Читать книгу A Statin Nation - Dr Malcolm Kendrick - Страница 4

Almost ten years ago, I wrote a book called The Great Cholesterol Con. I tried to outline, as clearly as I could, why the central ideas about cardiovascular disease (CVD, i.e. basically heart attacks and strokes) were absolutely, completely and totally wrong. I knew that the impact would be instant and earth shattering.

There would be an immediate realisation that saturated fat and cholesterol have nothing whatsoever to do with CVD. Medical experts and opinion leaders would reverse their thinking, and the public would fling their statins into the nearest dustbin. Guidelines would be hastily rewritten around the world. My Nobel Prize would be polished furiously in Sweden. My acceptance speech was already written and it was a cracker … humble, witty, incisive.

History reveals that it hasn’t quite worked out that way. It is true that, over the last ten years, the guidelines have been rewritten, but they now advise that hundreds of millions more people need to be put on statins, at ever-lower levels of blood cholesterol. Furthermore, people have never been more terrified of having a high cholesterol level than today. Supermarket shelves groan under the weight of low-fat foods, designed to lower cholesterol. Benecol sales seem to be going through the roof, rather than down the drain. I think it would be true to say that the ‘Cholesterol hypothesis’ has never been more potent than now.

Oh well. Perhaps I should rewrite the ending of the story about the emperor’s new clothes … ‘So perfectly had everyone allowed themselves to be fooled, that even when the little boy shouted “but he isn’t wearing any clothes” the crowd just turned on him, and told him to shut up and stop being so stupid. The End.’

Undeterred, I am having another go, despite the fact that insanity has been defined as doing the same thing again and again while expecting a different result. (And before you say that’s an Einstein quote, check it out on Wikipedia.) Perhaps I just need to shout a bit louder and carry a baseball bat to be used at good strategic moments.

In truth, over the last ten years many things have changed. Some for the better, some for the worse. Of course, whether you think things are better or worse rather depends on which side of the argument you are on.

Prescribing statins has continued to rise inexorably, with the latest recommendations in the UK being that every single man should be taking a statin by the age of sixty, regardless of whether they have any other risk factors for CVD. The official ceremony when you ‘reach the age of lifelong statination’ is significantly younger in the US, as you might expect.

Looking at this latest development from a different angle, it is now possible to have ‘perfect’ cholesterol levels, ‘perfect’ blood pressure and ‘perfect’ every other single risk factor, yet when you reach a certain age the danger of suffering a cardiovascular (CV) event is so frighteningly high that you will have to take a drug, every day, for the rest of your life. (An event is a heart attack, stroke or hospital admission with angina, or suchlike.) Of course, hardly anyone has perfect risk factors, which means that the average age when a man is required to take a statin is about fifty, and about ten years later for women.

‘And lo, it came to pass that all of the peoples in the world, past middle age, hast been defined as having a new medical condition that shalt be called “statin deficiency syndrome” (SDS).’ By order of the management. In other words, your cholesterol level can be low, medium or high, but the actual figure does not matter a jot, you still need a statin to lower it further. This remains true, even if your cholesterol level is lower than that found in any population in the world, even it if is lower than 99.99 per cent of anyone currently alive.

We now live in the ‘upside down’, a world where there is no cholesterol level that cannot benefit from being lower. A world where cholesterol can cause CVD, even when it is abnormally low. Try and pick the logic out of that, my friend. And if you do, please let me know how you did it.

If things continue their inexorable direction, the next argument – which is already being made – is that CVD gradually develops with ageing. Ergo, you should really start taking statins when you are a child. My prediction is that it will soon be recommended that everyone starts ‘statination’ in their early twenties, and must continue … forever. You read it here first. Then we truly will have a ‘statin nation’ instead of the rather pathetic 14 million statin takers we now have. Or at least are supposed to have. In truth, a lot of people don’t take them, even when they tell the doctor that they do.

And in addition to the ‘statination’ of the entire adult population, we now have ever lower limits for treating blood pressure. About thirty years ago, hypertension was diagnosed if you had blood pressure of over 160/110mmHg. As with cholesterol levels, this target has fallen and fallen. At the time of writing we have reached 130/80mmHg, which means just about everybody has it.

Simultaneously, the concept of pre-hypertension has gained traction. Pre-hypertension means that you don’t have blood pressure quite high enough to be diagnosed as hypertension, but you are nearly there and, as is the way of things, you will inevitably become hypertensive. Ergo, you might as well start taking drugs to lower your blood pressure now.

What else? We have a new medical condition known as pre-diabetes. A state of having a highish blood sugar level, but not actually high enough to be diagnosed as diabetes, at least not until they lower the diagnostic threshold once more. However, my friend, bad luck, you will inevitably develop diabetes over time so you might as well start the medications now.

Osteoporosis (thinning of bones), is something that women tend to get more than men, and if you have it you must start taking drugs for the rest of your life. These drugs (such as alendronic acid or risedronate) are usually called bisphosphonates and, as an added bonus, you will also take a calcium supplement and vitamin D at the same time.

But that’s far from the end. In the same way that we now have pre-hypertension, pre-diabetes and the inexorable lowering of cholesterol levels, there has been pressure to further widen the market for osteoporosis drugs. This has led to the creation of a new condition called osteopenia, which means thinnish bones, not quite osteoporosis, but getting there. Pre-osteoporosis, if you like. So, guess what, time to start the medications to thicken up the old bones. To be taken forever, for the rest of your life. And you may have noticed a certain trend here …

Now, heart disease. Whilst you’re religiously taking statins, you might as well take an aspirin to add further protection. But aspirin can damage the lining of your stomach, so you should also take an anti-acid drug, such as omeprazole, to prevent this, which gives you two more drugs to take – for the rest of your life. Then, if you are unlucky enough to have had an episode of chest pain, which might or might not have been related to your heart, there are a whole load of other drugs that you will be put on for the rest of your life. An ACE-inhibitor, a beta blocker, clopidogrel, etc. It doesn’t much matter if the pain seemed cardiac, you can’t be too careful you know.

So today, without really trying and without having any disease diagnosed, you can be on at least eleven drugs. Two to lower blood sugar, two blood pressure lowering drugs, aspirin, omeprazole, alendronic acid, the calcium/vitamin D combination, clopidogrel and a statin. In fact, in one of the places where I work I’ve toyed with the idea of getting a large stamp with a list of these drugs imprinted on it. This will save me the time of writing them out for every single bloody patient who comes to my surgery. Just a quick whack on the prescription … all drugs present and correct, sir.

The simple fact is that the medical world that has emerged in the last ten years is not just a statin nation. It is, in my view, a completely bonkers, over-medicated nation. (I did not feel that this might be such a catchy title for the book but, you never know …) And is all this a good thing? A 2017 Cambridge University study on the increasing use of medications revealed that:

 Almost half of the over-65s in England are taking at least five different drugs a day

 Some were taking up to 23 tablets every day (and I’ve have known them take far more)

 The proportion taking no pills at all is just 7 per cent

 Heart disease pills, such as statins, accounted for nearly half the medicines taken

 Taking up to five tablets a day increased the danger of premature death by an estimated 47 per cent

 Those taking six medicines or more a day were nearly three times as likely to die prematurely1

In fact long ago, when I was a medical student, we were told that no one should be on more than five medications, due to potentially damaging drug interactions, etc. The harms would overwhelm any benefits. Today … prescribe five drugs minimum or you are not really trying. ‘An undermedicated patient … off with his doctor’s head!’

Some voices protest at this dystopian brave new world, and there is now a growing movement called Too Much Medicine supported by medical journals and an increasing number of doctors. The basic theme is, ‘Can we stop prescribing so many damned drugs – please. And can we also stop, or at least reduce, all this screening and monitoring and measuring.’

Unfortunately, although I view this movement with benign approval, I rate its chances of success as equal to that of King Canute (now, rather disappointingly, called King Knut) in holding back the tide. Most people, it seems, love to take drugs and submit themselves to every possible screening test known to man. You cannot be too careful, you know. Oh yes, you can.

Most doctors love to prescribe drugs. It gives them something to do, I suppose, and is the fastest way of getting patients out of the surgery. Furthermore, the major medical societies, the experts, the guideline writers, those advising governments around the world want more, more and even more medicine. And so, to no one’s great surprise, do the pharmaceutical companies.

I can see the attraction. Pop a few pills and all your health concerns simply disappear. Don’t bother to exercise, continue to work far too many hours, drink far too much and relegate good personal relationships to a waste of precious time. Never mind … all health problems are banished if you swallow a few pills every day. Good luck with that, my friend.

A more recent phenomenon, which has grown rapidly alongside mass medication, is the highly contentious and censorious world of nutrition. Eat this, don’t eat that and absolutely never, EVER eat that … Fortunes are made promoting various, completely mad diets. People used to eat pretty much what they liked but, in the last decade or so, nutrition has become a battleground with various foods becoming the enemy, feared and distrusted. Food has always been an emotive issue with different foods being viewed as good and bad, but there has never been a time of such unrestrained warfare.

Whilst writing this introduction, a documentary was released by Netflix called ‘What the Health’. The programme reported various claims, including:

 The World Health Organisation (WHO) has classified bacon and sausage as carcinogenic to humans, on the same level as smoking

 Eating one egg a day is as bad as smoking five cigarettes a day

 The risk of heart disease is 50 per cent for meat eaters, 45 per cent for vegetarians and 4 per cent for vegans

 One serving of processed meat a day increases risk of developing diabetes by 51 per cent

I must remember to warn my pussycat to stop eating so much meat, but he doesn’t seem keen on vegetables. I have no doubt that these claims are the purest, refined, organic baloney. Equally, according to The Times this documentary cited two pro-vegan organisations among its frequently listed sources,.

It is true to say that similar warnings about a range of foodstuffs are unnervingly common. The American Heart Association (AHA) majestically proclaimed a ‘Presidential Advisory on Harms of Saturated Fat’. Commenting on it David Katz, MD, director of the Yale University Prevention Research Center, and founder and president of the True Health Initiative described the new AHA advisory as ‘one of the most important papers addressing the topic of saturated fat and health outcomes’. He added, ‘The conclusion is perfectly clear and entirely decisive: saturated fat from the usual dietary sources increases the risk of heart disease, and its replacement with wholesome foods and unsaturated fats reduces that risk.’2

I nearly choked on my cornflakes. Except, of course, I do not eat cornflakes because they taste of nothing and are instantly converted to sugar in your digestive system. My breakfast of choice is full fat Greek yoghurt with walnuts and honey. Failing that, bacon, eggs and sausages or sometimes a cheese and ham omelet, which is much more difficult to choke on and, as I shall demonstrate, far healthier and less likely to cause CVD. But back to this ‘Presidential Advisory’; let’s compare it with a Swedish review from 2013, which stated that:

Butter, olive oil, heavy cream, and bacon are not harmful foods. Quite the opposite. Fat is the best thing for those who want to lose weight. And there are no connections between a high fat intake and cardiovascular disease.

On Monday, SBU, the Swedish Council on Health Technology Assessment, dropped a bombshell. After a two-year long inquiry, reviewing 16,000 studies, the report ‘Dietary Treatment for Obesity’ upends the conventional dietary guidelines for obese or diabetic people.

For a long time, the healthcare system has given the public advice to avoid fat, saturated fat, and calories. A low-carb diet (LCHF – Low Carb High Fat, is actually a Swedish ‘invention’) has been dismissed as harmful, a humbug and as being a fad diet lacking any scientific basis.

Instead, the healthcare system has urged diabetics to eat a lot of fruit (=sugar) and low-fat products with considerable amounts of sugar or artificial sweeteners, the latter a dangerous trigger for the sugar-addicted person.

This report turns the current concepts upside down and advocates a low-carbohydrate, high-fat diet, as the most effective weapon against obesity.3

Back and forth the argument goes, with no one listening on either side whilst facts are twisted and manipulated on all sides. I can see this battle going on for another fifty years, at least. Yes, the Lilliputians and Blefuscans do like a pointless war.

If the authorities have failed to make you sufficiently worried about eating fat, you can be made to fear drinking alcohol as well. Years ago, the recommended limits for safe alcohol consumption were 52 units for men and 28 for women, per week. Oh, happy days. However, as with everything else, these limits have tightened and tightened. It is difficult to keep up, but I think we are now down to two units a day as the absolute maximum for men. This issue was reported in The Guardian:

England’s chief medical officer has defended tough new drinking guidelines, insisting that the updated advice is not scaremongering but based on ‘hard science’. The new recommendation of only 14 units of alcohol, or seven pints of beer, a week means that England now has one of the strictest drinking guidelines in the world.

Dame Sally Davies, the chief medical officer for England, robustly backed the advice in a round of broadcast interviews on Friday, saying that other countries would follow suit because of new research on the health risks of even moderate drinking.

Speaking on BBC Breakfast she said: ‘My job as chief medical officer is to make sure we bring the science together to get experts to help us fashion the best low-risk guidelines.

‘If you take 1,000 women, 110 will get breast cancer without drinking. Drink up to these guidelines and an extra 20 women will get cancer because of that drinking. Double the guideline limit and an extra 50 women per 1,000 will get cancer. Take bowel cancer in men: if they drink within the guidelines their risk is the same as non-drinking. But if they drink up to the old guidelines an extra 20 men per 1,000 will get bowel cancer. That’s not scaremongering, that’s fact and it’s hard science.’4

Anyway, the direction of travel is abundantly clear. Not drinking at all, ever, is ‘journey’s end’ for the experts on alcohol. And not eating saturated fat, ever, is ‘journey’s end’ for our dietary experts. At the same time, new limits for cholesterol, blood pressure, diabetes and suchlike will mean that everyone will be on multiple medications from ever younger ages, with new lifelong drugs being added on a depressingly frequent basis.

Left to their own devices, experts drift inexorably to extremism. After all, what is the point of having an important new guidelines meeting if you can’t then tighten, ban, enforce or demand that everyone must do something different. The inevitable end result being either ‘nothing’ or ‘everything’. This is now a well-defined phenomenon of ‘group-think’, as outlined in this article in the Spectator: ‘To become an extremist, hang around with people you agree with. Cass Sunstein – co-author of the hugely influential Nudge and an adviser to President Obama – unveils his new theory of ‘group polarisation’, and explains why, when like-minded people spend time with each other, their views become not only more confident but more extreme.5

Over the last ten years, I have watched a large branch of medicine heading in a very strange and extreme direction. I had hoped that various guidelines would become so ridiculous, so distanced from reality, science and logic, and anything else that there would be some kind of backlash. But backlash there came none. Not yet, anyway.

I am not the first person to notice the direction of travel. Well over twenty years ago an article appeared in The New England Journal of Medicine. It was called ‘The Last Well Person’ and with remarkable prescience it covered pretty much everything that needs to be said on this matter. I shall quote a couple of passages.

I have not met a completely well person in months. At this rate, well people will vanish. As with the extinction of any species, there will be one last survivor. My guess is that the extinction will occur sometime in late 1998. Before we can speculate about the last well person, we need to understand what is happening. Why are they vanishing?

The demands of the public for definitive wellness are colliding with the public’s belief in a diagnostic system that can find only disease. A public in dogged pursuit of the unobtainable, combining with clinicians whose tools are powerful enough to fine very small lesions (a lesion is just a damaged, or diseased bit of the body) is a setup of diagnostic excess …

What is paradoxical about our awesome diagnostic power is that we do not have a test to distinguish a well person from a sick one. Wellness cannot be screened for. There is no substance in blood or urine whose level is reliably low or high in well people. No radiological shadows or images indicated wellness. There is no tissue that can undergo biopsy to prove a person is well.

This magnificent article then goes on to describe the last well person in some detail. A man who has chosen a job with as little stress as possible, living in an area of the US with a mean wind-chill factor, in a temperate range, in January. He has a screening test for blood sugar, cholesterol, carcinoembryonic antigen, prostate specific antigen and occasional stool tests. He did have two unnecessary colonoscopies because of false positive tests for blood in his bowel movement, and now abstains from meat for a week before any stool test. Also …

He consumes 15 per cent of his calories as fat, with the remainder split between protein and carbohydrates. He completely avoids saturated fat, salt, sugar and red meat, and all but trace amounts of vegetable oil, which he uses in his wok to stir-fry his vegetables. He was a regular eater of tofu until he heard Garrison Keillor say on the radio that Tofu did not extend anyone’s useful life, but only that last few weeks in a terminal coma.

Every day he takes vitamins C, E, B6, and a small amount of D, several doses of kelp; and a concoction of dried seaweed mixed with desalinated sea water, along with a baby aspirin. He takes three doses of bulk laxatives, eats a bowl of bran, and drinks eight glasses of water daily…6

Who’d have guessed that this beautifully constructed, somewhat tongue in cheek account of the horribly dystopian lifestyle of the last well man is now almost mainstream behaviour?

Amongst the many doctors I meet, there has been much grumbling about this ever-increasing medicalisation. I regularly hear such phrases as ‘bloody monkey medicine’. But those in charge of the medical research complex are highly resistant to any change of direction, and very few people risk popping their heads over the parapet. Dare to challenge the experts and you can expect a vicious reaction.

Fairly recently, a few of us mad cholesterol sceptics were proving more successful than usual in criticising mass statin prescribing. This was not to be allowed. One of the big names of cardiology, Professor Steven Nissen, was stung into action. He wrote an article in the Journal of the American Medical Association entitled ‘Statin Denial: An Internet-Driven Cult With Deadly Consequences’, which gives a good sense of the scientific tone of what followed. I presume he felt that his mighty Olympian thunderbolt would keep me, and my fellow cult leaders, firmly in our place. I wish I had known I was running a cult, I could have made some real money.

Tom Naughton, a fellow cholesterol sceptic, writer and humorist, wrote a blog on the Nissen article, and most amusing it was. One of the comments in his article made me laugh and laugh. So, dear reader, I nicked it (with permission):

You didn’t really tell about the worst part of the cult.

Don’t forget how cult members are initially recruited with flattery and promises of magnificent rewards in order to get them to pledge nearly all of their family’s assets to the cult. Having ‘proven worthy,’ they are taken to ‘education camps’ where they are isolated with other recruits and forced to memorise and recite back the cult doctrines. Access to outside information or perspectives is forbidden, and any questioning is swiftly met with threats of ostracism and expulsion.

Once sufficiently indoctrinated, the recruits are coerced into several years of working long, mind-numbing hours of labor at penury ‘wages’ – ostensibly for the good of the cult, while the poohbahs at the top enjoy riches and lavish lifestyles.

Oh wait. Wrong cult. That’s the ‘medical school/internships programs’ cult.

Never mind. My bad.

Cheers!

And a very powerful cult it is too.

Anyway, where was I? Oh yes, explaining that medicine is heading towards an extreme place that is in danger of damaging us all. Health is not the lowering of numbers on a blood test, nor endless scanning and screening in a desperate attempt to find perfect health. It is a very different thing indeed. Positive mental attitude, for one.

In fact, the WHO, in its very first meeting, stated that health is ‘a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.’ Absolutely true. Most of which has very little to do with the medical profession.

I would also argue that almost all of what we now call ‘preventive medicine’ has nothing to do with prevention at all. Detecting high blood pressure, for example, is not prevention. It is just finding a problem at an early stage. Cancer screening, again, is not prevention. It is just finding the problem at an early stage. Screening is not preventing.

Moreover, lowering blood pressure is doing nothing for the underlying disease process. You are just lowering a measurement that may or may not be very helpful. Indeed, some anti-hypertensives have been found to lower blood pressure very effectively, yet increase the risk of CVD death.7

The same phenomenon of simply lowering numbers has also been found in the world of diabetes. The ACCORD Study, using multiple interventions to lower the blood sugar in people with diabetes, as far as possible, found that this had no effect on CV mortality, but significantly increased overall mortality (overall mortality = the risk of dying of anything): ‘As compared with standard therapy, the use of intensive therapy to target normal glycated hemoglobin levels for 3.5 years increased mortality and did not significantly reduce major cardiovascular events. These findings identify a previously unrecognised harm of intensive glucose lowering in high-risk patients with type 2 diabetes.’8

More recently, the findings of ACCORD were confirmed by another study that made exactly the same point. Namely, that the more you lower the blood sugar level with drugs, the greater risk of death. Insulin was fingered as the most damaged drug of all. ‘The pattern of mortality risk across levels of HbA1c (long term measure of blood sugar levels) differed by glucose-lowering regimen. Lower HbA1c was associated with increased mortality risk compared with moderate control.’9

Finding things that are ‘wrong’ and then attempting to batter them back down to ‘normal’ does not necessarily end well. Instead, we have been fitted to what I call the ‘Procrustean bed of medicine’.

‘In the Greek myth, Procrustes was a son of Poseidon with a stronghold on Mount Korydallos at Erineus, on the sacred way between Athens and Eleusis. There he had a bed, in which he invited every passer-by to spend the night, and where he set to work on them with his smith’s hammer, to stretch them to fit. In later tellings, if the guest proved too tall, Procrustes would amputate the excess length; nobody ever fitted the bed exactly – so they died.’10

Clever people those Greeks.

I believe that we need to move away from defining more and more people as ill, then chopping or stretching things back to ‘normal’. Instead we need to move towards ‘a state of complete physical, mental, and social well-being’.

I cannot cover everything, but I want to try to help people understand CVD. I will outline the current ideas and explain as well as I can, in some detail, where these ideas have gone wrong, and will sign off by trying to outline the most important things that you can do to maintain good CV health. But before getting into the guts of the matter, I must add that I am not attacking conventional Western medicine. This has been, in many ways, a spectacular success with hip replacements, antibiotics, anesthetics, the treatment of major trauma and the prevention of many diseases that have been a scourge of humanity for millennia. Smallpox, syphilis, polio. Dentistry, new heart valves, painkillers, orthopaedic surgery … I could go on and on.

However, in CVD prevention, medicine has grabbed the wrong end of the stick and then rushed off, with grim determination, in the wrong direction. I intend to change things round, then the experts can rush back madly from whence they came and head off in the right, damned direction. No offence, guys. Well, not much.