Searching for the true cause of heart disease...

"The mind is like a parachute—it only works if it’s open”. Anthony J. D’Angelo.

I’m what you’d call a “lifelong learner”. But, you know, recently I almost feel like it might be time to stop reading health research—I’ve been finding so many articles and books that question beliefs I’ve held throughout my pharmacist career! But I always try to keep an open mind and it’s led me down some interesting rabbit-holes of research. One thing we need to remember about science is that it constantly advances. Accepted practices (like using leeches as a treatment in the days of Hippocrates and Galen) eventually are found to be not so great and are replaced with something better. I’m beginning to suspect people of the future may look back on some of our current practices and wonder why we weren’t smart enough to figure out where we went wrong...

One topic I’ve been reading about questions the effectiveness of antidepressants, that I recently wrote about HERE earlier this month.

A second topic is the idea (first proposed by Nobel Prize-winning researcher Otto Warburg in the 1920s) that cancer is a disease caused by altered metabolism, rather than randomly damaged genes. In this theory, the energy factories of the cell (mitochondria) become damaged by chemicals, oxygen radicals, etc. and over-produce energy, leading to production of oxygen radicals that damage genes and a cell that constantly divides... what we know as cancer. I wrote about research into this alternate theory of the cause of cancer HERE in February 2021.

Another series of articles currently in the medical press is questioning the “lipid hypothesis” --the entire idea that fat is bad and increases the risk of heart disease. Open your mind and read on...

My current reading

I remember the first time I saw an article offering evidence that fat and cholesterol in our diet did not cause heart disease. I was sitting on a sunny balcony in Spain, six years ago, newly retired with time to finally catch up on reading pharmacy/medical articles. As I recall, I was reading the Medical Letter, a highly reputable summary of journal articles and research. My jaw dropped when I read that the risk of heart disease does not correspond with levels of LDL-Cholesterol in the blood for many people. For decades, lowering this number has been the goal of therapy using cholesterol drugs for almost everyone.

I read about entire populations who have extremely high blood cholesterol but zero risk of cardiovascular disease (the Masai in Africa, for example), and many people with low blood cholesterol who wind up in Emerg anyway with a heart attack. I saw critiques of the original cholesterol research that included only 7 countries that lined up with the proposed theory, while there were data available for over 20.

Although Statin cholesterol-lowering drugs are likely helpful for a segment of the population with inherited cholesterol problems (familial hypercholesterolemia), for most people these drugs quite likely are doing something else to show a reduction in heart disease in studies, as LDL-Cholesterol does not correlate with heart disease risk when the results of many studies are analyzed together in a “meta-analysis”.

As I dug further into the research, I realized there are plenty of studies that question the lipid hypothesis. Note that the definition of “hypothesis” is “an assumption, an idea that is proposed for the sake of argument so that it can be tested to see if it might be true.” Using the scientific method, any evidence that the hypothesis is not correct requires a re-evaluation of the assumption. For some strange reason (could it be the billions that these drugs generate??) this has not happened with cholesterol-lowering drugs. This is in spite of the observation of many “paradoxes” that supporters of the theory cannot explain (for example, the “French paradox”, with their diet high in saturated fats but a low rate of heart disease). Studies using newer methods of analyzing blood are also suggesting that LDL is less important to heart disease risk than HDL, triglycerides and a particular type of high-density LDL particles that couldn’t be measured before.

It turns out that statins also have anti-inflammatory, anti-clotting, and antioxidant activity, all of which help to prevent heart disease. As some doctors argue, if the drugs are working, what difference does it make what the mechanism is? But using the proper scientific method would require that an alternative hypothesis be tested: that one or more of these actions explain the success of drugs that also lower cholesterol, while drugs that only lower cholesterol (like fibrates and ezetimibe) don’t appear to actually save lives. Perhaps there are drugs with fewer side effects that could accomplish the same results.

I was unable to find any studies into this hypothesis, although I did see calls for further study into the issue. However, I have read that the drug, colchicine (used for many years to reduce inflammation caused by gout) is being tested for preventing the inflammation that many researchers now believe is at the root of heart disease risk. The results should help to clarify the issue.

Down another rabbit-hole

So, all of this has led me to another related topic... What causes chronic inflammation in the body? One alternative hypothesis being studied proposes that elevated insulin in the blood causes inflammation that is at the root of many chronic diseases, including cardiovascular disease. Diabetes and heart disease are known to occur together and diabetes is believed to be a risk factor for heart disease. But what if the process of diabetes, where more insulin is needed to handle blood sugar even before blood sugar increases (a condition known as “insulin resistance”), is actually the root cause of heart disease? Or, paddling further upstream, what if the excess refined sugar in our diet which stimulates increased insulin secretion is the real culprit?

The occurrence of heart disease started increasing dramatically back in the 60s when convenience foods were introduced to the market in North America. These highly-processed foods contained trans fats, now known to increase cardiovascular disease risk, along with increased salt, sugar, preservatives, colouring agents and more.

Governments and health organization were looking for strategies to reverse the dramatic increase in heart disease and, noting that the plaque that clogs arteries in heart disease patients contains fats and cholesterol, presumed that increased amounts of these substances in the typical North American diet must collect directly in the arteries when levels are elevated in the blood. The “answer” was to cut fat from the diet as much as possible and lower the amount of fats circulating in the blood.

However, reducing the fat content of food meant it lost much of its flavour. Adding extra sugar restored taste to products so, as food processors cut fat from products, the carbohydrate content steadily rose. Even “food pyramids” promoted by government organizations as the basis for a healthy diet, put strong emphasis on carbohydrate foods without initially distinguishing between processed and unprocessed forms, while recommending the avoidance of fats as much as possible.

Eventually, scientists realized we need fat in our diet, and added recommendations to consume what they called “healthy fats”—omega-3 oils found in fish, some seeds, and nuts. They continued to recommend substituting saturated fats with unsaturated fats from plant sources, mostly seeds. Unfortunately, many of these oils contain mostly omega-6 fats that promote inflammation (as opposed to omega-3s that reduce it), skewing the balance between these two. Newer research suggests that these huge diet changes, increased sugar and a shift in the types of fat, have contributed to the continuing rise of heart disease risk as well as obesity in North America. Eventually more emphasis has been placed on eating whole, non-processed foods.

New research

But what about the “evil” saturated fats? A new study on butter demonstrated that consuming it increases our HDL-Cholesterol, known as the “good cholesterol” that reduces risk of heart disease while also increasing LDL. Now, that was a surprise!

With newer cholesterol tests, researchers were able to see that a lack of “good” HDL-Cholesterol correlates much more strongly with cardiovascular disease risk than high “bad” LDL-Cholesterol does. Triglycerides seem to be more important than LDL too. And the ratio of triglycerides to HDL says a lot about your risk. Having a ratio of 2 (or not more than twice the amount of triglycerides as HDL), correlates with a reduced risk of heart attack. You can calculate this yourself from a routine blood lipid test if your doctor gives you a copy. Currently, emphasis is placed on having a ratio of total cholesterol to HDL of 4 or less (meaning that at least ¼ of blood cholesterol is in the HDL form), stressing the importance of having plenty of HDL.

And, guess what? Refined sugar in the diet raises triglycerides. There we go... sugar as the culprit again (not fat). Cutting sugar from the diet (i.e., eating a lower-carb diet) may turn out to be the most important action we could take to reduce the risk of heart attack and stroke. Research continues...

As for fat? Healthy fats just may include reasonable amounts of butter, cream, and tasty cuts of meat with the fat left on. It seems that we ran with a hypothesis that was never proven, while questioning scientists were hushed and reportedly lost funding grants if they voiced objections too loudly. The great diet experiment with low fat and high carbohydrates hasn’t worked to reduce heart disease, obesity or cancer. It’s time to pay attention to new research that questions old assumptions made decades ago that have not changed the course of heart disease (or cancer).

Reconsider your food choices

There’s a problem with the amount of sugar in the typical North American diet, much of which is hidden in processed foods. As well as contributing to cardiovascular disease risk, excess carbohydrate, particularly in the form of highly refined white sugar and white flour, where fiber and other nutrients have been removed, may contribute to increased risk of many chronic diseases.

But, don’t just take my word for it. Look up the references below, if you’d like to read the science. Join me down the rabbit-hole...

References:

Is there more to a healthy diet than cholesterol?—Nature

Dietary fructose and its association with the metabolic syndrome in Lebanese healthy adults: a cross-sectional study—Diabetology and Metabolic Syndrome

The PURE Study Implications—European Heart Journal (2018)

The Great Cholesterol Myth, Revised and Expanded: Why Lowering Your Cholesterol Won’t Prevent Heart Disease (2022)—Jonny Bowden, PhD and Stephen Sinatra, MD

The Great Cholesterol Con—Malcolm Kendrick

The Cholesterol Myths (2000)—Uffe Ravnskov