While the Internet has put valuable information at our fingertips, it has also exposed us to alternative facts and pseudoscience about many health conditions, often from self-proclaimed experts who attract people looking for alternative medical treatments. The dictionary defines pseudoscience as a collection of beliefs or practices mistakenly regarded as based on scientific facts.
One branch that has been gaining momentum over the last few decades is cholesterol denialism. Quite simply, this is the idea that cholesterol has nothing to do with the development of heart diseases. We’re not talking about skepticism or debate. Cholesterol denialism is being promulgated by those who are no longer following or even questioning the evidence: They’re denying it. Anybody who makes such a claim is saying something that is factually untrue.
Skepticism is no longer warranted
If you look at the history of cholesterol as a heart disease risk factor over the course of the 20th century, there was a time when some people could question the evidence and say, “I don’t think that it’s good enough to show that cholesterol has something to do with heart disease.” And that skepticism was probably justifiable up until the 1990s. That’s when we started to see studies showing that when you treat cholesterol with statins, the degree of cholesterol-lowering is directly proportional to the cardiovascular benefit. In fact, you see this in a very straight line where the more you lower cholesterol, the more your heart disease risk goes down.
We now know this holds true regardless of which cholesterol medication you take. In this century, we demonstrated the benefits of nonstatin-based drugs, like ezetimibe and PCSK9 inhibitors. Statin denialism, an offshoot of cholesterol denialism, doesn’t have a leg to stand on either.
Current debate: What numbers to measure
There are newer and legitimate discussions that can be had in the realms of prevention and treatment of heart diseases, such as how to best measure cholesterol. The standard cholesterol test includes total cholesterol, HDL cholesterol, LDL cholesterol, and triglycerides. We used to talk only about good (HDL) cholesterol versus bad (LDL) cholesterol.
In fact, it’s a lot more complex than that because now we can measure aspects that many people have still not heard of, like apolipoprotein B (ApoB), a particle on the surface of all bad cholesterol molecules that facilitates the creation of plaque. Measuring ApoB tells you how many LDL particles you have (the higher the number, the greater concern). In fact, you can make the argument that maybe we should just measure ApoB and forget all the other calculations like HDL-to-LDL ratios and non-HDL cholesterol.
Current debate: How to measure heart disease risk
There’s much debate going on now about how to better identify who’s really at high risk and who’s really at low risk, so that we don’t spend unnecessary resources treating low-risk people. We’re getting so complex that we’re measuring biomarkers and doing scans, like coronary artery calcium scans, on people at great cost to decide whether we should give them a medication, like a statin, that literally costs pennies a day. A widely accessible, no-cost indicator is a risk calculator.
In 2013, the American College of Cardiology and American Heart Association (ACC/AHA) introduced a new cardiovascular disease risk calculator to help determine who should be treated with cholesterol-lowering medication. Earlier this year, the AHA and kidney disease researchers collaborated on a new calculator called PREVENT (Predicting Risk of cardiovascular disease EVENTs). It’s based on data from 46 different sources representing 3.3 million people. The 2013 calculator was based on just 25,000 people. PREVENT also takes into account important metabolic and renal factors, such as BMI and estimated glomerular filtration rate, which have roles in elevating cardiovascular risk.
After you plug in your health data, PREVENT gives estimates for cardiovascular disease overall and separate estimates for atherosclerotic cardiovascular disease (caused by plaque buildup) and heart failure, generating both 10-year risks for people ages 30 to 79 and 30-year risks for people ages 30 to 59. It slightly underestimates risk relative to the older calculator, which slightly overestimated risk. That means many people who would have previously been told that they needed a statin will not be told that anymore.
Current debate: When to start cholesterol-lowering treatment
Risk calculator results are just one factor in deciding how to manage high cholesterol. You’ll want to weigh the advantages of medication for your circumstances with your doctor. Some people who seem to be low risk are at higher risk than they think when you actually look at their numbers and lifestyle. You often see patients in their 60s who also have high blood pressure and are a little bit overweight but say “I’m healthy. Why do I need medication?” Well, they’re actually not that healthy: They have a lot of risk factors.
There’s also a debate about how much benefit there is to lowering cholesterol. If you have high cholesterol but no history of heart disease, making you a candidate for primary prevention, the magnitude of the risk-reduction benefit will be lower than for somebody who’s already had a heart attack or a stroke and will take medication for secondary prevention. A very high-risk patient will benefit more from the medication than a lower-risk patient because they’re at higher risk to begin with. But that isn’t to say there’s no benefit for primary prevention: There is.
Current debate: Are lifestyle changes enough for primary prevention?
Lifestyle changes are important, including when you’re on cholesterol-lowering therapy. But they’re often not enough to move the needle. The reality is that most high cholesterol is genetic. Diet affects it a little bit, but it’s probably not the main driving factor. After six or 12 months of trying diet and exercise, if your numbers barely budge, you have to acknowledge that diet and exercise alone aren’t enough.
Also, many people find that changing lifestyle habits simply isn’t feasible because of the system we live in. Why is our diet worse now than it was 100 years ago? Because as a society, we moved from a rural state of being into an urban state of being where most of us have sedentary jobs, working in front of a computer all day. If you have a flexible enough work schedule that you can go for a run during the day, that’s great. But that’s not an option at many companies. It would take a system-wide change that recognizes the importance of an exercise break for adults just as we do for kids who take PhysEd classes in school. Improving your diet is great, but it can be hard to cook for yourself, especially if you have a long workday and a two-hour commute. Sometimes you just pick up prepared food on the way home because you’re tired.
The bottom line
We’ve established that cholesterol has a clear role in the treatment of heart disease. The issues now are about how best to treat it, how best to measure it, and how best to risk-stratify people, which are fascinating topics of discussion. However, they’re not topics of discussion people should be having online—they’re ones you should have with your doctor.
