New guidelines for converting healthy people into patients

With their new guidelines the National Cholesterol Education Program’s (NCEP) expert
panel (1) exaggerates the risk of coronary heart disease (CHD) and the relevance of high cholesterol and ignores a wealth of contradictory evidence. A few examples.

To claim that 20% of patients with coronary heart disease have a new heart attack after ten years the panel has included minor symptoms without clinical significance. Most people survive even a major heart attack, many with few or no symptoms after recovery. What matters is how many dies and this is much less than 20%.

The predictive power of a high cholesterol is overrated. In the 30 year follow-up of the Framingham cohort for instance, high cholesterol was not predictive after the age of forty-seven. (2) It is not a strong predictor for women, Canadian men and patients with established CHD either. In Russia, low cholesterol is a predictor of CHD2 and individuals with familial hypercholesterolemia may live just as long and have a risk of CHD just as low as that of normal people. (3)

No doubt the statins lower coronary mortality, 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 CHD was 94.3%, which improved to 95.4% with statin treatment. For healthy people with high cholesterol the effect is even smaller; in the WOSCOPS trial, the figures were 98.4% and 98.8%, respectively. These figures do not take into account possible side effects which usually appear more often. In animal experiments the statins have proven carcinogenic. In the CARE trial statin treatment was followed by more breast cancer.

In the EXCEL trial, total mortality after just one year was much higher in those receiving statins. Unfortunately the trial was stopped before further observations could be made. (2) We need more experience before introducing mass-prevention with potentially carcinogenic drugs.

The panel ignores that a systematic review of relevant epidemiological and experimental studies found no evidence that dietary fat has effect on atherosclerosis and cardiovascular disease.(4) Most important, coronary and total mortality were unchanged in meta-analyses of the dietary trials.(4)

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, destroy the art of cuisine and the joy of eating, and divert health care money from the sick and the poor to the rich and the healthy.

Uffe Ravnskov

Magle Stora Kyrkogata 9

S-22350 Lund, Sweden

uffe.ravnskov@swipnet.se

read the editor's answer below

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

2. Ravnskov U. The Cholesterol Myths. New Trends Publishing, Washington D.C. 2000.

3. Sijbrands EJG, Westendorp RGJ, Defesche JC, de Meier PHEM, Smelt AHM, Kastelein JJP,
Kaprio J. Mortality over two centuries in large pedigree with familial hypercholesterolaemia:
family tree mortality study. BMJ 2001; 322: 1019-1023.

4. Ravnskov U. The questionable role of saturated and polyunsaturated fatty acids in
cardiovascular disease. J Clin Epidemiol 1998;51:443-60.

5. Hooper L, Summerbell CD, Thompson RL, Capps NE, Davey Smith G, Riemersma RA,
Ebrahim S. Dietary fat intake and prevention of cardiovascular disease: systematic review. BMJ 2001;322:757-763.

Editor's answer:

October 1, 2001

Uffe Ravnskov, MD, PhD
Magle Stora Kyrkogata 9
S-22350 Lund,
Sweden

RE: Letter # JLE10564

Dear Dr. Ravnskov:

Thank you for your recent letter to the editor. Unfortunately, in view of the many submissions we receive and our space limitations in the Letters section, we are unable to publish your letter in THE JOURNAL.

After considering the opinions of our editorial staff, we determined your letter did not receive a high enough priority rating for publication in JAMA. We are able to publish only a small fraction of the several thousand letters submitted to us each year, which means that published letters must have an extremely high rating.

However, we are forwarding a copy of your letter to the author of the article. The author may or may not reply to you personally. We do appreciate your taking time to write to us and thank you for the opportunity to look at your letter.

Sincerely,

Jody W. Zylke, MD
Contributing Editor, JAMA