What Oprah might have said had she contracted with Pharma instead of General Motors in 2004.
“Researchers report that only 35% of adults who are eligible to take statins for prevention of cardiovascular disease are actually using them. They said that misinformation about statins’ side effects could be a factor.”
-Medical News Today, Dec. 4, 2023
I’ve been pulling people off statins for so long I forgot that I never publicly posted about why. Maybe it was more subconscious – I wasn’t up for the backlash. Or the long winded explanation. I’m feeling good today though, so if you’re interested in going down that rabbit hole, this blog is for you.
I appreciate that my patients trust me. Some of them want to fully understand all the nuances of why we’re doing what we’re doing, and an equal number just trust in the process. I respect both. Stepping behind the curtain of “science” is dicey business. I feel like that’s been obvious for ages, but you normal hardworking folks probably weren’t aware of the industry shenanigans until 2020 rolled around. You were just supposed to “trust the science.” Remember?
That sentiment is all well and good in theory, but it has sadly been forever corrupted by vested interests, i.e. industry paying for research used to promote the products they profit from selling. Hey – humans are animals and animals care about one thing and one thing only: survival. Oh, and money. Money and survival. And sex – definitely sex. But for brevity, I’ll roll sex in with survival. If you can look at ‘science’ through the lens of studies being published and promoted by animals wanting to live to see another day in their job and profit (and maybe have sex) while doing so, then this whole cluster will make more sense.
Reading scientific studies takes skill and practice. And caffeine...a lot of caffeine. Sometimes alcohol. The authors of these studies are assumed to demonstrate at least a modicum of integrity when conducting research. Otherwise, what are we even doing here? You’re not allowed to ‘cherry pick’ studies whose results don’t align with your interest. You’re not supposed to ‘pay people off’ to falsify study results. You can’t ‘change the endpoint’ of your study halfway through because the data isn’t turning out the way you predicted. And you certainly can’t ‘pull participants’ out of your study because they reported having side effects from your intervention/medication in order to make your results look better.
But they do. They do it all the time.
When you publish a paper, you’re expected to ‘disclose conflicts of interest’. Why? Because it’s unethical not to, that’s why. If you have no conflicts to disclose, it lends credibility to your research findings. It means what you’re saying is probably legitimate. Otherwise, I don’t know if I’m reading real information or just some shady shit.
It’s sad to say, but data-manipulated industry-funded ‘science’ forms the very foundation of mainstream medicine as we know it today. Studies cost money. Lots of money. Who has money? Pharma has money. If someone wants to promote a finding or make it disappear, it takes dollars to make that happen.
I am not trying to sound all dark and sinister. Real science is truly how we question, investigate, and get smarter, better. Without open, honest scientific debate, we will not advance. Real scientific research published in closely scrutinized studies is how we move the needle forward.
Just keep in mind, humans do the studies. Humans review the studies. Humans sponsor the studies and sponsor the journals the studies are published in.
And never forget, humans are animals who are hungry for money, power, and sex.
Heart Disease, Cholesterol, & Statins:
Wading Through the Swamp
Evaluating the Real Risks & Benefits of Cholesterol & Statins
Heart disease is the number one cause of death in this country. Period. You might have an unfiltered Camel Straight hanging from your lip, an aggressive cancer strangulating your left lung, a fresh bullet wound from Frankie Four Fingers in your aorta, and the CIA reading your text messages to Putin, but all bets in Vegas say your heart is the ticking time bomb that’s gonna take you out in the end. Your heart needs oxygen and when something jams up the vessels that bring it that oxygen, it’s game over.
For decades, it was believed dietary fat and saturated cholesterol were the drivers of this disease process. That conviction was so strong that the winners of the 1985 Nobel Prize for discovering statin medications (Michael S. Brown, Joseph L. Goldstein) predicted the eradication of heart disease by the early 21st century. Forty years and billions of statin prescriptions later, heart disease is still the first place record holder for death.
What is Coronary Heart Disease?
“Coronary heart disease is a type of heart disease where the arteries of the heart cannot deliver enough oxygen-rich blood to the heart.” -National Institutes of Health (NIH).
If you're reading this, chances are pretty good you have a heart. Having a healthy heart is a big deal because your heart has a big job. It has to pump oxygenated blood through miles and miles of blood vessels to all the rest of your body. Or you will die. No oxygen means no working organs. That’s no bueno. The heart not only has to pump oxygen to your entire body, but it also has to pump oxygen to itself to keep working.
What kind of a deal is that?
It’s like being a mom – you get to do your laundry, his laundry, your kids’ laundry and then you have the privilege of waking up and doing the same damn laundry again tomorrow. Heart disease is like you managing to do everyone else’s laundry but running out of steam before getting to your own. When it comes to laundry, your kids don’t care – they'll just go to school in the same dirty crap for the rest of eternity. Your body isn’t so forgiving. If the heart can't get oxygen to itself and everything else, the entire system grinds to a halt. It needs oxygen – or no one’s getting clean laundry.
Statins: Part 1
“A recent Centers for Disease Control and Prevention (CDC) report estimates that nearly 1 in 4 adults aged 40 and older in the United States uses a cholesterol-lowering medication, with statins being the most commonly used medication.” Aug 17, 2023
The ‘statins’ are a powerhouse class of medication used to lower cholesterol. They’ve been around for a while and are well known to be the most efficacious tool to date for lowering cardiovascular risk. Lovastatin, developed by Merck, was the first FDA approved commercial statin approved for human use on September 1, 1987. As of the date of this writing, there are eight statin medications approved for use by the FDA.
Atorvastatin (Lipitor)
Fluvastatin (Lescol)
Lovastatin (Mevacor, Altoprev)
Pravastatin (Pravachol)
Rosuvastatin (Crestor)
Simvastatin (Zocor)
There are over a billion people worldwide taking these drugs. Some quick math means Pharma is grossing more than a trillion dollars in annual revenue from the sales of statins alone.
There’s no question that statins lower cholesterol. I’m not going to try to convince you that statins are all bad or that you should flush your Lipitor down the toilet right now. My objective in writing this is to explain how we have been massively deceived by the entire narrative surrounding statin medications. The story of statins was brilliantly concocted fear porn swallowed hook line and sinker by a billion people – a billion people who deserve to know the whole truth behind heart disease, cholesterol, and statins.
Let’s go.
What We Thought Caused Heart Disease: A Short Story
Cholesterol, right? Too much red meat, too many eggs, too much fat? Everyone knows this. They told us that for years. Cholesterol is fat. Fat makes you fat. Stop eating fat.
Come with me on a brief walk down Memory Hole Lane, shall we? Let’s go all the way back to the 1950s.
There was this guy. Ancel Keys.
Ancel was a physiologist (we’re on a first name basis) who published his ‘dietary fat causes coronary heart disease’ hypothesis in 1952. This ‘lipid hypothesis’ was based on data from ‘The Seven Countries Study’ in which Ancel reportedly observed a correlation between cholesterol and heart disease. He looked at seven countries, their average total cholesterol plotted against rates of heart disease, and voile. Perfectly linear relationship. It was his conclusion that if we removed saturated fat from our diet and drove cholesterol levels down as low as possible, heart disease would be a thing of the past.
The lower cholesterol is, the better.
Interesting side note (and classic example of aforementioned unethical ‘cherry picking of data’): Ancel collected observational data from 23 countries – not just the seven he reported on. If you look at cholesterol and heart disease from all 23 countries, there is absolutely no correlation between the two. Once again, zero correlation between cholesterol and heart disease across all 23 countries studied.
As a matter of record, Ancel was also bought and paid for by industry. He forgot to disclose this ‘conflict of interest’. That’s two strikes, Ancel. Bad Ancel.
Almost immediately after this “groundbreaking research” was published, data began pouring in supporting this ‘lipid hypothesis’ of heart disease idea. I mean DECADES of industry funded data. Study after study – all confirming the same findings. Fat and cholesterol were associated with coronary disease and therefore one must cause the other. Nail in the coffin. Debate settled. Fat and cholesterol needed to go.
The USDA Weighs In On Cholesterol
Well, that’s easy enough. The government thought so, anyway. In 1977, the USDA updated its dietary guidelines and released them to the American public. Anyone remember? You got it:
Don’t eat fat. Eat more carbs.
We Gen Xer’s and Boomers remember this absolutely moronic food pyramid published by the US Department of Agriculture in 1992.
"Research sponsored by Industrial Agriculture finds Industrial Agriculture
should be the foundation of the food pyramid!”
Good Lord. It's like a headline from The Onion.
Saying goodbye to butter was tragic. Thankfully, at the same time we were told cholesterol and fat were evil, we were being told sugar was...good? Amen. Sugar’s still on the table.
Sure, it was. Just empty calories. Free bees. I remember learning in medical school that the only people who needed to worry about sugar were dentists. What’s to worry about? Filling cavities put their kids through college. Please. That’s job security.
Enter An Important Industry Character: Sugar
From a dietary standpoint, this wasn’t the end of the world. Who doesn’t like sugar? I loved sugar. That was an easy move for me. I don’t think I ate fat for 20 years. Remember Snackwells? Omg. ZERO fat in Snackwell cookies. Those little sandwich cookies were fire. I could eat an entire box in one sitting. Absolutely NO fat. Free calories. Just like drinking water or breathing air. Right?
It seemed like overnight, fat was gone. Saturated fat was actually sentenced to solitary confinement. The food industry pulled all the fat out of food and replaced it with sugar. In addition to all the new low-and-no-fat foods on shelves, other exciting fake foods were ushered in to take the place of fat. Ultra-processed fully hydrogenated oils were used to make margarine, ‘vegetable oils’ (side note - they don't use any actually vegetables to make vegetable oil), and deliciously flavored coffee creamers. What could possibly go wrong?
A few things, actually. Thirty years after the first statin medication was approved, and 40 years of us eating nothing but sugar, this unfortunate information was revealed:
“A newly discovered cache of industry documents revealed that the sugar industry began working closely with nutrition scientists in the mid-1960s to single out fat and cholesterol as the dietary causes of coronary heart disease and to downplay evidence that sucrose consumption was also a risk factor.”
Funny little world. The sugar industry in bed with the guys making cholesterol lowering medication? Well, slap me silly and call me crazy. Turns out science has been bought and sold since science was science. They lied. And they lied about lying. The University of California San Francisco (UCSF) published these inconvenient documents in the Journal of the American Medical Association (JAMA) revealing scientists were paid off to produce fraudulent studies implicating fat and cholesterol as the most likely causative factors in heart disease.
See? This is why you don’t lie. Lies always come out. Don’t do it. Just be honest.
Decades of industry sponsored research. Gazillions of dollars in hush hush agreements. Corruption at the deepest level between Big Sug and Big Pharm. Try as they did to make fat and cholesterol the root of heart disease, scientists knew it was something else altogether. Something they hoped to keep secret forever. But it was right there, hiding in plain sight.
It was sugar.
The internal documents confirm the ‘Sugar Research Foundation’ had a lot to lose, but even more to gain. When refined, sugar was like heroin. Processed sugar is eight times more addictive than cocaine. High fructose corn syrup is even worse. Just like the drug cartel, they paid off scientists – 3 Harvard professors to be precise. They paid them to produce studies showing sugar was good and fat was bad.
Can you believe this? I mean, this is Harvard. I never in a million years would have thought Harvard would hire anyone capable of falsifying their publications.
“Critics cheer resignation of ‘anti-Semitic plagiarist’ Harvard President Claudine Gay: Bye Felicia” -FOX, Jan 2, 2024
Sorry, I couldn’t help myself.
Fun fact – The documents uncovered by UCSF also disclosed one of the Harvard professors that was paid to publish fraudulent research on ‘sugar is good, fat is bad’ went on to be named head of the USDA.
You literally can’t make this shit up.
That same criminally run USDA went on to develop the 1977 dietary guidelines to restrict real, God-given foods like butter, red meat, and coconut oil because they “caused heart disease”. Eat all the processed sugar and refined grains that you want. Grains are the foundation of the Food Pyramid. Sugar is “an empty calorie”. Fat will kill you.
So fat was gone. Cholesterol was down. Heart disease rates should have hit the floor. Right?
No – that didn’t happen. Heart disease actually went up. Wayyy up. Rates of heart disease TRIPLED, to be precise.
OK – so we have Ancel in bed with Big Sugar and Big Sugar in bed with Big Pharma. We have an inconvenient truth that needs to be buried.
Time to call in Big Science.
Big Science Rescues The Lipid-Hypothesis
The Framingham Study
One of the major landmark trials sold to the public sealing the deal on the causal link between cholesterol and heart disease was the Framingham Study. This was a large study in Massachusetts that started in 1948. The investigators followed 5000 patients over several decades and published several risk factors observed to be associated with the development of heart disease, including diabetes, smoking, high blood pressure, and high cholesterol.
The investigators did find a correlation between cholesterol and heart disease. Home run for Pharma.
But it was only in a small subset of people in the study – people with something called ‘Familial Hyperlipidemia’ (FH). FH is a genetic condition which affects about 1 in 300 people. These folks have impressively high total cholesterol levels, typically over 300. In those patients, there was an observed correlation between high cholesterol and heart disease risk. Time for Industry to celebrate right?
Maybe not.
What was more interesting was that there was no difference in the cholesterol level between FH patients who developed heart disease and those who didn’t. What?? The gene responsible for causing FH also increases risk for clotting. That will be important to remember for later. So, to restate, Framingham studied thousands of people and their associations with various risk factors for heart disease. Here were their conclusions in terms of which increased risk:
Smoking? Yes.
Diabetes? Yes.
Hypertension? Yes.
High cholesterol? Yes, but….
The cholesterol/heart disease correlation wasn’t found throughout the study. It was only observed in this one group of participants with really high cholesterol levels due to a genetic condition (FH). But when evaluating those participants as a separate group, there wasn’t any correlation between cholesterol levels and heart disease. That detail may have been incidentally left out of the study findings.
A completely unreported finding was that as cholesterol levels went down in older participants, mortality went up. So if you were 65 or older, death from any cause went up as cholesterol went down.
According to Framingham, you want MORE cholesterol as you get older, not less.
The Numbers Game
I’m going to side bar over here to something that makes me positively crazy:
Misleading statistics.
Mark Twain said it best, “There’s liars, damn liars, and statisticians.”
The results of your drug trial suck? Who cares. We’ll make them look good by spinning the numbers. Scientists can turn shit into gold with statistical manipulation. You’d be absolutely amazed – or horrified - at the mathematical gymnastics done by some investigators before submitting their studies for publication.
Remember this?
“The vaccine is 98% effective!”
Outside of downright lying, how can they say this? We all know that isn’t true. They can get away with this by mixing and matching how they report two important statistical terms: relative versus absolute risk reduction. These are similar but very different ways to view the potential benefit a medical intervention might have.
I absolutely hated statistics in college. You are likely going to hate me for the same reason after reading this section, but it’s important so hang in there with me for a minute...
Absolute risk reduction is a real number. Let’s say we do a study where 10 out of 100 people in our control group (no treatment group) have a heart attack. In our treatment group, only 5 out of 100 people have a heart attack. The absolute risk reduction is just the difference between the two risks: 10% - 5% = 5%. Boom. That’s it. 5% fewer people had a heart attack because of the treatment.
Relative risk reduction is statistical gymnastics. It shows how much risk is reduced in relative terms compared to the original risk. See, it already sounds shady. The relative risk reduction is calculated as the absolute risk reduction divided by the risk in the control group. In our above example, that would be 5% / 10% = 0.5, or 50%. Wow! That sounds much more impressive, doesn’t it? This means the treatment reduced the risk of a heart attack by 50% compared to not getting the treatment.
Even if that sounded all gobbledygook, you can see how I took the same exact study findings, the words ‘risk reduction’, and arrived at two totally different conclusions. That vaccine reduces my risk by 5%? No thank you. By 50%?? Yes please.
Absolute risk reduction is also referred to as ‘Numbers Needed to Treat’ or NNT. It’s the inverse of the absolute risk reduction and it’s just what it sounds like. How many people need to take this drug to prevent one heart attack. In our little study here, the NNT is 20 (1/5%). Twenty people need to take the medication for one of them to avoid a heart attack. That also means 19 of those people get ZERO benefit but are subject to the same potential for harm or side effects from the therapy.
Apologies for grinding you through this, but this very basic misunderstanding of benefit and risk is extremely common among medical professionals. It’s referred to ‘health illiteracy’ because your doctor is just as illiterate about statistics as you probably are. Physicians are taught about informed consent. But I took statistics in college – not med school. I bet any money if you asked your doctor if the risk reduction they were talking about was absolute or relative, they would have no idea what you’re talking about.
Keeping everyone in the dark about the numbers makes us all easy to manipulate. Science uses absolute risk to report potential harms and then turns around to use relative risk to report benefit. It's insane. But it's classic industry B.S.
This is one of my favorite examples:
Comparison of absolute & relative risk benefits of cholesterol reduction in the JUPITER RCT
Data from the “Justification for the Use of Statins in Prevention: An Intervention Trial Evaluating Rosuvastatin” (JUPITER) randomized controlled trial (RCT) [20], expressed as the percent of subjects in the rosuvastatin group (Crestor) compared to the placebo group without myocardial infarction (MI) mortality.
The JUPITER trial was massive. It included an incredible 18,000 participants. It was perfectly positioned to lay down the hammer on any doubt the industry had on its superstar statin, Crestor, and it's earth-crushing power over heart disease.
"Dr. Steven E. Nissen, director of cardiology at the Cleveland Clinic, proclaimed, “It’s a breathtaking study. It’s a blockbuster. It’s absolutely paradigm-shifting,”
Paradigm shifting?! omg. Are you ready for it? Participants taking Crestor had a 54% relative risk reduction in deaths due to heart attacks. WOW. 54%?? That's incredible! Call the White House! It sounds almost too good to be true - until you do the rest of the math.
54% relative risk reduction converts to a 0.41% absolute risk reduction.
To be clear, the landmark study that had everyone wetting their pants over Crestor had a 0.41% absolute risk reduction. Less than one half of one percent of study participants experienced benefit. And these odds are the best of the best - a drug company funded the trial. This is their own data - the link is below. Check it out for yourself. I wish I was lying to you.
Less than one half of one percent benefited from taking Crestor.
This mentally ill math is done to intentionally mislead consumers. Pharma knows how to spin data, cherry pick it, extort it, and when it’s not convenient, make it just disappear. It’s unethical, it's immoral - it's outright deception. This is the madness which results in malpractice.
Statins: Part 2
Should I take a statin?
I am a medical doctor, but I might not be your medical doctor. This is not medical advice. This is just me telling you the numbers based on the statistics I just taught you against your will. If we look at the data in terms of Relative Risk reduction, it doesn’t look too bad. If we remove the smoke and mirrors, however, it’s just plain terrible. Here’s what we know from the available data on the potential benefit of statin therapy which comes almost exclusively from industry sponsored trials citing data couched as relative risk reductions. So even with the shenanigans, this is as good as they can make the data look:
High Risk People (known heart disease or high risk for heart disease in the next 10 years)
39 people need to take a statin every day for 5 years to prevent one non-fatal heart attack .
Low Risk People (less than 10% chance of having a heart attack or stroke in the next 10 years)
217 people need to take a statin every day for 5 years to prevent one non-fatal heart attack.
313 people need to take a statin every day for 5 years to prevent one non-fatal stroke.
I don’t know about you, but I find this underwhelming at best. Want to know what the "Numbers Needed to Treat" for Tylenol is? Tylenol?? It's TWO. You need to treat two patients with Tylenol for 30 minutes to alleviate ONE headache. Even that is pathetic.
I should also mention here that in addition to being almost all industry-funded trials, the researchers remove any participants who had side effects from the statin medication. It’s called a “pre-randomization run-in". Just helps them pick ‘the most suitable candidates’ for the study.
lol, ok.
If you have had a heart attack, your cardiologist is going to put you on a statin. Period. Without even knowing what your cholesterol is you are leaving that hospital on a statin. Let's say you take that statin medication for 5 years without side effects (because remember they took those people out of the trials), you do so with the understanding that if you don't, you're gonna die. Maybe not tomorrow, but sooner than you otherwise would have - right? OK. On average, if you take that statin for 5 years how much would you think taking it would add to your days here on earth? A few extra months? Several years? Nope. Guess again.
4.2 days.
4 days? Are you serious?? Those had better be some good f*ing days. Good grief...
"A new national study has shown that nearly 75 percent of patients hospitalized for a heart attack had cholesterol levels that would indicate they were not at high risk for a cardiovascular event, based on current national cholesterol guidelines.” -UCLA Health
In European countries, there was no reduction in death rates in people taking statins compared to people who didn’t.
One of the largest studies to date on this subject was the Heart Protection Study published in the Lancet in 2002. They removed a whopping 36% of study participants during the ‘run-in’, then used the term ‘non-compliance’ to explain why they removed them in their paper. Someone felt achy on their statin? They were cherry picked out of the trial.
These are the most lucrative medications ever. They are prescribed to more people than any other drug. They claim to be your golden ticket to avoiding the number one cause of death worldwide. Real benefit? According to the math, it is marginal at best - if you remove the variables of unethical pay offs, cherry picking, removal of inconvenient data, and statistical manipulation, of course.
So if benefit is largely out. What about risk?
Statins: Part 3
How Do Statins Work?
We know unequivocally that statin medications lower cholesterol. No one is debating this. Statin medications work in the liver to inhibit an enzyme called HMG-CoA reductase which makes cholesterol. Lower HMG-CoA reductase? Lower cholesterol.
Statin side effects are extremely common, however. More than 50% of patients who have been prescribed one stop taking it within one or two years due to side effects. Pain and fatigue are the most reported adverse events, but there are others to take note of. These medications are not benign – they carry real potential for harm.
Potential Side Effects
No drug is without risk. No good comes without some degree of danger. We don't always jump into something for which the full extent of risk is known. I get that. But we know there are well established risks associated with statin medications. You should be 'informed' of what they entail. Here are some of them:
Liver toxicity: Statins can cause liver enzymes to increase, indicating potential liver damage.
"The toxicity of statins includes myopathy, rhabdomyolysis, elevated liver enzymes, acute kidney injury, and diabetes."
Muscle damage: Statins can lead to muscle pain, weakness, and in rare cases, a serious condition of rapid muscle break down called rhabdomyolysis.
"Statin-associated muscle symptoms (SAMSs) vary considerably in frequency and severity, with a spectrum extending from myalgia with normal creatine kinase (CK) levels or asymptomatic hyperkalemia to potentially life-threatening rhabdomyolysis and necrotizing autoimmune myopathy."
Memory loss: The FDA warns that some patients may develop cognitive issues while taking statins. There is increased risk for Alzheimer’s and Transient Global Amnesia.
“FDA adds diabetes, memory loss warnings to statins” - Reuters, Feb 29, 2012
Increased diabetes risk: Statins have been associated with an increase in blood sugar levels and a higher risk of developing type 2 diabetes. Diabetes being one of the biggest risk factors for heart disease...
"FDA's review of the results from the Justification for the Use of Statins in Primary Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER) reported a 27% increase in investigator-reported diabetes mellitus in rosuvastatin-treated patients compared to placebo-treated patients."
Erectile dysfunction: Cholesterol forms the backbone of all steroid hormones, including testosterone. Reducing cholesterol reduces testosterone, and low T is good friends with ED.
"The systematic review procedure was applied successfully to collect evidence suggesting that both statins and fibrates may cause ED."
Mitochondrial damage: Your mitochondria are little gasoline statins inside each and every one of your cells. They provide the power. Statins have both direct and indirect effects on mitochondria which negatively impact their ability to supply energy and glucose to your body.
"Emerging evidence suggest that statins impair mitochondria, which is demonstrated by abnormal mitochondrial morphology, decreased oxidative phosphorylation capacity and yield, decreased mitochondrial membrane potential and activation of intrinsic apoptotic pathway."
In contrast to their potential harms, we believe statins have two slightly beneficial effects on the body: they lower inflammation and decrease the risk of clotting. Given that heart disease is one which involves both inflammation and clotting, this is interesting. These effects might explain why patients who have already had a heart attack seem to demonstrate slight benefit from taking these medications.
The Real Deal On Cholesterol
Look, cholesterol is important. We know this because every single solitary cell in your body makes it. Cholesterol is a key component of every cell membrane. Your brain is a great big ball of cholesterol. There are rare genetic disorders that can occur resulting in an inability to produce cholesterol. These babies don’t survive. Low cholesterol isn’t ‘good’ - often it’s bad. Low cholesterol is associated with shorter life expectancy, mood disorders like depression and suicidality, and low hormone levels,
Cholesterol is essential. You need cholesterol to make estrogen, testosterone, DHEA, synthesize vitamin D, build every single solitary cell membrane in your whole body. You make cholesterol for a reason - and it isn't to kill you from heart disease.
Bottom line is this: Cholesterol does not and cannot cause heart disease by itself.
Heart disease is an inflammatory disease that the liver is trying to repair. Cholesterol is sent to damaged arteries to repair them. It is insulin resistance, oxidation, and endothelial damage that result in cholesterol being found at the scene of the crime. That's why we find it there. It isn't causing the problem, it's there to help fix the problem.
You arrive home to find your house is on fire. You see the fire department is there. Did the firemen set the fire or are they there to put it out?
Is there a correlation between cholesterol and heart disease? Sure there is. But it is not at all straightforward, and clearly not causational. The conclusion that cholesterol simply causes heart disease is weak at best. There is an association between the two because of multiple other factors.
What Really Causes Heart Disease
I think I've demonstrated that cholesterol is not the defacto cause of heart disease. Here's the real story. Heart disease is a disease of the immune system. It is the result of inflammation and clotting. This increase in clotting and inflammation is largely the result of something called insulin resistance. Poor lifestyle choices, ultra processed foods, lack of exercise, and smoking contribute to this vascular inflammation. When the arteries serving the heart (and everything else) become inflamed, they become damaged. The liver attempts to heal this damage by sending out a repair crew of phospholipids, protein, and cholesterol. THAT is why we see changes in lipid levels in the setting of coronary artery disease.
Chronic inflammation due to insulin resistance
Endothelial damage
Oxidation of LDL cholesterol
Arterial plaque formation and progression
Most people have absolutely no idea that they are walking around with pre-diabetes, insulin resistance, or metabolic syndrome. These are the real killers.
If your cholesterol is high, but your fasting insulin and blood sugar are low, I don’t care.
If your cholesterol is high, but your insulin and blood sugar levels are high as well, we have a problem.
Statin medications absolutely, unequivocally lower cholesterol. If they have any cardiovascular benefit, however, it has nothing to do with their effects on lipids. Statins have two other mechanisms of action: they have anti-inflammatory properties and a slight blood thinning effect. I would liken their benefit to that of aspirin. Perhaps this explains the Framingham findings in patients with FH.
So I will concede that statins do have some benefit in some patients – benefit similar to that of aspirin.
The attack on total or LDL cholesterol is completely misguided. We have so many other biomarkers that are far better.
NMR CardioIQ
Fasting insulin
Hemoglobin A1c
Coronary calcium score
hsCRP
Homocysteine
Total cholesterol/HDL ratio
Triglyceride/HDL ratio
What can I do to lower my risk?
Lots. Start here:
Control your blood pressure (ideally <120/80)
Control your blood sugar (hemoglobin A1c should be <5)
Optimize your waist circumference (<40" in men, <35" in women)
Control your triglyceride levels (<100 mg/dL)
Optimize your HDL levels (>50 mg/dL)
Don’t eat ultra processed foods
No refined carbohydrates
Correct insulin resistance (fasting insulin <5)
Keep moving - but knock it off with the triathlons already
Manage Stress
Quit smoking
Supplements to improve immune system function and insulin sensitivity (omega-3 fatty acid, vitamin D, berberine, ubiquinol, polyphenols, fiber)
The 'lower the better' for total and LDL cholesterol dogma is over. Like most things in the health space, reducing risk for heart disease comes down to largely diet and lifestyle measures. I'll close on my data destroying campaign with this article published three months ago in the British Medical Journal. You'll see why there is obviously no industry funding here. This work was the result of a 22 year trial on 177,860 participants aged 50-89 without diabetes, not on statin therapy. Take us on out, gentlemen:
"Is LDL cholesterol associated with long-term mortality among primary prevention adults?
A retrospective cohort study from a large healthcare system."
Kevin E Kip, David Diamond, Suresh Mulukutla, Oscar C Marroquin - BMJ, March 18, 2024
Low LDL cholesterol linked to higher odds of dying from cardiovascular mortality.
LDL of 100 to 189 mg/dl had the lowest risk of long-term mortality.
High total cholesterol or high triglycerides to HDL ratio increased risk of heart attack.
Only a fraction of people with cardiovascular events have high cholesterol.
Conclusion
While statins have a well-documented effect on lowering cholesterol, the rest of the story leaves us in a bit of a quandary. We've established a few inconvenient truths here:
LDL cholesterol does not cause coronary disease
High cholesterol is protective against all cause mortality in older patient populations
Statins do not appreciably decrease cardiovascular risk
Outside of slight anti-clotting/anti-inflammatory properties, statins have an unfortunate side effect profile
The low fat, high carbohydrate diet increases risk for insulin resistance
Insulin resistance is the number one driver of atherosclerosis
Metabolic biomarkers like triglycerides, HDL, hemoglobin A1c, and fasting insulin are much better indicators of risk and of the real pathophysiology that drives heart disease
But that's just what the science shows.
Before making any medical decisions, you deserve fully informed consent. Don’t ever just blindly accept a prescription from your doctor and walk out the door. You want to understand what’s wrong, what your treatment options are, what are their risks and benefits. Ask questions, expect answers. Your doctor should have them or at least be willing to find them. If not, look for one who does. In the end, it’s you who makes the call in accordance with that you believe is best for your body given the best possible information.
Don't forget - you are the patient. It's your body. Us doctors over here? We work for you.
It's essential for both patients and healthcare providers to consider the bigger picture of disease prevention. I always go back to this mantra in my head:
The further away we get from nature, the more we fuck it up.
I don't believe statins are going to save us from heart disease. In the end, keeping those heart vessels open is about way more than cholesterol. It’s about nurturing the entire system – from the food we eat, to the way we move, to the time we dedicate to sleep, to the way we manage our perceived stress. Our system operates as one cohesive network of energy. We need to optimize each and every part of it to ensure our heart has the best chance to thrive.
Take good care of your heart. It's the only one you got: )
B-roll...
“Saturated fats are not associated with all-cause mortality, CVD, CHD, ischemic stroke, or type 2 diabetes” - DeSauza, 2015
“Paradoxically, MCE participants who had greater reduction in serum cholesterol had a higher rather than a lower risk of death. Collective findings from randomized controlled trials do not provide support for the central diet-heart tenet that the serum cholesterol lowering effects of replacing saturated fat with linoleic acid translate to lower risk of coronary heart disease or death” - Ramsden, 2016
“Available evidence from adequately controlled randomized controlled trials suggest replacing SFA with mostly n-6 PUFA is unlikely to reduce CHD events, CHD mortality or total mortality.” -Hamley, 2017
“Hiding unhealthy heart outcomes in a low-fat diet trial: the Women's Health Initiative Randomized Controlled Dietary Modification Trial finds that postmenopausal women with established coronary heart disease were at increased risk of an adverse outcome if they consumed a low-fat 'heart-healthy' diet” - Noakes, 2021
“Statin treatment results in a surprisingly small average gain (5 days) in overall survival within the trials' running time. For patients whose life expectancy is limited or who have adverse effects of treatment, withholding statin therapy should be considered.” - Kristensen, 2015
Resources
Many adults eligible for statins for heart disease prevention are not taking them, 2023
Lack of an association or an inverse association between low-density-lipoprotein cholesterol and mortality in the elderly: a systematic review, 2016
Sugar Industry and Coronary Heart Disease Research: A Historical Analysis of Internal Industry Documents, 2016
Intake of saturated and trans unsaturated fatty acids and risk of all cause mortality, cardiovascular disease, and type 2 diabetes: systematic review and meta-analysis of observational studies, 2015
Re-evaluation of the traditional diet-heart hypothesis: analysis of recovered data from Minnesota Coronary Experiment (1968-73), 2016
The effect of replacing saturated fat with mostly n-6 polyunsaturated fat on coronary heart disease: a meta-analysis of randomized controlled trials, 2017
Hiding unhealthy heart outcomes in a low-fat diet trial: the Women's Health Initiative Randomized Controlled Dietary Modification Trial finds that postmenopausal women with established coronary heart disease were at increased risk of an adverse outcome if they consumed a low-fat 'heart-healthy' diet, 2021
The effect of statins on average survival in randomized trials, an analysis of end point postponement, 2015
Most heart attack patients' cholesterol levels did not indicate cardiac risk, 2009
FDA adds diabetes, memory loss warnings to statins, 2012
Statins and risk of incident diabetes: a collaborative meta-analysis of randomized statin trials
HMG-CoA Reductase Inhibitors (Statins) and their Drug Interactions Involving CYP Enzymes, P-glycoprotein and OATP Transporters-An Overview, 2021
Statins, myalgia, and rhabdomyolysis, 2020
Statins and mitochondria, 2016
Lipitor, Thief of Memory: Statin Drugs and the Misguided War on Cholesterol, 2004
FDA Drug Safety Communication: Important safety label changes to cholesterol-lowering statin drugs, 2016
Do lipid-lowering drugs cause erectile dysfunction? A systematic review, 2002
Historical Review of the Use of Relative Risk Statistics in the Portrayal of the Purported Hazards of High LDL Cholesterol and the Benefits of Lipid-Lowering Therapy, 2023
Is LDL cholesterol associated with long-term mortality among primary prevention adults? A retrospective cohort study from a large healthcare system, 2024
LDL-C does not cause cardiovascular disease: a comprehensive review of the current literature, 2021