Wednesday 31 July 2013

High cholesterol is good when you are older

The obsession of cholesterol during the past half-century has been a triumph of dogma over evidence. There are many aspects to this but one simple but little-known finding is that in people over the age of 60 those with the highest cholesterol level in the blood have the longest survival. It is this age-group that the incidence of death and other cardiac events occur.

The evidence for this comes from three sources.

The first was an investigation of a group of women aged 60 years or more who were living in a nursing home in Paris.  They were followed up for five years and it was quite clear that those with the lowest serum cholesterol had the worst survival. The death rate in those with a serum cholesterol of 4mmol/L was 5.2 times the death rate in those with a serum cholesterol of 7mmol/L. If you are a woman and above the age of 60, do you really want to have a low cholesterol?

The graph shows the death rate per year based on blood (serum) levels of cholesterol. As the subjects become older the death rate inevitably increases, but more so in those with the lowest cholesterol levels.

The evangelists of the diet-cholesterol-heart hypothesis would not like this evidence, and it effectively has been suppressed - no-one seems to know about it.  They might argue that the reason for the high death rate in those women with low serum cholesterol is that they were dying of cancer, but this possibility was eliminated at the start of the study and during the five-year follow-up during which 53 of the 92 women died, autopsy revealed cancer to be the cause of death in only one.

Another interesting result was that at the onset of the study the average serum cholesterol of women known to have coronary heart disease was 5.9mmol/L. The corresponding cholesterol was higher at 6.3mmol/L in those who were not known to have coronary heart disease. Again we see an advantage of a high cholesterol.

A second study of the elderly was undertaken in New Haven, Connecticut, a community-based study of 997 persons aged more than 70 years with follow-up for four years. The coronary heart disease mortality was once again that a higher level of serum cholesterol was associated with a lower death rate from coronary heart disease.

This graph shows the death rate but at a single point after four years. For men and women the lowest death was highest in those with the lowest cholesterol, less than 5.2, and lowest in those with the highest cholesterol, greater than 6.2.

A similar result came from the Honolulu Heart Program, a study of 3572 men aged 71 to 93 years. Survival over a period of six years was expressed in four groups (quartiles) based on blood cholesterol levels. Those with lowest serum cholesterol level had the worst survival, that is the highest mortality. The results were unchanged when first-year deaths were discounted, the purpose of this being to avoid the possible effect of low serum cholesterol and death being due to present but undiagnosed cancer.

In this graph we see the percentage surviving. It was clearly lowest in the quartile with the lowest cholesterol.

“A generally held belief is that cholesterol concentrations should be kept low to lessen the risk of cardiovascular disease. However, studies of the relation between serum cholesterol and all-cause mortality in elderly people have shown contrasting results….Only the group with a low cholesterol concentration had a significant association with mortality…. We have been unable explain our results. These data cast doubt on the scientific justification for lowering the cholesterol to very low concentrations in elderly people.”

The conclusion appears to have been suppressed in the interest of those who benefit from the diet-heart-cholesterol hypothesis - pharmaceutical companies, food manufacturers and the academic departments which derive their funding from them.

There have been no studies published that show anything other than this detrimental effect of a low cholesterol level above the age of 60. To see the truth in younger age-groups you will need to wait for another post shortly.

Tuesday 30 July 2013

The best time for conception - maximum vitamin D

It is possible that some couples work out carefully the moment when they should conceive their offspring but the moment is, I would imagine, usually spontaneous. Hence birthdays are fairly evenly spread throughout the year. But perhaps we should more carefully about conception as it is clear that babies born in the late autumn and early winter have significant health advantages. This was known to pre-Christian pagan people, hence the spring festival of Easter is the name derived from Oestre the pagan goddess of fertility. Maypole dancing is another spring fertility rite.

The point is that pregnancy during the summer means that the developing baby receives across the placenta the maximum quantity of vitamin D, much more than if its gestation were during the winter months. Vitamin D is very important for the developing baby, the benefits extending into adult life.

The main benefits are biological. An autumn-born baby has a reduced risk of developing diabetes in childhood and multiple sclerosis as an adult.

Schizophrenia is more likely to occur later in life in a baby born in the spring and summer. This is also true in Australia, the disadvantage months there being October–December. There is no variation in Singapore, which is on the equator.

A little girl born in the autumn will have about 50 years later, on average a later menopause than if born in the spring, and a late menopause is biologically a good thing. Sporting champions tend to have on average an autumn birth.

Then there is educational achievement, but here we find a confounding factor. The school year in Europe starts in September. This means that a child with a birthday in October-November will have age advantage over a child born in July–August. At the beginning of schooling this gives almost a full year advantage, almost 20% of lifespan at that age. After several years of school the age advantage will be lost, but the vitamin D advantage will continue.

For further details see eBook "What Vitamin D can do for your Baby", price 99p

Monday 29 July 2013

Statins are no longer worthwhile - minimum £1.46M to delay one death

Statin drugs have been used on a wide scale since the early 1990s, following the success of clinical trials initiated a decade earlier. In the primary prevention of deaths from coronary heart disease (CHD) the subjects do not have clinically obvious disease - no angina, no previous myocardial infarction (MI, "heart attack"). The definitive study was in the West of Scotland, men aged 55–65 with serum cholesterol >6.5, the subjects having the world's highest incidence of CHD deaths at 840 per 100,000 per year.

This corresponds to a mortality rate of 4.2% in the untreated subjects after the five-year duration of the study. In the subjects randomly assigned to pravastatin the mortality rate was 3.1%. This was an absolute reduction of 1.1% (not very impressive) and a proportionate reduction of 25% (this spin is used in publicity, much more impressive!). What it means in practice is that for every 100 such men taking pravastatin for five years one will not die, 4.2-3.1 (this is sometimes called the NNT, number needed to treat to achieve one endpoint).

Since then, during a period of about 30 years since the onset of the West of Scotland study (called WOSCOPS) several other studies appeared and overall the proportionate mortality reduction was about 20%. But also during this time the death rate from CHD has dropped enormously, and it must be acknowledged for reasons that are not clear.

Currently in the UK and western Europe in general, the death rate from CHD is about and probably now less than 20 per 100,000 per year. This is 0.02% per year or 0.1% at five years, very different from the time of the West of Scotland study. The proportionate reduction would be the same, 20–25% but now we see the absolute reduction being from 0.1% to 0.08%. This means that we must now give a statin to about 4,000 men aged 55–65 for five years to prevent one death. Strictly speaking this applies to men in the West of Scotland. With a lower disease incidence in the south-east of England, we would need to give statins to about 8,000 men to prevent the one death..

The UK price of generic statins is about £0.1 per day, which is a total of £1.46M per year to delay one death every five years in the West of Scotland. Is this good value for money? The propriety price is about £1 per day, ten times greater.

The UK price of generic statins is about £0.1 per day, which is a total of £1.46M per year to delay one death very five years. Is this good value for money? The propriety price is about £1 per day, ten times greater.

In the west of Scotland at the time of the study the death rate from CHD of men aged 35–44 was one tenth that of the older men studied. This means that today we would need to give statins to about 40,000 younger men to prevent one death every five years (annual cost = £14.6M), and for women more than twice this.

The general advice from NICE in the UK is that about £20,000–30,000 would be an appropriate expenditure to achieve one year of good quality life. At this return we would expect the young man whose life is prolonged to live for another 500 active years. NICE has not made an up-to-date judgment on statin therapy.

The era of statin therapy must now draw to an end, just as the epidemic of CHD has almost come to an end. 

It is unlikely that this information will officially enter the public domain.