Sunday 16 August 2015

Cholesterol is not a poison - official

After more than half a century of us being brainwashed the truth is starting to emerge. Up to now, cholesterol  has been viewed as a poison. It is a chemical that if taken by mouth allegedly causes disease (ill-effects) in all people and it is dose-dependent - the more taken and the higher the blood level, the greater the detrimental effect. The other effect of a chemical is an allergic reaction, which affects few people and is not dose dependent (small amounts can cause big effects). 

We have been told constantly that "Cholesterol is Bad". Where did this misinformation come from? Does it make sense that food that humankind has been eating for centuries or millennia suddenly became responsible for an epidemic of heart disease that emerged in about 1924, reached it peak in about 1970 and which has now declined by more than 95%? 

The diet-cholesterol-heart story has dominated our lives and our eating habits. The food industry has had major problems in respect of milk production in particular. There have been winners - the manufacturers of non-butter spreads and other low cholesterol and low fat foods. There is an obvious need to control obesity but this is about the quantity of food not its constituents.

Fortunately most people seem to have paid little attention to the diet-cholesterol story. I am intrigued to watch and enjoy the cooking programmes on the television, especially BBC Saturday Kitchen on a cold wet winter weekend. There is a major Italian influence, as a result of which the recipes generally include lots of eggs, butter, and double cream, with a generous pinch of salt. Our diet police must have been most unhappy with this programme, but now things have all changed.

A major influence on out diet was the Seven Countries Study, by Ancel Keys. The conclusion was probably written before the study was performed and was independent of the findings. It formed a major basis of the diet-heart-cholesterol hypothesis. Since then many studies have shown an absence of effect of cholesterol and fat on blood cholesterol levels and our health, but much of this evidence has effectively been ignored or suppressed.

A diet study from Canada in the British Medical Journal on August 15th 2015. The conclusion stated: "There was no convincing lack of association between saturated fat intake and CHD [coronary heart disease] mortality." The use of the expression "lack of" is an interesting spin - presenting bad news as somehow good. The statement could and should have read: "There was no convincing association between saturated fat intake and CHD mortality." 

But now the evidence of the failure of the diet-cholesterol-heart hypothesis is overwhelming and it can no longer be suppressed or ignored by the custodians of public diet.

The US Dietary Guidelines Advisory Committee has just released the latest edition of Dietary Guidelines for Americans. The important and surprising messages are :

  • cholesterol is no longer regarded as a "nutrition of concern";
  • there is no limit on fat consumption (apart from controlling weight gain).

And so we can now eat with a clear conscience the foods that we (or at least I) enjoy so much - full English breakfast, Ham and Eggs, Duck breast, Eggs Benedict, Sausage & chips fries, and more. I confess however that I eat these infrequently.

And do not forget that blood level of cholesterol is not a good predictor of heart disease, and above the age of 60 years a high level is a good thing. This information is suppressed but perhaps it will come into the public arena in the way that the misinformation of dietary cholesterol has now emerged.

Wednesday 5 August 2015

Sir Patrick Leigh Fermor (2)

Sir Patrick Leigh Fermor DSO OBE, 1915-2011

Paddy, as he was known to his friends, was a remarkable character, who turned out to be not only an adventurer and a war hero but also one of the best English travel writers of the 20th century.

During his childhood his parents were in India, where his father was a government geologist. He was cared for by his Nanny, who gave him a great deal of freedom and adventure in a rural environment. The restrictions of life came as a great shock to him when at the age of five he went to boarding school, subsequently to schools for “difficult children”.  

Life throughout his schooling was not happy. He was clearly disruptive, a difficult child. He had no ability for anything mathematical, but he loved history, geography and languages.

When at the age of eighteen, the time came for him to leave school (he was in fact asked or commanded to leave), he decided not to go to university but to walk to Constantinople, Istanbul as it is today. He enrolled himself therefore into the university of life, and what he learned was amazing.

He left London in December 1933, taking the ferry to Hook of Holland, close to Rotterdam. From then on, and initially in heavy snow, he was on his feet and the almost two-year adventure had begun. He kept notes of his journey but it was twenty years later that he wrote his remarkable books about his journey.

The first book is entitled “A Time of Gifts”. It describes his journey from Rotterdam through the Netherlands and into German, along the Rhine, over the great European watershed to the Danube and through Bavaria, Austria, and Czechoslovakia (as it was then) to the Hungarian border. During the journey he learns the languages, the history, and the physical and social geographies of the lands that he crossed.

The second book of the series isBetween the Woods and the Water”. He describes his journey through Hungary and into Romania, describing his meetings with many people from various ethnic groups.

The third book had not been completed at the time of his death, but copious notes were available. The book was finally completed and published in 2013. It is entitled The Broken Road. It continues his journey through Romania and then into Bulgaria. He reached Constantinople but then returned to Greece. 

The book ends with his journey around Mount Athos, visiting many of its ancient monasteries. He decided to stay and to live in his beloved Greece with all its history and traditions.

Patrick Leigh Fermor wrote several other books of his life in Greece, for example “Mani”, about the barely accessible peninsula at the south of the Peloponnese where he made his home.

During the Second World War he fought as a British officer with the Greek resistance. He parachuted into Crete, where he joined the resistance against the Nazi occupation. He and Captain W Stanley Moss, supported by local partisans, captured General Heinrich Kreipe, commander of the Nazi army of occupation. 

They held him for three weeks moving at night to escape intense searches by the German army in Crete. They managed to smuggle him out of Crete to a boat that took him to Egypt. This adventure was described in the book (by Moss) and film "Ill met by Moonlight" (1957).

Leigh Fermor was in a way a sort of James Bond character and he certainly became a great hero among the Greeks.

When he ultimately realised that he was dying he decided to return to England to say “Goodbye” to his friends. He died the day after his arrival in England, at the age of 96.

I would like to give you an extract of his journey after he arrived in Greece, from the third book, “The Broken Road”. The setting is a monastery on Mount Athos, Salonika.

18th February (1935), Esphigmenos. I got up rather earlier than usual today, soon after my morning tea, of which Father Damascene gave me two cups, and putting on my soft Bulgarian moccasins, as it was a glorious, sunny day, prepared to spend the morning up on the hillside. Delving in the bottom of my rucksack for the A Shropshire Lad my mother gave me last birthday, I found an envelope full of Capstan Navy Cut. This was a real find, and getting out my best  pipe (unsmoked for nearly a month) I stuffed it full and set it alight. I’m sure the good God never breathed incense with more delight than I felt then. Pipe tobacco, after a month’s cigarette smoking, is an ecstasy too deep for words.”

The details of his journey are remarkable, but I would like to draw attention to his discovery of a supply of tobacco in his rucksack, and then his thoughts on smoking.

A current Post describes the observation that if you are going to smoke (I emphasise that I do not smoke) then the place to live is Greece.

The sun appears to protect against the damaging effects of smoking. It seemed to work for Patrick Leigh Fermor as he remained active and healthy until his death at the age of 96 years.

Greece - smoking and the sun (2)

At one time life was simple and we knew all the answers. The cause of disease (and everything else) was God, often acting in response to the sins of mankind. The public health officials of the time might have advised “less sin”, but either the population ignored the advice or the concept was flawed.

The most important discovery of the Age of Enlightenment was “ignorance”, the realisation that divine intervention was at the very best unreliable, and probably non-existent. We were therefore ignorant of the causes of disease.

Yuval Noah Harari, in his remarkable book “Sapiens - a brief history of humankind” proposes that the unique attribute of Homo sapiens, the present humankind, is our ability to create abstract ideas, to create fictions. Our many gods are clear examples of this. Fictions are our attempt to explain the world as we experience it. We use fictions to try to make sense of the diseases that afflict us. Often these indicate the blaming of the victims for the errors of their ways, eating the wrong foods, not taking sufficient exercise, or, the greatest sin of all, smoking.

In the absence of divine activity we must search for physical explanations for diseases. We can classify inherited disorders, which can be genetic (from the moment of conception) and congenital (abnormalities of our construction), and both of these in the past have been ascribed to divine retribution for the sins of the parents. Disease acquired after birth can be due to environmental factors, which can be physical (injury, heat, cold), chemical (poisons meaning too much, or deficiencies meaning too little), or biological (a wide variety of micro-organisms).

The elusive nature of “proof” is described and advanced by “Hill’s Criteria”, in an associated Post.

Science starts with observation. We look for clues to give us a way to construct a fiction of causation, called a theory or hypothesis, or a paradigm when it receives general acceptance. But fictions are not absolute truths and fictions change with increasing knowledge.

Causation is complex. For example we have seen that although we accept that cigarettesmoking is the major cause of lung cancer, the fact that only 10% of heavy smokers die from lung cancer indicates that other factors must be considered. These can be viewed as “susceptibility factors”, or perhaps “protective factors”. We can regard disease as the result of interaction between “the cause” together with susceptibility or protective factors, which might be genetic or environmental.

Clues to the identification of susceptibility and protective factors, and indirectly to causation, can be gained from comparing disease incidence in different populations, that is the geography of disease. This is an important dimension of epidemiology. An example is the “Greek paradox”.

I have been warned that data from Greece may not be entirely reliable as it is a country with an unusually well-developed culture of fiction. However WHO data that includes Greece is the best data that we have and we cannot ignore it.

Greece apparently has the highest prevalence of cigarette smoking in Western Europe, as we can see in Table 1. (cigarette smoking has a higher prevalence in the former Soviet countries in Eastern Europe)

Figure 1: percentage of adults who smoke

However Greece has within Europe the lowest age-standardised death rate from coronary heart disease (CHD). The paradox is that cigarette smoking is considered to be a major causative factor of CHD. Where there is a high prevalence of cigarette smoking we expect to find a high death rate from CHD, but not so in Greece. In Table 2 we see age adjusted death rates in men from myocardial infarction (data from WHO 1986).

Figure 2: age standardised death rates from myocardial infarction

Why is it that cigarette smoking in Greece does not cause the high incidence of premature death from CHD that it does in other countries?

“The Seven Countries Study” written Ancel Keys has been the subject of a previous Post. Although methodology was far from perfect and conclusions were not very objective, the study provides a great deal of data. It was very influential in its false conclusion that animal fats cause CHD, and this led to inappropriate diet manipulation over a period of 50 years, continuing to present time.

The study recorded CHD death rates in population samples in some countries within western and central Europe. From the data presented we are able to see that as expected the risk of a man dying from CHD increases with the number of cigarettes smoked. This is obvious if we look at countries in Northern Europe. 

Figure 3: CHD death rates and smoking - northern Europe

The slope of the graph-line rises steeply, indicating that as the number of cigarettes smoked increases, the CHD death rate increases substantially.

However the slope of the graph-line is different in what was then Yugoslavia, mainly Serbia (study population from Belgrade). In this more central country of Europe, the graph-line once again shows an increasing incidence of CHD death with an increasing number of cigarettes smoked, but the graph-line is not as steep.

Figure 4: CHD death rates - northern and central Europe

This indicates that the damaging effects of smoking in Serbia are not as great as in the northern countries.

If we now look at Greece and Italy, countries in the south of Europe we see a graph-line that is almost flat.

Figure 5: CHD death rates and smoking in Europe

This indicates that the risk of CHD death at the age in the study is very low in those who do not smoke, and this is what we expect. However the risk increases only marginally in those who smoke heavily.

What this means is that the risk of a heavy smoker dying from CHD increases dramatically as we move north through Europe. If we look at the low or no cigarette smoking rates in the three European regions we see little difference. If however we look at the heavy smoking group we see a major difference.

It appears to be fairly safe someone in Greece to smoke heavily but it is very dangerous for someone in the northern countries of Europe.

But this feature of Greece and Southern European countries is seen in more diseases than CHD. There is a similar observation of the incidence of breast cancer and colon cancer having a diminishing incidence in the south of Europe compared to the north.

Figure 6: cancer rates and latitude in Europe

The first observation of a latitude effect of cancer incidence was in North America.

Figure 7: Cancer and latitude in Americas

Death rates from cancer increase in the northern parts compared to the southern parts.

The obvious and most simple difference between places closer compared to more distant from the equator is the climate, and in particular the different intensity of the sun.

The observations of cancer death rates and the effect of cigarette smoking on CHD death supports the proposal that exposure to the sun (avoiding severe sunburn) is a great advantage to our health, and reduces the risk of damage from cigarettes.

There is evidence of a help from vitamin D and the sun in thosewho are diagnosed with lung cancer, in an associated Post.

If someone wishes to enjoy good health and a long life but nevertheless wishes to smoke, then it is advisable to live in Greece - see Post Sir Patrick Leigh Fermor (died aged 93).

Lung cancer and the benefit of the Sun (2)

We try to understand the world around us. This is the purpose of science, and the scientific process starts with simple and then carefully controlled observation. Experimentation is the final phase of the process, but this is not always possible due to a variety of constraints. We have looked at Hill’s criteria of proof, but observation is of great importance.

We all know as the result of careful observation that lung cancer isusually caused by cigarette smoking.  

People who smoke heavily have, after thirty years, a higher death rate from lung cancer than those who smoke few cigarettes or who do not smoke at all. About 10 % of heavy smokers will die from lung cancer, but it is exceptionally rare in non-smokers. There is an intermediate death rate in moderate smokers.

As only 10% of heavy smokers die from lung cancer, there must be co-factors. There must be one or more reasons why these 10% are subject to the bad luck of lung cancer whereas the majority of heavy smokers have managed to avoid this cause of death.

A reason why someone does not die from one disease is that he or she dies from something else earlier, perhaps warfare or childbirth. Although dying from something else might be a factor in protecting 90% of heavy smokers from dying from lung cancer, it is not just this. 

Coronary heart disease (CHD) is a major cause of death associated with cigarette smoking. We have also seen in a previous post that at the time of the study 20% of people died as a result of CHD, irrespective of whether they smoked or not. But cigarette smoking brings forward death from CHD by about 10 years. The death rate at the age of fifty years is twice as high in heavy smokers as in non-smokers, but cigarette smoking does not increase the lifetime CHD death risk.

Greece appears to be a location in which the population is somehow protected from the adverse effects of smoking. The gradient of increasing smoking related deaths as we move from southern Europe to northern Europe suggests that this might be an effect of the climate. The suspicion from this observation is that the sun might be protective, and there are many other examples of this.

Is there any other observation that the sun might be protective against lung cancer? The answer is "Yes". 

Dr AG Kargar of Basle recently reviewed 12 observational studies that have investigated people with lung cancer and compared them to controls without lung cancer. The objective was to review the relationship between lung cancer and vitamin D status, judged by either intake or blood levels. The higher the blood levels of vitamin D, the lower the risk of death from lung cancer (standardised for number of cigarettes smoked and duration of smoking).

Figure 1: Lung cancer risk and vitamin D status

The result was that the greater the vitamin D status, the less was the risk of lung cancer. We can see this in Figure 1. In column 2 the risk of lung cancer in people with the lowest blood level of vitamin D is standardised as 1. Those with the highest blood levels of vitamin D (column 1) have a lower relative risk of lung cancer at 0.84. We see then same when we look at the dietary intake of vitamin D. The risk of lung cancer is lower in those with high intake (column 3) compared to those with the lowest intake of vitamin D (column 4).

The author suggests that: “Further studies are needed to investigate the effect of vitamin D intake on lung cancer risk and to evaluate whether vitamin D supplementation can prevent lung cancer.” This is a standard way of ending the report of an observational study and it is of course self-evident. The scientific process is like a wheel that continually rotates to create an increasing understanding of the world about us.

However it must be remembered that there is more to the sun than vitamin D. Vitamin D is an index of sun exposure as well as being an active vitamin (pre-hormone). It is necessary to evaluate whether vitamin D supplement can “prevent” (that is, reduce the risk of) lung cancer, but also whether controlled sun exposure has a similar or even greater benefit.

This would lead us from observation to experimentation. It would require a prospective randomised controlled trial (RCT) of a volunteer group of people. It would take many years to reach a conclusion, perhaps 30 years. The organisational challenge would be immense and the cost very high. It is unlikely to take place because of these challenges and the lack of the financial rewards that are the hopes of pharmaceutical innovations.

There is another observation that suggests that the sun is of benefit in the outcome from lung cancer. If the diagnosis and treatment of lung cancer occurs in the summer as opposed to the winter, then the outcome is much better. It is difficult to think of an explanation other than that the sun gives a survival advantage. A further observation indicates an advantage in those taking vitamin D.

vitamin D sun lung cancer
Figure 2: Survival from lung cancer and time of the year.

We can see in this Figure 2.  Survival from lung cancer is worse if diagnosis and treatment occur in the winter months (columns 1 and 5) compared tot he summer months (columns 2,3,4).

If we then add the effect of taking or not taking a vitamin D supplement we can see an additional important effect.

Figure 3: Outcome from lung cancer, season and vitamin D supplement.

In Figure 3 we see the season effect repeated, but now we can see the additional effects of taking (yellow column) or not taking (green columns). 

The best survival of 70% (yellow column) is in those who are diagnosed and treated in the summer and who are taking vitamin D supplements.

The worst survival (30%, green columns) is in those diagnosed and treated in the winter and not taking vitamin D supplement.

(Zhou W, Suk R, Liu G, et al. Vitamin D predicts overall survival in early stage non-small cell lung cancer patients. Am Assoc Cancer Res 2005; Abstract LB-231.)

If someone smokes of cigarettes, then it is advisable to stop. If not, it is advisable to improve vitamin D status by maximising sun exposure (but avoiding sunburn), or taking a vitamin D supplement by mouth, or both.

Perhaps the best plan is to live in Greece (see Post - Greece and also Post - Sir Patrick Leigh Fermor).

The important thing is that the way to reduce the risk of lung cancer is not to smoke. The purpose of this post is to draw attention to the importance of the sun on human health and its likely benefit in respect of cancer.

Sunset over the Mekong, from Ventienne - magic