Saturated Fat and Coronary Heart Disease, Part III: Cognitive Dissonance

"Die wahrheit triumphiert nie, ihre gegner sterben nur aus." -- Max Planck

(Truth never triumphs, its opponents just die out.)

In Part II of this series I wrote that this installment would be about the "best research" those supporting the saturated fat-cholesterol-heart disease link or "causal chain" might use (here's Part I). In the process of doing my homework for that post I came across something I think fits in here because I essentially want you to have some idea of what you'll be up against.

This supplemental entry began when I hit the blog of Dr. A (a reader & commenter here) in the UK: Livable Low Carb. I'll show you a couple of the graphs she posted in a moment, but for now, how about a quote from the British Heart Foundation website on Diet?

It is now universally recognised that a diet which is high in fat, particularly saturated fat, sodium and sugar and which is low in complex carbohydrates, fruit and vegetables increases the risk of chronic diseases – particularly cardiovascular disease (CVD) and cancer. These risks are outlined in the World Health Organization 2003 report Diet, nutrition and the prevention of chronic diseases. The more recent World Health Organization Global strategy on diet, physical activity and health emphasised further the need to improve diets in individuals and populations across the world.

The dietary changes which would help to reduce rates of coronary heart disease (CHD) in the UK population were detailed in the 1994 report of the Government's Committee on the Medical Aspects of Food and Nutrition Policy (COMA). This recommended a reduction in fat intake, particularly saturated fat intake, a reduction in sodium intake and an increase in fruit and vegetable and complex carbohydrate intake. In the 2003 report Salt and Health, the Scientific Advisory Committee on Nutrition (SACN) (which replaced COMA in 2000) repeated COMA’s guidance on salt intake in adults and introduced additional guidance on reducing salt intake in children. In 2005 the Government dietary objectives were reiterated in Choosing a Better Diet: a food and health action plan.

Research from the World Health Organization and others highlight the specific importance of low fruit and vegetable consumption as a cause of CHD. The World Health Report 2002 estimated that around 4% of all disease burden in developed countries was caused by low fruit and vegetable consumption, and that just under 30% of CHD and almost 20% of stroke in developed countries was due to fruit and vegetable consumption levels below 600g/day. The World Health Organization has yet to calculate the precise proportion of the disease burden due to high sodium intake or high saturated fat intake. [emphasis added]

I considered clipping some of that, but it would only serve to dilute what is clearly intended to be a VERY STRONG MESSAGE: reduce fat, especially saturated fat and eat more fruits & vegetables. But why? This is something I'll get into in much more depth in the final entry, but here's just a tidbit. When you really start digging into CVD stats it becomes clear that CVD deaths and CVD incidence are constantly conflated or at best conveniently left ambiguous. If a researcher wants to tell you that reducing saturated fat has been successful, he'll haul out CVD death stats and indeed, there has been a tremendous decrease in death from CVD over the past decades. But they'll rarely tell you in the same breath that the incidence of cardiovascular disease -- i.e., heart attacks and other CVD markers -- is pretty much as high as ever. So, is the reduction of death more likely a function of decreased saturated fat intake or more likely some other factor like improved urgent and emergency care in the face of a heart attack? As usual, a review of Occam's Razor seems appropriate.

So, now, here's a couple of Dr. A's graphs for saturated fat consumption and fruit & vegetable consumption trends since 1975.

saturatedfat
Saturated Fat Consumption
fruitandveg
Fruit & Vegetable Consumption

Oh, did I mention? This data comes from the very same website as the quote, above, the British Heart Foundation. You know what? I'm fairly confident that I could take any kid of normal mental function, explain the parameters including the distinction between CVD incidence and death, ask him or her about association and cause, and get the obvious conclusion: time to look elsewhere.

But kids are naturally honest about such things. For them, it'll be another 20 years before they are "fortunate" enough to get paid for lying and manipulating, which brings us to the second case study in cognitive dissonance. Let's begin with the names, 'cause I always name names.

These names, of course, are prominently displayed in large bold font right after the title of the study: Lipid levels in patients hospitalized with coronary artery disease: An analysis of 136,905 hospitalizations in Get With The Guidelines (PDF)

Amit Sachdeva, MD, Christopher P. Cannon, MD, Prakash C. Deedwania, MD, Kenneth A. LaBresh, MD, Sidney C. Smith, Jr, MD, David Dai, MS, Adrian Hernandez, MD, and Gregg C. Fonarow, MD.

Far less prominent, requiring a magnifying glass, are the financial disclosures.

  • Christopher P. Cannon, MD; grants: Accumetrics, AstraZeneca, Bristol-Myers Squibb, GlaxoSmithKline, Merck, Sanofi- Aventis, Schering Plough
  • Prakash C. Deedwania, MD; consultant of AstraZeneca and Pfizer
  • David Dai, PhD; employee of Duke Clinical Research Institute
  • Gregg C. Fonarow, MD; research from Pfizer and GlaxoSmithKline; consultant and honorarium from Abbott, AstraZeneca, GlaxoSmithKline, Merck, Pfizer, and Schering Plough; and chair of the Get With the Guidelines Steering Committee

No potential conflicts of interest there, eh? I guess that "disclosure" is the name of the game, now, and not the simple fact of the matter. Here's a novel idea: how about simply publishing and paying attention to studies where financial disclosures are unnecessary? Yea, yea, it's impractical and I also don't want to unfairly paint with too broad a brush. Moreover, I'm no Luddite when it comes to the great contributions over time of doctors, researchers, and yes: drug companies. But isn't this getting out of hand?

This was a captivating study to read for the cognitive dissonance, the subject of this entry. Remarkable to me is that I can detect no data manipulation or even evasion of data and facts (until the conclusion, which is an evasion to take your breath away). That's what's so interesting. It's all there. Everything is there to make the same childlike conclusion as we did up above: time to look elsewhere.

Here, let's take a look.

LDL Distribution
LDL Distribution

Now that's almost as perfect of a Bell Curve Distribution as you're ever going to see -- and I'd guess that if LDL levels actually ran to zero in people that you'd see an absolutely perfect distribution. I remind you: these are the LDL levels of 137,000 people admitted to a hospital with coronary artery disease. Let's imagine a scenario, for example, measuring blood alcohol content in people involved in automobile accidents. Would that be a Bell Curve, or, would you naturally expect that the higher the BAC, the more accidents (an ever increasing curve)? Now there you have a definite causal relationship and the data is going to show it unambiguously.

Now let's look at some quotes from the study (PDF).

  • Half the patients hospitalized with CAD had admission LDL <100 mg/dL, and LDL <70 mg/dL was observed in 17.6% of patients.
  • Less than one quarter of patients had an admission LDL >130 mg/dL.
  • There were 54.6% of patients hospitalized with CAD with admission HDL levels <40 mg/dL.
  • HDL ≥60 was observed in just 7.8% of patients.
  • Ideal levels (LDL <70 mg/dL and HDL ≥60 mg/dL) were observed in only 1.4% of patients hospitalized with CAD.
  • Among the 21.1% of patients receiving lipid-lowering medications before admission, LDL levels were modestly lower (94.3 ± 36.4 mg/dL) and HDL levels were similar to those not previously treated with lipid-lowering medications (39.6 ± 2.6 mg/dL).
  • Although high serum concentrations of LDL are a major risk factor for CHD, patients may present with CAD events despite LDL levels, which are not considered elevated and fall well within guideline-recommended targets. In the present study, almost half of patients hospitalized with CAD have admission LDL <100 mg/dL, and 17.6% of patients had LDL <70 mg/dL. Even when only patients without prior history of CHD, other atherosclerotic vascular disease, or diabetes were studied, 72.1% have admission LDL <130 mg/dL and 41.5% had LDL <100 mg/dL. Thus, a substantial proportion of patients present with their first or recurrent CHD events well within the current guideline-recommended targets for LDL.
  • Many of these patients presenting with CAD had HDL levels, which are associated with excess risk. High-density lipoprotein cholesterol is inversely related to the risk of CAD. Even modest increases are associated with lower risk for nonfatal MI or death from CHD. There were 54.6% of patients hospitalized with CAD with admission HDL <40 mg/dL. In addition, fewer than 10% of patients had HDL ≥60 mg/dL. Ideal levels (defined as LDL <70 mg/dL and HDL ≥60 mg/dL) were present in only 1.4% of patients hospitalized with CAD.

How about let's put this final quote in bold.

The present study demonstrates that among patients hospitalized with CAD, the admission lipid levels are below that of the general population.

And, so, what's the OBVIOUS conclusion from all these data points, observation and reasoning?

In a large cohort of patients hospitalized with CAD, almost half have admission LDL <100 mg/dL, whereas less than a quarter have LDL >130 mg/dL. The LDL levels <70 mg/dL are observed in only 17.6% of patients. Admission HDL levels are <40 mg/dL in 54.6% of patients hospitalized with CAD, whereas <10% of patients have admission HDL levels ≥60 mg/dL. Ideal lipid levels (LDL <70 mg/dL with HDL ≥60 mg/dL) are seen in only 1.4% of patients hospitalized with CAD. There were reductions in admission LDL and HDL levels over time. These findings provide insights into the lipid levels encountered in recent clinical practice for patients hospitalized with CAD. These findings may provide further support for recent guideline revisions with even lower LDL goals. They also may suggest a clinical need for developing effective treatments to raise antiatherogenic HDL. [emphasis added]

Shorter version: lower the cholesterol guidelines even more (and, hey, why not throw in a few billions of dollars more of statin Rx?), because heart attack victims already have average cholesterol levels less than the general population. OBVIOUSLY; more lower, please. And, while we're at it, let's come up with a few billion dollars market for meds to raise HDL.

Hey, maybe they could hire me to consult on that last point, since my HDL runs in the 130s and directly measured LDL in the 60s. Of course, that requires no meds, but only a diet of real foods high in natural, healthful saturated fat, plenty of animal protein, some veggies, fruits & nuts -- and occasional bouts with full fat, raw dairy.

So, no chance for me to cash in, I guess. I'll have to content myself with naming names of those who put their livelihoods above your health and are willing to engage in head-spinning cognitive dissonance to hold their lucrative positions of authority.

Comments

  1. ThePaleoGarden says:

    Richard,

    The best way to sum it up is to quote Feinman when these low-fat priests start spewing their unfounded rhetoric leftover from when they used leaches to treat people, when the low-fat hypothesis was formed before insulin was understood.

    “The deleterious effects of fat have been measured in the presence of high carbohydrate. A high fat diet in the presence of high carbohydrate is different than a high fat diet in the presence of low carbohydrate.”
    Richard Feinman, PhD

    The low-fat priests are recommending an ABNORMAL HIGH CARB/SUGAR diet. I refuse from now on to call their diet “low-fat”, I will call it what it is, ABNORMAL HIGH CARB/SUGAR diet.

    The paleo diet is the NORMAL CARB DIET. I refuse from now on to call my diet “low-carb”, as if to imply it’s somehow abnormally low, low from the “norm”, when the norm is defined by these high carb/sugar addicts. The gloves are off. “Low-fat” is no long in my vocab, “high carb/sugar” is what they are. “Low-carb” is no longer in my vocab, when I’m not amongst my brethren calling it paleo, I will describe it as “normal carb” to the high carb/sugar addicted thugs.

  2. Hey Richard,

    This is just a bit off-topic for your current post, but check out ripped Sam from 1910:
    Front: http://www.shorpy.com/node/7215
    Back: http://www.shorpy.com/node/7174

    What do you suppose he was eating? Some extruded “energy” amalgam? :/

  3. LeonRover says:

    OOne can only get such a smooth histogram with sample sizes order 100 k. (To a working statistician this pic is BEAUTIFUL.)

    Where is the histogram showing LDL levels in the general population? Without such a pic a the phrase “the present study demonstrates” is simply not true, ‘cos there a’int no demo!

    However, more to the point, to say that a general population sample in the 100,000′s would HIGHER lipid levels, means that the histogram would have its mean and median further to the right. Moreover, it would be obvious by eyeballing that samples are different.

    Surely if lipid levels are LOWER in the CAD admissions and HIGHER in the gen pop, then LOWERING the lipid levels of the gen pop will bring MORE CAD admissions. As noted elsewhere, this is cognitive dissonance, but it is also the type of argument used by a defence lawyer when faced with trying to defend statements made from the mouth of the accused! The jury always sniggers.

    So, spend money (statins) on lowering LDL levels, then hospitals will see more CADs. It a win win for pharma and for hospitals.

    Finally, there is the explanation that it is a misprint by the publisher: the sentence should read

    ” These findings may NOT provide further support for recent guideline revisions with even lower LDL goals. ”

    What I detest about these kinds of conclusions, that the rest of us are taken for congenital idiots who cannot see a logical fallacy.

  4. …and here’s a nice colourful poster summarising this study in all it’s cognitive dissonant glory (if that’s actually a term??):

    I stumbled across this pdf last year when I started researching low-carb/paleo nutrition – this one page pretty much convinced me that the whole lipid hypothesis is complete and utter bunk.

    Shmaltzy

  5. Truly scary stuff. If these mainstream scientists are as wrong as it would appear, then thousands or maybe hundreds of thousands of people must be dying needlesy each year!

  6. Richard, some people might disagree with your ideas regarding the AHA study. But I don’t, of course. LDL levels by themselves, without considering the subfractions (sdLDL, oxLDL, etc.), are not risk markers!!!

  7. Richard,

    If people want a quick study of the hunter-gatherer eating habits, have a look at this month’s issue (Dec.) of National Geographic.

    Michael Finkel offers a stunning look at the Hadza people from around Lake Eyasi in northern Tanzania. There is quite a vivid desription of their hunt, cooking, and eating of their favorite meal – the baboon. Here’s a quote from the article: “They will eat almost anything they can kill from birds to wildebeest to zebras to buffalo. They dine on warthog and bush pig and hyrax. They love baboons.”

    They do hunt giraffes for food & use poisoned arrows. But these arrows cannot kill elephants; so what do they do? Here’s what the article says: “If hunters come across a recently dead elephant, they will crawl inside and cut out meat and organs and fat and cook them over a fire. Sometimes, rather than drag a large animal back to camp, the entire camp will move to the carcass.”

    The article covers other issues – religion, politics, kinship, ideology – but in small doses and the results are surprising. The low-carb community should read this & rejoice. They do eat edible tubers, in-season berries, and honey (there is no description of this part of their diet) but what stands out is the consumption of baboon meat (especially their favorite part – the brain).

    Here’s the self-explanatorty caption at the top of the front page of the article: ” They grow no food, raise no livestock, and live without rules or calendars. They are living a hunter-gatherer existence that is little changed from 10,000 years ago. What do they know that we’ve forgotten?”

    There is some romanticizing of Rousseau’s “noble savage” in this piece of writing and the writer laments the inevitable arrival of the modern world as it gets closer and closer to them. For the low-carb community (hmmm, normal carb community) this reaffirms what we already know about the Paleo diet -namely that it is the normal way to eat. If this article is read by a vegetarian, it will literally make that person sick.

    Dominic

  8. my ldls are normally around 140 – 160. when admitted to hospital last year my ldl was calculated at 97. And 99 the following day. I have read elsewhere that during an MI ldl levels can be somehow shocked downwards. Several weeks post MI my ldl levels were back above 140. Another factor to consider. I have read that this is common.

  9. I see the study authors have mentioned this “limitation”:

    •Lipid levels obtained in the first 24 hours of hospitalization may still be
    altered by the acute phase response and thus may not be entirely
    reflective of the baseline steady state lipid levels.

  10. Excellent article! The cholesterol hypothesis is just that – a hypothesis (theory). It has never been proven despite all of the subverted studies that are meant to “prove” it. The first question we should always ask when a study reveals its “findings” is, Who FUNDED the study? The outcome will always be what the funder wanted it to be. Also, if you have some (ok, a lot) of time to read, get hold of The Cholesterol Con by Anthony Colpo. You’ll find a short piece about it on YouTube. Cholesterol has squat to do with heart disease. And the Mediterranean Diet? Guess what the leading cause of death in Italy and Greece is? You guessed it – heart disease.

  11. And now for the obligatory defense of self-interest comment:

    It’s true that those in the mainstream medical field tow the party line. It’s also true that many of them do so because to not do so would be to lose financial benefits (I’ll leave the true believers, and those who have developed the habit of never thinking too independently about anything out of this). However, what everyone in the paleo (ie: enlightened, intellectually active and honest) community should do well to realize is this: the pharmaceutical companies are under the same pressure to tow the line as the doctors are!

    They don’t set the standards for what’s considered healthy nutrition and exercise. They don’t decide which types of foods get subsidized and which don’t. Yes, of course pharmaceutical companies, being big businesses, have lobbyists for these things – and some private industry or particular company always wins at the expense of some other industry or company – but ultimately it’s the government which decides. Ultimately it’s the government which says that it’s it’s responsibility to make *some* decision. That they’re our parents. Do you honestly think that any company, or even any industry as a whole, can fight that premise? No, all they can do is hope to play into it.

    In any situation like that it’s always the individual (popularly refered to as “the consumer”) which loses – and it’s always the producer (not the government) which takes the blame. As it stands now, people do what they do in nutrition because, well, that’s what the government says they should do (they think it’s “uncorrupted” by money, ironically). They take the government’s advice on faith.

    It could be better – but government would have to get out of the way. Even those individuals who eat 200 grams of carbs every day are worse off for having the government tell them that that’s what they should be doing than if they came to that conclusion themselves. While, of course, their reasoning for doing so would be false if they had done it themselves, at least it would be their own reasoning. At least they would have some scientific basis from which to be persuaded.

    Once upon a time in this country the government didn’t concern itself with the health of it’s citizens. It used to say, whenever some out of their mind, activist subgroup of people wanted it to, that that’s not our business. Yes, during this time people figured out how to produce alot of carbs. They didn’t do so because they said to themselves “we’re trying to find the optimal nutritional regimine possible given the nature of the human genome.” They concluded that carbs were preferable to periodic famines – and so they produced them. The reason why they (later on) came to the conclusion that those things were optimal nutritionally was because of one thing: government policy.

    Government policy – more concerned with the “general welfare” of masses of people rather than the individual’s health – saw the fact that carbs were cheap, plentiful, and durable, and so they concocted the lie (and created the agencies to promote and enforce that lie) that they were healthier to0. They did this to further their own ends. The government is concerned with avoiding food riots, and with using grains as leverage in international diplomancy; not with the health of the individual. So is it any wonder that they would step in front of the people’s march towards technological and scientific harmony, once they had what they wanted to keep themselves in power?

    So greed, financial gains, conflicts of interest – whatever you want to call them – aren’t the real problem. They are just symptoms of a far more profound cultural and political disease. Everything – all of the dogmatic intellectual stagnation – that has happened in the health care, food, exercise, pharmaceutical, and medical education industries (and many, many more industries actually, if you care to look into them) ever since the government got what needed to stay in power it is the result of government meddling into something only the individual should be responsible for: doing his best to learn what he needs to do to maintain his health.

    • I don’t really disagree with you, and I’m well versed in and support free markets.

      That said, it’s important to understand also that big corporations are really a function of government as well. In fact, I think it’s becoming increasingly difficult to draw distinctions. So, while I’m all for individual rights, property rights, the right to produce & trade, I also recognize that what we observe in the big corporate sector likely would not exist in a free market where there’s no shielding of personal liability by law.

      I’ve come to believe that it’s the shielding of personal liability that’s at the very root of what’s wrong. You might also not that government officials are also generally shielded from personal civil liability.

      • They’ve definitely blended into one, you’re right about that. However, I still think it’s important to always point out who started that. The only way to untangle them is to refrain from further inculcating in the average, non-philosophical person’s mind that the root of all of this is self-interest, financial incentives, and a lack of market regulations.

        It’s that notion which created the mess – with the founding of things like the FDA and USDA – in the first place.

  12. So called “experts” explain us that, after all, eggs are fine, but saturated fat is the vilain – http://www.youtube.com/watch?v=WuX287Lltr0

  13. Came across this quote from Carl Sagan and thought you would appreciate, if you aren’t already familiar with it:

    “We have designed our civilization based on science and technology and at the same time arranged things so that almost no one understands anything at all about science and technology. This is a clear prescription for disaster.”

    “The truth may be puzzling. It may take some work to grapple with. It may be counterintuitive. It may contradict deeply held prejudices. It may not be consonant with what we desperately want to be true. But our preferences do not determine what’s true.”

  14. Jared Bond says:

    Well, Dr. A’s blog is now inexplicably missing from the web… I’m trying to find the data he used to make those graphs. I’m doing a report, and simple, easy-to-understand graphs like that make the most profound statements. (I’d like to get data for the US too, and from before 1975.)

    I looked on http://www.bhf.org.uk, but I can’t tell where to get the data. Can anyone help? And also, what happened to Dr. A??

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