Reading Time: 7 minutes

I received the following comment, I assume, from Dr. Garth Davis.

If this is Garth, great. If it is a troll, also OK, as this gives me the opportunity to fully discuss important issues about science communication and poor quality vegan diets.

For context, my disagreement with Garth started over the plant-based diet documentary film The Game Changers.

I have been very disappointed in the reception of The Game Changers by the plant-based community. I have a lot of respect for James Wilks–he is both well-meaning and clearly very intelligent–as well as many of the other people involved in the film.

However, there is very clearly a great deal of exaggeration in the film and of taking license with the facts to sell a story. This story gives the impression of benefits to meatless diets, especially with respect to athletic performance, that are not commensurate with a sober and impartial look at the evidence, and using means that misrepresent the facts. Layne Norton has provided a helpful overview of many of the important factual problems with the film.

However, these factual errors will not be the focus of this article. Instead, I will discuss what the role of factual errors is in scientific communication, as well as what I think the real problem with The Game Changers is: namely, that it poses a real risk of harm to the health of viewers who follow its advice by promoting a poor-quality diet.

Good Enough nutrition science communication

Some might excuse this problem with the film by arguing that switching to a healthy plant-based diet can and does have dramatic, positive health benefits for many or most people, even if the film does take some liberties with some of the facts.

According to this point of view, when talking to lay audiences, a precise representation of the facts is less important than a representation of the facts leading the audience in essentially the right practical direction.

In fact, precisely representing the facts might get in the way of representing the essential practical truth of the facts: being precise with the science might actually prevent one from telling a compelling and essentially true story that might be of benefit to audiences.

(The nuances of a strictly entirely true story, for instance, might be so complicated that they detract from the main point.)

This is a point of view that I struggle with all the time. And I think that there is some important truth to it. Ultimately I reject it as a starting point for science communication, though, for two reasons.

The harms of Good Enough science communication

First, powerful stories that involve misrepresentation of individual facts, even if that misrepresentation of individual facts leads to a “proper” representation of the big picture, eventually take on a life of their own and can be used for other purposes.

For instance, the insight that saturated fat intake is probably a dietary risk factor for cardiovascular disease can be conflated with fat phobia. This fat phobia, in turn, might be endorsed because it is “good enough” and leads to restriction of saturated fat.

This fat phobia, which is probably scientifically unjustified, then can be used by other interests to promote the idea that, so long as one does not eat fat, one will not get heart disease. Perhaps this is also “good enough” because it causes people to avoid saturated fat.

But, finally, this leads to endorsing high-sugar, low-fat products as “heart healthy”. Since they have little fat.

A story that was “good enough” over several permutations of “good enough” becomes counterproductive and harmful. What’s worse, this problem becomes entrenched in institutions of authority and a part of the orthodoxy and very difficult to change.

Exhibit A:

Honey Nut Cheerios Certified as “heart healthy” by American Heart Association

As I showed using a very basic risk calculator, while LDL levels, which are modified by fat and dietary cholesterol intake, are an important risk factor for cardiovascular disease, they are not the only risk factor modified by our food. If they were, then unhealthy plant-based diets, which do not contain dietary cholesterol or much saturated fat, would not increase risk of cardiovascular disease.

Yet, this breakfast cereal of clearly questionable nutritional value (nearly half of the carbohydrate content is from added sugar) is certified by the American Heart Association for the sole reason that it contains little saturated fat and dietary cholesterol.

Yet this is clearly at odds with current science, which shows that of all macronutrients analyzed, replacing saturated fat with carbohydrate and probably especially refined carbohydrate has a very modest impact on lowering LDL compared to other macronutrients. Substantial evidence suggests that refined carbohydrate might not be an improvement on saturated fat for lipids after all, and each might raise risk of coronary heart disease to an equivalent degree compared to other sources of energy.

Refined carbohydrates are associated with coronary heart disease to a similar degree as saturated fats

Yet because of the longstanding and myopic focus on saturated fat and dietary cholesterol–so long as it is low in each, it must be heart-healthy!–this distortion, this health-washing continues with the blessing of the American Heart Association. Dislodging this entrenched misinformation will be very challenging indeed.

This is why we must always insist on the facts and only the facts. Before we know it, our distortions have gotten away from us, and the story we invented is no longer the one that we control.

Good Enough science communication is a slippery slope that most certainly will be exploited by parties whose interests are not science. And there are many such parties. Science is fragile. Money is powerful.

Good Enough nutrition science communication may yield short-term benefits at the expect of long-term loss of trust

This leads to my second reason for rejecting the Good Enough point of view: it will produce short-term gains but for the reason I discussed above (and others), it will erode trust in science.

Not only will intelligent people see through the flimsy justifications for this or that Good Enough-based policy or recommendation or claim, but the unintended consequences will also lead to a loss of trust in science itself. Because while what was communicated was not itself science, it was portrayed as science; thereafter, science will be viewed with suspicion, for no fault of its own.

This will in turn impede scientific authorities’ future efforts in bringing about or guiding policy change that is consistent with science, which will be a great loss for everyone.

Scientists will come to be seen as having “agendas” and as selectively communicating the facts. This distrust will give rise to alternative sources of authority, who will themselves make the fanciful storytelling of the Good Enough storytellers look tame by comparison. Witness: the rise of the ketogenic diet and LCHF.

So I reject Good Enough and insist on strict adherence to reporting the facts. This is a substantial constraint in telling a good story, but not, I believe, an impossible one to overcome. So far, very few people in the nutrition science space have seemed to really try to do both. We seem to have so little faith in the truth.

The main problem with The Game Changers is that its message might harm substantial numbers of people

But even if I thought that the kind of science communication that distorts facts in service of communicating an overall “accurate” practical point of view was justified, would this apply to The Game Changers? I think not.

As I argued in this post, The Game Changers is a film that represents plant-based diets as healthier than omnivorous diets without respect to quality–in fact, mainly promoting poor-quality plant-based diets, presumably to appeal to the broad public.

Why The Game Changers risks harming the health of those who follow its advice

In doing so, the film not only does not use the means-ends reasoning that Good Enough science communication does, it actually risks harming viewers who follow its advice. This is why, from no point of view except, perhaps, a very ruthless kind of ethical or environmental veganism, can the information communicated in The Game Changers be justified.

Unless supplemented by explanations that whole foods are necessary to unlock the health benefits of plant-based diets, and that junk food plant-based diets are harmful to health (which would contradict the message of several key scenes in the film, as I document in my post), by no means can the film be justified or should it be endorsed by health professionals, whose professional obligation is to the health of human beings and not to the well-being of animals or the environment.

One debates opinions but discusses science

That aside, if this really is Garth, I would be glad to discuss this issue and others, but not to debate. The only positions that I have that are “set in stone” are principles. I think that we will broadly agree about both these and about what the science says.

Interpreting science is really just about reporting what the literature says. It is almost mechanical. While it is complicated in the details and while a priori philosophical commitments can affect how one “assigns weight” to different kinds of evidence… my belief is that reasonable people, if they invest the appropriate time and seriousness, will ultimately come to essentially agree on the details, strengths, limitations, etc. of what the current body of literature says. From this point of view, either a person is ideologically motivated and thus not a part of a scientific discussion and not worth seriously talking to, or they are not ideologically motivated and a discussion is possible.

Given the above, if a discussion is what you want, Garth, I am down for that. Let us arrange it.

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Reading Time: 6 minutes

As a former Paleo dieter (for 10 years!), the ideas that grains are nutritionally deficient, meat nutritionally rich, and carbohydrates inherently harmful were deeply engrained in my habits of thinking. So much so that my first forays into eating whole grain bread after learning about plant-based diets were marked by an anxiety that lasted for years–“am I eating carbohydrates instead of fats for an ideological reason, at the expense of my health? Surely these plant-based writers cannot be right?”

Well, certainly the plant-based writers are not right, as I understand now that they could not impartially analyze their way out of a wet paper bag. Still, those days of carb anxiety are long over, as I now understand carbohydrate and fatty acid metabolism to a sufficient degree as to now be inoculated from the Paleo/keto/low-carb/low-fat macronutrient fear-mongering. (When I say “understand”, I mean that I understand how little we know–and how, when popular nutrition writers inveigh against carbohydrates or fats in the diet, they are, to be generous, reading the scientific literature creatively.)

But what had lingered was the sense that, because grains are nutritionally deficient relative to meat, I needed to be especially careful to avoid the nutritional downsides of wheat bread, of which I ate copious quantities.

See for example the bloggings of the major Paleo writers.

Chris Kresser:

Robb Wolf:

So surely whole grains have a well-justified bad reputation?

It is worth noting that neither writer actually explains how the “nutrient density” algorithms determine the rankings that they report. My guess is that, as with much they write, they did not in fact critically analyze the primary sources that they used to make their recommendations but instead used the ready-made listings that agreed with their biases.

That is my guess, in any case, because when I actually looked at the raw data, I saw a different story, which is significantly more complex. This was purely accidental, just the result of playing with Cronometer. Yet what I found shocked me.

For instance, here is the nutritional profile for 2500 calories of whole wheat bagels:

10 whole wheat bagels, 2500 calories

Now here is 2500 calories of lean ribeye, the favored cut of the online so-called carnivore subculture.

36 ounces of ribeye, 2500 calories

All-ribeye diet: severely deficient in 9 nutrients, moderately deficient in 4. All-bagel diet: severely deficient in 6 nutrients, moderately deficient in 1.

In other words, if one could choose between only wheat or meat, and one was aiming at nutrient adequacy, the answer is clearly wheat.

Of course choosing between eating only meat or only wheat would be insane, but the former is, as I said, just what one online subculture has chosen to do. (I am just reporting the facts.) Not a coincidence, Robb Wolf, mentioned above, helped to promote the growth of this subculture.

What happens when one slightly diversifies the plant foods?

2500 calories, half lentils, half wheat bagels:

Half wheat bagels, half lentils

All-ribeye diet: deficient in 13 nutrients: severely in 9, moderately in 4.
Half-bagel, half lentil diet: deficient in 6 nutrients, severely in 6.

What about reducing wheat and lentils to 43% of total calories each (86% together), putting almonds at 9% of calories (a handful of almonds), and making up the final 5% of calories broccoli and carrots (a handful of each) and sardines (a single sardine, 1.6% of calories)?

I call it the Poverty Omnivore Diet, and it is very nearly my own diet (as an amateur athlete, I add supplemental protein for optimal recovery and muscle mass, and a lot of berries):

A diet of 86% legumes and grains, with very modest quantities of nuts and vegetables

Add sunlight, and you are meeting all of your vitamin, mineral, and protein needs in spades.

For reference:

Again, for comparison, here is an all-ribeye diet:

To provide a further contrast, it is easy to find claims by pseudoscience pushers online that animals are more “nutrient dense” than plants:

That said, a few points are in order.

First, it is sometimes claimed that meat nutrients are more bioavailable than plant nutrients. For a few minerals, this might be true, but I’m not aware of any evidence that this has a meaningful impact on nutrient sufficiency. If readers are aware of such evidence in an otherwise nutrient-rich diet such as the one I have posted, please leave a comment or contact me.

Second, the idea that grain consumption led to worsened health at the beginning of agriculture has led to much speculation that grains per se are suboptimal foods. A paper that reviewed all of the literature on the subject, published in 2011, concluded that stature certainly diminished in most (but not all) human populations during the transition to agriculture. Yet in its discussion, it focused on famine as the likely explanatory factor, not grain intake per se:

Furthermore, if grain consumption and agriculture was the cause of reduced height, then average height would not have increased dramatically over the past few centuries (the Western diet is still heavy in grains):

Finally, if grains replacing meat were the cause of reduced height during agriculture, then vegetarian children wouldn’t be of similar height as omnivorous children. Yet they are.

So why are Paleomyths about meat being more nutrient-rich than plants so widespread, despite the actual story being much more complicated (to say the least)?

My guess is that this is largely motivated by modernity anxiety. For all of human history, humans have idealized and romanticized simpler ways of life, as exemplified by our hunter-gatherer ancestors. We imagine our hunter-gatherer ancestors all ate large quantities of meat. It follows that we should eat meat. We therefore look for sciency-sounding reasons for this belief. Folks like Chris Kresser, Robb Wolf, and Mark Sisson all provide these sciency-sounding reasons. Because this is what we already believed anyway, and we are just looking for reasons to believe it, instead of critically evaluating what these bloggers write, immediately we think “ahhh so that’s why!” We are already primed to believe, not to question. And so we believe. Or at least, once upon a time, I did.

The reality is that the role of plant foods in our ancestors’ diets is substantially more complicated than these writers let on. For instance:

And the rabbit hole goes much deeper. But that is a subject for another post.

Suffice to say, every scientific field is more complicated and richer in controversy than we think at first. Often, we first access a scientific field via a popular writer who tells a good story and appeals to pre-existing beliefs to sell that story. Yet no matter if they are a New York Times bestseller or a famous columnist or respected by large popular audiences on the Internet, we should always be skeptical of the new things we learn, especially if they resonate with and make sense of what we already believe. Unless we are aware of and have critically assessed the relevant body of scientific literature, there is no way whether we are being sold a good yarn or something with strong basis in scientific fact. Until we know better, we need to proceed through life with the assumption that most of what we know is simply a “best guess” based upon “something that we heard that sounded credible”. Because that’s all it really is. My journey through nutrition science, especially with respect to grains, carbohydrates, meat, etc., has taught me that over and over again.

UPDATE

Some people have pointed out that ribeyes should not have carbohydrates. I do not know why the entry at the USDA has ribeyes with carbohydrates. Therefore, I have found a new ribeye entry:

Slightly better than the ribeye I included originally. Still not as good as grains.

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Reading Time: 8 minutes

One of the most popular and potentially deadly nutrition documentaries of recent years

The Game Changers is a documentary available on Netflix and iTunes. It is the best-selling documentary of all times on iTunes and will likely prove to be one of the most famous nutrition documentaries for years to come.

The Game Changers however has a fatal flaw that puts a substantial number of its viewers at substantial risk of potentially deadly adverse health outcomes. Here’s how.

A famous study

The below graph is from an abstract for a very famous and popular article (among cardiologists) published by researchers at Harvard in 2017.

It shows that eating more healthy, whole plants is associated with a lower risk of heart disease. Meanwhile, eating more meat (“animal foods”) is associated with higher risk of heart disease. So far, so good.

But what makes this study so popular among cardiologists is that it also shows that eating unhealthy, refined plant foods is associated with higher risk of heart disease.

Cardiologists use this paper to communicate an important point:

Going plant-based is not enough.

One must eat healthy plant-based foods. If one replaces meat with unhealthy plant-based foods, this might make one’s health even worse. There is even a name for this: junk food vegans.

Oreos are one of the classic vegan junk foods and is indeed widely promoted by animal rights organization PETA:

According to the above study and others, one is not doing one’s health any favors by swapping meat for vegan pizza, ice cream, and Oreos. While vegan junk food might taste good, a plant-based diet rich in junk foods is actually worse for health than the average omnivorous diet.

So not all vegan diets are created equally. Some are even created worse.

Junk food vegan? Or whole foods? How The Game Changers confuses and may endanger lives

So it is surprising and disappointing that this now well-known fact among plant-based health experts was not conveyed in The Game Changers. In some scenes, the film even seemed to suggest that replacing meat with junk food would produce better health.

This is false and will lead to worse health among viewers who get this impression.

An analysis

To objectively characterize this problem, I quantitatively and qualitatively analyzed every line in the film, using a search function on a document containing all speech in the film, then collating all statements containing particular keywords. Below is a screenshot of this work:

(This file can be downloaded here.)

Here’s what I found.

The word “plant” or “plants” appeared 69 times. The vast majority (65) were in a context arguing in favor of their consumption in lieu of meat, without specifying what kinds of plant foods should be eaten.

The word “meat” appeared 57 additional times. These were also all in the context of advocating their reduction, without addressing what they should be replaced with.

The concept of whole foods veganism was never introduced; emphasis instead was placed on hyperprocessed vegan foods

In only two occasions were “whole foods” mentioned, and only in passing. They are as follows:

“A whole food, plant-based diet is gonna optimize the growth of blood vessels into damaged tissue, it’s gonna lay down new tissue in tendons and muscles, it’s gonna stimulate their immune system to fight off infections.” (31:41)

“When you eat a healthy, whole foods, plant-based diet, it changes the expression of your genes.” (1:15:14)

(For the remainder of this review, I will be including in parentheses the time point in the video where the quotations can be found. My timepoints might differ slightly from yours, depending upon the release. Adjust accordingly.)

The term “whole food plant-based diet” is a staple among advocates of plant-based diets in the medical community, yet in neither of these cases was the concept explained. This was a grave mistake. While plant-based diets can be healthful, if they are composed of junk foods, they can be harmful if they replace a diet containing more meat and less junk.

Alarmingly, there were two statements that seemed to endorse vegan junk foods.

This is from Derrick Morgan, an NFL player and a key interviewee in the film:

“Yeah, I love to eat. In the beginning I was like, I gotta psych myself out to say I don’t care about flavor anymore. It wasn’t really a sacrifice. She was still cooking, you know, mac and cheese and chicken wings. Just plant based.” (00:59:51)

This line implies that nothing needs to improve diet, so long as one goes vegan, and one will enjoy improved health. One can eat the same mac and cheese and chicken wings, but if they are plant-based, they become healthy.

This is harmful misinformation.

The second line is from his wife Charity:

“These are plant based burgers. Grill up, smell, and taste like beef. And I’m making truffle mac and cheese, buffalo wings, kale caesar salad, crispy Brussels sprouts with a smoked sauce reduction, and we’ll finish off with a peanut butter cheesecake.” (01:01:10)

Plant-based burgers on plant-based refined buns with plant-based buffalo wings and peanut butter cheesecake.

Sounds a lot like the unhealthy plant-based diet associated with higher heart disease mortality.

Here are some images from the film:

There was a similar scene with Rip Esselstyn (38:17), showing relatively more healthy plant-based foods. Yet while the scene with Charity and Derrick Morgan and teammates focused on the deliciousness of the junky vegan food, the health superiority of the foods introduced in the scene with Rip at the firehouse was never explained. In other words, there was an asymmetry in representing healthy versus unhealthy plant-based diets, and this asymmetry leaned in favor of unhealthy plant foods. This is a serious and harmful flaw.

A caveat?

There was one part in the film where James speaks on the harms of refined carbohydrates. He says:

“I already knew that processed carbs like white flour and sugar can lead to weight gain, but what I didn’t realize is that unprocessed carbohydrates like oats, bananas and sweet potatoes are associated with decreased body fat.” (58:38)

Yet this comes just one minute before the long scene showing the football players talking about and eating junky vegan foods.

Which part did you remember? The seconds dedicated to the harms of white flour and sugar? Or the minutes of video dedicated to delicious-looking junky vegan foods containing white flour and sugar being consumed by some of the film’s stars?

The promotion of unhealthy vegan foods–and thus unhealthy vegans–was it intentional?

The promotion of unhealthy foods was not an accident. It was intentional. The word “vegan” was mentioned 11 times. In 9 cases, all that was implied was that a vegan diet was better than a diet containing meat, without specifying what kind of vegan diet.

Alarmingly, in 2 cases, vegan junk food was endorsed:

It’s best to lead by example. Most people say, “Oh, I just can’t become vegan.” I said, “You’re right. It’s a process to it.” I’ll give you guys some vegan chocolates. (01:17:22)

Really just… I like pizza. If I’m about to just chow down, like really get it, – man, a lasagna. – If you like chicken nuggets, okay, they have vegan nuggets. If you like meatballs, they got vegan meatballs. A lot of pizza, pasta and burgers. Sometimes even at the same time.

I will not give a time stamp to that line. Why? Because it was the closing line of the movie.

The film closed by emphasizing unhealthy vegan food. This implies that the lack of emphasis on healthy vegan food and the focus on unhealthy vegan food was an intentional design feature of the film.

Look at the following graph again:

And think for a moment about what the apparently focus on unhealthy vegan foods implies.

This problem could have been fixed with just a few minutes of a single interviewee emphasizing and explaining the importance of a plant-based diet that is rich in whole foods, but in the entire 83-minute documentary, this was never done.

Not once.

Instead, the film closed with a line endorsing a plethora of unhealthy vegan foods. “Sometimes even at the same time.”

A website that is just as confusing and harmful as the film

On the Core Principles page of the website, we find the following paragraph:

While most people understand that sugary drinks like soda, fried foods like potato chips, and refined flour products like white bread or pastries are definitely not ideal for optimizing health or fitness, few people understand that a diet based on animal foods — whether whole (like chicken breast and eggs) or heavily processed (like bacon and cheese) — is of far greater concern than misguided fears like “eating too many carbs”. And even fewer understand that the overwhelming body of scientific evidence shows that choosing a diet centered around a wide variety of plants, especially in their whole form, is the single most powerful tool we have for the prevention, treatment, and even reversal of many of our most common diseases.

The first sentence alone is confusing. For people who do not understand precisely what carbohydrates are and confuse them with white bread and pastries (not realizing that many healthy carbohydrates also exist), this first sentence seems even to excuse hyperprocessed foods like these, suggesting that animal products are more harmful. This is false. Animal products are likely less harmful than such foods.

But the second sentence is the real zinger. Let’s look at the most confusing part:

the overwhelming body of scientific evidence shows that choosing a diet centered around a wide variety of plants, especially in their whole form, is the single most powerful tool we have:”

The operative word is not “especially”. It is “only”. “Only in their whole form” is how this phrase should read. Refined, junky plant foods are not helpful for the prevention of disease. Yet this sentence implies that the whole food part of a plant-based diet is optional. This is not true, and a diet consisting of many refined foods will cause greater harm to health than the average omnivorism will.

When we click on the Recipes page, we find similar ambiguity with the opening image:

Junk food, veganized.

This will not improve health. Foods like these replacing other breakfast foods like eggs may well harm health.

The role of animal foods and unprocessed foods in a healthy diet

This does not imply that junk foods should never be consumed. They can be consumed, in moderation. Yet the film never makes this distinction. This is unfortunate because this basic piece of nutritional literacy would be helpful to people who believe that simply avoiding meat will improve their health.

It will not.

If most of your calories are coming from hyperprocessed foods like pastries, bagels, crackers, donuts, etc., then your health would probably be better off if you replaced these calories with animal foods.

Without these caveats, the film should be regarded as harmful for the public health and not be promoted or shown in public institutions. Contrary to what James Wilks claimed on the Joe Rogan Experience, this film effectively does not primarily extol the health virtues of healthy plant-based diets. Rather it really does prioritize the promotion of veganism–in the name of health but, for many people who will be confused by the film’s messaging, despite the negative health consequences that will ensue.

Coming from someone who consumes a predominantly whole foods plant-based diet, I believe much to my dismay that this film risks causing significant damage to the cause of predominantly plant-based diets.

Coming from someone who consumes a predominantly whole foods plant-based diet and who believes that predominantly plant-based diets can be healthy and should be much more widely consumed, I believe much to my dismay that this film risks causing significant damage to this cause.

If you want optimal health on a plant-based diet, the large majority of calories must come from unprocessed foods. If you would like ideas about how to achieve this, Google “whole foods plant-based diet”, and you can get started.

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Reading Time: 3 minutes

A common refrain of Health At Any Size people is that, “But only 5% of people achieve sustained weight loss!”

Then follows the suggestion that, therefore, nobody should try to achieve sustained weight loss.

This 5% figure is a fiction, as one can see from scientific reviews of the research literature. Read carefully:

In fact, in the right circumstances, an impressively large % of overweight people can maintain an impressively large amount of weight loss. Read the above. It is simply wrong that long-term weight loss is “impossible”. A large number of people do it, and they do a lot of it.

But for a moment, let’s pretend that the 5% figure was correct: only 5% of people maintain sustained, long-term weight loss, right? Here’s the kicker: for most people we give medical treatments, an even smaller percentage will benefit.

Yep, not only is weight loss possible among a rather large % of people, but even if were only 5%, this would still be better than many of our mainstays of medical treatment.

How can this be? Let us take a look. Statins.

Only about 7% of individuals will benefit from a statin. Now this benefit will be equal to about 99 months of life, but only 7% of people will benefit from a statin.

In many weight loss studies, many more than 7% could sustain long-term weight loss! Does this mean we should throw statins out as a medical treatment, because we’re throwing out weight loss?

Blood pressure medications. Only about 1 in 125 people will avoid death from taking a blood pressure medication. Throw out blood pressure medications?

Mammograms. Only about 1 in 2500 women will avoid death because of mammograms. Throw out mammograms?

Prostate cancer screening. Only about 1 in 50 men will avoid death because of prostate cancer screening. Throw out prostate cancer screening?

Colorectal cancer screening. Only about 1 in 1250 people will avoid death from colorectal cancer screening. Throw out colorectal cancer screening?

Metformin for diabetes. Only about 1 in 14 people will avoid death by being treated by metformin for 10 years. That’s *still* worse than the number who will lose weight in many studies.

Am I cherrypicking? Nope. The case for drugs not causing a benefit in most people was also made on http://sciencebasedmedicine.org in an article called “Most Patients Get No Benefit from Most Drugs“.

These are easily demonstrable, widely accepted facts. Modern medicine saves lives. It improves the quality of life. But on the whole, it is pretty weak. However, applied many times over and to many people, and we get millions of lives saved. It adds up.

But what about weight loss? How much death would be avoided per person assigned to receive weight loss in a clinical trial setting?

According to this paper, which analyzed a total of 15 weight loss randomized controlled trials involving 17,186 obese participants, about 12 pounds of weight loss in obese subjects over a mean follow-up period of just 27 months resulted in a 15% reduction in death from all-causes. Including only trials with a follow-up period of 4 or more years yielded the same result.

Just 12 pounds? With a mean follow-up of just 27 months? 15% reduction in total deaths.

Still, for comparison’s sake, I calculate the number of people needed to attempt weight loss to avoid one death in the 27-month follow-up period using the findings of the above paper:

187

Not as good as metformin, roughly comparable to blood pressure medication, vastly superior to mammograms and colorectal cancer screening. So again, throw out blood pressure medications, mammograms, and colorectal cancer screening?

Even though modern medicine saves millions of lives, much of it is still weak compared to long-term weight loss. Yet the HAES people say that because not everyone can lose weight, nobody should try to lose it.

If that’s the argument, then to be logically consistent, the HAES people should reject the screening and treatment of many chronic diseases and much of modern medicine.

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Reading Time: 5 minutes

Most popular health experts are unscientific

Many popular health experts claim to be science-based. They will often provide hundreds of references to support their claims. But citing many references does not mean one is scientific. It only means that one has collected many references.

Most self-proclaimed health experts are in fact very unscientific. They over-interpret the scientific literature. They create controversies where there are none. They form strong conclusions from weak data. They cite papers that support their views and ignore ones that don’t. They dedicate their entire body of popular work to buttressing an ideology or set of ideologies.

Their goal is not science per se but rather the promotion of a certain point of view. And, when credible people or organizations express disagreement with their conclusions, like clockwork they deploy conspiracy theories to dismiss that person or organization. They behave like cult leaders more than they behave like scientists.

What is sensational and sciency succeeds in the current media environment, not what is scientific

We want answers regarding how to be healthy. So when someone who is passionate provides us with an extensive, plausible-sounding series of arguments, we want to follow. How else, after all, are we going to become healthy, than by trying SOMETHING? And that something, provided by the extensive scientific-sounding claims from popular health experts, is likely to be better than nothing. So we do it.

But why THIS something? Why this advice?

Because it is sensational. Whatever is sensational generates greater buzz in the popular media. Thus, whatever we are exposed to is likely the result of a selection process, where the sensational survived and the drab perished. Sensational plus sciency equals pop health. (Sciency: appearing to be scientific but not actually being so.)

Whoever can be sensational and sciency at the same time, wins. The work of Gary Taubes and his countless low-carb followers is a perfect example of this. It is very sciency and very sensational. The work of Michael Greger and his followers (as well as his predecessor John McDougall) functions similarly. Sciency and sensational. Overturning the received wisdom. With “science.”

But what we really want are claims that are true. The current media environment that has gotten the claims to our doorstep is not giving us what we really want. We want the best way of achieving health according to a reasonable, scientific understanding of everything published to date. And the media is not giving us this because it rewards sciency and sensational, but it has no mechanism for ensuring that what is sciency is actually scientific.

Popular experts must have a scientific mentality if we want for their advice to be at the cutting edge of science

The true scientific mentality consists of a constant effort to understand the world and then to test–and if necessary–disprove that understanding. This is because the person with the scientific mentality really wants to know what is actually true. The person with the scientific mentality is happy if they discover that their current beliefs are not true, because that brings them one step closer to beliefs that actually ARE true.

For this person, false beliefs are a barrier to truth and must be rooted out. This is what people mean when they talk about falsification. Falsification is central to science because it is central to progress toward a final theory of reality, which is the scientist’s ultimate goal. This sounds very lofty, but it also has important practical applications.

A final theory of reality is extremely serviceable, because if we understand exactly how the world works, we can more readily create useful technologies. Thus, in the field of health sciences, science and benefit to patients go hand in hand.

A scientific mindset is the best way to serve patients: false and harmful/unhelpful theories are discarded while true and beneficial theories remain. It follows that an expert that is truly scientific should be trying to constantly overturn their own beliefs. And that promoting just one set of beliefs without criticizing them is a failsafe sign that one has identified someone who is not scientific.

We therefore reach our simple, singular criterion for identifying which popular health experts are science-based and which are not:

A science-based health expert will consistently and competently criticize the design, methods, and findings of studies that agree with the positions that they have taken previously.

They must demonstrate consistent evidence of a scientific mentality. Such an expert will consistently seek out the limitations to their positions. This is actually easy. Because almost all health science has limitations or flaws, we can constantly be gaining a deeper and deeper understanding of how the new and old science is or might be flawed.

Practical recommendations for nutrition and fitness are almost never 100% certain

Health scientists do not come to conclusions or recommendations based on certainty. In almost no area of health science does certainty exist. This is especially true for nutrition and fitness science. Rather, health scientists come to conclusions and make recommendations DESPITE limitations and flaws. Health scientists must weigh the different bits of evidence, with all of the flaws and limitations that are a part of each, against each other. The scientist will always look at evidence in health science and frown.

The recommendations that the health scientist will make are those that make him frown the least. Recommendations in health science are almost always a matter of nodding solemnly, wishing we had better evidence, and then making the recommendation. It is literally impossible to do that in an unbiased and informed way if one does not systematically understand the flaws and limitations of the different positions. Furthermore, since practical recommendations are always hedges, they should change over time as new evidence comes to light which then tips the scale in one direction or the other.

Therefore, a person who is not actively engaged in trying to understand the problems with the science underlying their own recommendations cannot possibly be coming to conclusions based on a scientific understanding of the evidence, and they cannot be updating their point of view in light of new evidence.

A person not constantly questioning their own beliefs in light of the evidence and growing cannot possibly be at the cutting edge of the science.

What most popular health experts do, versus what they should do

Therefore, ask yourself:

Does your preferred health expert seem to be concerned with findings the flaws and limitations of the evidence supporting his or her recommendations?
Do they go deep in looking at the scientific papers and evaluating the design, methods, or findings?

Because if not, then ask yourself:

What is that popular expert actually doing?

We take it for granted that a popular health expert does not behave in the above way, i.e. in a way that is scientific. We take it for granted that popular health experts constantly hype their beliefs, that they should represent a consistent certain point of view, year after year. And certainly this is a more successful strategy for getting a message out.

But shouldn’t we demand that this be balanced by at least some indication that the health expert is concerned with the objectivity of their position? And shouldn’t we be concerned when we see no indication that they are?

Our current system of health science communication has failed, but the way to change is clear

How has our current system of popular health experts helped us? How has it generated anything but confusion? I suggest that we hold popular health experts up to higher standards, to the standard of actual scientists:

What demarcates whether a person is science-based or not is whether they frequently criticize the evidence supporting their own positions. By this criterion, almost no current public health experts are science-based. And I think almost none in fact actually are, so I think this criterion gets things right. The problem is that we have as consumers incentivized hype.

If we want good health information, we need to start incentivizing earnestness. I believe that evaluating health experts on the basis of the above criterion will help to accomplish that.

In the meantime, we also need to explain to children starting at a young age just what science is. It is NOT the next, best cool thing. It is a laborious and constantly unfolding process, especially in the area of health. And the defining feature of this process is thoughtfulness and self-doubt, and the people who balance thoughtfulness and self-doubt with popular communication are the people we should trust. Not hypesters.

I wrote almost a year ago that I wanted to release a quack list. Well, a quack list could easily be generated based on the above criterion. It would include almost all popular health experts. Almost all claim to be science-based, but almost none actually are science-based.

And I really do think that this criterion is a fair one. It’s just radical. But maybe what we need in this age of insane health claims and gurus is exactly that: a radical point of view.

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Chris Kresser, a frequent guest on the Joe Rogan Experience, is awful. This post will explain why.

Kresser is not science-based. He spreads misinformation about health and nutrition science. I cannot detail why all of this misinformation is misinformation because it would take many hours, and I have many other things to do.

I can however explain at significant depth why he is wrong about one particular fact. In doing so, I hope that readers will take away how unreliable he has been about this one particular issue. And I hope that this will cause them to be a little more cautious about everything else that they read from him.

Some may argue that everyone is wrong about some things. This might be true, but this argument does not apply to Chris Kresser. Chris Kresser systematically rejects science, opting to instead promote ideas wildly at odds with the evidence and conspiracy theories to explain why he is right and scientists are wrong. He often purports that modern medicine is out of step with the current science and that he is on the cutting edge. (This is false. In fact, Kresser merely riffs off of popular science books that have claimed the same and is himself often not familiar with the actual scientific literature.)

I cannot emphasize how much Chris Kresser is, in a word, systematically wrong. But perhaps the following post can be a lesson. I have titled this “Part 1” in case I need to make more of these posts to convince others and actually have enough energy to keep doing so. Most likely, I will not, but it is always possible.

Without further ado, Chris Kresser ladies and gentlemen…

Kresser has an incredibly slick and very aesthetic website. As you can see next to the title, his articles are even “Fact Checked”.

“Fact Checked”! What does that even mean?

From the website:

In other words, people on Kresser’s staff, whose salaries he pays and who are not financially independent of him and his extreme views (as we shall see in a moment), must fact check Kresser.

Anyone got any guesses about just how impartial these “fact checkers” who are fact-checking their boss are likely to be? My guess: anywhere from “not very” to “not at all”.

Kresser opens by citing the World Health Organization and pointing out according to recent studies that cardiovascular disease is largely preventable.

True, but what is the largest risk factor according to this study?

“Raised apoB/apoA1 ratio.” Hmm, what is apoB?

As we see from a seminal 2016 article published by the European Atherosclerosis Society Consensus Panel:

ApoB, short for apolipoprotein B, is the constituent lipoprotein on LDL particles.

What does that mean? This is not a primer on blood lipids, but it basically means this: in order to dissolve in the blood, cholesterol needs a protein carrier. This protein carrier dissolves in the blood. The protein carrier for LDL cholesterol is called apolipoproteinB, or apoB. There is one apoB per LDL molecule.

So, remember, the apoB/apoA1 ratio is the ratio of the protein carrier for LDL to the ratio of… wait, what’s apoA1? Easy peasy. ApoA1 is the lipoprotein carrier for HDL.

Remember that lipid panel you got? LDL and HDL are the major components. Well, this is them.

In other words, the ratio of apoB to apoA1 is roughly equivalent to the ratio of LDL to HDL. So what this paper is saying is that the ratio of LDL to HDL is the most important risk factor for cardiovascular disease.

Let’s jump forward.

Here Kresser claims that he is going to “debunk 3 common myths about heart disease.” One of these myths is that high cholesterol in the blood is the cause of heart disease.

But wait a moment. Isn’t a high ratio of LDL/HDL a risk factor for heart disease?

Let’s keep that question in mind as we move forward.

Here Kresser claims that the medical establishment is still diagnosing and treating heart disease according to science that is 40-50 years old. Interesting, because my cardiologist friends seem to be constantly updating their techniques and approaches to cardiovascular disease. Also: I didn’t know that Chris Kresser is a cardiologist!

Perhaps more interesting is this:

“More recent (and higher quality) evidence doesn’t support it.”

Oh really?

Here’s Kresser’s next paragraph:

Clicking on his reference, we see the following:

In other words, on average eggs do not increase the LDL to HDL ratio, which as we saw above in Kresser’s first reference was one of the best predictors of cardiovascular disease risk.

But then…

We see that in hyperresponders, or 25% of the population, this ratio probably is increased: LDL goes up faster than HDL.

Let’s check out the final two paragraphs of this paper. Read the highlighted portions carefully.

First, here:

In other words, up to one-third of the population (people with type 2 diabetes are about 10% of the population) may be susceptible to atherosclerosis (diabetics, as mentioned earlier in the paper, not shown in this blog post) or to a worsening of the LDL/HDL ratio upon consuming dietary cholesterol.

In other words, things are a lot less clear than Kresser lets on.

This, coming from the very article that he is citing in favor of a dogmatic view that dietary cholesterol is unimportant.

That is not what the article that he is citing says.

To put the icing in the cake, the final sentence comments on current recommendations on dietary cholesterol:

Why? Since a large proportion of the population might respond negatively to intake of dietary cholesterol, the paper suggests that dietary cholesterol might best be minimized.

In other words, the article that Chris Kresser cited to show that dietary cholesterol “does not increase the risk of heart disease”? It recommends to minimize intake of dietary cholesterol.

I do not mention this to argue that dietary cholesterol necessarily should be restricted. I only point this out because it makes clear that Kresser is selectively reading the scientific literature in order to make a biased and partisan case for one point of view, while the very literature he cites makes both a more nuanced case and gives the exact opposite recommendation.

What about saturated fat? Kresser writes:

Let’s take a look at the reference, shall we?

Ah, Mensink and Katan’s classic meta-analysis of 60 trials. “Some studies,” Kresser wrote. “Some?”

Still, it’s an old meta-analysis. A more recent one was published in 2016, with Mensink as the sole author, commission by the World Health Organization:

Clocking in at 72 pages, this report contains everything one would want to know about fatty acid replacement, including 91 studies:

“Some studies.”

Let’s revisit that statement again.

“These studies are almost always short-term, lasting only a few weeks.”

Really?

Here is a sampling of one page of the list of 91 studies that Mensink used in his analysis:

84 days, 42 days, 49 days. And that’s just among 10 studies. Some of these studies lasted over 90 days. And many lasted over 50. “Lasting only a few weeks”?

Yeah. OK. Sure.

Here is a characteristic table from the study, showing a powerful relationship between the replacement of saturated fat with other macronutrients on blood cholesterol levels:

In other words, robust changes in blood lipid markers in response to replacement of saturated fat by other macronutrients.

But fine, let’s ignore those studies. What about Chris’s other studies?

Apparently all of those other studies show that cholesterol levels don’t go up with saturated fat?

The reference cited is an article from Stephan Guyenet’s blog.

In it, Stephan makes the case that the observational studies show little relationship between saturated fat and blood cholesterol.

But hey, wait a second…

Observational studies? In other words, nutritional epidemiology? Chris Kresser is now using nutritional epidemiology to demonstrate that there is no relationship between saturated fat intake and blood cholesterol?

But wait- I thought- I thought Chris Kresser thinks nutritional epidemiology is worthless.

Here is what Chris Kresser says about nutritional epidemiology:

I quote: “Pseudoscientific”.

And he uses the entire post to take cannon ball shots at nutritional epidemiology from every angle in like fashion, with quotes such as:

And with sections such as this:

In other words, Chris Kresser lambasts nutritional epidemiology. UNLESS… UNLESS… well, unless it shows that there is no relationship between saturated fat intake and blood cholesterol.

Well, why the fuck not! If nutritional epidemiology shows it, it’s probably true! Nutritional epidemiology is proof that there is no relationship between saturated fat intake and blood cholesterol, even when the randomized controlled trial literature shows a strong relationship.

BUT… nutritional epidemiology is wrong about everything else.

Right Chris Kresser?

Still, if I were playing Devil’s advocate, I would say that, well, Chris could shoot back:

“Yeah sure nitpicker Bass. Blood cholesterol responds in the short-term RCTs. Yeah, and maybe I misspelled “months” as “weeks”. But the point is, how do we know over a long period of time that blood cholesterol declines in response to lower saturated fat intakes? It might be a temporary effect rather than a long-term effect. The long-term data we have shows that, on the order of years, there is no effect of saturated fat intake on blood cholesterol. It might be observational, but it is the only data we have. So at minimum, even though I have repeatedly argued that epidemiological data are trash, we have to accept that blood cholesterol might not be reduced by reducing saturated fat.

QED”

Maybe Chris is right. Maybe we don’t know if there is any effect of reducing saturated fat on blood cholesterol…

If we were living in the 1960s.

Because two very famous studies that sought to test the diet-heart hypothesis (as he calls it) did, in fact, study this very question: could reduction of saturated fat over the course of years cause reduced blood cholesterol levels?

The first in Circulation, an official journal of the American Heart Association:

And it found:

Oh shi-

Here are the methods. Basically, 40% of calories in fat were replaced in the normal diet by unsaturated fat:

Chris Kresser, ladies and gentleman:

But wait, there’s more!

The Oslo Diet-Heart Study, also published in Circulation, this time in 1970:

What happened to the cholesterol?

Yep, it went down.

Here are the methods (from the 1968 version):

So what is it Chris? Do we believe the randomized controlled trial literature of hundreds of studies, verified by at least two long-term trials?

Or the observational epidemiology?

Another question: why is it that Chris forgot about these incredibly famous studies when reporting the role that unsaturated fat plays on blood cholesterol?

Then Chris Kresser decides that a 6-foot grave isn’t deep enough and wants to go even deeper. So, he talks about low-carbohydrate diets:

What a coincidence! A new, comprehensive, 24-page report on low-carbohydrate diets, including every study and meta-analysis on the various effects discussed was recently published by the National Lipid Association in the Journal of Clinical Lipidology:

To be sure, the National Lipid Association is one of the most respected lipids organizations in the world. And researchers from many of the world’s most prominent universities are on the authors list.

And here is what it found on the effects of low-carbohydrate diets on blood lipids:

“A high saturated fatty acid (SFA) content in low-CHO and very-low-CHO diets is a key factor for an increase in LDL-C.”

In other words, while low-carbohydrate diets higher in mono- and polyunsaturated fats caused lower total and LDL cholesterol, diets higher in saturated fats caused higher total and LDL cholesterol.

And here’s the thing. Kresser could have known that when he wrote this published this article June 11, 2019. There were dozens of papers showing increased LDL cholesterol levels in response to low-carbohydrate diets and a dozens of reviews and meta-analyses that point out that the fatty acid composition is critical in determining the response of LDL cholesterol to these diets.

But did Kresser talk about that at all? Nope.

If he had talked about it, he could have helped people who had high blood cholesterol to keep it lower. Ah, but yes, according to him, blood cholesterol is not important for cardiovascular disease, so he doesn’t need to help his readers prevent increased blood cholesterol levels.

Which brings up an interesting point: why is it important for him to argue that dietary cholesterol and saturated fat don’t increase blood cholesterol if blood cholesterol does not cause heart disease?

My guess: Chris is defending his turf at every point possible as someone who recommends high meat intake and “natural” remedies. It is straight from the denialist’s playbook: make the chain of denial so long, impenetrable, and ridiculous that nobody wants to even bother challenging it.

Oh, but let’s continue:

I can’t even.

He is literally saying that a diet high in saturated fat will cause a decrease in blood cholesterol in half of the people to whom it is fed. This is not supported by a single study out of hundreds, and is totally invented by Chris Kresser.

It’s as if even with his throwaway paragraphs, he wants another opportunity to make things up.

Let us continue.

Ancel Keys claiming that the diet-heart hypothesis is dead? Let’s actually look at the original article.

First let us note that Chris Kresser leaves out the first and last sentences, only quoting the middle to make his point. Let’s take a closer look at these sentences.

The first argues that blood cholesterol is important and that thinking otherwise will cause confusion among the public:

The last sentence points out that fatty acids are important (meaning saturated fats):

In fact, this was a restatement of the positions that he had maintained since the 1950s: Ancel Keys early pointed out that dietary cholesterol had only a modest effect on blood cholesterol levels, while he demonstrated through the Seven Countries Study and subsequent work that saturated fats played a decisive role in cardiovascular disease. Which is exactly what he says again in this letter to the editor.

Yet Chris wants to use this letter to imply that Keys had reversed his position:

It is a total distortion of the facts. Kresser literally took a quotation out of context to make the author look as if he believed the opposite of what he really believed.

Are we seeing a pattern here? However Chris Kresser can land a shot, he does. He denies that saturated fat raises cholesterol. He denies that cholesterol causes heart disease. He denies that saturated fat causes heart disease. He denies that statins prevent heart disease. He distorts the clinical trial evidence and mischaracterizes it. He cites only epidemiological studies, while in other articles calling epidemiology pseudoscience. He ignores any mention of RCT data that would definitively repudiate his claim. He cherrypicks meta-analyses and declines to provide context. He tries to make it look like Ancel Keys reversed his position.

And no matter what claim he needs to defeat, he can always come up with some way of cherrypicking evidence or quotations or ignoring to make it appear defeated. It is one of the most flagrantly dishonest styles of scientific argumentation that I have read in my life.

We’re not done yet.

In a Research Spotlight, Kresser suddenly reverses his position completely and affirms the pivotal importance of LDL cholesterol for cardiovascular disease:

You couldn’t make this up if you tried. It is one of the most flagrantly ridiculous endings to a ridiculous article that I have read in my life.

Oh it gets worse. You didn’t think it could. But it does.

He continues, describing a recently published study that demonstrated how to reduce blood cholesterol through lifestyle. There were three groups:

And according to Chris, they saw a modest decline in LDL cholesterol:

What did the group interventions consist of? I looked up the methods paper. And I have highlighted the relevant portion:

Yep. That’s right. Saturated fat restriction. In both groups that saw an improvement in LDL cholesterol, there was saturated fat restriction.

Chris concludes, praising the intervention:

And with that, the conclusion:

All of that text. All of that work. Just to show that how dishonestly/incompetently Chris Kresser wrote a single short article. Kresser writes hundreds of articles. A substantial proportion are total BS just like this one, argued using an identical ad hoc, cherrypicking methodology that focuses on proving the point rather than being objective.

But how is it possible to know which ones are good and which are nonsense? Here’s a tip: I recommend not reading anything he writes.

And now I am off to hang myself with my shoelaces.

This world. Too much for me.

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Reading Time: 2 minutes

I recently read this article from Scientific American:

This is a good opportunity to remind the reader–in a very schematic way–why science trumps patient or clinical experience for making recommendations.

Sure, this is obvious to many people. But it is worth repeating, because apparently even the editorial staff at the Scientific American needs reminding.

This post will focus on one statement in the article:

“Because if we dismiss everything that isn’t patented or presciption-only [sic], we dismiss people’s lived experiences.”

It is important to preface: nobody denies that patient experiences are very important, only that they cannot be the direct basis for guidelines or recommendations in the popular press or on social media.

If patient experiences became the direct basis for recommendations, then we would literally have to recommend everything. Placebo, regression to the mean, confounding by other simultaneously applied treatments, and any number of other confounding factors will ensure that virtually every treatment has someone to recommend it.

While treating individual patients, their experiences can be useful or at least they can be navigated when they are not harmful. Patient experiences can also lead to new hypotheses to test using science. If science vets these hypotheses, they can become recommendations.

But to imply that patient experiences should OVERRIDE current scientific findings for making population-based recommendations is deeply offensive to those who think that science is superior to hearsay, folk remedies, etc.

Science does not make medical doctors “gods”. It does however place within our therapeutic arsenal (when we know how to use it appropriately) the most powerful system for generating and testing practical knowledge that humanity has yet devised.

In an age of widespread medical nonsense (spread via social media), this is especially important to emphasize. Science protects people from charlatans, who, exploiting plausible-sounding scientific stories, patient testimonials, and science illiteracy, peddle treatments that are useless, harmful, or divert consumers from getting effective medical treatment–leading to real harm.

Scientific American (@sciam), by publishing such statements, promotes thinking that is diametrically opposed to science. This is disappointing. Because this is Science 101.

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Reading Time: 5 minutes

As a follow-up to the podcast discussion with Dave Feldman, I am musing a bit offline about what exactly his LHMR study would show even if atherosclerosis did not progress in his subjects much.

Because we already know that other factors besides LDL also modify risk.

Here is an interesting calculator that David Nunan (@dnunan79) sent me me: chd.bestsciencemedicine.com/calc2.html.

Now, based on it and using Framingham data, here is what would happen to risk if total cholesterol is 8 mmol/L (310 mg/dl), HDL is high, in a 74-year-old female who is 74 and physically active.

This image has an empty alt attribute; its file name is EKKYt3qW4AI9mBn.jpg

7% chance of having a cardiovascular event.

Just one-in-thirteen!

Same exact risk factors but 45 years old instead of 74 years old?

Just 2%, or 1-in-50.

Yes, maxed-out total cholesterol but just a 2% chance of having an event at age 45.

Now let’s look at the same exact risk factors but as a 74-year-old male.

Not great, but still only a 15% 10-year risk of heart attack.

What about a 45-year-old male?

Less than 4% chance. With maxed-out cholesterol.

Now here’s what happens if in a 74-year-old male, keeping the same total cholesterol and HDL cholesterol, keep the same age, BUT get a) untreated hypertension, b) diabetes, and c) add a father with heart disease.

Suddenly you go from 7% to 100%!

Now here’s what happens if you keep all those same risk factors and reduce cholesterol from 310 to 77.

This image has an empty alt attribute; its file name is EKKYvR4XUAA4NzG.jpg

Your risk of heart disease drops from certain to about 56%.

Nothing changes except cholesterol. Big drop in risk, but this drop is clearly not everything, and a lot of residual risk remains.

Now here’s what happens when you go low cholesterol, high physical activity, and take away all those other risk factors as well.

Risk down to less than 3% over ten years! In a 74-year-old.

Basically, non-HDL cholesterol (which roughly approximates LDL cholesterol if I am not mistaken) here accounts for about a doubling of whatever one’s baseline risk is.

That’s either massive or modest, depending on your point of view. So, according to Framingham, if you were like Dave’s population of interest and got everything dialed in except LDL cholesterol (in other words, if you were a 45-year-old, male lean mass hyperresponder practicing a healthy lifestyle on a ketogenic diet), what would we expect?

We would expect a very low rate of cardiovascular disease progression.

In other words, the model predicted by Dave Feldman in his LMHR project is the exact same as the one predicted by Framingham.

Only if we saw dramatically high rate of progression of atherosclerosis among LMHRs or a dramatically low rate would we be surprised. And for Dave’s study, we would not expect a sufficiently large sample size or methodologically rigorous design to detect a reduction to an already very low risk.

Despite this, these patients would still be about three times as bad off with respect to heart disease than if they had lower cholesterol.

As a reminder, here is the same risk profile as above except with low instead of high cholesterol:

So having very high cholesterol is roughly three times as bad as having low cholesterol while having a healthy lifestyle. But this three-fold elevation still does not result in an extremely high absolute risk.

As a side note, let’s also take a look at the role of diabetes vs. total cholesterol. Here is perfect everything, age 74, female, physical activity, etc., except for diabetes.

4.4% risk of cardiovascular event in the next 10 years.

Now here is perfect everything, age 74, female, physical activity, etc., except for 310 mg/dl total cholesterol (and no diabetes).

7.1% risk of cardiovascular event in the next 10 years.

So having high cholesterol is clearly worse than having diabetes according to our current knowledge. But they are somewhat comparable.

However, contrary to what Aseem Malhotra says, having high lipids is in fact somewhat worse than having diabetes.

But what if we add high lipids and diabetes together and take away physical activity?

Suddenly risk jumps to 18%.

In other words, all of these risk factors are synergistic. They work together to increase risk of cardiovascular disease.

It’s not one or the other. Insulin resistance or cholesterol or smoking or hypertension or age or sex.

All are important.

Statins are thought to be a great drug not because they are the cure-all of cardiovascular disease (they are not), but because they reduce a major risk factor in a safe way.

The same cannot be said about inflammatory cytokines, which, when blocked in the CANTOS trial, caused an increase in sepsis.

We use statins by reason of historical accident: not because LDL is everything, but because as a species we found a way to reduce a major risk factor and haven’t been able to do the same with the other risk factors to the same degree.

Reducing LDL does not solve the problem of cardiovascular disease. It just causes a substantial reduction in risk. But really reducing risk requires an attack on several fronts. None of these can be neglected if we want to minimize risk of deadly and debilitating heart attacks.

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Reading Time: < 1 minute

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Reading Time: < 1 minute

Find my first podcast interview ever here:

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