by pkingDesign
My article below was published this week at both The Conversation and in Australian Doctor. I figured I’d get in third.
On the past two Thursdays, the ABC’s Catalyst program set off a chain reaction of protest from sections of the medical community, aghast that the non-medical media would question the accepted wisdom that dietary saturated fats kill people and statins save lives.
The issue dominated the medical media, and Professor Emily Banks, chair of the Advisory Committee on the Safety of Medicines, warned the ABC to pull the second program. Yet the show went on: as befits a catalyst, it remained unaffected by the reaction it had produced.
AMA president Dr Steve Hambleton claimed the programs “gave extraordinary weight to an opinion that is a minority view,” while his predecessor Prof Kerryn Phelps put her weight behind the minority view, tweeting “Time for Australian therapeutic guidelines on cholesterol and statins to be revisited.”
Plenty of fat spitting from the frying pan in all directions—so what is a non-expert to make of it?
As a GP who has no intention of ever mastering lipid epidemiology (for fear of brain supersaturation), in these situations I whip out my most discriminating organ: my sceptic’s eye.
The result? Surprisingly, the two Catalyst programs scored almost polar opposites on the sceptometer.
The first Catalyst program
This starts with a fellow called Dr Jonny Bowden saying:
I think it’s a huge misconception that saturated fat and cholesterol are the demons in the diet, and it is 100% wrong.
At the phrase 100 per cent, my sceptometer already gives a twitch. Just who is this confident expert?
A quick search reveals Jonny bills himself as the Rogue Nutritionist to promote his 14 diet books. His website contains twenty pages of online shopping for bottled pills for Anti-Aging, detox, liver clearing, immune support and brain power. This nutritionist is no trusty Rosemary Stanton. He has lost me already.
Next up, cardiologist Dr Stephen Sinatra: at least he should know a thing or two about cardiovascular risks. But I Google his name too, while I’m there.
The home page of his website has more shopfront than Myer. His personalised brand of pills flash like Vegas signs: 20%-off sales here, special deals there. Buy Dr Sinatra testosterone—sorry, T-support—or click through to ‘anti-aging bombshell’ Longevity Plus, before spending $55 on an ‘energy booster to refuel your cellular engines’. Er, no thanks, my engines are fine.
I’m on a roll now. The next expert is Dr Michael Eades, and it turns out he’s the sort of expert who suggests that your weight loss solution is Metabosol™ Ultimate Success Pack, full of Diet Aid natural ingredients which he will sell to you for just $209.95. Have these guys never heard of broccoli?
During Catalyst, Dr Eades questions the motives of the multibillion dollar food industry fuelling our phobia of fat in the diet. He comments:
That’s not science. That’s marketing.
At last: a statement where I can unreservedly accept that he would be an expert.
Honestly, even at this early point, I give up. The sceptometer has blown a fuse. My head tells me I should analyse the message, not the messenger, but that task now appeals about as much as arguing the fine print with visiting Mormons.
For now, I’ll stick with the 2012 Cochrane Review that suggested a modest (14%) reduction in heart attacks when participants tried to lower their saturated fat intake, although no conclusion could be drawn on overall mortality. Certainly no reason to change my mainstream dietary advice.
The second Catalyst program
With a heavy heart (probably the trans-fats) I await the second Catalyst which focuses on statin medications, but to my pleasant surprise, the first commentator is respected academic Professor Rita Redberg, who prefers editing JAMA Internal Medicine to selling vitamin cure-alls. I have long been a fan of her Less is More series which applies the blowtorch of best-available evidence to common medical interventions which our profession probably over-uses.
It’s hard to quibble with anything in her opening gambit:
The marketing concentrates on the fact that you can lower your cholesterol as if that was the end in itself, which it is not. Cholesterol’s just a lab number. Who cares about lowering cholesterol unless it actually translates into a benefit to patients?
The crucial question, then, comes down to mortality data in randomised control trials (RCTs). As end points go, death is easily measured, and all my patients consider it suitably clinically relevant.
Says Redberg:
One or two people in a hundred will benefit from taking a statin. What people don’t understand is that means the other 98 will get no benefit at all. It’s not going to reduce their chance of dying.
Despite the shocked reaction to the Catalyst episodes, the science behind the claim that we overprescribe statins—the world’s most profitable drug class ever—has been steadily building for years.
This may be a revelation for the general public. And for doctors who rely on pharmaceutical reps for a substantial portion of their medical education. However, we learned this back in 2010 from an all-cause mortality meta-analysis of 11 RCTs looking at primary prevention (no history of heart attacks) in people at high cardiovascular risk.
Its conclusion was fairly unambiguous:
This literature-based meta-analysis did not find evidence for the benefit of statin therapy on all-cause mortality in a high-risk primary prevention set-up.
Is this enough to show statins simply ‘don’t work’? No. But it is more than enough to make one suspect we may have overstepped the mark with many of the 40 million people currently prescribed statins.
And the mark—the cutoff point recommended by expert panels—keeps shifting lower, encouraging more treatment. Catalyst pointed out that eight out of nine of the 2004 US guideline panel members had a direct conflict of interest after declaring financial ties to the companies that manufactured statins.
This ‘guideline’ conflict is, if anything, worsening. According to a September 2013 BMJ report:
Widespread financial conflicts of interest among the authors and sponsors of clinical practice guidelines have turned many guidelines into marketing tools of industry. Financial conflicts are pervasive, under-reported, influential in marketing, and uncurbed over time.
Because of their popularity and the sheer enormity of the profits involved, statins provide one of the most concerning examples of this type of market engineering.
This second Catalyst episode goes on to mention publication bias, pharmaceutical sponsorship potentiating biased reporting of outcomes, withheld trial data (see the AllTrials campaign) and the distasteful phenomenon of Key Opinion Leaders. These are specialist doctors identified and sponsored by the pharmaceutical industry to educate other doctors about diseases for which there is a branded treatment.
So was Catalyst wrong to air a program which, as National Heart Foundation CEO Dr Lyn Roberts pointed out, might encourage some people to stop taking their statins without consulting their GP?
No; I think the more likely effect is that people will start raising the issue with their GP, which is a good thing.
Although I can understand the NHF’s concern after suffering through the snake-oil salesmen in the first program, I think the second chapter effectively introduced an important debate—and certainly everybody is now talking about it.
So in the end, I’m glad I sat down for the sequel, despite my overheated sceptometer warning against it.
I did have to watch the dial anxiously when Jonny the Rogue Nutritionist returned to plug his Coenzyme-Q10 pills. But then, I’d also watch the dial if I ever attended a GP educational session and discovered that the specialist talking was a sponsored Key Opinion Leader and his topic was statins.
Dr Justin Coleman is a GP at Inala Indigenous Health Service, Brisbane. He is a Senior Lecturer at Griffith University and University of Queensland, and President of the Australasian Medical Writers Association (AMWA). As the Naked Doctor, he blogs about overdiagnosis and overtreatment on Croakey.
drjustincoleman 
Justin
You seem to have misrepresented the Cochrane review in which you seem to place so much trust.
You state it showed “…a modest (14%) reduction in heart attacks when participants tried to lower their saturated fat intake”.
The review focused on a trials in which overall fat in the diet was reduced and/or modified. Contrary to your claim, it showed no reduction in risk of heart attacks. Incidentally, there was no reduced risk of stroke, diabetes or cancer either. You say that “…no conclusion could be drawn on overall risk of death.” Actually, the study clearly showed that overall mortality was not reduced in any of the analyses.
The 14 per cent reduction in risk you refer to related to a composite ‘catch all’ endpoint of ‘cardiovascular events’. However, if you’ve read the Cochrane review you’ll also know that once studies that had systematic differences in care between the active and control arms were removed, the statistical significance of the result disappeared. The same was true if the analysis was confined to studies where the only dietary difference between active and control arms concerned fat.
In other words, this largest ever meta-analysis on the effects of fat reduction and/or modification showed no benefits in terms of morbidity or mortality. None.
Is your faith in the wisdom of mainstream dietary advice still as unshakeable as ever?
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Thanks for you interest, John.
I agree that the 14% reduction was in CV events; I used that phrase in my first draft, but because I was writing for a non-medical audience, I changed it (dubiously, in retrospect) to ‘heart attacks’ instead.
I do not have unshakeable faith in mainstream dietary advice; indeed, I am surprised to hear it suggested I am an ‘unshakeable faith’ type of guy! If enough evidence comes along that we should cease to recommend a reduction in saturated fats, I’ll run with it; no reason I wouldn’t.
Having read the 100-odd comments about my article on The Conversation website, and including yours above, I am yet to be convinced. The Cochrane review, even accepting your comments about it, doesn’t provide enough evidence to actively stop recommending a reduction in the average Western diet intake of fats.
I find Rosemary Stanton’s recent summation of the dietary fats debate quite a reasoned approach; found at https://www.mja.com.au/insight/2013/42/rosemary-stanton-fat-facts
I might add that, having read your blog (a far more impressive blog site than my own, by any measure), I suspect our views would also differ on a number of other topics, including the MMR vaccines-autism link, the specific benefits of a number of supplements and vitamins, and of homeopathic doses of arnica.
I admire your scepticism and questioning of mainstream medicine but, judging by your blogs, you seem to actively advocate for ‘alternative’ explanations with far less regard for the rules of evidence.
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Justin
“The Cochrane review, even accepting your comments about it, doesn’t provide enough evidence to actively stop recommending a reduction in the average Western diet intake of fats.”
Can you provide some robust evidence for this advice? Otherwise, are we to assume that you do not have regard for the “rules of evidence”?
You clearly take exception to things I have written on my blog, but you are utterly vague about why you disagree with them. Instead of picking topics that perhaps just pique your bias, I suggest you be more specific and accurate (and scientifically rigorous) in your approach. Just as I suggest you should have been in your reporting of the Cochrane review.
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p.s. I see, over at The Conversation, you got called out for ad hominem attacks. Do you make a habit of this sort of thing?
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Thanks again, John.
One of my favourite shows on Australian TV is the ABC’s ‘Media Watch’, which has tonight just done a wonderful ‘ad hominem’ job on the Catalyst program. Please watch the episode or read the transcript here .
As you will have read over at The Conversation, I do think there is a time and place for looking at the messenger rather than just the message. I will quote my own reply to Peter, below, because I am genuinely interested in what others think about the questions I raise there.
But I do find harsh your description of me as being ‘utterly vague’ about why I disagree with your opinion that MMR causes autism and your promotion of homeopathy…I was merely brief, not vague! And I will remain brief: I have absolutely no intention of my blog turning into a forum for arguing the merits or otherwise of homeopathy. You have every opportunity to host that sort of pretend-evidence-based discussion on your own blog if you wish.
My post at The Conversation: Peter, I stand guilty as charged! I’m a Collingwood fan, and for the first Catalyst episode I played the man, not the ball (ad hominem, non ad pilam?)
In my defence, Catalyst chose the messengers and I strongly suspect that less-compromised experts would have presented a more nuanced case.
It does raise an interesting dilemma, though, for non-experts—no doubt the majority of readers of this article. I am a GP who reads (and writes) more than many of my peers, but like all GPs, I need to make a range of decisions throughout the entire breadth of medicine, based on evidence I read.
I have a passionate interest in how doctors choose which evidence is likely to be ‘on the money’.
Hence my predilection for Cochrane reviews, journals like the BMJ, and analysis by people in whom I have developed a long-term trust—or, for topics I know little about, perhaps even experts who are trusted by people I trust.
This is not ideal, but for the true ‘generalist’ it is practical.
If Rosemary Stanton or Garry Egger tells me that opinion is shifting on saturated fats, I’ll allocate a lot of my precious time weighing up the evidence they present, because I owe that time to my patients. If a bloke selling anti-ageing pills on an infomercial claims ‘Lab tests have proved…’, I won’t bother checking his sources. My ‘ad hominem’ filter!
By way of contrast, I recently authored the RACGP response to the Medicines Australia paper on transparency of payments to doctors from the pharmaceutical industry. A disturbing number of angry responses from doctors indicated that some or most of their drug education was from pharmaceutical reps or dinners—often justified because they saw the opposing reps as well, and so balanced out the bias!
I wonder which rep was responsible for educating them about the concept of overtreatment?
My practical solution is to avoid reps in the first place—and citations by people who sell suspect products—but instead I use less-compromised people to direct me to the relevant papers.
I’d be interested to hear from other generalists. What is your approach?
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Jusint
First of all, please, please do not misrepresent me. Where did I state that MMR causes autism? Where have I ‘promoted’ homeopathy? Is resorting to ad hominem attacks and not sticking to the point your stock in trade?
My approach, Justin, is to report the science as accurately and fairly as I can, and, where relevant, to bring in my clinical experience. Regarding dietary fats, I don’t think the latter is particularly relevant, but the former certainly is.
You misrepresented the Cochrane review and I note you’re happy for your errors to stand. I wouldn’t rely too heavily on Rosemary Stanton to guide you either – she also doesn’t appear to have read the Cochrane review properly.
Again, I ask you, what evidence do you cite for the conventional wisdom on fat? (Please do not plead time poverty. If you don’t do the research, then perhaps you’re not in a position to offer informed comment in the first place).
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Thanks John
I have published all the comments you have posted, and I think we will just have to agree to disagree.
You have particular firmly-held views on dietary fats and alternative medicines and I suggest readers, if interested, have a read of your blog.
Could I please suggest that you post any further comments either in the public forum at The Conversation or on your own blog, thanks?
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An interesting Op-Ed piece appeared in the New York Times yesterday, co-authored by Rita Redberg. Found at http://www.nytimes.com/2013/11/14/opinion/dont-give-more-patients-statins.html?emc=edit_tnt_20131113&tntemail0=y&_r=2&
It raises concerns about this week’s new American Heart Association guidelines which have lowered the recommended threshold for statin treatment from 10-20% 10-year cardiovascular risk, down to a 7.5% 10-year risk.
Note for Australian readers that we usually work with 5-year risks, which are roughly half of the 10-year risk. Therefore the new US recommendations now advocate statin treatment at around a 3.5% 5-year CV risk.
According to the authors: “Statins should not be recommended for this vastly expanded class of healthy Americans. Instead of converting millions of people into statin customers, we should be focusing on the real factors that undeniably reduce the risk of heart disease: healthy diets, exercise and avoiding smoking.”
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