The Cholesterol Conundrum

For the last sixty years, we have all been listening to the beating of the cholesterol is bad for you drum. But is it really true? Is cholesterol actually bad for you? What's the evidence?


The truth is that this is a very complex story, and the evidence is all over the map. Everyone is confused, and believe me, that probably includes your doctor.


Broad studies proven to be wrong

The problem with the statement that cholesterol is bad is that our advice is guided by a set of very broad brush studies that look at large populations but need help to apply to the individual. Furthermore, an increasing number of studies combining data from many different studies (systematic reviews with meta-analysis) show that the conclusions drawn from landmark studies like the famous Framingham study are wrong.


And it's not only the high cholesterol is bad story, but also the idea that we should all be on statins. Statins, a group of cholesterol-lowering drugs, are some of the most prescribed medications on the planet. Yet the data supporting their effectiveness is very poor, and the conclusions between many studies are inconsistent. In fact, currently if there are any conclusions to be drawn from meta-analysis, they are that, for most of us, they have minimal effect on mortality!

The challenge is that because it has now become a fact that high cholesterol is bad for you, trying to get any traction with the idea that it simply may not be true is almost impossible. Mainstream medicine has decided that it is proven, so even discussing alternative ideas puts one in the world of the quacks.

But the truth of the matter is that the science does not support the evidence backing the current position that elevated cholesterol levels!

Flaws in methodology

First, a quick look at an essential concept. There are two types of intervention in medicine. The first is primary prevention. These are those things we suggest individuals who are not ill do to prevent an illness. The second type is secondary intervention, the things we do after you have become sick, ill or have undergone an event. So primary interventions are aimed at individuals who are seemingly well and have not had, say, a heart attack, whilst secondary interventions are those that we pursue to prevent a second heart attack after you have had one, or perhaps a second stroke after an initial one.


It seems logical and indeed common sense to suggest and believe that a secondary intervention which has been shown to work will work as a primary intervention. But as it happens, it is not valid. A group of ill patients that have already selected themselves out of the general population by having a heart attack or stroke do seem to benefit from being on a statin. Still, as I have stated, they are already different from the general population because they had an event and, as such, may have other predisposing factors.


The data seems clear if you have had a heart attack or stroke and we put you onto a statin drug that lowers your cholesterol, the risk of having a second heart attack or stroke is significantly reduced.

But you cannot say that if you put many people who have not had either a heart attack or stroke onto the same medication, you will prevent them from having one, and indeed this is the case.


The famous Framingham study and Key's Seven country study of 13,000 individuals set the whole cholesterol story in motion in the 1960s. However, a recent analysis of these studies demonstrates flaws in methodology. In the case of the Keys study, he conveniently left out France because the French data did not support his theory despite a relatively high fat diet. Cherry picking at its worst.


But high cholesterol alone is not enough to cause problems. Many people have high cholesterol and never have blood vessel disease, a heart attack or a stroke. Conversely, many have normal or below-average cholesterol, have blood vessel disease, and experience a heart attack or stroke.


Dietary restrictions regarding fat have never been proven to change your risk! Indeed they led to the crazy era of hydrogenated vegetable oils, aka margarine, which is very bad for your health.


So what's the rub? It's simple, the story is much more complicated. Measuring cholesterol is a tiny part of the story.


If the issue is not fat, then what is the culprit? What does cause heart disease and strokes? For anyone who follows my blogs or has read my book, the answer is easy.

Sugar is the culprit, not fat. A fact that has been known for the very same 60 years. A fact carefully buried by the sugar and food manufacturing industries.

So enjoy your eggs and the butter on your toast. Enjoy some cheese and fat in your diet, making it more flavorful and richer. Be French, or Italian or Spanish in your cuisine. Cut the carbs and not the fat.


Finally, and yes, I know that it is a case study of one, consider following my father's advice. When I inquired about his cholesterol level to see if my elevated levels were familial, he replied, "yes, I did let my GP test it once. It was quite high". And what did you do about it, I asked? He laughed and said, "I never let him measure it again". My father, who retired after a distinguished medical career ending as a professor emeritus of medicine, died at the age of 91. Indeed I suspect if he had not smoked until 80 and ruined his lungs, he would have made it to 100 and above.


Do I worry about my cholesterol levels? Short answer no. I have much better things to do. Would I let a doctor put me on a statin? Short answer no. But that's a personal choice, and I am perhaps overstating my opinion. But I believe, along with an increasing number of other professionals and the research, that we need to take a long hard look at the cholesterol story and consider very carefully whether we have gone down the wrong road. It will not be the first time in medical history.


My book explains what you need to do.

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