cholesterol
A correspondent alerted me to a new movie, Cholesterol: The Great Bluff, that she had watched on Canadian TV. The premise of the movie is that all those doctors and scientists are wrong: cholesterol is good for you, it has nothing to do with heart disease, and statins are useless and dangerous drugs maliciously promoted by Big Pharma solely to line their pockets. She was skeptical, but couldn’t find any criticism or reviews of it. I couldn’t find any reviews either, so I thought maybe I’d better write one.

The film is in French with English subtitles, and I was not able to watch it, but I was able to read the complete transcript online.

I was appalled. It had snazzy production values, made a very persuasive case, featured interviews with scientists, and might be very impressive to a naïve viewer; but it was a mishmash of propaganda, half-truths, omissions, and misinformation. It is a biased polemic that badly misrepresents the truth about cholesterol, heart disease, and statins.

Misleading appeals to emotion

Its typically irrational, emotional appeals start with the opening scenes. An attractive, fit, muscular man is shown. Captions read “Push-ups 75, Sit-ups 100, Daily laps 50, Total cholesterol 258.” The viewer is meant to jump to the conclusion that his high blood cholesterol doesn’t matter. But of course, we have no basis for that assumption. We don’t know anything about his risk factors. That cholesterol level, in conjunction with his other risk factors, might or might not mean he is at significant risk of a heart attack.

They criticize statin ads for telling us that “An insidious evil can eat away at us, even if we feel healthy.” They present this as if the evil of cholesterol is a myth. Of course, there are many diseases that can eat away at us while we feel healthy, and atherosclerosis is one of them. High cholesterol doesn’t cause any symptoms, but it does increase the risk of a heart attack.

“Cholesterol has been the subject of fierce scientific disputes.” Not so much. There has been an evolving consensus that developed as new evidence became available.

Ancel Keys

Ancel Keys was one of the first to suggest that it was saturated fats that caused heart disease.

Saturated fats would cause your total cholesterol to go up – which was the only thing they could measure in those days. And that would clog your arteries and give you a heart attack. It was called the diet-heart hypothesis.

The movie gives the impression that Keys observed cholesterol-containing xanthomas on the skin and only assumed that there were similar deposits in the arteries that could lead to heart attacks. He didn’t need to assume that. It was demonstrable.

The movie rightfully debunks Ancel Keys’ infamous 7-country study that purported to show a correlation between the amount of fat in the diet and the levels of cholesterol in the blood. The study was fatally flawed, and the movie correctly shows how Keys omitted data and manipulated facts to make them look like they validated his hypothesis.

Framingham misrepresented

Doctor Michel de Lorgeril, a French cardiologist and researcher, tells us the landmark Framingham study “absolutely confirmed that tabasco was a cause [No, I don’t think so!], that high blood pressure and sedentary living were causes. But the researchers were disappointed to find that there was no connection between cholesterol and cardiovascular diseases.” That is demonstrably untrue. The Framingham study identified a number of risk factors for cardiovascular disease, and one of them was elevated blood cholesterol.

A cholesterol skeptic presented as an expert

Dr. Uffe Ravnskov is interviewed. He is one of the worst possible choices of experts to interview; his bias is clear. He is the author of The Cholesterol Myths and a member of THINCS (The International Network of Cholesterol Skeptics), an organization whose mind is irrevocably made up, whose avowed purpose is “to oppose [emphasis added] that animal fat and high cholesterol play a role” (rather than to look at the evidence). Several years ago I wrote an article about THINCS showing how they distort the data and spread misinformation. He claims that in Framingham there were more deaths among people whose cholesterol levels decreased. That’s a distortion: the Framingham study found more deaths among people with a low level of the “good” cholesterol HDL. After Framingham identified high blood cholesterol levels as a risk factor, other studies confirmed that. They went on to determine that lowering cholesterol reduces risk, and the degree of risk reduction can be measured by the degree of cholesterol lowering.

Confusion between dietary cholesterol and blood cholesterol

They spend a great deal of time criticizing the low-fat diet recommendations and the marketing of low-cholesterol and low-fat foods. They are beating a dead horse. Based on the evidence, mainstream medicine has rightfully rejected the idea that dietary cholesterol is an important cause of high blood cholesterol levels. And it has been shown that a low carb diet is healthier than a low fat diet.

Homocysteine and other hypotheses, and conspiracy theories

They interview a scientist who hypothesized that elevated homocysteine was causal. He implies that his research was squelched by “the cholesterol people.” In reality, homocysteine has been identified as a risk factor, but is not a significant enough one to use it for risk factor screening. High homocysteine levels can be reduced with B vitamins, but that doesn’t reduce cardiovascular risk.

Another scientist says a secretary(!) at the NIH “called him out in the hall and said, “Doctor Mann, if you continue your opposition to Ancel Keys, it’s going to cost you your research grant.” And, shortly after, it did.

They present other hypotheses. Lack of exercise causes cardiovascular disease. No, sugar is the cause. The sugar industry has suppressed research. Gary Taubes blamed sugar for pretty much everything in his book The Case Against Sugar, which I found less than convincing.

Questionable interpretations of studies

They cite a study where men with high cholesterol levels were fed a low cholesterol diet and treated with the cholesterol-lowering drug cholestyramine. It found only “a very slim reduction in cardiovascular risk.” They emphasize that study rather than the many more studies where cholesterol was lowered much more effectively with statins to achieve a much more significant reduction in risk.

Dr. Michel de Lorgeril did a study where risk was reduced 50-70 percent by a Mediterranean diet. He says people refused to accept his results because the cholesterol levels did not change. They asked, “how can you lower the risk of heart disease without lowering cholesterol levels?” The obvious answer is that cholesterol is not the only risk factor. Scientists have never said it was.

Did Big Pharma deceive us?

When the first studies showed that statins reduced risk, everyone started prescribing them. Dr. de Lorgeril says “I couldn’t intellectually question the clinical trials published in international medical journals. It seems inconceivable to me that investigators could cheat or lie in order to deceive the whole medical community.” They point out that most clinical trials were funded by statin manufacturers, which they assume destroys their credibility. (Industry funding doesn’t mean we should ignore studies; it just means we should exercise caution.) They say no one dared question the results; criticizing statins would be suicidal.

They bring up the example of Vioxx, saying the laboratory had deliberately hidden information about potentially fatal side effects. There are two sides to that story. Anyway, malfeasance in one case would not prove malfeasance by other companies in relation to other drugs. But de Lorgeril says it was a horrendous surprise that pharmaceutical companies could lie. He says “we may have been deceived,” but provides no evidence of deception in the case of statins. He says after this realization in 2005-6, “all clinical trials on statins were proved to be negative, which meant that they were shown to have no beneficial effects.” That is demonstrably untrue. Since 2006, clinical trials have continued to demonstrate the efficacy and safety of statins, as anyone can easily confirm by a PubMed search.

They point out that cholesterol is an essential compound produced by our bodies. True. They imply that lowering it is harmful. Not true. Recent studies indicate that lowering cholesterol to unprecedentedly low levels is associated with improved outcomes.

Statin side effects

They grossly exaggerate the side effects of statins. They offer a scaremongering testimonial claiming that a statin caused a devastating case of Alzheimer’s that was cured by stopping the drug. In reality, people on statins are less likely to develop Alzheimer’s. Anecdotal reports of side effects abound, but in placebo-controlled trials, the incidence of most side effects is no greater with statins than with placebo.

“I don’t want to know.”

The movie ends by asking numerous people DO YOU KNOW YOUR NUMBER? And most of them brag that they don’t know and don’t need to know. One even said he wished his cholesterol level were higher. It reminded me of people bragging that they haven’t immunized their children. They are still healthy…so far…

Denialism

Members of THINCS and the others interviewed in this movie consider themselves cholesterol skeptics. Skeptics are people who ask for evidence. These people go beyond skepticism to denial. The evidence is there, but they refuse to accept it. They people interviewed in this movie are cholesterol denialists and statin denialists.

I recently wrote an article on statin denialism for Skeptical Inquirer, where I addressed most of the same issues covered in the film. I covered the evidence for the efficacy and safety of statins and showed that the reports of side effects were exaggerated. I encourage you to read my article, if only to brighten your day by making you laugh out loud about the claim that table salt is mostly glass and sand.

Conclusion: a denialist rant, not science

The film will probably be impressive to naïve viewers, but it’s one-sided and it certainly doesn’t represent good science. Far from being a “big bluff,” statins are one of the most valuable medicines in the modern armamentarium; I take them myself, for solidly evidence-based reasons. They’re not perfect. They only help a fraction of the patients who take them; but we have no way of identifying who will benefit, so we have to treat a lot of people to benefit the smaller number who will be spared a heart attack or a premature death. I consider them darned good insurance. People who watch this movie will be dissuaded from getting that insurance, and some of them will suffer heart attacks that could have been prevented.

This is just one more example of why people shouldn’t get their scientific information from movies or online videos. Viewers should not accept any claim in a movie without fact-checking it for themselves.

Addendum

Apparently the movie and I were both too harsh in our criticism of Ancel Keys. There is a white paper on his Seven Countries Study that critiques the published critiques of his study and tries to set the record straight. I continue to think that the seven countries were not a properly representative sample, but I don’t think Keys lied or was guilty of any misconduct. My real point was that his epidemiological data did not justify the widespread low-fat dietary recommendations that were based on it.

I linked to the PURE study to support my statement that a low carb diet had been shown to be healthier than a low fat diet. The PURE study did show that, but it was imperfect and its results far from definitive. The point I intended to make was that the dangers of dietary fat have been exaggerated and it is generally accepted today that a healthy diet need not be low-fat.

I said there were two sides to the Vioxx story, and there were. I did not say which side I thought was correct. I do think there are nuances to the story that are often overlooked.

I realize the reference to tabasco in the transcript as a cause of heart disease was a typo for tobacco, but I left it in because it tickled my fancy.

Posted by Harriet Hall

Harriet Hall, MD also known as The SkepDoc, is a retired family physician who writes about pseudoscience and questionable medical practices. She received her BA and MD from the University of Washington, did her internship in the Air Force (the second female ever to do so),  and was the first female graduate of the Air Force family practice residency at Eglin Air Force Base. During a long career as an Air Force physician, she held various positions from flight surgeon to DBMS (Director of Base Medical Services) and did everything from delivering babies to taking the controls of a B-52. She retired with the rank of Colonel.  In 2008 she published her memoirs, Women Aren't Supposed to Fly.