A recent study from the New England Journal of Medicine showed that the death rate from heart disease has fallen by over 50% during the period from 1980-2000. The authors concluded that the dramatic drop can be equally attributed to medical advancements in treatment and better management of heart disease risk factors, respectively.
While this large decline is great news, the heart disease situation remains more mixed than it first appears. Of the roughly 340,000 deaths avoided since 1980, only about 82,000, or 24%, can be attributed to cholesterol management (using the now standard IMPACT statistical model (pdf)), despite the relentless National Cholesterol Education Program that was begun in 1985 at the behest of the NHLBI. More worrisome, another large study states that 70% of the decline in deaths came in people that still have heart disease. Other doctors also point out that any drop in heart disease deaths does not mean there is a drop in new cases of heart disease.
Translation: we still have a lot of work to do.
Closer to the “Truth”
The perception of reality can mean different things to different people. To some, those numbers above mark an unbelievable success – a triumph of science over nature. To other researchers, those same numbers reveal troubling contradictions about the actual causes of the disease.
And that’s where the questions started for Uffe Ravnskov, MD.
Does cholesterol cause heart disease or do they merely have an association with each other? How do HDL and LDL relate? What role do high fat foods really play? What if all of those studies about cholesterol were wrong?
Dr. Ravnskov, a founding member of the International Network of Cholesterol Skeptics, takes all those positions and goes even further in his book, “The Cholesterol Myths” published by NewTrends Publishing. One part detective mystery, one part conspiracy theory, Ravnskov tears through piles of medical studies digging towards the “truth.” His thesis is rather simple: cholesterol does not cause heart disease. We put emphasis on the word cause for good reason: Ravnskov’s entire argument hangs on tearing apart the correlation-versus-causation dichotomy. For the most part, he succeeds but at a cost to his text.
A Myth Unraveled?
Ravnskov lays out his attack into a series of myths he wants to dispel for readers. Some myths are bold like “High-fat foods cause heart disease” while others are down right incendiary, especially when he claims to bust the myth that “the cholesterol campaign is based on good science.” Putting down the entire research community is good way to get attention and attention he received. This book was publicly burned on Finnish television upon publication. So much for reasoned debate.
Once you get past the burnings, you will see this work is undeniably strong on laying out a solid foundation in science for those who aren’t so inclined. Ravnskov meticulously breaks down the correlation-versus-causation argument in a way that lends itself to being understood. You will definitely understand the difference between the two, even if you only manage to make it twenty pages into the text.
Cholesterol Myths really shines when it sticks to deeply interpreting studies findings within the scientific paradigm Ravnskov sets up. His work goes to great lengths to uncover shoddy science in some of the landmark cholesterol-heart disease studies. In some cases, Ravnskov uncovers pure gold for his readers. Case in point, one of Ravnskov’s first myths deals with a study examining the Masai people, an indigenous people who did not consume a western diet, for a diet-heart disease connection. From Page 36 [emphasis added my own]:
“Professor Mann studied a much greater number of hearts and aortas from Masai individuals of all ages and found that the coronary vessels of the Masai were just as atherosclerotic as those of US citizens, perhaps even moreso. But severe sclerotic changes [in Masai], so-called raise lesions, were rare; the sclerotic changes in the Masai were situated inside the vessel walls, leaving the inner surface of the vessels smooth. And in the 50 hearts he studied there was no evidence that myocardial infarction has occurred in any of them.”
Moments like this really let Ravnskov’s investigatory skills shine; he masterfully dissects the cannon of cholesterol research like few other authors we have ever read. And during these infrequent moments in the text, you can see what this book could really be – a true guide to the future of heart disease research – but ultimately that is not this text.
At its best, Cholesterol Myths is a scathing review of literature instead of a gateway to where this literature should guide the national discussion. Instead of using his knowledge to lead us into a more beneficial discussion on heart disease, Ravnskov exhausts his mental energy on tearing down cholesterol. At times, I found myself hoping he would direct that massive brain of his towards constructing a new paradigm in which we could view heart disease. Don’t hold your breath for that one.
Instead, Ravnskov frequently leaves the reader to infer ulterior motives about each study he rips into, all without ever saying it explicitly, a sort of intellectual dishonesty that I did not appreciate as a reader. Additionally, the book’s nine myth sections overlap and repeat each other often. Invariably, he finds problems with about every major study that shows a relationship between cholesterol and heart disease.
From the beginnings of Myth 6, you can see a familiar line of reasoning repeated throughout the book:
“It is extremely difficult to design even the initial steps of a scientifically acceptable trial. The standards of science are high, however. In fact, they are so high that, even if we manage to select a test group and a control group with almost identical risk factors for heart disease, we must remember that almost identical and absolutely identical are not the same thing, and that we will never know all the factors that may, or may not, contribute to the development of the disease in these people.”
While he is technically correct, studies that contain a control group mitigate these confounding factors. No study will ever be perfect but we can’t use that as an excuse to dismiss significant research findings completely. Ravnskov is wise to highlight study oversights but that does little to forward the heart disease dialogue. Arguments like the above really dog this book in our opinion – and they appear far too often.
Where we go from here
Simply addressing heart disease as a cholesterol problem has not brought the world any closer to eradicating it. Ravnskov’s arguments about the sometimes flimsy science surrounding cholesterol theory are an extremely valuable addition to this discussion. His commendable goal of educating the public on the many problems with the singular cholesterol argument was accomplished ten times over in this volume. Even a casual reader of this work comes away from it with a better understanding of the scientific method and heart disease in general – and that is a welcome development.
Still, Cholesterol Myths misses the larger target in our opinion. After destroying cholesterol in his book, Ravnskov does not forward any additional theories on the causes of heart disease. This may not seem like much of a problem but it is in the scientific world. The best theory ‘wins’ out in science because it can explain the most behavior present in a given situation; it need not explain all of the behavior.
With a chronic disease like heart disease, it has already been well established in scientific literature that many factors, like stress and inactivity, contribute. Only one of these factors, cholesterol, is ever considered in this text – and in that way this book is attempting to topple a myth that simply does not exist anymore. Even, more, Ravnskov may thoroughly debunk cholesterol as a singular cause of heart disease but he freely admits there is a correlation between the two.
From Myth 2 in his work:
“Table 2B shows, in accordance with many other studies, that more heart attacks occurred among those with the highest cholesterol levels. The differences were not impressive, however, considering that the figures were not adjusted for anything but age….”
Major studies controlling for various factors show somewhere between 10-33% of the total heart disease death rate decline can be attributed to cholesterol reduction, depending on the country in question. While this doesn’t prove cholesterol singularly causes heart disease, it definitely shows cholesterol is somehow involved.
And thats just the problem for us. These conflicting facts often leave us in the lurch during Ravnskov’s elaborate presentations, knowing cholesterol plays some role with heart disease but not truly being the cause. Admittedly, uncovering the cause of heart disease may be beyond the scope of his book but Ravnskov’s omission of a more comprehensive theory looms largely over this book.
Overall, this book is a necessary addition in the discussion about heart disease. Ravnskov’s book should be read by anyone with a critical eye and a curiosity about the origins of heart disease. But it could have been so much more.