Intended for healthcare professionals

CCBYNC Open access

Rapid response to:


Effect on cardiovascular risk of high density lipoprotein targeted drug treatments niacin, fibrates, and CETP inhibitors: meta-analysis of randomised controlled trials including 117 411 patients

BMJ 2014; 349 doi: (Published 18 July 2014) Cite this as: BMJ 2014;349:g4379

Rapid Response:

It is no surprise that drugs to raise HDL are of no benefit but useful to see it confirmed in this paper. There is an association between low HDL and cardiovascular disease because they have a common cause, not because one causes the other. That cause is a diet high in sugar and carbohydrate [1]. Over a period of 2.5 million years prehistoric man became genetically adapted to eating 5% carbohydrate, 75% fat and 20% protein [2]. Since the start of agriculture 8,000 years ago we have increased carbohydrate consumption and this has been further increased by the misguided advice in the last 40 years to eat less fat. We now eat 60% carbohydrate, 20% fat and 20% protein. Our genetic makeup is unchanged so we are not adapted to the new diet. The increased carbohydrate consumption is a major factor in causing modern diseases of civilisation.

Lowering carbohydrate intake very effectively raises HDL and lowers triglyceride. I increased my HDL from 0.9 to 2.3mmol/L. The reason more people do not do this is the erroneous fear of cholesterol. A low carbohydrate diet can increase the total cholesterol level. Mine went up from 3.5 to 6.7mmol/L. This fear is irrational. There is no relationship between cholesterol level and heart disease. People with high cholesterol levels live longer [3] and have less cognitive decline in old age [2].

There are two points which are used to wrongly support the idea that raised cholesterol is dangerous. Firstly there is a weak association with heart disease in men under 65. This is because stress causes both heart attacks and raised cholesterol, not because raised cholesterol causes heart attacks [4]. Secondly statins reduce the incidence of heart attacks. This is because of their anti-inflammatory and anticoagulant effects, not due to cholesterol lowering. Because of an increase in other causes of death such as suicide and violence, when used in primary prevention, statins have no effect on average lifespan. They will change the diagnosis on a death certificate but not the date [5].

People also fear that eating fat will cause weight gain. This is not true. A Swedish expert committee, having looked at all the evidence, recommended that a low carbohydrate high fat diet is best for weight loss and will improve health markers, for example it will result in “a greater increase in HDL cholesterol without having any adverse effects on LDL cholesterol”[6].

Cereal, toast and orange juice for breakfast result in low HDL with more deaths. Bacon, eggs, lard and tea result in high HDL with fewer deaths [7].

A paper about the Norwegian HUNT 2 study [3] asks the question “Is the use of cholesterol in mortality risk algorithms in clinical guidelines valid?” The answer is, “No, the use of cholesterol in mortality risk algorithms in clinical guidelines is not valid”. However, HDL and triglyceride are highly predictive of mortality.


1. The Art and Science of Low Carbohydrate Living by Jeff S Volek and Stephen D Phinney
2. Grain Brain by David Perlmutter
3. Is the use of cholesterol in mortality risk algorithms in clinical guidelines valid? Ten years prospective data from, Journal of Evaluation in Clinical Practice Volume 18, Issue 1, Article first published online: 25 SEP 2011,
4. Ignore the Awkward! How the Cholesterol Myths are Kept Alive by Uffe Ravnskov
5. Statin Nation, video produced by Justin Smith
6. Dietary Treatment for Obesity, A Systematic Review of the Literature, Swedish Council on Health Technology Assessment (SBU),
7. Cholesterol Clarity by Jimmy Moore

Competing interests: No competing interests

27 July 2014
William T Neville
General Practitioner
Abbey Road Surgery, 63 Abbey Road, Waltham Cross, Hertfordshire, EN10 7JQ