Saturday, 14 February 2015

The Great Cholesterol Con?


Had a recurrent difficult consultation over the last few weeks - a lady had had routine blood tests done as part of her NHS health check which had shown a raised cholesterol. It is generally accepted (and pretty widely known) that high cholesterol levels lead to an increased risk of diseases such as heart attacks. This is based on a wide body of evidence from multiple studies and meta-studies backed up by government organisations such as NICE and mostly by the most important source of all - Wikipedia.

This lady had read a book called "The Great Cholesterol Con" which suggests that cholesterol is not linked to heart disease at all, and there is nothing to gain from lowering it at all. For this purpose she had started a "sausage diet" where she ate 1-2 sausages every meal, breakfast, lunch and dinner, along with the rest of her food. Predictably her cholesterol was crazy high. I tried to talk her through the evidence behind the ideas of lowering cholesterol, but I hadn't read the book so couldn't do this very effectively. I asked her to come back the next week so I could have some time to do some research. She was a little bit annoyed about this - she felt as a doctor I should know all this already, but agreed to return.

I read up on the arguments in the cholesterol book, which are based around inconsistencies in the Framingham Heart Study which suggested that as your cholesterol dropped, your risk of heart disease rose. It seemed as though this book was very selective in the data which it displayed to portray its arguments (well summed up by this review of a similar book) and ignored huge swathes of evidence which did indeed suggest high cholesterol levels (rather than just all cholesterol) are bad for you. You obviously need some cholesterol (and some salt, sugar, etc) but having too much can be a problem.

I collected up all of my research and information and bought it back to the next consultation with this lady. She was having none of it, and told me I had been taking backhanders from the statin producing pharmaceutical companies to peddle their wares. I tried to explain that as the patents on drugs such as Simvastatin had expired there would be no specific drugs company to try and pay me off, but the more I tried to disagree with her the more angry I made her. 

This was a loosing battle - I guess all we can do is display the evidence to the best of our ability and let people make decisions for their own health based on that. It was just upsetting that this wasn't a concious decision to damage her own health (like someone who smokes 40 a day, knowing full well it is bad for them) but a misinformed decision to try and help her own health, possibly guided by someone more interested in book sales than helping people. That said, she is coming back next week for another round of discussion, so wish me luck!


  1. How could one debunk the conspiracy theory ? That is near to impossible.
    But to be optimistic like you, one need drop talking about his view, and focus in showing her the faults in her logic and data. Which you did.
    What about a practical experience where she eat an ice cream in your office and you collect her blood after a few minutes ( saturated with chylomicrones) and let her decide and keep the tube. ( but I'm afraid that might fire back )
    Anyway, I hope she knows eating healthy and exercie will help and no money go to the drug company that way.
    I love your morale by the way.

  2. I admire your persistence, I felt a bit guilty as when I read about the lady my knee-jerk was to just leave her make her own decision after the evidence was presented. But after thinking about it a bit, I feel maybe it's worth discussing with you to see what you think of the following:

    Perhaps it's not worth trying to convince your patient that high cholesterol is bad but to try and optimise other risk factors you can agree on. How's her blood pressure, glucose tolerance, any diabetes, drinking, smoking? She knows your view, she knows the prevailing medical advice, what more is there to be achieved? Is it too much effort/time for just one risk factor?

    I also can NOT find anything in the brief descriptions of the book I read that says it advocates *higher* cholesterol (I assume you mean LDL for this) for protecting against heart disease. It just seems to rage on about statins. Perhaps you could direct the conversation more towards a healthy diet (food pyramid) and exercise, which should lower the cholesterol, and makes intuitive sense as being healthier anyway. Nobody would say a sausage is healthy, why not try skinless chicken, etc?

    You're not going to get her to adhere to a statin anyway, not by a long shot. Even if she tolerates them perfectly, there's a massive nocebo effect working against you now.