Cholesterol Doublethink

[Guest guest]

A NEW MEDICAL RIDDLE FOR THE 21ST CENTURY

http://www.redflagsweekly.com/kendrick/2004_june11.html

 

Or How Cholesterol Doublethink Will – And Should – Drive You Crazy

 

By RFD Columnist Dr. Malcolm Kendrick

(email - malcolm)

 

Question: ‘How can something be a risk factor for a disease, when it isn’t

even there?’ This is my new medical riddle for the 21st Century.

 

Or, try this question instead. What is a raised cholesterol level? You

might think there is an answer to this question – but there is not.

 

Currently, we have an alleged risk factor for heart disease – a raised

cholesterol level – which must be lowered. But no-one will tell you what a

raised level is, or by how much it should be lowered. Whatever the level

may be, it would seem, you must lower it.

 

You may have heard about the latest Collaborative Atorvastatin Diabetes

Study (CARDS).This study, halted early, looked at giving atorvastatin

(Lipitor) to people with diabetes, and found wondrous benefits; with an

interesting rider:

 

‘One important finding was that these benefits were observed even among

patients whose ‘bad' LDL cholesterol levels were already quite low before

treatment. People with type 2 diabetes have a much higher risk of

cardiovascular disease but are currently only prescribed statin treatment

if their cholesterol levels are raised.’

 

- Professor John Betteridge, CARDS co-principal investigator and Professor

of Endocrinology and Metabolism at University College London

 

People with low cholesterol levels benefited from having their cholesterol

levels lowered? Doesn’t this seem strange? The whole point of statins was

to lower the cholesterol level in order to prevent CHD. And it’s true that

statins do lower cholesterol levels, and they do prevent CHD. They even

reduce overall mortality in high-risk men – although not in women, or

low-risk men.

 

Yet they also protect against CHD in people with low cholesterol levels. So

what is going on here? Can a low cholesterol level be a risk factor for

CHD? This surely makes no sense at all. And yet this fact is not commented

on. I have seen many reports on the CARDS trial, and no-one, not one single

person, has questioned the fact that statins work in people with low

cholesterol levels. Perhaps it would seem rude, or churlish to do so.

 

However, at the risk of sounding “not-nice,” I believe that this single

fact should completely destroy the entire cholesterol hypothesis. According

to the CARDS data, and many other studies as well, statins work no matter

what the level of cholesterol. Ergo, they do not work by lowering

cholesterol levels, as a low level of cholesterol cannot, by definition, be

a risk factor for heart disease. What is going on here? Hello……. Can anyone

hear me?

 

I don’t suppose when George Orwell wrote 1984 he truly thought that most of

what he wrote would come true. It was supposed to be a warning. One thing

he warned us of was double-think.

 

‘Doublethink means the power of holding two contradictory beliefs in one's

mind simultaneously, and accepting both of them. The Party intellectual

knows in which direction his memories must be altered; he therefore knows

that he is playing tricks with reality; but by the exercise of doublethink

he also satisfies himself that reality is not violated. The process has to

be conscious, or it would not be carried out with sufficient precision, but

it also has to be unconscious, or it would bring with it a feeling of

falsity and hence of guilt.’

 

In the strange Orwellian world of the cholesterol expert, double-think goes

like this.

 

‘A raised cholesterol level causes heart disease.’

‘What about people who have heart disease and a low cholesterol level?’

‘There is no lower limit for a cholesterol level, so one cannot have a low

cholesterol level.’

‘So, the level should always be lowered, no matter what it is?’

‘Correct.’

‘So the cholesterol level is always high.’

‘Correct.’

 

Possibly you think that I am making this nonsense argument up. But I am not:

 

Consider the following quote from the British Medical Journal taken from an

article by Professors MR Law and NJ Wald two years ago which made the

following observation:

 

‘Blood pressure lowering drugs should not belimited to people with high

blood pressure, nor cholesterol loweringdrugs to people with high serum

cholesterol concentrations. Theconstant proportional relation means that

there is value in modifyingrisk factors in people at high risk, whatever

the reason for thehigh risk and regardless of the level of the riskfactor.’

 

I have tried reading that paragraph slowly, quickly and both sober and

drunk, and it still makes no sense to me at all. Because, you see, I am

incapable of double-think. My brain must be too small.

 

I apologise a little for including the blood pressure comment in the quote,

but the whole thing so perfectly illustrates the double-think point that I

didn’t want to change it.

 

Anyway, let us use a little logical dissection to find out what this quote

really says?

 

‘Blood pressure lowering drugs should not be limited to people with high

blood pressure, nor cholesterol lowering drugs to people with high serum

cholesterol levels…..’

 

Let’s assume, for the sake of argument (concentrating only on cholesterol)

that a cholesterol level must, at some level, be normal. Call me an old

cynic if you like, but I don’t believe that a normal level of anything can

be a risk factor for a disease. Or, if it is, we must be terribly badly

designed. Try, for example, lowering a normal level of potassium in the

blood and see how long you live.

 

And if a normal level isn’t a risk factor, then the cholesterol level can

only be a risk factor when it is high. I think this is inarguable logic. If

it isn’t, then perhaps someone would be kind enough to enlighten me as to

the error of my ways.

 

The first question, therefore, should be to establish what is normal, and

what is high. But this step is not required; it would seem, in the world of

cholesterol levels. For the second part of the quote states:

 

‘The constant proportional relation means that there is value in modifying

risk factors in people at high risk, whatever the reason for the high risk

and regardless of the level of the risk factor.’

 

Just concentrate on the second part of that quote…’regardlessof the level

of the risk factor. In short, whatever the level of your cholesterol, it is

a risk factor. Which means that there is no such thing as normal, for

normal, if it is a risk factor, must be high. Because if it wasn’t high, it

couldn’t be a risk factor as normal is….normal and healthy.

 

So, according to Law and Wald, a normal cholesterol can be both normal, and

also a risk factor for heart disease. And now we find in the CARDS study

that a low cholesterol level can be low, and also a risk factor for heart

disease.

 

Thus a cholesterol level is a risk factor, no matter what the level

actually is. Which brings me back to my riddle. ‘How can something be a

risk factor for a disease when it isn’t even there?’ The answer is, when it

is a raised cholesterol level. How silly of you not to have guessed.

 

For those whose heads are now spinning, just read the whole article again

slowly, I assure you it does make sense. At least it did to me.