A new analysis of prior research suggests that higher levels of so-called bad LDL cholesterol is associated with longer life for older people. Not surprisingly, many cardiologists are outraged over the idea that bad LDL cholesterol might be good for senior citizens. After all, they have spent decades convincing people that lowering LDL cholesterol is essential for heart health. That is why statins have been prescribed to tens of millions of people.
The New Study Turns Conventional Wisdom Upside Down:
The investigators reviewed epidemiological studies in which bad LDL cholesterol (LDL-C) had been studied as a risk factor for cardiovascular deaths or mortality for any reason (BMJ Open, June 12, 2016). The subjects were people over the age of 60. In total, 19 studies were analyzed involving over 68,000 participants.
In theory, people with high levels of bad LDL cholesterol should have been at increased risk for deaths from heart attacks and strokes. So-called all-cause mortality should also have been higher when LDL-C was elevated.
What the Researchers Actually Found:
Contrary to expectations, no link was found between bad cholesterol and premature deaths. In this older population (people over 60) there was a surprising discovery. The higher the subjects’ LDL cholesterol, the longer they lived and the less heart disease they seemed to experience. This is exactly the opposite of what conventional cardiology would have predicted. Here are the conclusions in the words of the investigators:
“High LDL-C is inversely associated with mortality in most people over 60 years. This finding is inconsistent with the cholesterol hypothesis (ie, that cholesterol, particularly LDL-C, is inherently atherogenic). Since elderly people with high LDL-C live as long or longer than those with low LDL-C, our analysis provides reason to question the validity of the cholesterol hypothesis. Moreover, our study provides the rationale for a re-evaluation of guidelines recommending pharmacological reduction of LDL-C in the elderly as a component of cardiovascular disease prevention strategies.”
That’s doctorspeak for saying older people didn’t benefit by having low LDL cholesterol and may in fact live longer if their LDL-C is higher. They go on to challenge the foundation of cholesterol-lowering treatments by questioning the idea that LDL cholesterol causes clogged coronary arteries. This flies in the face of conventional medical wisdom and makes the billion-dollar statin industry flinch.
The Backlash About Bad LDL Cholesterol was Fast and Furious:
Cardiologists and other health professionals were quick to condemn the new study published in BMJ Open. They characterized the research as:
“Serious weaknesses and completely wrong conclusions”
Not a Totally New Story:
Although many people think of cholesterol as the enemy, it is actually essential for health. Not only does cholesterol serve as a building block for vitamin D, estrogen and testosterone, it is crucial for neurons in the brain. Without cholesterol our nerve cells would not function.
Results from the Honolulu Heart Program 2001:
One of the most interesting studies that has been forgotten over time is the Honolulu Heart Program. Scientists at the University of Hawaii studied 3,500 Japanese-American men born between 1900 and 1919. The volunteers’ total cholesterol levels were measured when they were middle-aged and again in the early 1990s, when they were elderly. Then the scientists kept tabs on who survived and who died.
To their surprise, the men with the lowest cholesterol levels had the highest risk of dying over the next several years. Those with cholesterol levels between 188 and 209 fared the best. Even men with elevated cholesterol, over 209, were less likely to die from any cause than those with the lowest cholesterol readings. The investigators confessed their confusion:
“We have been unable to explain our results. These data cast doubt on the scientific justification for lowering cholesterol to very low concentrations (<4.65 mmol/L) [less than 180 mg/dL] in elderly people…”
“Our data accord with previous findings of increased mortality in elderly people with low serum cholesterol, and show that long-term persistence of low cholesterol concentration actually increases the risk of death. Thus, the earlier that patients start to have lower cholesterol concentrations, the greater the risk of death.”
[Reference: Schatz, I. J., et al. “Cholesterol and All-Cause Mortality in Elderly People from the Honolulu Heart Program: A Cohort Study.” Lancet 2001;358:351-355]
Other Contrary Research:
No doubt most physicians prescribing statins to people over 60 are not familiar with the Honolulu Heart Program data, or if they are, they have conveniently ignored the conclusions. There are other studies, including a report to the American Heart Association in 1999 that suggested people with total cholesterol under 180 were twice as likely to suffer a bleeding stroke as those with cholesterol of more than 230.
The Japanese Experience:
Researchers in Japan have long noted that people with low cholesterol are more susceptible to bleeding strokes than people with higher cholesterol levels. A study of 12,334 healthy adults between the ages of 40 and 69 was conducted in 12 rural areas of Japan (Journal of Epidemiology, online, Jan. 5, 2011). The subjects were followed for nearly 12 years. The conclusions:
“Low cholesterol was related to high mortality even after excluding deaths due to liver disease from the analysis. High cholesterol was not a risk factor for mortality.”
The Bottom Line from The People’s Pharmacy:
The idea that low total cholesterol, or especially low LDL cholesterol could be associated with premature death comes as a shock to most health professionals. When such research is published it disappears almost without a trace or is forgotten or ignored because the data do not conform to the predominant paradigm. This cholesterol contrariness is not the only big shock to the cardiology community.
Over the last several months the basic foundations of American cardiovascular medicine have been challenged. Next to bad LDL cholesterol, saturated fat was the other villain behind heart disease. But a study published in BMJ (April 13, 2016) found that people who lowered cholesterol levels by consuming foods high in vegetable oil actually died faster than people eating a standard saturated fat-containing diet. This was data resurrected from the Minnesota Coronary Experiment. More details can be found at this link.
As if the cholesterol and saturated fat problem were not trouble enough, along came a large salt study published in the journal The Lancet (online May 20, 2016). The authors reported that a low salt diet like the one recommended by the American Heart Association (less than 1,500 mg of sodium per day) was associated with an increased risk for heart attacks, strokes, heart failure and death. You can listen to the lead author provide the details of the research at this link.
Not surprisingly the cardiology community was quick to respond that the study was flawed. The criticism was not unlike the remarks we are reading today about the new study suggesting that older people may actually live longer if their LDL cholesterol levels are higher.
We hope that no one would ever stop taking medicine without first discussing the research with health providers. At the same time, we would hope that physicians would keep their minds open. Medicine constantly changes as new data are revealed. Perhaps some of the old beliefs will change as research reveals alternate hypotheses and understandings.
Share your own thoughts about medical reversals (flip-flops) in the comment section below. Are you frustrated that the foundations of conventional wisdom about heart health are being shaken?
If you would like to read our chapter on heart disease and a contrarian cholesterol perspective you may find our book, Best Choices from The People’s Pharmacy of interest.