The Great Cholesterol Con

The Truth about What Really Causes Heart Disease and How to Avoid It

Boy, is the cholesterol hypothesis wrong. It is wronger than a very wrong thing. Yet it has mesmerized scientists, doctors, and the general public for years. —Introduction, p. viii

Dr. Malcolm Kendrick is a man on a mission—to challenge the conventional wisdom on heart disease and expose the “cholesterol con.” He gets right to the point in this book with a list of seemingly counter-intuitive “facts I hope to convince you are true.” Then he marshals more than enough evidence to prove his case as he reviews and explains hundreds of medical studies. Amazingly, he does this in a very readable and entertaining way, peppering the book with one liners and interesting quotes, like this one:

For every complicated problem, there is a solution that is simple, direct, understandable, and wrong. —H.L. Mencken

The first section of the book explains why the idea that eating fat somehow clogs arteries with cholesterol is completely preposterous. Dr. Kendrick believes it is a travesty of science that the cholesterol hypothesis remains popular despite fifty years of studies disproving it.

To begin setting the historical record straight Kendrick quotes perhaps the two most famous pioneers in the history of cardiovascular disease research—Dr. Ancel Keys and Dr. William Castelli.

Dr. Keys was the architect of the Seven Countries Study, which is still cited in support of the cholesterol/heart hypothesis, but almost everyone ignores this statement he made, “There’s no connection whatsoever between cholesterol in food and cholesterol in blood. And we’ve known that all along. Cholesterol in diet doesn’t matter at all.”

Dr. Castelli was director of the Framingham Study, the most influential, longest-running, and most often quoted study in heart disease research. He said the data in this study showed that, “The more saturated fat one ate, the more cholesterol one ate, the more calories one ate, the lower people’s serum cholesterol.”

Dr. Kendrick delves further into the science of the matter in a chapter entitled, “You Cannot Have a Cholesterol Level.” The average person is not aware of basic chemistry, let alone the extremely complex process of cholesterol biosynthesis that can still baffle experts much of the time. First of all, fat eaten does not magically turn into cholesterol in the body somehow. As Dr. Kendrick writes, “No biochemist has managed to explain this clever trick.” The chemical processes of digestion and metabolism are far too complex to be reduced down to the notion “swallowed fat turns into cholesterol deposits in the arteries.” Dr. Kendrick actually compares the cholesterol/heart hypothesis to beliefs in magic or medieval medical practices such as bleeding a patient to release “bad humors” from the blood.

The second point of science is that there’s no such thing as a cholesterol molecule floating in the blood because cholesterol isn’t soluble. Cholesterol molecules are incorporated, transported and synthesized by much larger host molecules—most of them are called “lipoproteins”—which are themselves constantly undergoing metabolic processing in various parts of the body.

There are various tests that attempt to measure the levels of the many different types of lipoproteins in the blood, but this is notoriously difficult. Levels of some lipoproteins remain relatively stable—one in particular remains the same over a person’s entire lifetime—while the level of other lipoproteins rises and falls dramatically in a matter of hours.

Much speculation about “good”, “bad”, “combined” or “total” cholesterol (which all really refer to lipoproteins) has made it into the popular press, but such labeling is pseudoscientific and very misleading. Again, the lipoproteins labeled “bad cholesterol” simply aren’t cholesterol. Even more unscientific are some claims that “good” cholesterol somehow absorbs plaques from clogged arteries. Dr. Kendrick says there is no evidence that this happens.

Furthermore, none of the above really matters as the title of chapter seven makes clear, “A Raised Cholesterol/Lipoprotein Level Does Not Cause Heart Disease.” Dr. Kendrick says that this chapter is where he really begins to go against medical dogma, but he also points out there are a growing number of doctors that share his point of view.

“For decades, enormous human and financial resources have been wasted on the cholesterol campaign, more promising research areas have been neglected, producers and manufacturers of animal food all over the world have suffered economically, and millions of healthy people have been frightened and badgered into eating a tedious and flavorless diet or into taking potentially dangerous drugs for the rest of their lives. As the scientific evidence in support of the cholesterol campaign is non-existent, we consider it important to stop it as soon as possible.”

—From the website of The International Network of Cholesterol Skeptics (or THINCS), a group of scientists, physicians, and other academicians from around the world who dispute the widely accepted lipid hypothesis of atherosclerosis.

In order to explain why cholesterol doesn’t cause heart disease, Kendrick begins with a discussion of strokes rather than heart attacks. In a stroke, a piece of arthereosclerotic plaque breaks off, travels down the bloodstream and causes a blockage. There are massive numbers of undisputed studies showing that there is no correlation between strokes and fat consumption or lipoprotein levels.

In fact there are many studies showing that low lipoprotein levels are associated with a massive increase in death from stroke, and may even be a cause. This phenomenon is most clearly seen in the formerly stroke-plagued country of Japan, where over the last fifty years lipoprotein levels have risen by twenty percent while the rate of strokes has fallen dramatically—dropping six-hundred percent. Heart attacks have also declined dramatically.

Dr. Kendrick believes the most important statistics to consider are those that measure total mortality levels in multiple studies conducted over decades involving hundreds of thousands of people. The data from these studies clearly show that lower cholesterol means greater risk of death from heart disease. Dr. Kendrick acknowledges that this assertion might seem incredible to readers accustomed to constantly hearing about the dangers of cholesterol, but it’s in black in white in the report “Cholesterol and Mortality: 30 years of follow up from the Framingham Study” which appeared in the prestigious Journal of the American Medical Association.

Next Dr. Kendrick points out some simple but startling facts that challenge assumptions about the cholesterol/heart hypothesis. Plaques only develop in arteries, not veins, even though veins are exposed to the same levels of lipoproteins. In fact, most parts of arteries don’t develop plaques, but branch areas, where blood flow swirls or changes direction quickly, have greater turbulence and do tend to develop plaques.

Because some scientists realize there are many reasons to doubt the cholesterol hypothesis, other lesser known theories have been put forward. Speculative books have been written about genetics, enzymes, co-factors, cellular receptors, intracellular transport systems, and oxidation, but according to Dr. Kendrick the claims about these theories are also greatly exaggerated. He explains how some of the terminology is dubious, downright mythological, or completely meaningless. He also gives some of the more egregious examples of manipulating data in chapters six and seven. He sums up this section, “Frankly, if you believe any of this, you will believe anything.”

What Really Causes Heart Disease?

To conclude the book Kendrick presents a theory of heart disease that is a minority viewpoint. Nonetheless, Kendrick’s extensive research leads him to believe it is the best substantiated theory. Reaching a conclusion was not easy:

“I began what turned into a 25 year journey of discovery. It has to be said that I have taken many wrong turns along the way. There were several years when I thought that heart disease did not actually have a cause, or causes at all, so often did I find myself in another blind alleyway. Eventually, everything did come together in a way that makes sense and is actually supported by the facts. The primary cause of heart disease is…stress.

“Well, hey, like haven’t about ten million people been saying this for the last fifty years? Indeed they have. However, there is a major problem here, which is that the word ‘stress’ doesn’t really mean anything at all. Or perhaps it means too many things. Or perhaps it means different things to different people.

“So how can anyone say that stress causes heart disease, when there is so little agreement as to what causes heart disease and there is even little agreement as to what stress actually means? It’s a good question. In order to answer it, I have to attempt to define rather more clearly what I mean by stress.”

Dr. Kendrick goes on to give a scientific definition of stress and present the evidence that it is the cause of heart disease, even though the exact details of how it works have not been completely proven. It is called the “Response to Injury” hypothesis and has been researched for more than 150 years.

The summary is that stress is anything at all which disrupts the nervous system or hormonal system of the body. Disruptions can be measured by what is medically termed “HPA-axis dysfunction.” When such disruptions occur, a chain reaction of hormonal and metabolic events occurs (too numerous to list here). Two events near the end of that chain reaction—spikes in blood sugar levels and cortisol levels—are known to cause injures to the lining of arteries. The body then heals the injuries in the arteries naturally by producing cholesterol (an extremely healthy substance that the body uses in many ways) to coat the injuries. If an unhealthy pattern of repeated stress and arterial injuries develops (or becomes chronic), then plaques build up, which can lead to strokes and heart attacks.

Of course there are reams of data to support this theory. In fact, pretty much all the research ever done on cardiovascular disease and any related topics agrees. Some world class researchers, such as Per Bjorntorp, connected the dots and published the very conclusive studies years ago. Dr. Kendrick believes that Bjorntorp, and others like him, deserve the Nobel Prize.

The heath care implications of the Response to Injury hypothesis are profound. Psychological and social factors (lo, even spiritual ones) in reducing stress might become more important in reducing risk of heart disease than medical treatment. There is of course, much research that moderate exercise and moderate alcohol consumption stabilize the neural-hormonal system, relieve stress, and reduce risk of heart disease.

But there are many reasons the theory has not caught on.

• It’s a case of missing the forest for all of the trees.
• Science has yet to make perfectly clear exactly how all the events in the stress-injury-response chain-reaction work.
• The current medical paradigm focuses on drug therapies prescribed in response to symptoms, not overall wellness and prevention of disease.
• Much information is being distorted or suppressed by drug companies.

The Experts Have Profit Motives

This last factor reason is a recurring theme throughout the book from the first chapter to the last. Dr. Kendrick believes consumers should at least be aware of how much money might be influencing the industry producing, distributing, and regulating “statins”, the class of drugs that is widely prescribed to “lower cholesterol.”

Sales of just one of the most popular statin drugs total more than $13 billion each year. The marketing budget alone for one that was recently launched was $1 billion. All the major manufacturers provide funding to researchers and doctors.

Dr. Kendrick freely admits he was personally involved in this apparent conflict of interest, “You can hardly find an eminent cardiologist who has not been given honoraria by at least one pharmaceutical company that manufactures statins. And the sums involved are far from small. We are talking, in many cases, hundreds of thousands of dollars per year. I know, for I—ahem—have signed some of the checks.”

There’s more controversy. Just last year the National Cholesterol Education Program came under fire for setting lower limits on cholesterol levels, meaning millions more Americans would be told to take costly statin drugs. Critics immediately complained about financial ties and the Washington Post reported, “The extent of the connections were stunning: of the nine members on the panel, six had each received research grants, speaking honoraria, or consulting fees from at least three and in some cases all five of the manufacturers of statins.”

Moreover, the statin manufacturers increasingly influence the research. Dr. Marcia Angell, who used to edit the New England Journal of Medicine finds this trend disturbing, “The drug companies increasingly design the studies. They keep the data. They don’t even let the researchers see the data. They analyze the data, they decide whether they’re going to even publish the data at the end of it. They sign contracts with the academic medical centers saying that they don’t get to publish the work unless they get permission from the drug company.”

How do Statins Work Anyway?

Just as Dr. Kendrick explains that cholesterol biosynthesis is not as simple as most people think, he also explains the complexity of how statins work. They don’t magically reduce cholesterol in the blood, as most people mistakenly assume. Rather, they inhibit certain enzymes that are essential to the body’s production of cholesterol in the liver. Most people also do not realize that cholesterol is very healthy and an extremely important substance for many body functions, including the following:

• Brain synapses – The vital connections between nerve cells in the brain and much of the nervous system are made almost entirely of cholesterol.
• Vitamin D – A highly important vitamin needed to create healthy bones and known to be protective against a number of cancers.
• Cell membranes – All cells in the body need cholesterol in the membranes to provide structural integrity.
• Sex hormones – Cholesterol is the building block for most sex hormones.
• Bile – Cholesterol is the key component of bile, which is released from the gallbladder to help with food digestion.

The irony is that because statins interrupt cholesterol production in the liver, the body ends up pulling lipoproteins from other parts of the body into the liver, so statins actually do reduce lipoprotein levels in the blood. Whether that is healthy or not is still a matter of debate among researchers. Many critics have also complained that the potential side effects of statins are not adequately publicized and understood. When statins were first tested in the 1960s and 1970s, some were rejected because clinical trials revealed that more people died when they took the drugs than when they took the placebo. In some cases, the cholesterol lowering agents very nearly doubled the overall mortality rate.

Over the years statin formulations have been changed and studies performed that the drug companies claim validate the safety and effectiveness of statins. Dr. Kendrick admits that more recent studies at least show that statins “don’t seem to have increased the overall death rate.” But neither have statins reduced mortality rates, so he remains skeptical and notes that one recent statin was withdrawn after being implicated in at least 100 deaths. Data from the FDA establish that another statin was the direct cause of death in 416 people.

Dr. Kendrick is not the only critic. The cover story in the January issue of Business Week explored the controversy in an article titled, “Do Cholesterol Drugs Do Any Good?” This article also questions financial motives, noting that several companies have tried to make a case for distributing statins in a polypil form to the entire population, or even putting them in the water supply.

The article also questions drug companies’ advertising techniques. One ad claims a 36 percent reduced risk of heart attack. The fine print reveals how that figure is arrived at. In a large clinical study, three percent of patients taking a placebo had a heart attack compared to two percent taking the statin. Several patients are interviewed because they are dealing with the common side effects such as diarrhea, muscle pain, cognitive impairments, and sexual dysfunction. A doctor and professor of medicine at a major research university is quoted asking, “What if you put 250 people in a room and told them they would each pay $1000 a year for a drug they would have to take every day, that many would get diarrhea and muscle pain, and that 249 would have no benefit? And they could do just as well by exercising? How many would take that?”

Congress is the latest to get in on the action. They debated giving the FDA power to force changes in TV drug ads just last month, and the primary ads they focused on were for statins. However, some commentators have said this is far too little too late.

Consumer Reports released a survery last year that revealed that 84 percent of Americans believe that drug companies “have too much influence over the government officials who regulate them.” More than two-thirds of those surveyed were concerned that drug companies actually pay the FDA to review and approve their drugs.

Dr. Kendrick recommends that patients and consumers examine the evidence for themselves, and his book is a good starting point. Additional issues he addresses are the dangers of statins for women (especially during pregnancy) and why medical research may turn the typical dietary advice on its head.

The Cholesterol Con is published by John Blake Publishing, Ltd. ISBN 978-1-84454-360-1. Video of Dr. Kendrick presenting The Great Cholesterol Con can be found by searching for his name on youtube.com.