Dr Aseem Malhotra, Honorary Consultant Cardiologist, Lister Hospital Stevenage

Academy of Medical Royal Colleges Choosing Wisely Steering Group

King’s Fund – Member of Board of Trustees

“ Half of what you learn in medical school

will be shown to be either dead wrong or

out of date within 5 years of your

graduation; the trouble is nobody can tell

you which half. The most important thing to

learn is how to learn on your own” David

Sackett

Ann Intern Med 1979; 90:85-91 Castelli W. Atherosclerosis 1996;124 Suppl:S1-

S9

Ideal Risk Factor Framingham Heart Study

‘Cholesterol and Disease’ Experts are called ‘Lipidologists’

What do Leading-Edge Experts Say?

One of the USA’s foremost is Thomas Dayspring, MD, FACP, FNLA, NCMP

Clinical Assistant Professor of Medicine, Director of Cardiovascular Education

2) LDLc is a near-worthless predictor for cardiovascular issues*

“The [Total/HDL] RATIO was found to be a better predictor of CHD

than TC, LDL, HDL and triglyceride -- not only in the Framingham Study,

but also in the Physician's Health Study and many other studies.”

- William P. Castelli (Framingham Director)

Lipids, risk factors and Ischaemic heart diseaseAtherosclerosis 124 Suppl. (1996)

S1-$9

Are we giving the wrong dietary

advice on saturated fat? 1970 American Scientist Ancel Keys, 7 countries study- saturated

fat – increased cholesterol- main dietary cause of heart disease.

Change in dietary advice in 1977/1984 – eat less fat and more

carbs! ( <30% fat <10% sat fat)

Food industry exploitation of “low fat” mantra has resulted in diets

high in refined carbohydrates (sugar)

Prevalence of obesity and type 2 diabetes in western population

has rocketed since.

But Selective data. Keys’ observational correlations didn’t appear

so strong when other countries included.

Keys’ received research funding from Sugar industry

But saturated fat increases HDL (good) cholesterol to equal degree and affects LDL large type A particles, wheras small dense type B particles are more atherogenic (responsive to refined carbs)

Little effect on total cholesterol:HDL ratio- a better predictor of CHD events that total cholesterol alone.

Source and type of saturated fat may be important with some suggestion that dairy products may be protective

Re- analysis of unpublished data from Sydney Heart study revealed cardiac patients who replaced butter with safflower oil and margarine containing omega 6 had increased all cause and cardiovascular mortality despite a 13% reduction in total cholesterol

Cambridge MRC/BHF

Rajiv Chowdhury, Samantha Warnakula, Setor Kunutsor, Francesca Crowe, Heather A. Ward, Laura Johnson, Oscar H. Franco, Adam S. Butterworth, Nita G. Forouhi, Simon G. Thompson, Kay-Tee Khaw, Dariush Mozaffarian, John Danesh, Emanuele Di Angelantonio; Association of Dietary, Circulating, and Supplement Fatty Acids With Coronary RiskA Systematic Review and Meta-analysis. Annals of Internal Medicine. 2014 Mar;160(6):398-406.

A meta-analysis of 72 unique studies with over 600,000 participants from 18 countries led by the Cambridge Medical Research Council concluded that “current evidence does not support guidelines that restrict the consumption of saturated fats and encourage consumption of polyunsaturated fats in order to prevent heart disease.” The study raised questions regarding current nutritional guidelines that focused principally on the total amount of fat from saturated or unsaturated rather than the food sources of the fatty acid subtypes. One interesting finding was that the consumption of one particular fatty acid (margaric acid) which is a dairy fat, significantly reduced the risk of cardiovascular disease

Could better dietary assessment

methods help to clarify the

association?

Could better dietary assessment methods help to clarify the

association?

Aim: To investigate the association between saturated fatty acids measured in the blood and

the risk of developing type 2 diabetes (T2D)

Method: EPIC-InterAct StudyLarge case-cohort within the EPIC study

across 8 countries of Europe, with 340,234 adults with stored blood

12,403 incident cases of T2D ascertained16,835 random sub-cohort selected

3.99 million person years of follow-up

Interpretation & Conclusions

Different individual blood SFAs are differentially associated with risk of T2D

Dairy SFA’s inversely associated with type 2 diabetes risk

SFAs are not a homogenous group

Endogenous synthesis of saturated fatty acids associated with increasing type 2 diabetes risk encouraged by dietary starch, sugar and alcohol

Need to discriminate between sub-types of SFAs

Implications – “Take home message”

Need to take focus away from single nutrient (fat, SFA)

Source of the SFA matters

What replaces SFA in the diet matters

○ SFAs are often replaced with refined carbohydrates

- Many low fat products have high sugar content

Place more emphasis on foods and on diet patterns

Place emphasis on healthy diets within healthy lifestyles

Focussing on cholesterol “lowering” has been counterproductive. “who cares about cholesterol lowering if it doesn’t translate into a benefit for patients?” Prof Rita Redberg

Abramson J, Rosenberg H, Jewell N, Wright JM, BMJ 2013;347:f6123 doi:

10.1136/bmj.f6123 (Published 22 October 2013)

Call for retraction

“ there are only one or

two well- documented

(problematic) side

effects” Myopathy and

muscle weakness

occurred in one in

10,000 people he said

and there was a small

increase in diabetes -

Professor Rory Collins

–Guardian, March

2014

Statin controversy Statins – letter to Health Secretary signed by

leading doctors including the President of the RCP, Sir Richard Thompson, past chair of the RCGP, Clare Gerada, Chair of National Obesity Forum David Haslam, Prof Simon Capewell rejecting NICE move to lower threshold to offer treatment. (2014)

Guidance based upon industry sponsored data and several members of the GDG had financial ties to Pharma companies sponsoring statins. Side effects not taken into account including type 2 diabetes. Increased GP appointments –No mortality benefit in the group. No access to raw data

Loss of professional confidence

GPC “In light of the Cochrane review of the

effectiveness of antiviral influenza treatments, the

GPC will request that NICE refrain from

recommending a reduction to the current

treatment threshold for primary prevention of

cardiovascular disease with statin therapy unless

this is supported by evidence derived from

complete public disclosure of all clinical trials' data’

Harvard Researcher Wins Round in Brawl

With Oxford Peer Over Benefits of

Cholesterol Drugs

The verdict is in on a bruising spat between researchers at Harvard University and

the University of Oxford over a paper questioning the value of prescribing

cholesterol- lowering drugs to people at low risk of heart disease.

The decision goes to Harvard—and that’s not great news for pharmaceutical

companies that make the medications.

The dispute began last October, when Harvard Medical School lecturer John

Abramson and colleagues from California and Canada published an analysis in the

BMJ—formerly known as the British Medical Journal—concluding that the

multibillion dollar class of cholesterol- lowering statin drugs conveys no overall

health benefit in low- risk cases.

Armstrong D, BloombergBusinessWeek, August 1, 2014

Statin Usage Survey

statinusage.com

nearly 75% of new users discontinue statins within a year of prescription

1. Side effects were the leading reason why patients stopped taking statins

More than six in ten respondents (62%) said they discontinued their statin due to side effects, with the secondary factor (17%) being medication cost. Only 12% of respondents cited lack of efficacy in cholesterol management as a reason for stopping their medication. On average, respondents who experienced side effects due to their statin stopped after trying two different statins.

Three out of ten respondents experienced side effects of muscle pain and/or weakness, and 34% stopped taking their statin because of these side effects without consulting with their doctor.

Sunday Times Investigation, 18th

September 2016 Sir Rory Collins, a professor of medicine and epidemiology at Oxford

University, led a review into statins, published in The Lancet earlier this month, which found that not more than one in 50 people will suffer side effects.

Collins, who believes millions more Britons could benefit by taking statins, is also co-inventor of a test that indicates susceptibility to muscle pain from them.

The test, branded as Statin–Smart, is sold online for $99 (£76) on a website that claims 29% of statin users will suffer muscle pain, weakness or cramps. The marketing material also claims that 58% of patients on statins stop taking them within a year, mostly because of muscle pain

Royalties from the licensing of the patent can be used to fund university research, but Collins and his co-inventors have waived personal fees.

Boston Heart Diagnostics said it stood by its claims about statin side effects and that they were based on published research. It also cited a US taskforce on statin safety that said randomised controlled trials — such as those used in the Lancet study led by Collins — had “major limitations” because patients with statins intolerance were often excluded.

Nearly Four Dozen RCTs of Cholesterol

Reduction Have Reported No Mortality

Benefit

DuBroff R. Evid Based Med 2017;22:15-

19

Unintended Consequences of

LDL Cholesterol Reduction Statin drugs are prescribed to millions of

otherwise healthy individuals at low risk of CHD.

Statin users mistakenly believe they can eat whatever they want (statin gluttony).

The increased risk of DM with statins may convert some healthy individuals into patients.

The promotion of low fat (high sugar) foods has contributed to the epidemic of obesity and DM that can actually lead to CHD.

The myopic focus on LDL reduction has distracted us from investigating other preventive strategies.

UK: The fat man of Europe?• 2/3 adults obese or overweight

• obesity will double by 2050

• 1/3 children obese or overweight

• Obesity costs NHS £5billion+

↑ ↑£10 billion by 2050

Burden of disease attributable to 20 leading risk factors in 2010

expressed as a percentage of global disability-adjusted life-years

Global Burden of Disease Group. www.thelancet.com 2012 380 2245http://www.telegraph.co.uk/news/health/news/11556593/Sugar-is-to-blame-for-obesity-epidemic-not-couch-potato-

habits.html

Fructose is not glucose

Common wisdom: A calorie is a calorie, and

“Sugar is just “empty calories”

But:

• Chronic fructose exposure promotes liver fat accumulation,

which promotes Metabolic Syndrome (toxicity)

• Metabolic syndrome ( 3 of hypertension, dysglycaemia, increased

triglycerides, decreased HDL, and increased waist circumference

• 66% of those admitted with acute myocardial infarction have

metabolic syndrome with 50% increased mortality or hospital

readmission at 1 year.

Elliot et al. Am J Clin Nutr, 2002

Bray et al. Am J Clin Nutr, 2004

Teff et al. J Clin Endocrinol Metab, 2004

Gaby, Alt Med Rev, 2005

Le and Tappy, Curr Opin Clin Nutr Metab Care, 2006

Wei et al. J Nutr Biochem, 2006

Johnson et al. Am J Clin Nutr 2007

Rutledge and Adeli, Nutr Rev, 2007

Brown et al. Int. J. Obes, 2008

Obese (30%)

Normal weight (70%)

240 million adults in U.S.

Normal weight,Metabolic dysfunction

(40% of 70%)

Obese and sick(80% of 30%)

57 million 67 million

Total: 124 million sick

72 million

168 million

Pioppi; the home of the

Mediterranean Diet

A book that marries the secrets of Pioppi with the latest cutting edge medical,

nutrition and exercise science to bust the myths prevalent in today’s weight

loss, and health industries

Myth busting

The Mediterranean Diet has been wrongly interpreted for decades

Eating fat does not make you fat and saturated fat does not clog the arteries

Cholesterol can be good for you! ( and if you’re over 60 “bad cholesterol” protects you from an early death)

Physical activity and obesity is a myth ( you can’t outrun a bad diet)

Dietary changes is more powerful than any drug for preventing and treating heart disease and type 2 diabetes (which is reversible) and effects/benefits are immediate

“ The preservation of the means of

knowledge among the lowest ranks is of

more importance to the public than all

the property of all the rich men in the

country” John Adams, 2nd US President, 1775.

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