Intended for healthcare professionals

Rapid response to:

Education And Debate

Risk factor thresholds: their existence under scrutiny

BMJ 2002; 324 doi: (Published 29 June 2002) Cite this as: BMJ 2002;324:1570

Rapid Response:

Potentially a very dangerous paper indeed

As Law and Wald previously established in their equally illogical
paper on the 'Time Lag Hypothesis' the French risk factors in men aged 45
- 64 are as follows:

French Risk Factors (From Law and Wald)

TC 6.1mmol/l
Systolic BP (their previous 'best BP risk factor') 150mmHg
HDL 1.3mmol/l
smoking 32%
(Add to this figures (from BHF)
average BMI 26.6
those never exercising 32%
CHD rate 128/100,000/yr

UK risk Factors

TC 6.2mmol/l
Systolic BP 148mmHg
HDL 1.3mmol/l
Smoking 29%
Average BMI 26.6
Those never exercising 24%
CHD rate 487/100/000/yr

Can Law and Wald fit these figures onto their semi-logarithmic scale

The suggestion that no levels of any 'risk factor' in the Western
World are currently 'normal,' and that what we call a normal blood
pressure is actually high, and should be lowered is dangerous nonsense.

Are Law and Wald aware of figures from Framingham which clearly
demonstrate that falling cholesterol levels are direclty associated with
an increased risk of CHD? 'There is a direct association between falling
cholesterol levels over the first 14 years and mortality over the
following 18 years (11% overall and 14% CVD death rate increase per 1
mg/dL per year drop in cholesterol levels). Anderson KM JAMA 1987

Are they aware of research by Marmot in Japan that demonstrates a
completely inverse relationship between rising cholesterol levels and
deaths from CHD. ' Considerable increases in total serum cholesterol
levels do not offer an explanation of the recent decline in mortality from
coronary heart disease in Japan.’ Okayama A, Marmot MG Int J Epidemiol Dec

There are literally hundreds of papers which totally contradict the
association between 'raised' cholesterol levels and death from CHD.

Shestov in his Lipid Clinics study in Russia even showed an inverse
relationship, with higher rates of CHD in hypocholesterolaemics. The
Honolulu study clearly demonstrates that, in those over fifty, a low
cholesteorl level is by far the most important risk factor for premature
death ‘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.’ Lancet 2001.

There is one curve, with regard to cholesterol lowering, that they
have not shown. Namely, the J shaped curve of total mortality with
5.2mmol/l at the bottom of that curve.

Law and Wald are, effectively, suggesting that almost everyone in the
Western World should be put on some kind of medication. This is dangerous
nonsense, and we should not be afraid to say so.

Dr Malcolm Kendrick

Competing interests: No competing interests

18 July 2002
Malcolm E Kendrick
Medical Director
Lifelong Learning Partnership