by Tim Noakes
What struck me most about the cardiologists’ open letter to the media was its timing. As a result, the front-page story in the following morning’s issue of the Cape Times was not about my being awarded South Africa’s most prestigious science award. Rather it was all about my supposedly unprofessional behaviour in expressing opinions that conflicted with those of the anointed UCT cardiologists. Was the timing of this letter mere coincidence, or had it been planned?
The gist of their complaint appeared to be that the simple act of questioning their cohesive professorial dogma was contrary to the Hippocratic Oath because it might harm patients. Yet one thing my Damascene moment had shown me was that it is our collective failure to question the causes of the global obesity/T2DM epidemic that is truly harming our patients and our nation.
I continue whimsically to believe that the function of universities is to advance knowledge, not to insulate professorial opinions from external scrutiny and thus institutionalise what I call the power of the anointed. I believe the very reason why universities exist is because we do not (yet) know everything. If we did, we would have no reason to invest so much in such costly institutions.
My opinion as an educator is that we are unlikely to foster future generations of inquisitive doctors and cardiologists wishing to improve standards of medical care through innovation and change if we follow these cardiologists’ reactionary educational approach. I can think of no favourable outcomes of attempts to suppress the opinions of those with whom we disagree – other than to protect the interests of those who have benefited from the surge in chronic diseases, including heart disease, over the past hundred years.
In the following months and years, the warning that the LCHF/Banting diet ‘might’ damage health would become the distinctive, recurring theme rallying the attacks directed at me by my professional colleagues. Of course, anything ‘might’ cause anything. The role of science is to discover what causes what. That is why we have universities, and why universities employ professors: to advance our diligent search for truth by considering any and all opposing opinions.
I interpret these professional attacks as a measure of the extent to which the pharmaceutical industry has captured our profession. Those whose careers have become partially or wholly dependent on a close relationship with the marketing arms of pharmaceutical companies simply will not tolerate anyone who dares question either the need for or the efficacy of any therapeutic intervention involving pharmaceutical products or related medical interventions.
In Deadly Medicines and Organised Crime, Danish physician and former Big Pharma insider Peter Gøtzsche writes: ‘The pharmaceutical industry does not sell drugs. It sells lies about drugs.’3 And in exchange for money and prestige, it manipulates its surrogates – embedded medical scientists and physicians – to disseminate those untruths.
Had I become an unwitting target of some of that money?
The UCT cardiologists further used their letter to espouse their expected industry-required advertorial claiming that statin drugs are ‘cheap’ and ‘make you live longer’. They suggested I should only voice my opinions in ‘the academic forum and the medical literature where they could be critically evaluated and challenged’ by my peers. In other words, there is no place for books written by academics for the general public, unless they regurgitate that which the anointed professors have approved. ‘To present these controversial opinions as fact to a lay public, in his un-refereed book, is dangerous and potentially very harmful to good patient care,’ they pronounced.
It is not clear to me how opinions can be inherently dangerous, except perhaps to those whose careers require that certain opinions are never heard.
The essential failure of these cardiologists, however, has been their assumption that the general public is wholly uneducated, with no capacity to think for itself. I believe that eventually, through the power of the internet and social media – the wisdom of the crowd – the public will demand to know why the faith and tax money it invested was so misplaced in these academics.
Perhaps it is the natural consequence of living in the ivory tower of academia, surrounded for too long by sycophantic surrogates whose career prospects are so dependent on pleasing their professors, the anointed. Ultimately the anointed become the victims of their own hubris and self-importance, believing they can program, like robots, an ignorant public on what to do and how to think. It is as George Orwell wrote in 1984: ‘The whole climate of thought will be different. In fact, there will be no thought, as we understand it now. Orthodoxy means not thinking – not needing to think. Orthodoxy is unconsciousness.’4
After four decades of regular intellectual interactions with the general public, my abiding impression is of the remarkable intelligence of the majority, most of whom have never enjoyed even an informal training in medicine or science. I have also learnt that this aptitude is not a function of social position or economic status.
That two journalists without any formal training in medicine – Gary Taubes and Nina Teicholz – could write the three most important general medical books of the past few decades, far more important than anything any cartel of academic cardiologists has yet contributed to the public discourse, is further evidence that traditionally educated professors do not hold a monopoly on medical wisdom.
The authors of the cardiologists’ letter to the media continued: ‘We understand some patients are placing their health at risk by discontinuing statin therapy and their prudent diets on the basis of this “expert opinion”. Having survived “Aids Denialism” we do not need to be exposed to “Cholesterol Denialism”.’
Then, in a final statement of hubris, they said: ‘Scientists and clinicians have an ethical obligation to ensure that the information they impart to their patients and the public at large is correct, in line with best available evidence, and will not cause harm.’
Conventionally trained cardiologists never consider that their dietary advice is the direct cause of the greatest medical threat humans have ever faced: the global obesity and T2DM epidemics that began after 1977 with the introduction of the ‘heart-healthy’, ‘prudent’ diet. Cardiologists continue to promote this diet unquestioningly on a daily basis to anyone whose blood cholesterol concentration exceeds 5.01 millimoles per litre (mmol/L). I wonder if any ever inform their patients that to prevent one major coronary event or stroke, these supposedly life-saving ‘miracle’ drugs must be prescribed to 140 low-risk patients for five years.5 For a single heart attack or stroke to be prevented in the group at lowest risk (but whose blood cholesterol levels are nevertheless above 5.01 mmol/L), 167 patients will require treatment for five years.6 After a heart attack, statins will need to be prescribed to 82 heart patients to prevent a single fatal heart attack, to 39 to prevent a single non-fatal heart attack, and to 125 to prevent a single stroke.7 More importantly, in those at low risk, statin therapy has no effect on the really crucial outcome measure: all-cause mortality, which is the measure of deaths from all causes (including, for example, cancer, T2DM and infection).8
When the ‘average postponement of death in statin trials’ (i.e. the extension in lifespan) is calculated, the results are equally unimpressive. In one literature review, Malene Kristensen, Palle Christensen and Jesper Hallas found that the ‘median postponement of death for primary and secondary prevention trials were 3.2 and 4.1 days, respectively’. (Primary prevention refers to trials in people without evidence of heart disease at the start of the trial, while secondary prevention trials are in people with established heart disease.) The authors concluded: ‘Statin treatment results in a surprisingly small average gain in overall survival within the trials’ running time. For patients whose life expectancy is limited or who have adverse effects of treatment, withholding statin therapy should be considered.’9
It is of little value to take a drug that might marginally reduce one’s risk of suffering a heart attack or stroke if it increases the risk of dying from something else, without any extension in life expectancy. B
ecause statin therapy is not without risk of long-term adverse consequences, including an increased risk to T2DM10 and perhaps Parkinson’s disease,11 some ‘mavericks’ suggest that healthy people should not take statins simply because they have an ‘elevated’ blood cholesterol concentration.12 Professor John Ioannidis is concerned that, given the prospect of one billion people using statins in the future, with cumulative global sales of statins approaching $1 trillion by 2020, ‘crucial evidence is still missing’.13
In fact, the evidence is not missing. But like the proven benefits of the LCHF diet in the management of IR and T2DM, the definitive proof that statins do not work is simply not seen. There are now at least 44 cholesterol-lowering trials, including the testing of eight different classes of drugs, all of which establish that lowering cholesterol through diet or drugs ‘does not significantly prolong life or consistently prevent CHD’.14 Thus Robert DuBroff proposes that ‘we must accept the empirical record even though it contradicts our long-held beliefs. Other researchers believe this reluctance can be explained by the tendency to “see what you want to see,” and ignore what you do not.’15 Clearly the UCT cardiologists do not want to see that which is so dreadfully inconvenient.
But on what evidence do conventionally trained cardiologists base their certainty in what they do?
Cardiology is responsible for initiating and performing more unnecessary, non-evidence-based and costly medical interventions than perhaps any other medical discipline. For example, the most lucrative therapy, coronary artery bypass surgery, is unnecessary for the vast majority of patients with stable coronary artery disease, including those with more advanced disease.16 It is also a procedure that carries significant risk of mental impairment. It has been shown that these patients can do extremely well on medical management without coronary artery bypass surgery.17 Similarly, in a meta-analysis of randomised trials comparing percutaneous coronary intervention (i.e. coronary artery ‘stenting’ and angioplasty – the unrestrained use of which ensure that cardiology is an especially lucrative medical speciality) with conservative medical treatment, the authors found that: ‘In patients with chronic stable coronary artery disease, in the absence of recent myocardial infarction [heart attack], percutaneous coronary intervention does not offer any benefit in terms of death, myocardial infarction, or the need for subsequent revascularization compared with conservative medical treatment.’ As a result, ‘we believe that many percutaneous interventions that currently are performed in patients with non-acute coronary artery disease are not justified’.18
There are essentially two reasons for this conclusion. Firstly, even patients with severe coronary artery disease are not at death’s door as we are led to believe. Research has found that these patients have an annual mortality of less than 1.5 per cent. In other words, when receiving standard medical care, 98 out of 100 patients will still be alive at the end of the first year of treatment.19 Secondly, complications caused by coronary artery disease, including heart attack and sudden death, arise when the coronary arterial plaque ruptures, causing the sudden obstruction of blood flow to the heart.20 However, the vast majority of these ruptures, perhaps as many as 85 per cent,21 occur in coronary arteries that are not considered candidates for bypass surgery, ‘stenting’ or angioplasty because the plaques that ruptured were considered too small to warrant any of these interventions.22
In their comment on the case for medical treatment in chronic stable coronary artery disease, Thomas Graboys and Dr Bernard Lown conclude by asking:
So why the more than 1 million annual invasive coronary procedures? Regrettably, left unmentioned is the factor that trumps scientific evidence – namely, the economic advantage that costly interventions afford to hospitals, to interventionist cardiologists, to cardiac surgeons, and to others. Medicine as a calling would be far better served if criteria for coronary artery interventions were determined by issues that truly matter to patients, such as survival and long-term well-being.23
Why are so many patients unaware of these facts? According to Dr Lown, a pioneering cardiologist, members of our profession indulge in ‘fear mongering’.24 Telling a patient he is ‘a walking time bomb’, ‘this narrowed coronary artery is a widow maker’ or ‘you are living on borrowed time’ places the cardiologist in control, establishing a parent–child relationship between doctor and patient. And the child is usually too scared to ask any questions.
Lown eventually decided to stop referring his heart patients for coronary angiography because he understood that, in the 1970s, the sole possible outcome would be coronary artery bypass surgery (today it is angioplasty or ‘stenting’). The reaction from his peers was interesting. ‘For the first time in my medical career I received phone calls from outraged physicians accusing me of abandoning science or of setting cardiology back to the Dark Ages,’ he said. Not much has changed, it seems.
Perhaps cardiologists should take heed of the old dictum that ‘those who live in glass houses should not throw stones’. If you make your money prescribing drugs or performing invasive procedures that have little or no proven benefit and which may cause harm, you need to be very wary of accusing others of doing harm. When it comes to the dietary advice that I promote, you should be especially cautious, as there is no published scientific evidence that it causes harm.25
My response to the cardiologists’ letter was published in the Cape Times on 17 September 2012. Titled ‘Time to admit that heart disease theory has failed’, it read:
Professor Patrick Commerford et al’s letter to the Cape Times (‘Noakes has gone too far’, September 14) refers. As I wrote in Challenging Beliefs, a 2010 meta-analysis of studies involving 347 747 subjects published in the American Journal of Clinical Nutrition found ‘no significant evidence for concluding that dietary saturated fat is associated with an increased risk of coronary heart disease or cardiovascular disease [CVD]’. A 2011 report from the Cochrane Collaboration, an organisation that is independent of the pharmaceutical industry, found that ‘there was no clear evidence for dietary fat changes on total mortality or cardiovascular mortality’. Thus the scientific evidence is clear: A low-fat diet has no proven role in the prevention of (coronary) heart disease. It is time that cardiologists began to teach this fact in our medical schools.
So if a high-fat diet does not cause heart disease then what does? In carbohydrate-intolerant subjects like myself, a low-fat/high-carbohydrate diet produces all of the following abnormalities, some of which are causally linked to arterial damage and heart disease:
1. Elevated blood glucose, insulin and glycated haemoglobin (HbA1c) concentrations. The best predictors of heart attack risk are blood HbA1c and random glucose concentrations. Elevated values in diabetics increase heart attack risk 7-fold. In contrast, an elevated cholesterol concentration increases heart attack risk about 1.3-fold, a value low enough in statistical terms to be potentially spurious.
2. Low blood HDL [high-density lipoprotein]-cholesterol and high triglyceride and uric acid concentrations.
3. Increased numbers of small, dense LDL-cholesterol particles. In contrast, a high-fat diet increases the number of large, fluffy LDL-cholesterol particles that are not related to heart attack risk.
4. Elevated blood lipoprotein(a) concentrations.
5. Obesity and, in my opinion but as yet unproven, elevated blood pressure.
6. Elevated ultra-sensitive C-reactive protein concentrations indicative of a whole-body inflammatory state.
7. Elevated blood homocysteine concentrations (due to dietary deficiencies in folic acid, vitamin B6 and B12 found in eggs and meat).
If the cause of heart disease was truly known (as is the cause of HIV/AIDS), then the condition should have disappeared with the universal promotion of the so-called ‘heart-healthy prudent diet’ and the annual prescription of tens of billions of dollars’ worth of cholesterol-lowering drugs globally. Yet one of the leading causes of death in the USA is now chronic heart failure caused by coronary heart disease. To service i
ts burgeoning heart disease problem, the US now requires twice the number of cardiologists currently in practice (17 000). If current dietary and therapeutic advice was effective, cardiology and cholesterol-lowering drugs should be going the way of the dinosaur. Instead both are major growth industries. No wonder both fear ‘cholesterol denialists’.
In 1900, when most Americans cooked in lard and ate a diet full of butter and dairy produce, pork and saturated fat in meat (but low in sugar and processed foods), heart disease was so rare that their most famous cardiologist, Dr Paul Dudley White, encountered his first case only in the 1920s (although the disease has since been described in grain-eating Egyptian mummies). Today in a nation that has replaced animal fats and dairy in its diet with ‘healthy’ carbohydrates, heart disease, like obesity and diabetes, is rampant.
With regard to statin therapy, I advise anyone who does not have established heart disease or genetic hypercholesterolaemia, and who is either already taking or considering using cholesterol-lowering drugs, to read The Great Cholesterol Con (2006) by Anthony Colpo. This book should also be required reading for all my colleagues, medical students especially, who are currently prescribing these drugs or who plan to do so in the future.
The theory that blood cholesterol and a high-fat diet are the exclusive causes of heart disease will, in my opinion, prove to be, like the miasma theory, one of the greatest errors in the history of medicine.