Intended for healthcare professionals

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News Roundup [abridged Versions Appear In The Paper Journal]

Cholesterol guidelines will triple numbers taking drugs

BMJ 2001; 322 doi: (Published 26 May 2001) Cite this as: BMJ 2001;322:1270

Rapid Response:

New guidelines for converting healthy people into patients

The National Cholesterol Education Program is based on the assumption
that it is possible to prevent cardiovascular death in a large number of
people. The expert panel´s main argument for the new guidelines is that
twenty percent of patients with coronary heart disease have a new heart
attack after ten years.1 To reach that number any minor symptom without
clinical significance has been included. Most people survive even a major
heart attack, many with few or no symptoms after recovery. What matters is
how many die and this is much less than twenty percent.
. No doubt, the statins lower the risk of dying from a heart attack, at
least in patients who already have had one, but the size of the effect is
unimpressive. In the CARE trial for instance, the odds of escaping death
from a heart attack in five years for a patient with manifest heart
disease was 94.3%, which improved to 95.4% with statin treatment.2 For
healthy people with high cholesterol the effect is even smaller. In the
WOSCOPS trial, the figures were 98.4% and 98.8%, respectively.2

These figures do not take into account possible side effects of the
treatment. In most animal experiments the statins, as well as most other
cholesterol-lowering drugs, produced cancer, and they may do it in human
beings also.2 In the CARE trial breast cancer was seen significantly more
often in the treatment group. In the EXCEL trial the increase of total
mortality in the treatment group after just one year was borderline
significant.3 Unfortunately the trial was stopped before further
observations could be made.

The original 1961 advice from the American Heart Association to eat as
much polyunsaturated fat as possible has been reduced successively to the
present “up to ten per cent”. But why this limit? Ten years ago the main
author of the new guidelines stated that “intakes above 7% of total
calories seemingly cannot be advocated with prudence” because, as he
argued, an excess of polyunsaturated fat may be carcinogenic in human
beings, just as they are in experimental animals.2 4 Besides, the benefits
of manipulating dietary fats have never been proved.2
Instead of preventing cardiovascular disease the new guidelines may
transform healthy individuals into unhappy hypochondriacs obsessed with
the chemical composition of their food and their blood, undermine the art
of cuisine, destroy the joy of eating, and divert health care money from
the sick and the poor to the rich and the healthy.

1. Expert Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults. Executive Summary of the Third Report of the
National Cholesterol Education Program (NCEP) Expert Panel on Detection,
Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult
Treatment Panel III) JAMA 2001; 285: 2486-2496.

2. Ravnskov U. The Cholesterol Myths. New Trends publishing,
Washington DC 2000.

3. Bradford R H, Shear C L, Chremos A N, Dujovne C A, Franklin F A,
Grillo R B, Higgins J, Langendorfer A, Nash D T, Pool J L, Schnaper H.
Expanded clinical evaluation of lovastatin (EXCEL) study results. Arch
Intern Med 1991; 151: 43-49.

4. Grundy SM. George Lyman Duff Memorial Lecture. Multifactorial
etiology of hypercholesterolemia. Implications for prevention of coronary
heart disease.
Arteriosclerosis 1991; 11: 1619-1635.

Competing interests: No competing interests

28 May 2001
Uffe Ravnskov
Magle Stora Kyrkogata 9, S-22350, Lund