The Cholesterol Myth

Part 8: A Question of Ethics

Is it ethical to impose a regime on people in the hope that heart disease will be reduced? Surely prevention is better than cure, you may say. But is it? Such an attitude ignores the real possibility that such intervention may do more harm than good. 'Preventative' medicine as practised in the case of heart disease, takes two forms. Firstly we are to change our lifestyles, and secondly we are screened by our doctors on an opportunity basis.

But this screening is not prevention of the disease, it is merely the early detection of it. For such procedures to be of use a number of criteria are well established. One important one is that the disease should be both common and serious, as screening for an uncommon disease will throw up many false results. These will inevitably incur the cost of further testing, and cause unnecessary anxiety which itself is harmful.

The first problem with screening in CHD, is deciding what to test for. As a predictor of coronary risk, total blood cholesterol turns out to be irrelevant, and merely testing for that is regarded by many experts as misguided. Far more reliable, they claim, is measurement of HDL (the 'good' cholesterol). However, in a test of the accuracy of checking for HDL at various laboratories, values differed by as much as 40% in 95% of the samples tested. In another study, 16 instruments manufactured by nine companies were tested in 44 laboratories. In this test, although the inaccuracies of the machines were lower at 3.6-4.4%, biases attributed to the methods used ranged from -6.8% to +25%. The accuracy of desktop machines is even more suspect.

A third study to evaluate the ability of cholesterol screening to detect individuals with blood cholesterol abnormalities concluded that 41% of those with abnormal levels would not be detected using present guidelines.

Another criterion is that an effective treatment for the disease is available, as there is little point in early diagnosis or detection of a disease for which there is no effective remedy.

Some will say that we do know the cause of coronary heart disease; it is high cholesterol, or too much fat in our diets, or not enough exercise. Or it could be something else. In 1981, two hundred and forty six 'risk factors' for heart disease were listed. That number is now well over three hundred. These so called risk factors include having English as a mother tongue, having a diagonal crease in the left earlobe, not taking siestas, not eating mackerel, snoring and wearing tight underpants. What a list of this size really tells us is that we have little idea what causes coronary heart disease. And it is certain that if all the 300 plus do play a part, we have no chance of defeating the disease.

A director of the Health Education Programme of the American Medical Association denounced the lifestyle changes with their false promise of benefit as a quasi- religious crusade when in 1984 he wrote: " Constant lifestyle self-scrutiny in search of risk factors, denial of pleasure, rejection of the old evil lifestyle and embracing a rigorous new one are followed by periodical affirmations of faith at revival meetings. . . the self-righteous intolerance of some wellness zealots borders on health fascism. Historically, humans have been at greatest risk while being improved in the best image of their possibilities as seen by somebody else."

Telling people who feel fit and well that they are not and, that if they do not make major changes to their lives, they could drop dead at any moment, not only worries them unnecessarily, it can have a profound effect on their attitudes to life. The benefits of mass screening are doubtful and the risk of harm is high. Such intervention, therefore, can only be justified ethically when either the patient has requested it or symptoms are such as to make it desirable.

If we go to our doctor with a complaint and he treats us with the best medical knowledge, he should not be held responsible for defects in that knowledge. If, however, the doctor initiates treatment without being consulted by the patient, then he is in a very different situation. Cochrane and Holland write that before advocating a course of action in such circumstances, " He should, in our view, have conclusive evidence that screening can alter the natural history of disease in a significant proportion of those screened." If he does not, he may be held responsible for any harm done.

But in the case of heart disease, recognised medical standard tests and ethics have been thrown out the window. The recommendations were forced on the public even before they had been tested, and now the perpetrators are afraid to admit that they could have been wrong. But until they do, whole populations are suffering unnecessarily.

In the United States blood cholesterol level testing for all is routine and that nation is becoming a nation of 'cholesterophobics'. More concerned with death than with life, many interviewed said that their lives were ruined as, if they had a treat, it was accompanied by feelings of guilt. One of COMA's principles is that the measures should " afford a reasonable prospect of improvement in life expectancy overall, and in the quality of life for the population as a whole." Experience around the world, and particularly from the United States, makes it certain that neither of those principles will be met.

In Britain, general practitioners, practice nurses and health visitors are starting to use desk-top cholesterol testing machines, the majority of which have been loaned by drug companies. A suggestion in the Lancet is that this is designed merely to enhance the drug companies' profits by increasing sales of cholesterol-lowering drugs, and questions their ethics. There is also the question of the psychological harm that could be done to people in view of the United States experience of the inaccuracy of such machines.

Medical bias towards illness

There is evidence that the medical profession is biassed in favour of diagnosing illness rather than health. A classic example was a test run in New York on 1,000 11-year-old children and their tonsils. On first examination 61% were found to have had their tonsils already removed. The other 39% were re-examined by a group of doctors who recommended tonsillectomy operations for 46% of them. The rest were again examined by yet another team and, again, nearly half were recommended for operations to remove their tonsils. After three examinations, only 65 of the original 1,000 had not been recommended for the operation. The test ended there as they ran out of physicians to perform the examinations. However, if the physicians had had their way, it is obvious that a great many unnecessary operations would have been performed.

High error rate in diagnoses

The bias towards illness may also combine with a high diagnostic error rate. Post- mortem examinations in a British university hospital showed that of the patients who had died of a diagnosed specific heart disease, over half had actually died of something else. And when the same sample was tested in different laboratories, different results were given in 25% of cases. Diagnostic machines, it seems, are no better. In a competition between doctors and computers in 83 cases recommended for pelvic surgery, pathology showed that both the doctors and computers were right in only 22 cases. In 37 the computers proved the doctors' diagnoses wrong, in 11 the doctors showed the machines to be in error and in 10 cases they were both wrong.

Variations between countries

There also exists a large variation between diagnostic and prescribing practices between countries which makes comparisons between them of little use. For example, in Britain, a patient is 7 times more likely to be prescribed a course of vitamins than in Sweden, and in Sweden, 8 times more likely to get gamma globulin medication than in Britain. United States surgeons perform operations twice as readily as in Britain and the French will amputate almost anything. Appendicitis and deaths attributed to it is diagnosed in Germany 3 times more frequently than in any other country.

And so to the cost

In the late 1980s, intervention alone in the United States was estimated at $14 billion a year. The cost of cholestyramine for an estimated five million people at 1990's prices was $10 billion to which up to another $10 billion must be added for laboratory tests and doctors' services. In Britain, if we also undertook a mass screening and cholesterol reducing programme, it has been suggested that drug treatment would be recommended for 10% of men aged 40-69 and, as a result, the NHS drug bill in England and Wales, £2.3 billion in 1992, would be increased by 20%. To put it in terms more familiar to the average person, the cost of the drugs alone would be between £80 and £120 per person per month. The evidence suggests that for that money we might be able to delay a fatal heart attack in the average person by between 3 days and 3 months - but shorten that person's life by a larger amount as he or she died of cancer, osteoporosis or stroke.

The effect on the NHS

Sir William Beveridge set up the National Health Service on the assumption that "there exists in any population a strictly limited amount of illness which, if treated under conditions of equity, will eventually decline." It was calculated that the cost of the service would fall as the rates of illness went down. No-one considered that the NHS would redefine and broaden its service to such an extent that only budgetary restrictions would keep it from expanding indefinitely.

The increasing sophistication of treatments available and demanded of the National Health Service are putting it under a tremendous strain. To spend scarce money and resources on any unnecessary treatment is waste, but to waste billions of pounds on such unproven and dubious hypotheses as the present, so-called 'healthy eating' recommendations is quite irresponsible and, in the long term, can only be harmful.

Dr Halfdan Mahler, Director General, the World Health Organisation recognised such waste when he said in 1984:

"The major - and most expensive - part of medical technology as applied today appears to be far more for the satisfaction of the health professions than for the benefit of the consumers of health care."

Side effects

The current 'diet-heart' strictures and media pressure aimed at ever lower blood cholesterol levels, have driven more people towards unnatural and unhealthy cult diets. Consequently, there has been a rapid rise in the incidence of infant malnutrition, deficiency diseases and other killer or debilitating diseases. Without sufficient dietary fat, the body is unable to use the fat soluble vitamins. Without vitamin D the body cannot utilise calcium. In conjunction with an increase of bran in the diet, this is another possible factor in the growing incidences of diseases such as osteoporosis and rickets.

Vegetarian traits are increasing. As animal products are the only natural source of vitamin B-12, Vegans, who eat no such animal products, run a real risk of pernicious anaemia. Bottles of pills are not a good substitute as they are generally poorly absorbed. Fermented soy products, such as tempeh, and spirulinas found in health-food shops, which are supposed to contain vitamin B-12, for the most part contain only analogues of the vitamin which are not active for humans and which, in some cases, actually block vitamin B-12 metabolism. Children of Vegans also usually have a lower body weight and height and suffer other health problems.

Doctors in Britain are reporting cases in 'the muesli belt' of severe nutritional disorders which include kwashiorkor, marasmus and rickets which are due solely to their parents' food faddism. Until recently, these diseases were only found among severely malnourished children in Africa. In Britain it is becoming so serious that they suggest that such cases should be regarded as forms of child abuse. But are the parents to blame? Could not some of the blame for this deplorable situation be fairly laid at the doors of the nutritionists?

Doctors in the USA also are reporting ever increasing numbers of children suffering from nutritional dwarfing and other deficiency problems attributable entirely to pressures to eat nutrient-poor, low-calorie foods because they are 'healthy'. These children are destined to have far-reaching problems beyond just being smaller than their peers. It has been shown that adults whose birth-weights early rates of growth were low have a much higher incidence of CHD. Brain growth and intelligence are also found to be much lower in such undernourished children.

We really seem incapable of learning from previous experiences. During World War II, when we are supposed to have been so healthy, protein-calorie deficiency was so pronounced that in many people pathology showed there was as much as 25% loss of muscle from their hearts - and similar patterns of protein deficiency are found today.

And it is not just humans who suffer side effects. In the constant quest for ever leaner meat, food animals are being engineered which could not survive naturally. Belgian Blue cattle, for example, bred to provide lean meat, have double muscles. This makes the calves too large to pass along the birth canal and they have to be delivered by Caesarean section. Other cattle and pigs are fed hormones to make them grow with less fat. As yet it is anyone's guess what the long-term consequences of this will be on both the animals and humans.

The strictures against red meat also mean that fewer cattle and sheep are being reared and more fields are used to grow cereals, rape and other vegetable crops. Unlike the animals, which on the whole produce natural fertiliser for the pastures, the vegetable and cereal crops require large amounts of manufactured nitrogen fertilisers to be spread. As we know, these leach in ever-increasing quantities out of the soil to pollute our water supplies. Grass, the food of the cattle and sheep, on the other hand, locks the nitrates in the soil, thus preventing pollution.

The Mediterranean diet

The 'Mediterranean' diet is healthier than ours, we are told. We should eat what the French, Italians and Spanish eat. That could be right - but not for the reasons usually given.

The Mediterranean diet is what the health fanatics advocate because, they say, it is low in fat. This is nonsense! Obviously, they have never been there. They don't seem to know that northern Italians love butter, that bowls of pork dripping are sold on Spanish markets or that the Spanish spread it thickly on their toast for breakfast. They don't know that goose fat is used to make cassoulet in the south of France, or that throughout the Mediterranean the sausages, salamis and pâtés all contain up to fifty percent fat.

The Mediterranean diet may be healthier than the British but, contrary to popular belief, it is very far from being a low-fat diet!

However, there are a number of major differences between the Mediterranean countries and Britain that may play a significant part in their effects on health. Not only is the food eaten by the average working family in southern Europe very different from that eaten by a typical family in Britain, more importantly, the way it is bought, presented and eaten is also different. A brief list of the principal differences is tabled below.

Cholesterol testing

Imagine it is 2.00 a.m., you are lying in bed when you hear a noise downstairs that you know is caused by a burglar. You know how quickly your heart starts to race. Well, that is how quickly your cholesterol level can rise - and for the same reason. One of the effects of the 'fight or flight' reflex is to raise blood cholesterol. Any form of physical or mental stress has this effect. So if you run to your doctor's, your cholesterol level will be higher than if you walked; if you have been standing it will be higher than if you sat. If you are anxious, or your doctor looks worried, it will be higher. If your blood cholesterol were tested hourly throughout a day, or daily over a month, it would not be unusual to find a wide variation in values.

Blood cholesterol levels also rise naturally as you get older so that while a reading of 9 mmol/l is high at the age of twenty, it is perfectly normal if you are fifty.

Cholesterol measurements are not very accurate - less than eighty percent - even when conducted in a laboratory. A survey showed that on the same sample, laboratories could differ by as much as 1.3 mmol/l. When it is tested with a doctor's desktop machine the accuracy will inevitably be lower.

To put it in perspective, let us assume that you are around thirty years old and your cholesterol level is a perfectly respectable 6.0 mmol/l. You hurry to the surgery and are anxious about the result. This could raise it by twenty-five percent to 7.5. If it is sent to a laboratory giving the high readings it could be raised by a further 1.3. Your perfectly normal 6.0 is now a high 8.8!

In fact, so many variables affect cholesterol levels that a one-off test is a waste of time, and an unnecessary worry for the patient that can do more harm than good. Bear that in mind if you are subjected to a cholesterol test.

References:

P S Bachorik, T A Cloey, C A Finney, D R Lowry, D M Becker. Lipoprotein-cholesterol analysis during screening: accuracy and reliability. Ann Intern Med 1991; 114: 741-7.
G L Myers, et al. College of American Pathologists ? Centres for Disease Control collaborative study for evaluating reference materials for total serum cholesterol measurement. Arch Pathol Lab Med 1990; 114: 1199-1205.
A L Cochrane, W W Holland. Validation of screening procedures. Brit Med Bull. 1971; 27: 3.
I Sharp, M Rayner. Cholesterol testing with desk-top machines. Lancet. 1990; i: 55.
H Bakwin. Pseudodoxia Pediatrica. N Eng J Med. 1945; 232: 691.
L H Garland. Studies on the accuracy of diagnostic procedures. Am J Roentgenology, Radium Therapy and Nucl Med. 1959; 82: 25.
O Peterson, E M Barsamian, M Eden. A study of diagnostic performance: A preliminary report. J Med Educ. 1966; 41: 797.
H E Sigerist. From Bismarck to Beveridge: Developments and trends in social security legislation. Bulletin of the History of Medicine 13 (1943): 365.
Office of Health Economics, Prospects in Health Publication No. 37. London, 1971.

See also www.Cholesterol-and-Health.org.uk, an easy to read website about this whole topic from what cholesterol is, why you need it, and how it is made in the body, to what happens if you take cholesterol-lowering drugs such as statins.

Last updated 18 September 2000