I’ve seen quite a few patients recently who don’t believe that cholesterol plays a role in heart disease.
The interesting thing about these patients is that they tend to be incredibly health conscious. They exercise regularly, watch what they eat, and are generally quite health literate. They are also inquisitive and willing to modify their behavior based on how they can feel better and live longer.
Essentially, these people are the ideal patients - engaged, educated, and motivated - except for one thing: they don’t think I’m right about what causes heart disease. And they are absolutely adamant about not wanting to take any statins.
They come to this perspective based on information they’ve seen from a handful of wellness influencers on social media.
Some of the people that are cited to me frequently are PD Mangan, Dave Feldman, and Aseem Malhotra. The influencers in this space read the medical literature, link to scientific papers, and have come away with the conclusion that LDL cholesterol just doesn’t play a role in the pathogenesis of cardiovascular disease.
Given the essentially universal medical consensus about the causative role of LDL cholesterol particles in the progression of cardiovascular disease, it’s tempting to dismiss the cholesterol skeptics.
And that’s what many doctors do.
But I think that dismissing these people is wrong for a few reasons.
The first is that they have huge followings and they’re incredibly influential. And more than that, they’ve helped a lot of people get healthy and improved their lives. Being willing to engage in the exchange of ideas in a good faith intellectual debate is the right way forward.
The second reason is that these people are really smart and there’s a lot that the cholesterol skeptics are right about.
I want to address this topic in a way that does it justice, so I think we’ll make this a two part newsletter. This week I’ll write about what these folks get right about heart disease and next week I’ll write about why I think they’re wrong about LDL cholesterol.
So let’s get into what the cholesterol skeptics are right about.
There’s more to heart disease than just LDL cholesterol levels
While the first step in the process of coronary artery disease (also called heart disease, CAD, or atherosclerotic cardiovascular disease), is a cholesterol containing particle getting deposited in the walls of an artery, this is nowhere near the only step.
There are a ton of other factors in heart disease.
High blood pressure, endothelial dysfunction, hyperinsulinemia and insulin resistance, oxidative stress, and inflammation all play a huge role.
A focus on cholesterol levels alone provides an incredibly incomplete risk assessment. When I discuss heart disease with my patients, I always talk about their cholesterol numbers, but there are a lot of other things that we discuss as well.
When you read the cholesterol skeptics, they point to the failure of the medical profession to emphasize these other risk factors as proof that we don’t know what we’re talking about.
This is an area where there’s always going to be a bit of natural disagreement between those in the medical field (who prescribe medicines) and those who aren’t in the medical field (and don’t prescribe medicines).
The reason doctors are so focused on LDL cholesterol levels is that they’re something we can easily modify with prescription medications (and not just statins).
Things like endothelial function, inflammation, oxidative stress, and insulin resistance are absolutely modifiable. But those modifications occur over a long period of time, and they happen through changes to our diet, sleep, exercise, stress, and sunlight exposure. None of these factors are as easily or as quickly modified as LDL cholesterol.
So LDL cholesterol is naturally going to be the focus of a doctor’s appointment - when you’re a hammer with a prescription pad, everything looks like a nail.
The corollary to the first point: insulin resistance is a really big deal, and it’s underemphasized by doctors and the public health community
Insulin resistance is an influential factor in the development of a huge amount of chronic disease: heart disease, cancer, Alzheimer’s, hypertension, diabetes.
Basically you name the chronic disease, and insulin resistance is implicated.
You may have heard the phrase metabolic syndrome, a somewhat amorphous term that essentially refers to whether we have clinical signs of insulin resistance present.
You can think of insulin resistance and metabolic syndrome as functionally the same thing. And they show up through a handful of easy to measure elements:
Abdominal obesity
Elevated triglycerides
Low HDL cholesterol
High blood pressure
High blood sugar
Doctors know a lot about insulin resistance. We screen for it, there’s a billing code for it, we think about it. We know about the link between insulin resistance and disease.
But I’ve observed two hurdles in making it a focus of the doctor visit: first, it’s hard to explain, and second, the treatments for it are lifestyle based.
You can’t say “insulin resistance” to the average patient and expect it to mean anything without a fairly complicated explanation. And since there’s no drug to treat insulin resistance, a lot of doctors would rather focus the limited time in a patient visit on things that they can treat with a drug (which is something the patient can’t get anywhere else) rather than a conversation about diet, exercise, and sleep (which the patient can get elsewhere).
And you can add to the difficulty here that insulin resistance isn’t something that’s all that easy to directly measure.
When I talk to my patients about their cardiovascular risk, I always mention the ratio of triglycerides to HDL (a high ratio suggests insulin resistance). But I find it really hard to communicate that what I see on their lipid panel may actually be a reflection of metabolic syndrome and insulin resistance since those terms haven’t made it into the public consciousness the way that “bad cholesterol” has.
We prescribe a ton of medications, sometimes to people who may not really need them
When you look at any of the professional guidelines from medical societies on treatment of cardiovascular disease, it’s clear that a holistic approach is the preferred method of risk assessment and disease prevention.
The guidelines incorporate lifestyle modifications, pay attention to weight and nutrition, and don’t just suggest throwing medications at people.
In practice, however, those guidelines are a justification to simply assess risk and then prescribe a statin, or blood pressure pill, or diabetes medicine.
I mentioned above that doctors are always looking for a medical treatment that can be given with a prescription pad. And hopefully, I’ve been able to explain why this is the case - we want to use the unique tools that we have to provide a service that patients can’t get elsewhere.
And so while the eagerness to prescribe medications often comes from a good place, the interaction that many patients have with the health care system doesn’t end up in a good place.
Too many patients that we are trying to take care of end up with a growing medication list despite worse and worse health. That means that physicians are often failing their patients.
You can argue about the motivations, but I don’t think you can really argue with the end result.
Many of my patients don’t need a doctor as much as they need an overhaul of their diet, a weightlifting and cardio regimen, and a focus on high quality sleep. But this is hard to help people with in the confines of a medical appointment.
All too often, the prescriptions don’t change the overall trajectory of health, and we keep giving them out despite the fact that it’s clear that more medication isn’t always the right answer.
Public health officials have gotten a lot wrong. And government involvement in nutrition science has been a net negative
One of the biggest reasons that the cholesterol skeptics are able to convince people of their views is that the establishment has been wrong about a lot.
The science of dietary fat and cholesterol are nowhere near as settled as the “official” recommendations would have you believe. This has been chronicled extensively in really valuable books like Good Calories, Bad Calories and Big Fat Surprise.
And you also need to recognize that our governmental nutrition recommendations are deeply influenced by the food industry. It’s easy to read a book like Food Politics and come away cynical that the recommendations made by the government under the guise of making us healthy are really just a scam perpetuated by Big Ag and Big Food that leads to confusing healthwashing under the guise of marketing and a sick population.
The cholesterol skeptics have been pounding the drum on this stuff for a long time, and I don’t think that mainstream medicine does a good enough job of addressing these problems.
The scientific evidence establishing a link between meat consumption and cardiovascular disease is pretty pathetic, but that doesn’t stop the American Heart Association from putting out articles telling us that “eating a plant-based diet at any age may lower cardiovascular risk,” as though it’s anything other than a hypothesis that needs testing.
When it comes to diet, many physicians (as well as the public health community and the official government recommendations) have accepted a level of evidence that would never be considered acceptable to prescribe a drug.
This isn’t acceptable, and the skeptics are right about it.
The cholesterol skeptics are worth paying attention to and we should think about what we can learn from them
As I suggested earlier, sometimes there can be a lot to learn from the folks who distrust the mainstream scientific consensus.
I hope you’ve learned something new from thinking about how the cholesterol skeptics view heart disease.
Next week, I’ll talk about why they’re wrong about the relationship between cholesterol and heart disease.
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