broscientist Mark Sisson or comedian Tom Naughton.

Some of this transgenic research has demonstrated how much more important cholesterol is than triglycerides in causing heart disease.

Low carb apologists often complain that experimental animal models have their limitations in helping us understand heart disease in humans.  It’s a bit silly to read their protests that mice, for example, were not fed proper low carb diets, as if that makes any difference.  Researchers use these experiments to methodically examine every important variable they can imagine.  Do you remember when I introduced you to Anitschkow, the Russian pathologist who first induced atherosclerosis in rabbits with dietary cholesterol so long ago?  Even he understood that different animals processed cholesterol differently, and that they were all probably different than humans.

Even our closest primate relatives do not experience heart disease the same as us.

But the totality of the evidence is clear, and now that we are in the genetic age, it is ever more so.  Complaining that animals aren't good models for humans misses the forest for the trees.  My point here is that there is a huge body of knowledge behind current fat and cholesterol guidelines.  People who don't understand the science should at least understand their limitations and not attempt to contradict those who do know what they are talking about.

What has all this research taught us about biomarkers?  Well, total cholesterol is an excellent biomarker...

but nothing has yet upstaged good old LDL bad cholesterol.

The way lipoproteins work in the body is a very complicated business.  Chances are the information you see on the internet is seriously oversimplified.  We do need a way to measure what is happening in heart disease, and so far, the LDL score seems to tell us the most. 

This is because, unlike fibrinogen or CRP or any other particle that has been measured, LDL is the agent of damage to the artery.

Research with saturated fats fed to transgenic mice has demonstrated this.

As has research in humans.  Henry Buchwald has done remarkable work to clarify the importance of LDL.  Over a 25-year time frame, Dr Buchwald has shown through surgical bypass of the ileum, a procedure that forces the elimination of LDL from the body, he was able to reduce total and heart-related deaths, while not increasing the occurrence of cancer.

Steinberg, Interpretive History

The surgery worked because it caused the elimination of bile acids, removing cholesterol from the body.  Interestingly, dogs are great at converting cholesterol into bile acids for elimination, which is why they don't get heart disease. 

When bile acids are retained in humans, they result in elevated blood cholesterol.  Drugs have been used to prevent this from happening.

Ileal bypass was seen as a possible alternative to drugs for lowering LDL cholesterol many years ago.

Here you see Dr Buchwald's paper from 1990 at the outset of his study.  He believed his procedure would save lives because of its effect on LDL, and he was right.

Here is Dr Buchwald's paper from 2010 in which he announced his accomplishment.  Congratulations to him.

There is plenty of other research into LDL, of course.  Here it is shown that mutations in the LDL receptor are less important than LDL levels.  These mutations, of course, are what cause familial hypercholesterolemia.

The lowering of LDL levels has been shown to increase plaque stability, which Loren Cordain should like.

LDL was observed to be remarkably low in vegetarians long ago.  These numbers are amazing.

The body needs and uses LDL, of course, but it makes all it needs without a diet that adds more.

Still, LDL is not a perfect surrogate for heart disease risk.  In the context of drug trials, it is now known that some drugs can lower LDL dramatically without a corresponding reduction in cardiovascular events. 

However, LDL still seems to be the best way of identifying people at risk at the moment.  Don't misunderstand my argument in this video.  All these biomarkers give doctors valuable information that helps them determine the best treatments for their patients.  All I'm saying is, don't let someone distract you with this stuff so that you can more easily rationalize eating an unhealthy diet.  I think it's pretty interesting that the most important risk factor for heart disease, high LDL, is the one low carb diets can't seem to improve unless calories get super low.

What matters more than biomarkers is the risk of cardiac events.  Dean Ornish has already shown that this can be improved with the help of a healthy diet.  This study made him famous.

Ornish was able to regress heart disease and reduce cardiac events among his study subjects even though his diet raised their triglycerides.  Should this be viewed as a failed study because their triglycerides went up?  Or should this caution us about misunderstanding triglycerides?

It shouldn't have been surprising that Ornish could do this with diet. Atherosclerosis had been turned back in animals many times.  Here you see that vervet monkeys developed atherosclerosis on a diet of entirely normal western foods.  A realistic healthier diet was able to regress these plaques a little.  Ornish just used a more aggressive diet.

Here macaques responded this way as well.  On the left side of both graphs you see that atherosclerosis escalated on a high cholesterol, high saturated fat diet.  To the right you see a regression of the atherosclerosis took place when either the diet was changed to alfalfa meal or after a cholesterol-lowering drug was administered.

We know now that plant foods can regress heart disease.

Don't fruit and berries sound like a rather enjoyable therapy?

By contrast, nutrient-poor, meat-heavy diets are associated with advancing atherosclerosis.  Let's be clear that this is not health food.

I have shown you that all these biomarkers may reflect reverse causation, or may not be informative in some cases, or are not preferable to LDL.  More importantly, I have also shown you that all of these biomarkers can be brought within their target ranges through a plant-based diet.  Often the benefits of statins are explained away by cholesterol deniers as the result of other effects they have beside cholesterol lowering, but doesn't it make sense that all risk factors should improve as heart disease is healed?  And doesn't it also make sense to use diet to accomplish this instead of drugs?

If you unwisely choose to reject what the confusionists call the conventional wisdom, which is just a weasely way of saying the accumulated knowledge of medical science, they will not be there for you when you have a cardiac event.  They want page views and sales for their products today.  They won't be there to pay your medical bills or support your family when you have a serious health problem.  If you require hospitalization you will then be in the medical system, and you will be given medication that is not based on conventional wisdom or bias but on the real knowledge and experience of medical professionals, and they will give you targeted therapies to try to help you.  You will almost certainly be put on cholesterol-lowering medication, and your quality of life will be worse, and that will be if you are lucky.

My advice to you, if you will consider it, is to abandon internet nonsense and take care of your health through diet while you are healthy.  Whole plant foods will help you do this, and probably for less money than you spend on food right now.  

Don't those berries look delightful?  Yet there is a diet out there that tries to make an enemy of colorful fruits like these.  It's a diet where colors are less vibrant and flavors are never naturally sweet.  It's a diet that is heavy and gray.  It's the gloomiest diet, next in the Primitive Nutrition Series.

TPNS 42: The Confusionist Mind and the Good Old Days

Primitive Nutrition 42:
The Confusionist Mind and the Good Old Days

With this video I'll take a quick look at the personal beliefs of a couple cholesterol deniers and confusionists.  It seems it helps to have other fringe beliefs if you are to adopt fringe beliefs about cholesterol as well.

For a while, I took in the low carb media, including this podcast.  I saw that a cardiac surgeon, Donald Miller, was offering some sort of rebuttal to Dean Ornish.  My first thought was that he saw Ornish's diet as bad for his business, but the man's a doctor, of course.  He must be trying to give us his best advice, right?  Well I listened to this and never really heard a direct refutation of Ornish's highly successful work.  Instead, he offered a recitation of the usual bad science and flawed reasoning my videos are here to address.  Apparently, he found the folks at the Weston Price Foundation to be very convincing.

Here's his bio from a site for which he has written, LewRockwell.com.  The host of the podcast, Jimmy Moore, became aware of him through that site, so they must have a few things in common.  Dr Miller's interests are wide-ranging.

He is a believer in low-carb.  Read this and you'll see he has taken Woody Allen's comedy a bit too seriously.  He seems to have used a scene in the movie Sleeper to help him imagine a future in which his low carb ideas are affirmed by science.  He needs to imagine this in the future because the present isn't being very cooperative for him.

Browse his writings and you'll see he clashes with other present-day realities as well.  He has some truly unbelievable ideas about AIDS and HIV.  Here is a medical doctor who doesn't want you to get tested for HIV.

He also has radical views on water fluoridation, flu shots and of course, climate change.

Here are some views he chose to share following the attacks of 9-11.  You’ll need to pause the video to read these because I will not read them.  The man has some very radical political views.  Cholesterol denialism and low carb seem quite innocent compared to this.  Jimmy Moore says nothing to indicate to his listeners that this man has other radical, conspiratorial views that might put his hostility to public health institutions in some appropriate context.

Donald Miller's online article about low carb includes a reference to this study.  According to him, the Framingham study showed us that lower cholesterol would increase your risk of death.  He neglected to mention that Framingham actually made clear that for people under 50 cholesterol levels were directly tied to overall and cardiovascular mortality.  This Framingham study also makes clear that for older people, falling cholesterol is a reflection of the J-curve, which you know all about at this point.

There is a separate issue of how to treat lipids in the elderly.  Let's leave those decisions to their doctors. 

This is another source explaining the complicated nature of cholesterol in the elderly.  Miller doesn't indicate he understands any of this.

Here's another study to help Dr Miller with this issue.

And here's one more.

In the interview he names Chris Masterjohn of the Weston Price Foundation as an expert on cholesterol.  Search his name on Google Scholar and it is not at all clear he is a cholesterol expert.

This is Chris Masterjohn.

He runs a website called Cholesterol and Health and of course, he is offering what he says is the truth.  This truth is coming from a someone who somehow got himself into serious health trouble when he was a vegetarian.

He suffered from anxiety, isolation and anger.  He was lethargic and apathetic.  Then he developed 15 cavities and needed two root canals.  For some reason he thought being vegetarian would make him immune to tooth decay.  He thought soy made cavities impossible.

Bear in mind, all these problems, including the emotional ones, we should unquestioningly accept were caused by being a vegetarian.

It should come as no surprise that Masterjohn has posted at LewRockwell.com as well.  He is not concealing his hostile view of the federal government here, and somehow that is driving his beliefs about cholesterol.  You can better assess the information you get from him now.

By the way, the US government and the governments of all advanced nations have an interest in cholesterol levels because unlike Masterjohn and the other confusionists, they foot the bill in large measure for the poor health of their citizens.

Here are a couple highlights from his site.  I've already shown you how dietary cholesterol doesn't affect blood cholesterol much if you already have high cholesterol, so this post is easily dismissed.

He argues elsewhere that cholesterol doesn't cause heart disease but calcification does.

I guess he doesn't know that cholesterol concentrations correlate with the degree of calcification.

Here's another study for that.

Maybe this is why both calcification and cholesterol seem to raise the risk of dementia.

A common refrain among these retrograde voices on diet and health is that no one had our chronic illnesses long ago.

Dr Miller, for example, asserts in that podcast that 100 years ago coronary heart disease wasn't even a recognized entity, in his words.  Ignoring for a moment the accuracy of that statement, it wouldn't mean a lot if it were true.  Before 1628 and William Harvey's Anatomical Exercise on the Motion of the Heart, even the basic functions of the cardiovascular system were not understood.

Before modern medicine, the four humors were thought to determine sickness and health, so we wouldn't expect to see any disease accurately described in old texts.  In the field of cardiology, the first effort at a real clinical description of dysfunction came from William Heberden in 1768, when angina became a recognized entity, to borrow a phrase.

Angina is a symptom of coronary heart disease.   Therefore, coronary heart disease existed at least as far back as 243 years ago.

191 years ago some physicians were first connecting angina to coronary artery disease.

But let's back up a bit.  Just because a disease was not recognized does not mean it did not exist.  The oldest example of atheosclerosis we have comes from the 5000 year old Tyrolean ice man mummy.

The Ice Man ate fatty meats.  In addition to atherosclerosis, he had gallstones, which is another indicator that he probably had high cholesterol.

Atherosclerosis was present in Egyptian mummies as well.  These mummies are the preserved bodies of members of the upper class, who consumed meaty, high fat diets.

John McDougall has written well about heart disease in these mummies if you'd like to learn more.

It is clear that when Dr Miller asserts that coronary artery disease was not a recognized entity 100 years ago he is mistaken.  But let's give him the benefit of the doubt and look for another interpretation of his statement.  Maybe he meant that 100 years ago in the United States there was no heart disease or perhaps it was just rare.

That wouldn't be true, either.  Here you can see that 100 years ago cardiovascular disease was called the determining factor in a majority of deaths, and it was trending upward.  While progress was being made with infectious diseases, cardiovascular disease was on the rise.

In 1905, 18 people out of 10,000 were dying of heart disease in Massachusetts. 

That is more than in 2007.  Therefore, Miller is wrong under that interpretation as well.

We shouldn't assume they didn't have cancer in the good old days, either.  Today people live longer and methods of diagnosis are better, so of course we will see more cancer.  There is no way to tell just how much cancer existed in ancient times.

There is some evidence of ancient cancers, however.  This 2700 year old king provides us with the oldest known case of prostate cancer. 

It is entirely possible there is more cancer today, if only because we are fatter and more sedentary, two major risk factors for several cancers.

It's really easy to say things were better in the good old days but it's a bit harder to tell if that is true.  If you have a confusionist agenda, though, the temptation to make a questionable appeal like this must be irresistible   Without further inquiry one might have been impressed to hear a cardiac surgeon argue in favor of low carb diets.  But if we keep asking questions, it turns out he is just confused.  Let the case of Donald Miller MD serve as a warning.  Just because someone has good credentials in one field doesn't mean he has the slightest clue about anything else. 

One of the most common tactics among cholesterol confusionists and low carbers is to latch onto biomarkers other than cholesterol to make low carb seem healthy.  In the next video, I'll show you why their biomarkers aren't necessarily worth as much as the best known of biomarkers, LDL bad cholesterol.

TPNS 40-41: Playing Games With Your Heart

Primitive Nutrition 40:
Playing Games with Your Heart, Part I

In researching this topic it has become clear to me that those who promote saturated fat and cholesterol are just playing games with people's health. 

Here is an example of the use of misleading graphs in the cholesterol games.  This comes from a website called Perfect Health Diet.  This graph purports to show the relationship between healthy life expectancy on the y-axis along the left, and the ratio of animal to vegetable foods consumed on the x-axis at the bottom, with each point on the graph representing a country.  It appears that in countries that eat more animal foods people live longer, with Iceland all the way to the top right.  The Perfect Health Diet people think this is pretty powerful stuff.  "Take that, vegetarians!," they say.

This graph is misleading, partly because it basically represents the food ladder, where wealthier countries eat more animal foods because they can afford to. 

Look at the countries with the shortest life spans down at the bottom left and you'll see countries afflicted with poverty and infectious disease like Angola, Mozambique, and Swaziland.  At the other end of the spectrum you'll see industrialized nations with top health care systems like France, Sweden, and Denmark.  I guess the very smart people at this site think the only difference between Lesotho, with its rampant HIV epidemic, and Iceland, with its complete universal health care system, is the amount of saturated fat they eat.  Yes, I'm sure the vegetarians find this graph absolutely devastating.  Good job, Perfect Health people!

My question to confusionists who make this argument is why do you think cholesterol is more important in controlling infectious disease than sanitation?  40% of the world's population doesn't even have a hygienic toilet to use.  Don't you think that might be just a bit more important in affecting life expectancy than whether they eat butter or not?

By the way, if you are wondering what the people look like who have the audacity to say they have the perfect health diet, here you go.  For me, the words "perfect" and "diet" don't belong anywhere near each other.

Here's another graph they liked on that site.  This one shows all-cause mortality along the left and total blood cholesterol along the bottom.  As you might expect, what's happening here becomes obvious when you again look closely at the countries.  The countries with the highest mortality to the top left are places like Barundi, Mali, and Guinea.  The countries with the lowest mortality at the bottom of the curve are places like Germany, France, and Belgium.  Mortality rises again with cholesterol at the bottom right with places like Colombia, Uruguay, and Belarus.  You see the same phenomenon is at work.

There is more to this, though.  Look closely and you can see the creator of this graph chose to plot infectious and parasitic diseases separately.  It doesn't follow a U-shape like all-cause mortality does.  It starts high at around the 1000 mark on the left and then just plunges to zero near the middle. This effect is behind claims you may see online that high cholesterol protects against infectious disease.  If you buy into that belief then would have to believe that people with high cholesterol don't get sick much.  That's an argument I'd love to hear a cholesterol confusionists make.

Especially when evidence suggests lower cholesterol enhances immune function.

Not only does low cholesterol not increase mortality, statins don't either.  While cholesterol lowering through diet is preferrable on every level to drugs, drugs are still safer than high cholesterol.

When you see visuals like those two from the Perfect Health people trying to get you to doubt guidelines from responsible health institutions, remember these graphs.  This is an example of a similar use of graphs to deceive, in this case in regard to vaccinations. Upon first glance it appears the introduction of vaccines had nothing to do with past triumphs over infectious diseases.  The creators of these graphs don't want you to research any further than this.  If you do, you'll see these graphs are lies.

The downward trends in mortality rates were due to improved medical treatments, like the iron lung, or antibiotics that made vaccines unnecessary.  They don't account for improvements in sanitation that preceded the vaccinations.  These graphs show mortality rates but not infection rates, so you don't see the sickness and suffering the diseases were causing even if they were killing fewer people.   

Graphs like these are cynically intended to manipulate you and undermine your trust in responsible institutions.  The cholesterol graphs are no different.

The Perfect Health Diet couple were just getting warmed up with those misleading graphs.

Here they select a table from a study to argue that there is a Goldilocks range for cholesterol between 180 and 260.  Go lower and deaths increase, therefore lower cholesterol is less safe.  This is an interesting conclusion to draw from something they are calling the Japan Lipid Intervention Trial, which you see at the top.  What do you think the intervention was?  Broccoli or drugs?  Who do you think received the intervention?  The sick and weak or the young and fit?

Here is the table a bit closer.  These were people taking a drug called Simvastatin for six years.

Here is the study.  It was not called the Japan Lipid Intervention Trial, but it came out of the Japan Lipid Intervention Trial. The drug’s name is right there in the actual title.  They didn’t tell you the name of the specific study because that would tell you right away that this study was just looking at the effects of a drug, not diet.  It was a primary prevention study, meaning people who had no history of heart disease were prophylactically given the Simvastatin.  These were not people lowering their cholesterol through a healthy plant-based diet.  Statins are important drugs in the war on heart disease, but like all drugs, they do have side effects, and not everyone responds to them the same way. Because they were used in this study, this data has no bearing on diet, unless the Perfect Health people think Simvastatin is food. Also notice the last word in the title of the study, hypercholesterolemia.  Every single person in this study started with cholesterol equal to or over 220.  I guess the helpful Perfect Health people forgot to mention that key fact.

The text of the article makes clear what was happening.  Those with the lowest cholesterol were hyper-responders to the drug. 

Not everyone responds the same to drugs.  The effectiveness of statins is influenced by genetics and even the composition of the patient's gut microflora.

They thought the lowest cholesterol scores were likely caused by underlying diseases that ended up increasing mortality.  Of course, the selfless and giving Perfect Health people read this part, but no matter.  Why should they pass this along to you?  This is how the game of deception is played online with cholesterol.

Notice at the bottom right they make reference to a U-shaped curve.  Understanding reverse causation will help us see the deception in other cholesterol confusionist gambits.

Here's an example of how a U-shaped curve, or alternatively a J-shaped curve, appears with cholesterol confusionist propaganda.  This gentleman is of the opinion that low cholesterol will risk your life.  This was a study involving drugs as well, of course.

The American Heart Association has dismissed the J-Curve phenomenon, as they call it.  Co-morbidities, or underlying illnesses, lower cholesterol and increase the chance of death.  Low cholesterol is a sign of poor health in the portion of a population that are old and sick.

J- or U-curves exist for other health risks as well.  They exist for blood pressure, where very low blood pressure may indicate a very weak patient. Sometimes it is argued that you will live longer if you are a bit overweight.  This is usually based on statistics looking at the elderly, an important consideration.  Low BMI in the elderly may reflect poor health and not cause poor health.

This recent study found that body weight measured over a lifetime is more meaningful than body weight at the end of life.  This should be common sense.  It should also be common sense that cholesterol functions the same way.  Yet cholesterol confusionists use measurements in the sick and elderly, relying on the reverse causation fallacy again and again.

This is another example of end-of-life cholesterol measurements being abused by confusionists.  Here we see the logic of our friend Uffe Ravnskov again.  He thinks it is significant that blood cholesterol concentration after death does not predict atherosclerotic plaque, as though your plaque build up is purely a reflection of your lipids right before you die.  It doesn't take much thought to understand the deceptive nature of this argument, but let's look at it anyway.

First, measurements of cholesterol at autopsy are not necessarily accurate for technical reasons.  Here you see that postmortem cholesterol can be 13% lower than cholesterol before death.

This is a comparison of the degree of arteriosclerosis observed at autopsy in Japan compared to Minnesota back in the 1950s.  For the same age, the incidence of heart disease was far lower in Japan.  You can safely assume that their diets were far different.

The Japanese had much lower blood cholesterol as a result. Here you see cholesterol levels and age plotted on a graph.  Notice that the high-fat consuming populations like in Minnesota at the top exhibit the J- or U-curve, as their cholesterol levels plummet at the end of life.  You don't see a similar shape for the two Japanese-derived regression lines at the bottom.  Their cholesterol stayed in a similar range in old age.

So between these last two slides you see that there indeed is a powerful correlation between atherosclerosis at autopsy and blood cholesterol over a lifetime.

A more telling observation of the link between cholesterol and atherosclerosis might be better observed in cadavers of the young, as older individuals are likely to have more health problems to confound any observations.  Here you see the results of an examination of young people who died suddenly.  Fatty streaks which are the first stage of atherosclerosis were found to be strongly related to total and LDL cholesterol levels before death.

At the other end of the fitness spectrum from the aged and infirm were these highly-conditioned runners who suffered sudden death.  None had any evidence of heart disease, yet four of five had high cholesterol.  In spite of their fitness, they had enormous atherosclerotic buildup.

A related canard based on the relationship between cholesterol and mortality is the claim that more heart attacks happen to the elderly despite their diminished cholesterol concentrations.  Of course, lots of things start failing in your later years.  Among them is the stability of arterial plaques.  Once again, cholesterol over a lifetime is more important than cholesterol in old age.

I'll show you more of the tricksy tactics of the confusionists if you stay with me for Part II of Playing Games with Your Heart.

Primitive Nutrition 41:
Playing Games with Your Heart, Part II

You haven't seen all the shenanigans of the cholesterol confusionists yet.

Here's Mark Sisson again.  He is one of many to claim that cholesterol doesn't matter because half of first time heart attack sufferers have nominally "normal" cholesterol. He has a particular study in mind when he makes this claim.

I do find it appropriate his top supplement is called Damage Control, given the diet advice he gives.

Robb Wolf is another Paleo guru who thinks this same study tells us cholesterol levels don't matter.  Let's look at the study and see if we should agree with his carefully reasoned conclusion that "we", which I'm guessing Wolf doesn't think includes himself, are dumb when it comes to cholesterol.

Here's the news release for their study, which is linked within Wolf’s article.  We quickly see that the heart attack sufferers were deemed to have safe cholesterol levels based on current US guidelines.  The principal investigator of this study, Gregg Fonarow, did not conclude, as our two broscientists did, that cholesterol is a red herring in the fight against heart disease.  Instead he thinks the targets for cholesterol may be too high and should be lowered.  He also commented that very few patients had ideal cholesterol ratios by current standards. 

Like practically every other modern cholesterol study the confusionists embrace, cholesterol-lowering medications were involved, complete with their side effects - side effects you can be sure  the prescribing health care providers decided were worth the risks for these patients.  All this can be gleaned from the link Wolf provides himself, yet he didn't think any of this was worth mentioning.

Let's look beyond the press release to the actual study.  Pause the video if you like and have a look at the patient population's overall characteristics on the right.  Look at all those health problems. Do you see the third line down, prior myocardial infarction?  Those are heart attacks.  When Mark Sisson talks about people who are first time heart attack sufferers, he is only eliminating 16.5% of the people in this study.  What about the rest?  The authors weren't kidding when they wrote that "cardiovascular risk factors and comorbidities were frequently present."  I see overweight people. I see many with a history of high cholesterol for which only some have been given medication to control it. I see smokers, diabetics, and high blood pressure sufferers.  I see people as old as 79.

So let me ask you, in this patient population, do you think their cholesterol levels were normal by the standards of the Japanese in the Fifties?  Do you think they had stable low cholesterol their whole lives because they were eating plant based diets?  Or do you think this 100% American overweight group of heart attack sufferers mostly ate diets that were more likely to raise their cholesterol, only to have it fall at the end of life like you see at the top of this graph?  Who do these guys think they are kidding?  Abuse of the J-Curve phenomenon is a handy distraction for the illusions of the confusionists once again.

Here is an interpretive remark at the end of this study.  Perhaps LDL goals should be lowered even more, they say. 

Fonarow’s suggestion of lowering targets for LDL was met with derision by the low carbers.  Here we have a comedian, Tom Naughton, saying a cardiologist was practicing bad science.  This must be some kind of meta-joke.

Since then an important new study has provided support for the lowering of LDL targets in at-risk patients.  The latest and best research says Fonarow is probably right, even though he isn’t a comedian.

The accompanying editorial to this recent study could not have been more supportive of the plant-based nutrition strategy.  Humans are not anatomically or metabolically designed to be meat eaters, it said, not that I would put it that way.  This may be why we have heart disease. 

The suggestion that cholesterol targets be lowered has been met with derision by less amusing pro-fat bloggers as well.  Complaints like these have been heard before.  The very same arguments were made back when guidelines were lowered only to the point that total cholesterol of 300 mg per dL was considered normal.  We know that 300 is dangerous today.  In a country that loves its fatty animal foods, this knee-jerk response is predictable.  This is why judgment calls on public health standards are not left to fad diet promoters with audiences to please.  Yes, Robb Wolf, some of us have always been "dumb" when it comes to cholesterol.

Cancer is another favorite talking point for the cholesterol confusionists.  They want you to think low cholesterol makes it more likely you will develop cancer.  Low cholesterol in cancer patients is yet another example of a ploy based on the J-curve.  Low cholesterol is caused by cancer, not the other way around.

Here is an example of a study that makes this clear.

Actually, low cholesterol has been shown to lower your risk of developing cancer.  You didnt think a diet of cancer-fighting plant based foods could somehow cause cancer did you?  That would really be dumb.

Depression is yet another problem pinned on low cholesterol.  Once again, there are other explanations for any correlation between the two.

If low cholesterol caused depression, then why are people in Asian countries, with their low cholesterol levels, so much less likely to suffer from depression.  Depression, and the diagnosis of depression, are too complex to be explained through cholesterol. 

The next time you hear this argument, remember this slide.  It seems cholesterol correlates directly with completed suicide.

Often the pro-saturated fat propagandists will find a study here or there that seems to support their ideas.  I have to give them credit for looking so hard.  Misleading studies like theirs must be hard to find hidden among all the other studies they try to ignore.  Usually they will point to some small scrap of epidemiological data, where some population during a particular period of time seemed to do better in some health outcome in spite of eating more saturated fat.  They find these scattered studies to be highly significant, unlike the vast bulk of data they like to either nit-pick or pretend doesn’t exist.  Their studies are usually easy to dismiss.  I'll show you a good example of that. 

But first, have a look at this slide.  Here, epidemiological data seem to indicate that smoking prevents Parkinson's Disease.  Does that mean smoking is good for you?  No.  Epidemiology can never prove causation because there are always possible confounders that may skew results.  Here's another factor to keep in mind.  You should expect to see random results that defy expectations.  It would be unrealistic to believe there could be no statistical noise in data drawn from the real world.  Any gleeful trumpeting of aberrant and insignificant studies supporting cholesterol or saturated fat is best seen as confusionist desperation.

Here's another factor to help you weed through their garbage blogs.  Most of the studies the confusionists like to cite come from the post-statin era.  Any study conducted in the industrialized world attempting to compare diet with heart disease needs to account for the use of cholesterol lowering drugs.  As you see here, they are widely used.  I chose evidence from Sweden to set us up for one of those confusionist studies that are so easy to dismiss.

Here is a blog post excerpt from saturated fat apologist Anthony Colpo in which he finds validation for his fringe views with a fringe study.  Swedish farmers were followed over 12 years to see what dietary patterns lead to heart disease.  Fruits and vegetables were associated with lower heart disease but only if consumed with a lot of dairy fat.  If you think that sounds like a strange result, it is.  There are plenty of other studies linking saturated fat to heart disease in Swedes that the confusionists ignore.

To be left out of this study a farmer had to have been actually hospitalized with heart disease.  So if you had a history of heart disease in your family, or if you had high cholesterol and were put on statins, or if your heart disease had not yet put you in the hospital, you would be put in this study's cohort anyway.  As you can see, statins are not mentioned in this study, nor are any other lipid-lowering drugs.  This study lacks basic and necessary information, so it should be viewed with skepticism.

Ignore the abstract and look at the data.  Here you have a population with a mean age at the end of the study of only 62 years old. They collectively started with what would very conservatively be called borderline high LDL cholesterol.  More than a quarter of them were either hospitalized or died due to cardiovascular disease or coronary heart disease.  Remember, that age of 62 is the mean.  This does not seem like a very healthy bunch, does it?  Are you really going to base your personal choices on these people? And what are the chances that no one in this vulnerable group used cholesterol-lowering drugs that would have muddled any associations with diet?

So these men did worse if they used lower fat dairy products.  Are we to assume that the people opting for lower fat intake always ate lower fat over their whole lives?  Don't you think the people told by their doctors that they were at risk for heart disease might be the same ones who disproportionately chose to eat less saturated fat?  No adjustment is made for something so obvious. 

Here’s something else that’s strange.  Saturated fat was looked at in detail for dairy, but no other sources of saturated fat, beside fish, were mentioned.  Therefore, if someone preferred skim milk but ate many more high-saturated fat meats than the rest, eating bacon and burgers and liver every day, they would fall in the low dairy fat segment of this study anyway.  And of course, because Sweden is such a big dairy-consuming country, there is no dairy-free group.

So you see, there isn't a lot to be learned from this study.

Which is why it has only two citations in its search results.  The second search result is from professionally invested cholesterol confusionist Colpo, who thinks this study proves something about saturated fat in general.  Colpo is really cutting edge, I guess.

What about those two citations this study received?  Evidently at least two scholars thought this was quality research, right?

Well it turns out both are for the same author, who has her own theories to push about fat's connection to Alzheimer's and ADHD. Her expertise is in electrical engineering.

One off topic remark: Here is where Sweden stacks up in dairy consumption.  You would think with all that calcium they have amazing bones, right?

Nope.  They have a very high prevalence of osteoporosis.

Are you starting to wonder about the thought process of someone who would buy into all this garbage science on cholesterol?  I'll give you a peek into the confusionist mind in the next video.

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.

TPNS 34-35: Cholesterol Denialism

Primitive Nutrition 34:
Cholesterol Denialism, Part I

Search Amazon for books about cholesterol and saturated fat and you will see an interesting pattern emerge.  Bucking the conventional wisdom on diet and heart health is popular these days.  Maybe this will seem confusing and you'll want to find the truth...

If you search the words "cholesterol" and "truth" you’ll get more of the same.  That's the funny thing about the internet.

There are apparently people gullible enough to think that websites that say they have the "truth" really do. 

Fear is a great way to connect with an audience if you lack scruples. 

There are responsibly written books about vaccines that are accessible to the public, but in the world of vaccinology, there is no controversy, and the most cutting edge books are beyond the budgets and education of almost everyone.

With cholesterol it's no different.  Titles are targeted at emotions and priced to sell.

And just like with vaccines, the community of experts on cholesterol are not having a debate.  The science has moved forward.

The one thing all the cholesterol confusionists are sure about is that the conventional wisdom about saturated fat and cholesterol is wrong.  That doesn’t mean they agree on much beyond that. 

Heart disease is our number one killer.  Surely they must agree it's a problem.  So what do they think causes it?

The Weston Price Foundation is full of ideas and they seem to be hoping at least one of them will stick.  Chlorine, fluoride, artificial lighting, pasteurized milk.  All these need further study.  Why, they don't say.  Interestingly, they don't yet appear to be sold on smoking as a cause of heart disease, either.  They leave open the possibility that the urge to smoke is due to a nutritional problem, which for them is probably a lack of raw milk.  There is some creative thinking at this website.  I'll admit that.

Loren Cordain thinks it's whole wheat.  Maybe he hasn't gotten around to studying the evolutionary discordance of fluoridated water yet, as the Weston Price folks apparently have.

The deep thinkers at the International Network of Cholesterol Skeptics think it's stress, especially eating under stress.

Cholesterol skeptic in chief Uffe Ravnskov think heart disease is an infectious disease.  This is an interesting idea considering that it is most common in rich countries that otherwise don't have big problems with infectious disease.

No, they may not agree what causes heart disease, but they all agree that the most obvious contributors to it couldn't possibly be to blame.  Dietary saturated fat and cholesterol have been unfairly accused.  The funny thing is, virtually all international medical institutions see things differently.

The USDA has declined to set a minimum daily recommended intake for saturated fat due to its effect on cholesterol.

And the National Institutes of Health says that cholesterol causes arteriosclerosis.

The American Heart Association is also clear about the role of cholesterol in heart disease.

They are trying to raise your awareness of its dangers.

The World Health Organization says there is no dietary requirement for cholesterol.  The less you eat, the better.

A recent summit of international experts in dietary fats met to affirm the scientific consensus.  Saturated fat and cholesterol in the diet are strongly associated with heart disease.

How did this scientific consensus develop?  Through experimentation and observation stretching back more than 100 years.  Even if it were possible to show you all the evidence for the consensus view in a video series, I would not be the person to do it.  But I can show you a few highlights.

First, borrowing a slide from this presentation of Anton Stalenhoef...

We see the range of blood cholesterol concentrations in various mammals.  Newborn humans are way down there with the other mammals.  Adult humans can go quite high, however.  The letters "FH" here refer to familial hypercholesterolemia, or inherited high cholesterol.  Notice the broken Y-axis at the left.  That means the positions on the graph of those with inherited high cholesterol are actually deceptively low here.  Otherwise, they'd be literally off the chart.

As you saw, our cholesterol begins quite low.  Newborns in this study had total cholesterol way down at around 72 mg per dL. This is true even though the mothers in this study were all the way up at 297.  Milligrams per deciliter is the usual way cholesterol is measured in the US.  If you know your cholesterol number, how close are you to 72?

By the way, that 297 score for the moms is really high. 

Babies have been proven to develop safely and normally on diets low in saturated fat and cholesterol, but without the rise in blood cholesterol usually seen in infancy.  Kids raised this way have a healthier start in life.

Atherolsclerosis, which is the most common form of hardening of the arteries, starts with fatty streaks in the artery wall that look like this.

These fatty streaks start a process of thickening and hardening in the artery walls that begins in childhood.

This thickening process has been observed in the arteries of young people who died of unrelated causes.

For American ages 6 to 20 fatty streaks cover 25% of the lining of the aorta. The Japanese have half this amount.

Atherosclerotic lesions progress rapidly between 15 and 34 years of age. 

By the time Americans were old enough to fight and die in the Korean War, they had already developed extensive cardiovascular disease.

This is what atherosclerosis looks like.  I don't know about you but I don't want it.  Any of it.

Some top health institutions say they don't know what causes it, but this should be understood to mean that they don't understand the precise mechanism at a molecular level that causes it yet.  Therefore, it may be technically correct to say it has not been proven that saturated fat and cholesterol cause heart disease, but that would be misleading.   The same institutions will also tell you what risk factors raise your odds of experiencing it.  One of those risk factors is an unhealthy diet, which in part means a diet that includes too much saturated fat and cholesterol.

Since I don't want any of this, it is my choice to eat a diet that has no saturated fat or cholesterol.  Diet is a risk factor I can control, so I choose to eliminate that part of my risk.  That's my choice.  How much risk do you want?

Cholesterol research has an interesting history.  We'll look at that a bit in Part II.

Primitive Nutrition 35:
Cholesterol Denialism, Part II

The effects of diet on heart disease risk are seen across different ethnicities...

And across different cultures.

As you have seen, Loren Cordain wants us to have low cholesterol, much to his credit. 

That humans should have much lower cholesterol than is typical now is becoming a mainstream view.  Hunter gatherer populations with parasite burdens and vegetarians without parasites burdens both serve as the models here.  I'll pass on the parasites in favor of option B.

Lower is better because blood cholesterol has been shown to directly relate to rates of death from heart disease, even at the low end of the scale.

Cholesterol confusionists routinely start their chicanery by pretending to educate us about the important roles cholesterol plays in the body...

As if this would be news to the global community of medical researchers and scholars.  Of course, cholesterol has critically important functions in the body.  The question is, is it healthy to have chronically elevated concentrations of it?

Is high cholesterol unhealthy?  Let's look at other factors beside diet and genetic defects that can raise your cholesterol.  Being overweight can raise your LDL or bad cholesterol.  Old age is associated with higher cholesterol.

Chronic inflammatory disease can raise your cholesterol.

Acute mental stress can raise your cholesterol...

and this is well established.

This is one of the ways work-related stress makes you vulnerable to heart disease.

The threat of unemployment is stressful, too, so it can raise cholesterol as well.

Steroid use will raise cholesterol in body builders.  This is a great example of how the appearance of health and actual health are not necessarily same thing.

Higher cholesterol is also associated with Alzheimer's Disease.

The same goes for sleep apnea.

And of course, high blood cholesterol is also associated with metabolic syndrome, the consumption of an unhealthy diet, and cardiovascular disease.

This is all guilt by association, of course, but it is enough to convince me that lower is indeed better.

On the other hand, exercise and weight loss lower your cholesterol. 

Many plant foods lower your cholesterol as well.  There have been many studies showing this, which raises a question for the confusionists: If it's healthy to have high blood cholesterol and if plant foods like almonds and blueberries lower your cholesterol, does that make almonds and blueberries damaging to your health?

Cholesterol research has a fascinating history.  I recommend reading the articles in this series by Daniel Steinberg, author of The Cholesterol Wars.  I'll refer to this valuable material repeatedly.

In their lecture at the awarding of their Nobel Prize in Physiology or Medicine in 1985, Brown and Goldstein gave us perhaps the most often-repeated quote about cholesterol:  "Cholesterol is the most highly decorated small molecule in biology."  Among the thirteen Nobel Prizes it helped scientists earn, one never went to this man.

This is Nikolay Anitschkow.  Almost 100 years ago as a young experimental pathologist at the Military Medical Academy in St Petersburg, Russia, he demonstrated that atherosclerosis could be induced in rabbits simply by feeding them cholesterol.  Through his research, Anitschkov was the first to describe in detail the progression of heart disease and its connection to dietary cholesterol.  This has made Anitschkow a controversial figure for some, who question the validity of lessons learned from experiments on rabbits.    This theme is recurrent among those who sew confusion over cholesterol.  No animal model is ever good enough for them.  Do they not understand that animals that are especially vulnerable to diet-related diseases have been valuable in research precisely because they are so vulnerable.  Answers to specific questions are found faster this way.

Atherosclerosis had been described long before Anitschkow's work. Rudolph Virchow described its structure, observing that it was not a deposit on the interior surface of the artery, or endothelium.  In 1854 he recognized that it was the product of an inflammatory process.  Cholesterol confusionists usually base their arguments on the idea that inflammation, not cholesterol in the blood or diet, causes heart disease.  This is an either-or fallacy.  Inflammation was seen as important before diet was.  The presence of inflammation is not a matter of controversy today.

A yellowish, fatty substance was recognized as the major constituent in these plaques by Adolph Windhaus in 1910.  This substance is cholesterol.

In this context, we can see how Anitschkow in 1913 guessed correctly that dietary cholesterol could produce this disease.

The connection of diet to heart disease shouldn't be such a hard sell.  Carnivores do not develop atherosclerosis when they eat their natural flesh diets.  But feed an herbivore a carnivore's diet and it will develop atherosclerosis.

The connection of diet to atherosclerosis has been demonstrated in a long list of animal models.

Surprising to me, however, was that a fatty, cholesterol-rich diet has even been shown to induce atherosclerosis in a domestic cat, which is an obligate carnivore.

Steinberg, referring to the mid 1970's

Although virtually the entire medical world accepts and understands the role of saturated fat and cholesterol in the etiology, or causation, of heart disease, it was not always this way.  Opposing theories were preferred through the 1970s.

The pivotal role of blood cholesterol in the development of heart disease, an idea known as the lipid hypothesis, was not widely accepted in the United States until the 1980s.

The controversy over the lipid hypothesis did not abate in the UK until the 1990s.  The old cholesterol deniers are mostly long dead. 

In retrospect, the resistance to the lipid hypothesis is culturally understandable.  People love their fatty foods.  Those who vilify the federal government's role in educating the public about the dangers of cholesterol don't seem to appreciate that government agencies have changed their policies in response to developments in science.  Don't we want our institutions to react to new information?  This old government educational publication gave milk, eggs, meat and cheese, and even butter their own separate food groups.  When we see that it was believed that two tablespoons of butter per day promoted health, we can understand why some people had a long way to go to accept the dangers of such foods.

Animal models were just part of the rationale for the lipid hypothesis. It has been observed directly in humans as well.  In 1916, Cornelius De Langen demonstrated the effect of diet on blood cholesterol in humans.  He had noticed that the mostly vegetarian natives of Indonesia did not seem to suffer from heart disease.  He conducted his own diet experiment, feeding five natives a high-fat, high-meat diet.  This produced a dramatic elevation in blood cholesterol.

Since then at least 395 studies conducted in metabolic wards with carefully controlled experimental diets have collectively made the case for the effects of saturated fat and dietary cholesterol on blood cholesterol levels.

Just as importantly, the lipid hypothesis has been proven in epidemiological studies.  The most famous epidemiologist for the diet-heart idea has been Ancel Keys, and I'll talk about him next.  In the mean time, I suggest you pause the video and read this excellent short description of the role of cholesterol in promoting heart disease, if you don’t know much about it.  It touches on the difference between LDL, or bad cholesterol, and HDL, or good cholesterol.