Volume 3  Number 10  December 31, 2006
Second Opinions

Coronary on a Plate: Food, Fat, and the Diet Police

Part of the secret of success in life is to eat what you like and let the food fight it out inside.

Mark Twain

Americans follow news of medical research as closely as sports or the stock market. We are particularly avid for new findings about the health effects of diet and life style, because we have come to believe that no one gets sick anymore just because of bad luck. Instead, we see health as largely a matter of doing the right things, with the corollary that illness is a failure of some sort...

Marcia Angell, MD. Author and Former Editor, New England Journal of Medicine

The good, the bad, and the ugly lipids, (fats, including total cholesterol, HDL, and LDL cholesterol, saturated and trans fats) have become major obsession of the public and our medical industrial complex. Pictures of fettucine Alfredo adorn TV scare ads sponsored by manufacturers of statin drugs, and tacitly approved by the Federal Trade Commission, not to mention the National Institutes of Health, the diet police, and other self-appointed guardians of public wellness.

"Coronary on a plate" has edged into a descriptive phrase for a stupefying list of life-threatening foods peeping not only out of restaurant menus, but even emanating from mom's kitchen. This politically correct manifestation of food phobia has become the refurbished mantra of diet-watchers, cooking show hosts, and food critics. Coronary-provoking, life-threatening foods once included red meat, eggs, butter and other dairy products, (though once upon a time, Crisco® and margarine were the mainstay of deep frying.) but now dangers range from Big Mac's and Whoppers, to egg rolls and French fries soaked in trans fats, and other deep fried delectables, tuna salad with the wrong mayonnaise, even girl scout cookies (sic!), etc. For death-defying menus see here, here and here (though to be fair, McDonald's, Burger King, and Wendy's are all trying hard to satisfy the legislators and diet dictators by enlarging their offerings to include "healthier" fare).

Does Food Give You Heart Disease?

For starters, dietary cholesterol derived primarily from animal and shell fish food sources has very little influence on blood cholesterol. The average change in plasma total cholesterol levels is 2.2 mg/dL for every 100-mg change in dietary cholesterol. Viewed another way, if Americans decreased their intake to the recommended level of 300 mg cholesterol/day, an average 1% reduction in plasma total cholesterol would be expected. Is there a connection between cholesterol and other lipid levels in your blood and the risk of a heart attack? While the medical literature on the subject is voluminous, — certainly those with diabetes and certain metabolic disorders are at an elevated risk- there appears to be no convincing evidence of a direct relation between blood lipid (fat) levels in healthy normal subjects and the risk of coronary disease. Indeed not even the famous Framingham study could demonstrate a connection between diet, blood lipid levels, and heart attacks. Virtually no one denies that genetics, smoking, high blood pressure, and diabetes are major players, among the more than 240 risk factors for coronary disease. But decades of preoccupation with diet as a major villain in the litany of risks, if not causes of coronary disease, makes scant logical sense in view of certain contradictory facts.

Living Longer With Lipitor?

According to a loose network of researchers, known collectively as Cholesterol Skeptics (personal disclosure: I'm a member) if you don't already have clinical coronary disease, you probably won't live longer if you bring down your cholesterol level. Moreover, by taking statins*, the principal cholesterol-lowering drugs advertised to prevent heart attacks, and the largest selling drugs in the World, there is precious little evidence that reducing cholesterol levels affects longevity. A University of British Columbia Group reviewed five statin trials raised new questions about side effects. The report concluded that although patients on statins had a 1.4% lower rate of heart attacks, this was cancelled out by a 1.8% rate of serious events, including cancer. The researchers said that this is almost certainly an underestimate since only two of the trials provided details of any serious side effects. They asked the drug manufacturers for the missing data but received no reply. Their findings strongly suggest that, as with some treatments for high blood pressure, that if you lower your cholesterol you may change the cause of your death, but not the date on your death certificate.

Malcolm Kendrick, a British physician, who is an active Skeptic, refers to a study in the British Medical Journal which found no link between changing fat in the diet and heart disease. "At a global level the link with cholesterol and heart disease is far more tenuous than is generally supposed. For example in Russia at the moment, heart attack rates are rising dramatically, but their cholesterol levels are the reverse of what we are seeing in the US and the UK. Russians often have high levels of the so-called 'good' HDL cholesterol and low levels of the 'bad' LDL, but they still keel over from heart disease."

Even in the West the link is pretty thin, according to Joel Kauffman, a former professor at The University of the Sciences in Philadelphia. A review he did of statin use in 2003 pointed out that age, as reported in the JAMA, a major factor in heart disease, does correlate with high cholesterol. "When you correct for age," he concluded "there is almost no correlation between high cholesterol and heart disease." This is consistent with the finding that more than half the people not on statins who have heart attacks, have a normal blood cholesterol on hospital admission. This cholesterol challenge comes at a time when the government, the medical profession and the pharmaceutical industry have all joined forces in their approval and promotion of cholesterol-reducing drugs. Government figures released in 2004, for instance, show that heart attack deaths, though still the number one cause of mortality, are declining. Part of the credit for this is given to statins. (This is called "backward bias.")

The New England Journal of Medicine has published the results of a large trial reporting that the heart patients who reduced their cholesterol down to 200 mg/dl had a 16% drop in their risk of experiencing such "vascular events" as heart attacks and strokes (This is relative, not absolute risk, which is actually less than 2%) — see here and here.

Most Cholesterol Skeptics agree that the studies show that taking statins after you have obviously developed heart disease may reduce your chances of a further attack. ("secondary prevention."), though as noted above, it may also increase your chances of dying of cancer. "But the fact that bringing down cholesterol can help some male heart patients," says Kendrick "doesn't mean it's going to protect otherwise healthy people whose cholesterol is over 5.7 mM/l (225 mg/dl). Since that is the average level in the UK, it's an awful lot of people." One of the cholesterol-reducing drugs, Lipitor, is among the best-selling prescription drugs in the world with sales worth $18 billion. The message from this trial is likely to be that when it comes to cholesterol "you can't go too low." One officially recommended level is now 180 mg./dl.

Cautionary Advice for the Healthy True Believers

The so-called "cholesterol hypothesis" has held sway for over 50 years. Today, politically correct American foodies eagerly await the latest dietary pronouncements of, among others, the manufacturers of statin drugs, the Government, and the Health Department of the City of New York. Before the food police strike again, my advice is: Enjoy a dose of Egg McMuffin's, trans fat french fries, and an ice cream sundae with whipped cream before it's against the law.

*atorvastatin (Lipitor®), fluvastatin (Lescol®), lovastatin (Mevacor®), pravastatin (Pravachol®), simvastatin (Zocor®), rosuvastatin (Crestor®)

Martin F. Sturman, MD, FACP

Copyright 2006, Mathemedics, Inc.

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