Drug-Fueled Delusions

Running a Cholesterol Confusionist Gauntlet, Part 10 – Drug-Fueled Delusions

Cholesterol confusionists comb the literature on the effects of drugs looking for anomalies that they can take out of context and blow out of proportion. Here’s an example of how this works.

On the left, you see an excerpt from Colpo’s journal article. He cites multiple references to support his statement that drug trials have shown no association between the degree of LDL lowering and heart disease mortality. One of his references for this statement is on the bottom left. This is the same reference that occupies the right of your screen. If you check up on Colpo’s reference, you’ll see it doesn’t support his beliefs very well. I’ll quote the authors. “We now report that the rate of coronary events was associated strongly with the plasma LDL cholesterol concentrations during treatment in the total cohort consisting of the patients treated with pravastatin or placebo. This is not an unexpected finding, considering that the HMG-CoAs were developed primarily to reduce LDL concentrations and that a close relationship between plasma total or LDL cholesterol and coronary events is well established.” Now how does Colpo rationalize using this reference? It seems to say the opposite of what he thinks it does. This is a running theme. The people who know the drugs best do not doubt the lipid hypothesis.

The various references used by confusionists about drugs are worthless for their argument, in my view. Who doesn’t know that drugs have side effects? Who doesn’t know that drugs reach the marketplace before their effects on humans are fully understood? Drugs are devised to target specific metabolic phenomena in an effort to short-circuit or alter them. This is a list of genes that have been shown to effect the development of atherosclerosis in mice. Each one is a potential target for a drug. But no drug will exactly duplicate the effects of a healthy diet in a holistic way. Instead, any drug focused on one small effect within the amazingly complex chemistry of the human body will cause distortions of other processes. In the mind of the confusionist, the workings of the human body are governed by simple cause and effect relationships between a handful of perfectly understood variables. Any unexpected finding is not seen by them as a window to understanding our biology in a more nuanced way. Instead, it’s new fodder for their one-sided debate.

Experts in drug therapies are generally up front about the shortcomings of drugs, and will usually remind us that lifestyle modification is preferable to drugs.

The cholesterol spin doctors usually rely on populist and conspiratorial rhetoric. This excerpt from a past article by Colpo is typical of his style.  He calls attention to a drug trial with disappointing results for aggressive LDL lowering, in this case the controversial ENHANCE trial.  He uses the apparent failure of this particular drug combination in this one trial, here a statin combined with a drug intended to inhibit an enzyme called Acyl-CoA cholesterol acyl transferase, to call into question our basic understanding of lipid metabolism.  According to Colpo, the results of this trial show us that big pharma is just out to make a buck as it spreads this big lie about cholesterol.  How’s that for a giant leap of logic? He takes the conclusion of one drug trial and uses that to impugn the drug makers. But, Mr Colpo, I thought you said these drugs had all kinds of benefits! But that’s not all. Here we have a study that showed an apparent failure of a drug combination.  Do you think the pharmaceutical industry wanted this study to fail?  Do you think they cleverly devised a trial to show how ineffective their products are?  How does that make any sense?  The makers of these drugs are Merck and Schering-Plough.  How did this trial result help their business?  Does this result not show instead that the approval process is not designed to maximize profits? If you think about it for a few seconds you’ll see that Colpo’s conclusion is totally backwards. And here’s my big question: What the heck does this have to do with eating foods that lower cholesterol? Does Colpo think simvastatin and ezetimibe are whole plant foods?

A rational and fair-minded person should learn a little something about these drugs before jumping to conclusions the way Colpo did. To give fair consideration to the drugs in question, one would have to consider issues such as those raised here by the US investigator in the ENHANCE trial, Dr Evan Stein.  He points out that participants in the study may not have had enough atherosclerosis to demonstrate the effects of the drugs.  He says the failure of this trial was due to patient selection and study design.  Do you think Colpo took these issues into consideration?  Dr Stein takes the opportunity to dismiss those like Colpo who question the so-called “LDL hypothesis”.

I’ll add that this trial did not look at hard clinical endpoints. It just looked at changes in carotid intima media thickness.  This trial did not investigate actual cardiac events and those are what matter. I already explained in my The Best Low Carb Research video number 53 that carotid intima media thickness may not be an accurate marker of risk.  Colpo probably did not see my video so he may not know this.

The ENHANCE trial results have fueled some controversy. I’ll take a moment to present two sides in the debate over the meaning of ENHANCE.  In this video, Dr Stein points out that the objective of drug therapies is to lower LDL. He says this objective is also met by diets that cut out cholesterol and saturated fat. Both approaches lower LDL and that is why they both work.  Dr Stein is a top expert in lipids and heart disease.

His opponent in the debate, Dr Allen Taylor, argues that ezetimibe did not show good results in ENHANCE because it has off-target effects on reverse cholesterol transport.  It inhibits cholesterol clearance, worsening atherosclerosis even though it lowers LDL, due to unintended side effects.  As if he thinks cranks like Colpo might be listening in on this debate, he says, “This is not about LDL. This is about a drug.”  Now shouldn’t that be obvious? The controversy is not about LDL.  It’s not about diet.  And only someone with an agenda like Colpo would try to make it seem that way. Do you see how much research I have to do to address each of Colpo’s phony arguments? This was one drug trial. Do you really think he has a clue what he’s talking about?

As I showed you in The Primitive Nutrition Series, evidence has come in since ENHANCE  that lower LDL than today’s targets is indeed better.  This is not the only study to indicate this. 

Here’s another.  This is considered evidence to medical professionals.  In a world where people insist on eating foods that cause heart disease, these drugs are necessary.  Someone like Anthony Colpo who encourages you to eat these foods is doing his best to make sure drugs like these generate big profits for the drug companies far into the future.  But don’t expect him to pay the bills for those drugs for you when the day comes that you need them.

Here is the closest thing I could find to a non-ideological argument against treating LDL. Dr Rodney Hayward of the University of Michigan questions whether there is good evidence to try to reach target numbers for LDL through drugs. He believes that statins prove to be beneficial for high risk patients regardless of their LDL number.

Here he went so far as to say LDL should be ignored altogether. Read this slide and you’ll see this was a highly provocative statement.

Recently he publicly urged the Adult Treatment Panel IV participants to abandon the idea of treating to LDL targets. He considers the belief in these target LDL levels to be dogmatic and lacking in evidence.

He believes that the success of statin drug trials has been due to their pleiotropic effects, the same argument used by Anthony Colpo. So would it be right to assume that this well-informed yet contrarian expert would be in agreement with Colpo that the lipid hypothesis is a failed idea? He seems to be on the same page as Colpo, doesn’t he?

Actually, he’s not. He and his co-author for this opinion, Dr Harlan Krumholz of Yale, also say that one does not need to impugn the cholesterol hypothesis. Their argument is that the negative side effects of some of the lipid-lowering drugs might be more important than their benefits from cholesterol lowering. They are not disputing those benefits. It is clear that he thinks it is desirable to have low cholesterol. He is just wary of the effects of some drugs.

Krumholz restates this opinion here as well.

Their concerns are about drug cost and safety. I don’t know about you but I’m glad to see medical experts having debates like this.

It’s time for me to ask you what you think of Anthony Colpo’s case against the mainstream understanding of cholesterol. Is he an isolated voice of honesty and reason protecting you from a massive con job? Or is it he who is trying to distract, confuse, bully and misdirect so that he can pull off a self-serving swindle. Now you have heard an opposing view to his. It’s up to you to decide whom to believe. As you have seen, like most confusionists, he lacks a coherent counterargument to the lipid hypothesis. He is against pharmaceuticals but he thinks they have a lot of benefits. He thinks the examples of the Tokelauans and the Masai damage the lipid hypothesis even though they had relatively low cholesterol. He believes antioxidant status is the most important factor in heart disease despite the lack of scientific support for this view. He desperately tosses out off-topic and unsupported claims about issues of overall mortality, cancer, and depression to change the subject from diet-heart. And worst of all, nearly all his arguments are based on obvious distortions or half-truths, and the few references he can find that clearly support his views are usually of questionable quality. I have no doubt Colpo will have a response to these videos but I am fine with letting him have the last word. I’ve done enough work to address this particular confusionist. If you decide to follow his advice, that’s your responsibility now. I’ve done my job.

Just because the denialist arguments are not being seriously considered anymore, that does not mean there isn’t an active debate today over cholesterol. To end this set of videos, let’s have a look at how today’s legitimate questions about cholesterol are framed. On the one side of this debate presented by the Wall Street Journal, you have a doctor who calls for the use of statins in patients who are not experiencing symptoms but who do have high LDL. He is talking about the prophylactic use of statins, using them for primary prevention. He expresses a typical sentiment: “Good habits like diet and exercise are the foundations of good health—but sometimes they're not enough.” As a whole food vegan, when I read a statement like this I think, “if the diet wasn’t enough, maybe it wasn’t enough of a diet.” I rarely see experts beside the occasional Caldwell Esselstyn or T Colin Campbell advocate diets that are actually likely to dramatically lower cholesterol.

I am not criticizing this doctor. As a responsible and prevention-minded physician, he doesn’t want people to experience a health crisis before their cholesterol problems are addressed. He knows your first symptom of heart trouble may be your last. He also understands the importance of diet. I just wish medical authorities like him spoke with clarity and specificity about high nutritional standards. If they did this persistently and without the usual deference to the sacred cow of moderation, one day the culture might be moved, and most heart disease might disappear with high safety and low cost.

Below you see a quote from this same doctor regarding nutrition. This is the sort of thinking that frustrates me. Why advocate the consumption of fatty fish when you know it raises LDL? Doesn’t he know LDL is already far higher than its physiologic need in most patients? Why not advocate cholesterol lowering foods instead? It is my expectation that when this instruction is put into practice by the typical patient, set in his ways, he will go to his usual restaurants, just order the fish and then feel good about that choice. It is just assumed by most doctors that it is too hard to adopt a new diet based on whole plant foods. It’s easier to get Americans (who believe they need a big hunk of meat and saturated fat on their plate to feel like they have been fed properly) to comply with recommendations if you ask them to just eat meats that are less bad. Recommendations like these are not about nutritional excellence, in my opinion. They are about our prevailing culture and simple human weakness. It seems to me only the ethical vegans, with their strongly counterculture nature, are able to leave behind cholesterol-raising foods with no regrets, and that is unfortunate.

I just have to shake my head when I read a statement like this. He sees statins as a better economic value than fruits and vegetables. Maybe it’s true but that’s still pretty sad. I know where he is coming from, though. He knows it is his responsibility to help his patients the best he can, and in his mind that means asking them to pop a pill. He can at least trust them to follow through most of the time when they are given that instruction.

The other side of this debate is represented by a doctor who believes diet and exercise are preferable to the prophylactic use of statins to prevent heart disease. She seems strong in her belief that fruits and vegetables are the real answer. Surely she is willing to take an unpopular stand for nutritional excellence, right?

Not really. Even this doctor feels it is necessary to advocate lean meats and fatty fish. She makes no mention of plant-based sources of protein. Now you might say I’m just reacting this way because I’m a vegan. That must be my kooky vegan ethics talking, right?

I disagree. In a comparison between tofu and lean meat, the tofu absolutely trounced the meat for its cardioprotective benefits. The tofu even retarded LDL oxidation. But you can’t ask people to eat tofu instead of meat, can you? No, we wouldn’t want to inform people of the actual best strategies we know of to stay healthy

This is why I’ve made these videos. I want people to at least have the information they need. Misinformation is everywhere, even from responsible and well-meaning health authorities who seem to be deceiving themselves. The cholesterol confusionists will never rest. They will always try to pander to those who want to feel good about their vices. I don’t expect any better from them. But I have been very disappointed by the failure of those in positions of responsibility to shoot down the fad diets, to strongly assert obvious conclusions based on real science, and to offer clear and effective strategies to help people not just be healthier but instead be as healthy as possible. But from where I stand, they are in pander-mode as well:

 “Sure, go ahead and eat your meat. But dry it out a bit first by draining off the fat. That won’t help you very much and it won’t taste very good and consequently you probably won’t even be consistent about it. If we can manage to get you to choose the fish at a restaurant, they will likely have cooked it in butter anyway. But don’t dare try to mature your palate so you can enjoy the foods that will actually make you healthier. Remember, we’re cardiologists. If everyone got radical about eating healthy, we might run out of patients one day.”

“We’ll pretend that fish does not have undesirable baggage like saturated fat. We’ll pretend there is no other way to get the nutrients in fish that we say are so beneficial. You have to eat fish.”

They don’t actually think like this, but they may as well. Their advice would be exactly the same either way. Until the meat eaters who populate the medical profession actually face their own research and follow it to its logical conclusion, it will be up to people like you and me to set the example.

Cholesterol, Cancer, and Depression

Running a Cholesterol Confusionist Gauntlet, Part 9 – Cancer and Depression

Cholesterol confusionists say low cholesterol will increase your chances of suffering from depression or cancer. Therefore, they think you should eat fatty animal foods so your cholesterol will be high. It’s pretty hard to find an expert opinion from the domains of cancer or depression research who would endorse this strategy.

Let’s first consider cancer. Apparently, Mr Colpo buys in on the idea that low cholesterol somehow promotes cancer.

In his blog about me, Mr Colpo refers to the Los Angeles Veterans study, as you can see in the second line from the bottom on this slide. I’ve included an excerpt from a magazine article so you can see how the confusionists try to make this study about cancer. A trial was conducted which placed some men on a control diet high in saturated fat and others on an experimental diet lower in saturated fat and higher in polyunsaturated fat. Mr Colpo says the men on the low saturated fat diet had a higher mortality rate. At least the magazine article informs us that over the five years of the study the men on that diet were less likely to die of cardiovascular disease. Unfortunately, that group also had extra deaths from cancer. So just from looking at these two confusionist references, we can see that two separate issues have been raised. The first is that a diet lower in saturated fat seemed to protect cardiovascular health. Anthony Colpo had lower standards of truth telling here than Men’s Health because he decided you didn’t need to know that on the topic he is actually writing about, namely the lipid hypothesis, this study hurts his argument. The second issue is the question of whether either a diet high in polyunsaturated oils or low cholesterol will shorten your life despite your healthier heart by giving you cancer. These are two separate issues which the confusionists would like to conflate. They want to conflate them because it’s so clear that saturated fats and high cholesterol will hurt your heart. They need to attach a phony concern about cancer to distract you from that.

Here is a portion of the summary for this study. We see that the experimental diet did lower the cholesterol levels of the men who ate it.

And we can see that this translated into an avoidance of cardiovascular events. The lipid hypothesis is supported again. We also see here that, sure enough, there was a higher death rate in this group. Now that’s a problem. The researchers conducting the study said they did not believe the experimental diet was responsible for this.

Two of the original Los Angeles researchers reported a higher rate of cancer over an eight-year period in the experimental group.

This difference in cancer death rate was studied by other researchers. Yes, this one study in Los Angeles showed a higher rate of cancer on a higher polyunsaturated fat diet. But in other studies of this kind this trend did not continue. Other studies showed the opposite result. Overall mortality was not higher in the other studies, either.

Upon closer examination, more than half of the cancer deaths in the experimental group in Los Angeles occurred in men who did not adhere closely to the diet, so one can hardly connect their deaths to the experimental diet.

Here is the result of a recent huge study covering over 19 years that examined the relationship between cholesterol and cancer incidence. It was found that only a short-term relationship between cancer and cholesterol existed. Over time periods longer than five months, the association disappeared. I want to say as an aside, I cover a lot of ground fast in my videos. Some of these studies really deserve to be read carefully and understood and this is one of those studies. It’s a great one. You should look it up.

These researchers concluded that any association between cancer and cholesterol reflected – say it with me – reverse causation. They noted that some cancer cells were sucking up the LDL from the blood faster than normal cells, lowering cholesterol concentrations. This is one way cancer lowers cholesterol. They also made a very important observation. Subjects with high cholesterol would appear to have lower rates of cancer because their cholesterol levels were killing them through cardiovascular disease before their cancer had a chance to develop enough to be noticed. In other words, the people with high cholesterol were too dead to get cancer. That’s pretty obvious, isn’t it? If you aren’t dying of heart disease, you’ll end up dying later of something else, something like cancer.

Mr Colpo, this is an example of something called survivor bias.

If the confusionists were right that low cholesterol caused cancer, you would expect to see low rates of cancer in countries that eat lots of saturated fat and have high cholesterol. When you look at the countries that have the highest rates of cancer, it becomes obvious that this is not the case.

Of course, T Colin Campbell and his colleagues observed both low cholesterol AND low rates of cancer among the Chinese people they studied. This pretty much blows up that confusionist hypothesis. Campbell’s work is so inconvenient for the confusionists, it’s easy to see why they want to discredit him.

The cholesterol confusionists might want to retire this particular line of attack. This recent paper states that high cholesterol is strongly linked to prostate cancer progression. The authors consider cholesterol-lowering to be a way to slow down this particular cancer.

In this study, patients with esophageal cancer who had high cholesterol were more likely to have tumor cells enter their lymphatic system. That’s very bad news for them.

Let’s pull back from this odd focus on cancer to remember the big picture. Saturated fat is in animal foods, and there have been many studies that have pointed to an association between these foods and various cancers. Don’t let the confusionists confuse you when it comes to diet and cancer.

Let’s shift now to suicide and depression. Even if we decided to pretend there is a direct link between low cholesterol and suicide just as Colpo says, you would still be better off taking your chances with low cholesterol to avoid dying of heart disease. The mortality rate for heart disease is eighteen times higher than the mortality rate associated with suicide. Do you think Mr Colpo is really interested in saving lives with his conjecture about suicide and cholesterol? I don’t. Do you think the science linking low cholesterol to suicide is as strong as the science linking high cholesterol to heart disease? There is only one right answer to this question. Mr Colpo, like other Paleo cranks, does not apply his skepticism consistently. With his every argument he further demonstrates his bias. It’s all just a game to him. The evidence of a causal role for high cholesterol in heart disease is extremely robust while the evidence of a causal role for low cholesterol in depression and suicide is extremely weak.

As I said, in video 41, the epidemiology of depression does not seem to support this alleged relationship.

If we look at the whole of the 20th century we can see that it is claimed that rates of depression increased quite dramatically …

Just as the amounts of meat and dairy consumed increased dramatically…

Right along with the increase in heart disease.

Now don’t misunderstand me. I’m not saying saturated fat and cholesterol cause depression. As I said in video 41, depression is way too complicated to be explained this way. Also, I don’t necessarily believe that depression has increased over the 20th century. My point is that it’s hard to find epidemiological support for a connection between depression and cholesterol. Remember, the epidemiological research into heart disease, especially the Seven Countries Study of Ancel Keys, is one of the major pillars supporting the lipid hypothesis. If the link between low cholesterol and depression were so clear, there would be plenty of papers out there elucidating it. I’ve looked at the epidemiology of depression and I do not see a relationship with diet.

Mr Colpo’s claims about depression got me thinking about his buy-in on Paleologic and the uncomfortable contradictions that creates. Of course, humans evolved consuming certain foods, but of what use is that knowledge now? To Colpo, this means we should eat meat. But this creates a problem for him, a problem Loren Cordain intelligently anticipated and avoided. You see, for all his faults, Cordain does not rely on the typical denialist belief system.

Cordain looked around at the cholesterol numbers of hunter gatherers and realized that any diet fad based on human evolution would have to account for the low cholesterol levels that were likely the norm during the Paleolithic. Of course, he missed some of the most obvious reasons for this, such as low food energy consumption and parasitic infection.

If hunter gatherers have low cholesterol levels, then by Anthony Colpo’s logic they must be depressed and suicidal. But this does not seem to be true. Depression seems relatively rare among these people.

Here’s another reference for that. It names the !KungSan as being relatively free of depressive symptoms.

And the !KungSan had some nice low cholesterol scores. I think Colpo needs to choose between his belief in an evolved requirement for a meaty diet and his belief that high cholesterol somehow protects people from depression and cancer. Until he does, he seems to just be looking for any flimsy excuse he can find to eat meat and saturated fat.

There is plenty of reason to doubt that low cholesterol causes depression. I’m guessing most of you watching this know this paper. Vegetarian diets are said here to be associated with healthy mood states. That should be enough to dispel Colpo’s hypothesis but I have plenty more material than this.

The most obvious explanation for any perceived link between low cholesterol and depression is, of course, reverse causation. I showed you this slide in my video number 41. There are several plausible means by which depression might cause low cholesterol, and not the other way around. I won’t read this slide now to save time but you should read it.

Depression itself is believed to be responsible for a lowering of cholesterol for some.

The authors of this paper examining cholesterol and depression have no denialist agenda, so unlike Mr Colpo they did not ignore the multiple possibilities for reverse causation. These include poor health (which might lower cholesterol as well as mood) and poor appetite (which would reduce total calories and consequently cholesterol levels as well). They note that the evidence they’d seen from statin trials suggested that low cholesterol itself does not cause mental health problems.

Here’s another paper that found no association between cholesterol levels and depression.

Here is a 2008 meta-analysis looking at the relationship between cholesterol and depression. The results were all over the map. Higher total cholesterol was associated with lower depression. An inverse association with LDL was called non-significant. Higher HDL, which the low-carbers say protects them, was associated with more depression.

In these elderly subjects, men with low LDL and women with low HDL were more likely to be depressed, but these were elderly individuals who certainly had comorbidities. This is likely another example of reverse causation.

Here is a case study suggesting a link between low cholesterol and violent behavior but this has nothing to do with diet. Since genetic factors affect both cholesterol levels and mental health, it is possible some of the associations between cholesterol and mental health challenges observed in some studies are due to common genetic variants.

In this study, the opposite of what Colpo’s hypothesis would predict was observed. Older people who were depressed tended to consume more saturated fat and cholesterol. Maybe they felt the need to eat more comfort food. For me, it’s easy to imagine how a high-saturated fat diet might make you depressed. This is pretty obvious…

Having a heart attack would certainly make you feel a bit down, don’t you think? In this study, depression was three times more common in patients after a heart attack. Knowing this, I think I will try to reduce my risk of being depressed after a heart attack by trying not to have a heart attack at all. That’s a good plan, don’t you think?

I have seen several studies that showed a drop in cholesterol levels after a heart attack. Maybe following Anthony Colpo’s advice to eat lots of saturated fats will actually lower both your cholesterol and your mood eventually, since you’re raising your chances of having a heart attack if you follow his advice.

Also, if you eat more calorie-dense, saturated-fat-laden animal foods, you’ll probably pack on the fat, and that’s another path to depression. In this study, as saturated fat consumption went up, LDL went up as well, and so did body mass index.

I doubt you’ll be surprised to learn that obesity and depression are often a package deal.

Along these lines, having metabolic syndrome might make you depressed, too. Having metabolic syndrome does suggest low HDL so maybe that’s from where some of the talk of low total cholesterol and depression comes.

What about the idea that low cholesterol causes hostile behavior, sort of like the hostile way Anthony Colpo writes about me? In this study, a low fat, high complex carbohydrate diet improved symptoms of depression and hostility at the same time as it lowered cholesterol levels. Does this study not destroy Colpo’s half-baked ideas about depression and cholesterol?

Here’s one of Colpo’s more laughable passages. He references a study in which monkeys fed a so-called “prudent” diet had lower cholesterol and displayed more aggressive behavior than those fed a so-called “luxury” diet. Anyone calling a high-fat diet a “luxury diet” is making clear his taste in food, so this indicates a subtle bias to me.  A diet of 43% fat doesn’t sound so much like a luxury diet to me as much as a lethargy diet. Before I went vegan, I used to feel like I needed a nap after eating a fatty meal. Come to think of it, a nap would have seemed pretty luxurious to me back then, so maybe the name is appropriate.

Here’s the study Colpo is writing about. Check out the diets fed to the monkeys at the right. The prudent diet, that is, the one that made the monkeys more aggressive, featured such natural and prudent monkey foods as casein, wheat flour, sucrose, Crisco, and a fiber supplement called Alphacel. Now let me ask you, if you were a monkey who belonged in a rainforest somewhere eating figs, but instead you had someone feed you this garbage in your cage, do you think it might make you a bit more aggressive? As for the other diet, you can be sure the monkeys really felt they were luxuriating in their fantasy luxury diet of lard, butter, egg yolk, beef tallow, and wheat flour. They received hardly any Alphacel to move that glop through their bowels. Maybe the monkeys were more low-key on this diet because they were constipated. If you are tempted to joke that the monkeys may have been smarter than the researchers who conducted this study, I can understand where you’re coming from.

All that sugar and empty calories made me think those aggressive monkeys were probably having glycemic problems from that synthetic and cruel diet. Mr Colpo, you may be completely unaware that refined carbs cause hypoglycemia and consequently can lead to aggressive behavior. Depression can result as well. This is probably what those poor monkeys were being put through. I know you think you’re a real expert in nutrition but this is pretty basic stuff.

Here’s a study showing that cholesterol lowering with a statin did not effect anger, impulsiveness, or depression. How do you explain that, Mr Colpo? I wonder what he’ll say. Let’s see… If lower cholesterol hurts your mood but statins don’t, then maybe Colpo will say that statins must compensate for the bad effects of lower cholesterol by pulling through with still more pleiotropic effects, effects that make you happier. Maybe that is one more benefit of statins he’ll add to his big list.

Lastly, I present to you this recent study which investigated the effects on mood of removing meats from the diet. Thirty-nine people were fed diets classified as omnivorous, fish, or vegetarian. The vegetarian group experienced improvements in various mood measurements well beyond those demonstrated on the other two diets. This was another damaging study for Colpo’s nonsense hypothesis about saturated fat and mood. This study allows us to look past the complicated issues of low cholesterol and its causes and effects and instead brings us back to the practical issue of diet. This result should cause you to doubt that you need fatty animal foods to maintain your emotional health. I’ll add that a plant-based diet may enhance your mood even further should you contemplate the violence you are sparing innocent animals.

We have arrived at the final segment of my response to Colpo, the many references he makes to pharmaceuticals to make his case against the lipid hypothesis. Please join me in the next video.

More on Women and Cholesterol

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Colpo linked to one other epidemiological study.

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

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

Norway, Women, and Cholesterol

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

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

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

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

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

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

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

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

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

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

The oldest participants in this study were 84.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Fukui City and Japan

Running a Cholesterol Confusionist Gauntlet, Part 6 –
Fukui City and Japan

Mr Colpo likes a few epidemiological studies that I haven’t talked about in my other videos.

The first which I will address is the third reference from that blog post that earned him a place in The Primitive Nutrition Series. Let’s look at it.

It deals with residents of Fukui City in Japan. The authors investigated the relationship between serum cholesterol and all-cause mortality. They concluded that anything over 240 mg/dL is safe for cholesterol. 240 is considered high cholesterol by conservative standards. They are saying that 240 and up is just fine, without stipulating any upper limit. Wow! Either the authors believe cholesterol poses no threat no matter how high it gets – which would be a totally ignorant belief – or they forgot to mention there should be an upper limit at some point. Either way, this is a pretty serious omission telling us that this study should be approached with skepticism. For them, only the presence of a known genetic disorder should provide cause for concern.

They actually go so far as to imply that lacking such genetic disorders, cholesterol-lowering medications should not be prescribed, regardless of how high the patient’s numbers are.

Here you can see some of the other work of two of the authors of this paper, including the lead author. They tell us that in their super-sophisticated studies, they were able to determine that two eggs are more filling than two balls of white rice. That’s amazing! Good work, guys. They also tell us that in a controlled experiment, people eating at least two eggs a day lost more weight than people on the control diet. What was the control diet? They were asked to continue their usual diets. Did all the people in the control group eat the same “usual diet”? That seems unlikely. They state their conclusions from their work at the bottom here. Cholesterol is not a risk factor in Japan for all-cause mortality and eggs might be useful for body weight control. This is blue ribbon stuff.

In the study of people in Fukui City they were actually reworking the numbers from an older study, so these authors are using 18-year-old data.

Limitations of this paper stated by the authors are a selection bias of the participants and no exclusion for subjects with a history of serious diseases. This creates a strong possibility of confounding, as participants who were sick with cancer or anything else that might affect cholesterol levels might have affected the distribution of the death patterns. This is once again the phenomenon of reverse causation about which I have talked so much by now. Realize the subjects here were ages 40 to 79. Notice also their qualification that they are limiting the relevance of their conclusions to Japan. If you don’t live in Japan, they are not suggesting this study applies to you. I guess they are also suggesting that the Japanese are uniquely immune to the effects of high cholesterol for some reason. They do not attempt to explain why they think this might be so.

 There really is a serious chance of confounding when you look at their numbers. This study lacked statistical power. I have highlighted the number of participants and the distribution of deaths from cardiovascular diseases. I have already done enough work to show you that low cholesterol by itself does not cause cancer or infectious diseases or shorten lifespan. All-cause mortality is just a distraction. Colpo is disputing the lipid hypothesis so lets look just at cardiovascular disease. These are the numbers of deaths over a four-year timespan ending in 1990. That isn’t a very long time. It may seem significant that women had the highest age-adjusted relative risk of cardiovascular death with cholesterol scores between 140 and 159, but if you look at the actual numbers, we’re talking about only 12 women out of more than 15,500. It’s hard to conclude much from that just because with so few deaths that ratio more likely is influenced by confounders or it’s just statistical noise.

Moreover, look at the men in particular. Do you see how the relative risk jumps around in the three categories of cholesterol over 220? It goes from 1.9 down to 1.0 and back up to 3.1 in the highest cholesterol group. That’s not much of a trend, is it? Well, you should not expect to see much of a trend based on 9, 3, and 4 deaths in each category. That’s just not enough data. It seems that the Japanese in this study were like the Japanese in other comparisons. They had very low rates of heart disease. There just weren’t a lot of deaths here so the relationship of cholesterol to cardiovascular deaths is not clear within this data. Remember, the researchers did not exclude people with cancer or other serious illnesses. There were probably other important factors at play here. Maybe we could learn more from a population that experienced a lot of heart disease. Also realize the category named here is not coronary heart disease, it is cardiovascular disease.

In Asian countries, stroke is more common than coronary heart disease. The paper did not categorize mortality this way. Instead, it resolutely focused just on all-cause mortality, so it really isn’t even attempting to address coronary heart disease. Now, high cholesterol is a key risk factor for stroke, so don’t get me wrong about that. But the problem is, Asians have other important risk factors affecting their stroke rates. They eat a lot of salt and have more people with high blood pressure. They smoke a lot. That’s really important for stroke.

Here is further support for these assertions. In Japanese men, dietary salt increases the risk of death from stroke.

And the Japanese are some of the biggest salt consumers in the world.

They also smoke a lot, as I said. The study covered a period ending in 1990. Look how high smoking rates were there back in 1993.

Lastly, no mention is made of cholesterol lowering drugs. The Japanese were quick adopters of statins. On a side note, the research breakthrough that lead to the development of statins took place in Japan. To be clear, statin use probably did not affect that many people in that time period, but it is just one more factor that might be important when we are talking about such low rates of death from cardiovascular disease. As you can tell, I don’t find much in this study to threaten the lipid hypothesis. Indeed, it doesn’t even try to address that directly. It only looked at all-cause mortality. Colpo has picked another weak study for his weak case.

Do you remember how I said Colpo picked three studies that don’t support his title here? The first was highly technically flawed. The second did not look at saturated fat consumption in general, only dairy fat. And the third lacked adequate statistical power. All three had telltale signs of bias from their authors.  Yet Colpo thought they made a strong case against the diet-heart idea.

More epidemiology is ahead in my next video.