New cholesterol guidelines for converting healthy
people into patients
Uffe Ravnskov, MD, PhD
(Feel free to publish this site anywhere, but don´t
forget to tell from where it comes)
In the May 16 issue of the Journal of the
American Medical Association an expert panel from the National Cholesterol
Education Program has published new guidelines for "the detection, evaluation,
and treatment of high blood cholesterol" (read
the paper). Their writing seems to be an attempt to put
most of mankind on cholesterol-lowering diets and drugs. To do that, they
have increased the number of risk factors that demands preventive measures,
and expanded the limits for the previous ones.
But not only does the panel exaggerate
the risk of coronary disease and the relevance of high cholesterol, it
also ignores a wealth of contradictory evidence. The panel statements reveal
that its members have little clinical experience and lack basic knowledge
of the medical literature, or worse, they ignore or misquote all studies
that are contrary to their view.
Here come a few examples of the panel’s false
As an argument for using cholesterol-lowering
drugs the panel claims that twenty percent of patients with coronary heart
disease have a new heart attack after ten years. But to reach that number
any minor symptom without clinical significance is included.
Most people survive even a major heart attack,
many with few or no symptoms after recovery. What matters is how many die
and this is much less than twenty percent.
The panel also recommends cholesterol-lowering
drugs to all diabetics above 20, and to people with the metabolic syndrome.
If you have at least three of the "risk factors" mentioned below, you are
suffering from the metabolic syndrome:
Limits according to
the NCEP expert panel
above 88 cm in women; above 102 in men.
Some male "patients" can develop many risk factors with a waist
circumference of only 94 cm
150 mg/dl or more
Men less than 40 mg/dl
Women less than 50 mg/dl
High blood pressure
130/85 or higher
High fasting blood sugar
110 mg/dl or higher
Test yourself and your family! I guess that
most of you "suffer" from the metabolic syndrome. And this combination,
says the panel, conveys a similar risk for future heart disease as for
people who already have coronary heart disease.
Luckily, it is not true.
It is not true either, that cholesterol has
a strong power to predict the risk of a heart attack in men above 65. In
the 30 year follow-up of the Framingham population for instance, high cholesterol
was not predictive at all after the age of forty-seven, and those
whose cholesterol went down had the highest risk of having a heart attack!
To cite the Framingham authors: ”For each 1 mg/dl drop of cholesterol there
was an 11 % increase in coronary and total mortality (115).”
It is not true either, that high cholesterol
is a strong, independent predictor for other individuals.
In most studies of women and of patients who
already have had a heart attack, high cholesterol has little predictive
power, if any at all.
In a large study of Canadian men high cholesterol
did not predict a heart attack, not even after 12 years, and in Russia,
low, not high cholesterol level, is associated with future heart attacks
summary of paper).
Most interesting is the fact, that in some
families with the highest cholesterol levels ever seen in human beings,
so-called familial hypercholesterolemia, the individuals do not get a heart
attack more often than ordinary people, and they live just as long
(read the paper
and my comment).
Taken together such observations strongly
suggest that high cholesterol is only a risk marker, a factor that is secondary
to the real cause of coronary heart disease. It is just as logical to lower
cholesterol to prevent a heart attack, as to lower an elevated body temperature
to combat an underlying infection or cancer.
It has also escaped the panel’s attention
that the effect of the new cholesterol-lowering drugs, the statins, goes
beyond a lowering of cholesterol. The question is whether their cholesterol-lowering
effect has any importance at all because the statins exert their effect
whether cholesterol goes down a little or whether it goes down very much.
No doubt, the statins lower the risk of dying
from a heart attack, at least in patients who already have had one, but
the size of the effect is unimpressive. In one of the experiments for instance,
the CARE trial, the
odds of escaping death from a heart attack in five years for a patient
with manifest heart disease was 94.3 %, which improved to 95.4 % with statin
For healthy people with high cholesterol the
effect is even smaller. The WOSCOPS trial studied that category of people
and here the figures were 98.4 % and 98.8 %, respectively.
In the scientific papers and in the drug advertisements
these small effects are translated to relative effect. In the mentioned
WOSCOPS trial for instance, it is said that the mortality was lowered by
25 %, because the difference between a mortality of 1.6 % in the control
group and 1.2 % in the treatment group is 25 %.
When presented with accurate statistics on
the value of statins, almost all my patients have rejected
such treatment. To claim that the statins dramatically reduce a persons
risk for CHD, as was stated in the press by Claude Lenfant, the director
of the National Heart, Lung and Blood Institute, is a misuse of the English
The figures above do not take into account
possible side effects of the treatment. In most animal experiments the
statins, as well as most other cholesterol-lowering drugs, produce cancer
(90), and they
may do it in human beings also.
In one of the statin trials there were 13
cases of breast cancer in the group treated vid pravastatin (Pravachol®),
but only one case in the untreated control group, a scaring fact that is
never mentioned in the advertisements or the guidelines.
It is also an alarming fact that in one of
the largest experiments, the EXCEL trial, total mortality after just one
year's treatment with lovastatin (Mevacor®) was significantly
higher among those receiving statin treatment. Unfortunately (or happily?)
the trial was stopped before further observations could be made.
In human beings the effects of cancer-producing
chemicals are not seen before the passage of decades. If the statins produce
cancer in human beings, their small positive effect may eventually be transformed
to a much larger negative one, because side effects usually appear in much
higher percentages than the small positive ones noted in the trials.
Whereas possible serious
side effects of the statins are hypothetical, those from the previous cholesterol-lowering
drugs, still recommended by the panel, are real. Taking all experiments
together, mortality from heart disease after treatment with these drugs
was unchanged and total mortality increased, a fact that has
given researchers outside the National Cholesterol
Education Program and the American Heart Association much reason for concern.
The panel’s dietary recommendations
represent the seventh major change since 1961. For instance, the original
advice from the American Heart Association to eat as much polyunsaturated
fat as possible has been reduced successively to the present “up to ten
But why this limit? Seven
years ago the main author of the new guidelines, Professor Scott Grundy,
suggested an upper limit of only seven per cent, because, as he argued,
an excess of polyunsaturated fat is toxic to the immune system and
stimulates cancer growth in experimental animals and may also provoke gall
stones in human beings. These warnings have never reached the public.
Furthermore, the panel ignores
that a recent systematic review of all studies concerning the link between
dietary fat and heart disease found no evidence that a manipulation of
dietary fat has any effect on the development of atherosclerosis or cardiovascular
summary of the paper -this paper won the Skrabanek Award
For instance, in a large
number of studies, including the incredible number of more than 150,000
individuals, none of them found the predicted pattern of dietary fats in
patients with heart disease.
No supportive association
has been found either between the fat consumption pattern and the degree
of atherosclerosis (arteriosclerosis) after death.
Most important, the mortality
from heart disease and from all causes was unchanged in nine trials with
more radical changes of dietary fat than ever suggested by the National
Cholesterol Education Program, a result that was confirmed recently in
another review (read the paper
To suggest that diabetic patients should obtain
more than 50 percent of their caloric intake from carbohydrates seems unusually
bad advice. Many carbohydrates are quickly transformed into sugar inducing
rapid changes in blood sugar and insulin levels and thus stimulating a
rapid conversion of blood sugar to depot fat and chronic feelings of hunger.
Diabetic patients should eat more fat.
Is it a coincidence that the Americans’ decreasing
intake of fat during the last decade has been followed by a steady increase
of their mean body weight and an epidemic increase of diabetes?
Instead of preventing cardiovascular disease
the new guidelines may increase the mortality of other diseases, transform
healthy individuals into unhappy hypochondriacs obsessed with the chemical
composition of their food and their blood, reduce the income of producers
of animal fat, undermine the art of cuisine, destroy the joy of eating,
and divert health care money from the sick and the poor to the rich and
the healthy. The only winners are the drug and imitation food industry
and the researchers that they support.
Uffe Ravnskov, MD,
If you lack the scientific evidence for something written above you will
find it in my book, The Cholesterol Myths.
Exposing the fallacy that saturated fat and cholesterol cause heart disease.
Extracts from the book are
presented on my website:
The Cholesterol Myths