Box-Shaped Heart:A Journey Into The World Of Cholesterol Skepticism.

Do you have high cholesterol? About 60% of the adult population of the UK do so if you do you're not alone. I used to have it but I've not had it checked for years, decades even (or at least I don't think so - who knows what they check in hospitals or following blood tests?). Even if more people have high cholesterol than not, that doesn't mean it's a good thing. The lower your cholesterol, the better.

So why are some people, often people with some degree of influence, skeptical about cholesterol and its effects? I can't say I'd given it much thought but cardiologist Dr Christopher Labos gave a speech, live from Canada, this evening (UK time), for Skeptics in the Pub - Online - their 111th online event though - sadly - not a particularly well attended one, called 'How cholesterol skepticism became a pseudoscience' and it was actually quite interesting. If a little worrying for someone who has had, and may still have, high cholesterol - and someone who definitely has high blood pressure.

The talk, Dr Labos began by saying, would focus on the intersection between cholesterol skepticism and general anti-science, anti-vax, and Covid denial beliefs. He showed us a cover of The Atlantic magazine from September 1989 which featured an article by the journalist Thomas J. Moore. It made the claim that attempting to lower cholesterol was either pointless or dangerous - as well as being nigh on impossible.

While that may once have been a reasonable argument to make, science has moved on - both before and after 1989 - and those claims are simply untrue. Why do these claims get made about cholesterol but not about offer cardiovascular risks like diabetes, hypertension, and smoking?

Well, they once did. Quite famously, the tobacco lobby campaigned long and hard to prove that smoking was not bad for you and even, in some cases, that it was good for you. About a century ago, many noted medical people believed, and said, that we shouldn't even try to treat high blood pressure/hypertension. Some even said the greatest danger for those with high blood pressure came in trying to reduce it.

Knowledge, and understanding, of cholesterol is much newer than that of blood pressure. The latter was first measured back in 1733 while cholesterol is a 20th century discovery. So, initially - when little was known, cholesterol skepticism was understandable - perhaps even logical.

The Russian physician Nikolai Anichkov (1865-1944) was the first to demonstrate that cholesterol was linked to cardiovascular disease, specifically atherosclerosis. He did it by experimenting on rabbits but when he tried the same tests on rats and dogs it didn't 'work'. People at the time suggested that was because rabbits are herbivores and we humans are, like dogs and rats, carnivores. Even if many of us are not.

That led to a degree of skepticism but animal experiments, I believe, are not always a very good way to decide such things - plus they are unspeakably cruel. Chocolate, if enough of it is eaten, can kill a dog. That's not the case with humans. Unless, I suppose, you eat an incredibly large amount of chocolate. It turned out that dogs and rats happened to be two animals who were particularly good at converting cholesterol to bile acids and were, therefore, able to simply shit it out. Lucky dogs. Lucky rats. Apart from being experimented on, that is.

Anichkov's findings were largely rejected - and serious research into the links between cholesterol and heart disease didn't begin again for about thirty years. In the 1940s when, in the US, more and more people started dying of heart attacks.

Epidemiology studies took off. Including the Japanese Migration Study, the Seven Countries Study of 1955, and the Framingham Heart Study which began in 1948 and is still ongoing. Framingham, which coined the term 'risk factor', considered cholesterol, blood pressure, smoking, and physical activity and how these things affected the heart.

Diet studies followed in the wake of the epidemiology studies and, for the first time, people started looking into ways of lowering cholesterol and reducing the risk of cardiovascular disease. Often these studies would look at replacing saturated fat with polyunsaturated fat and swapping meat fat for vegetable fat/oil.

Not all the studies were positive. Three UK based studies found that corn oil, soya bean oil, or low fat diets did not reduce the risk factor of heart disease for people. But, Dr Labos contested - and some will disagree, diet is not an efficient way to treat cholesterol. It works for a small minority of people and, of course, it's always helpful to eat healthily (he mentioned that meat, rather than eggs, chips (including chip fat), was by far the largest dietary source of cholesterol, especially red meat) but most cholesterol is genetic. There being a difference between dietary cholesterol and serum cholesterol.

With that in mind, the only way to reduce cholesterol (for a majority of people) is through medication. A finding that led to some skepticism even though cholesterol was, and is, a major factor in heart disease. The skepticism arose, it seems, because although the link was clear it was unclear exactly how that link worked. Cholesterol science is confusing and complicated. Probably more confusing and complicated, even, than some of the slides and diagrams Dr Labos illustrated his speech with.

I didn't understand the graphs and I don't understand the science regarding cholesterol (in these blogs I try and report what people better educated and better informed than me have to say on the topics) though perhaps I should try and learn more. I'm not getting any younger as my ever increasing contact with doctors and daily blood pressure medication painfully underlines.

In the early days of attempting to lower cholesterol, some of the medicines - like clofibrate, weren't very good. Which caused further skepticism. 1984's Coronary Primary Prevention Trial of cholestyramine revealed that, like clofibrate before it, it did reduce cholesterol. But, importantly, it didn't actual reduce mortality rates. On top of that it had a side effect of giving some users such awful gastroenteritis that taking the drug became intolerable.

Weirdly, studies showed that there was a higher number of deaths by accidents, homicides, and suicides (violent deaths, essentially) in the cholestyramine study group than in the normal population. This could have been a freak result but it seems to have never really been explained. It led some to come to the conclusion that forcibly lowering one's cholesterol led to a loss of brain function and this led, indirectly, to that Atlantic article in 1989.

The game changer came with the arrival of statins. First developed by the Japanese biochemist Akira Endo (who's still about - and is now ninety years old - so something's working for him) using fungi and then mass marketed by the multinational pharmaceutical firm Merck & Co. Merck put out the first BIG statins and they had a BIG effect. They were 'blockbuster' drugs and had a clear benefit on reducing mortality via heart disease.

The evidence that statins worked was, and remains, overwhelming (while none of the so-called natural remedies that your hippy friends recommend to you work at all and have been proven not to in trial after trial) yet many people still strongly opposed the use, and development, of statins. So many studies were made regarding statins that to suggest some kind of 'big pharma' conspiracy is, frankly, ludicrous. Any conspiracy would need to involve tens of thousands of people, all seemingly unconcerned about others dying of heart attacks.

Despite everything, I believe humans are better than that - and they're certainly not that well organised. Lies spread that statins didn't work for women or for the elderly and some said statins had pleiotropic effects (which was part of the talk I must admit to getting lost during - I'd never even heard the word 'pleiotropic' before) but the evidence simply doesn't stack up.

Most of these debates, or arguments, are no longer relevant (Dr Labos suggested this was like relitigating the debate about Betamax being better than VHS - although it has to be said that nobody has been having that debate for about thirty-five years, an anachronistic example) and the idea that we're over treating people these days, pathologising normality, can be countered by the argument that in the past we didn't treat people well enough - and they died before their time.

Dr Labos' belief is that we have to rethink 'normal'. If we lived in a society where everybody smoked, we would consider lung cancer to be a normal disease. If everyone, or 60% of the UK population, has high cholesterol levels then we start to see cardiovascular diseases as normal. Which they may well be. But surely we should do all we can to help people avoid them. Heart attacks don't look fun. I worry about having one all the time.

Dr Labos' takeway from the talk was that if we lower cholesterol we reduce the risk of heart attacks and other cardiovascular problems. So why would we not try and do it, for ourselves and others? How we do it is irrelevant. If you're one of the lucky few and can do it with a change of diet then great. If you need to use safe and reliable, and now comparatively cheap, medication then so be it.

To do otherwise you would have to deny overwhelming proof and scientific consensus. This puts you alongside anti-vaxxers and Covid denialists and that's no place for anyone to be. It's a pathway to QAnon. Don't go there.

Thanks to Skeptics in the Pub - Online, thanks to Brian Eggo for hosting (even if he did claim that Together in Electric Dreams was by The Human League when it was actually a solo single by Philip Oakey in collaboration with Giorgio Moroder - although, it turns out, The Human League do now play it live), and thanks to Dr Christoper Labos who proved generous with his time, informative, and impassioned about a subject dear to his heart. As a bonus he even got his bowtied pooch, Toby, out for the camera.

I've got to see the doctor soon for a blood test and a prostate cancer test (just routine, apparently, though the unsolicited text from an unknown number scared the shit out of me) and maybe it would make sense to ask them to do a cholesterol test while I'm there. I don't want to die just yet. There's still a lot of things I want to do - and attending these Skeptics events are one of them.