Canibais e Reis

Download: cholesterol-mortality-database.zip (894 kb)

 

Total cholesterol level is negatively associated with most diseases

I would say this post was inspired by Dr. Stephan’s post about MRFIT’s total cholesterol mortality, published last 25th of July, in which a total cholesterol vs mortality chart was presented, with mortality divided in Total, CHD and Stroke and based on data from this post-MRFIT study published in 1989, in the New England Journal of Medicine,

Serum cholesterol levels and six-year mortality from stroke in 350,977 men screened for the multiple risk factor intervention trial. (pdf)

Stephan was guessing that the higher mortality rates observed at lower total cholesterol (t-C) levels were because of "higher cancer rates and higher rates of accidents and suicide". This is possibly true but these deaths are small (on a relative scale when compared with infectious/respiratory diseases) and don’t explain the whole mortality at low t-C, certainly not on worldwide scale (164 WHO countries) and probably also in the USA. The main causes of higher death rates at low t-C are "I.A. Infectious and parasitic diseases" (perhaps more than 50% of deaths), being the most important in low t-C countries "I.A.3. HIV/AIDS" (r=-0.37). Others causes are "I.B. Respiratory infections" (r=-0.68), "I.A.4. Diarrhoeal diseases" (r=-0.67), "I.D. Perinatal conditions (h) (r=-0.58), "I.A.8. Malaria (r=-0.65)" and I.A.5. Childhood-cluster diseases (r=-0.61)". But the main cause is HIV/AIDS, and its correlation with t-C levels is weak! How I got to these conclusions? Here is my explanation and data sources.

I thought it would be interesting to investigate the relation between t-C and mortality, but using (much more) detailed mortality statistics. Because there is published research showing that low cholesterol is not good for your health, I wanted to see exactly what is wrong about having lower or lowered cholesterol levels. For this purpose, I first collected some epidemiological on-line data, which wasn’t too difficult because I did a web search some months ago, to build my epidemiological database, and already knew where to find most statistics. The world’s average cholesterol levels are available from the British Heart Foundation. You can download the t-C data from here. And the world’s (very) detailed mortality statistics are available from WHO and you can download their most recent data from here. After this, you just need to do some number crunching, and this is exactly what I did.

I used the same template for the construction of this database as I did with the other database: I first merged the statistical data from 164 WHO countries (almost every country in the world) into the Excel file, then created an automated chart for easier visualization, and then studied the relationship (simple Pearson’s correlation analysis) between total cholesterol (t-C) and the several mortality parameters, which are these:

CONDITION:			CORREL:
I.B. Respiratory infections			-0.68
All cause mortality, age-standardized per 100,000			-0.67
II.H. Respiratory diseases			-0.63
I. Communicable, maternal, perinatal and nutritional conditions			-0.62
I.C. Maternal conditions			-0.61
I.D. Perinatal conditions (h)			-0.58
I.A. Infectious and parasitic diseases			-0.57
III.A. Unintentional injuries			-0.56
II.K. Skin diseases			-0.50
II.J. Genitourinary diseases			-0.50
III. Injuries			-0.50
II. Non-communicable diseases			-0.49
II.L. Digestive diseases			-0.42
I.E. Nutritional deficiencies			-0.41
II.G. Cardiovascular diseases			-0.30
III.B. Intentional injuries			-0.26
II.E. Neuropsychiatric conditions			-0.18
II.D. Endocrine disorders			-0.13
II.A. Malignant neoplasms			-0.08
II.B. Other neoplasms			-0.07
II.C. Diabetes mellitus			-0.05
II.F. Sense organ diseases			-0.05
II.N. Oral conditions			0.13
II.M. Congenital anomalies			0.17
II.L. Musculoskeletal diseases			0.23

The corresponding Excel database, with all the statistical data and automated charts can be download from here:

Download: cholesterol-mortality-database.zip (894 kb)

 

As you can see, the first "surprise" is that almost every unhealthy condition is inversely related with total cholesterol (t-C) levels. This means, of course, that higher t-C levels are linked to lower disease prevalencies, at least with those that are the most deadly. When everybody is saying that cholesterol is a deadly poison, we wouldn’t expect this, isn’t it?  Of course this doesn’t proves causality, but it should be a good reason for us to suspect that high t-C, after all, protects your overall health! Notice almost ALL parameters are negatively associated with t-C, so certainly cholesterol cant be bad to your health (I believe our livers know this very well, much better that we do). This is apparently also valid for cardiovascular diseases (CHD, not stroke) when TCmany researchers found and know about this for several decades now. Here is what Dr. Ravnskov, the spokesmen for the International Network of Cholesterol Skeptics, says: "A high blood cholesterol is said to promote atherosclerosis and thus also coronary heart disease. But many studies have shown that people whose blood cholesterol is low become just as atherosclerotic as people whose cholesterol is high". We may now ask what if blood cholesterol has nothing to do with atherosclerosis? And we could also ask if could atherosclerosis be an infectious disease?

 

Bad cholesterol, good cholesterol and bad science

It is quite fascinating to notice that high t-C, rather than being a malignant condition that would predict a short life expectancy, is actually associated with higher longevity, and not only with longevity but also with a healthy life, which is what we all want, isn’t it? High t-C actually predicts healthy life longevity, and current epidemiological data fully support this fact. Let’s just have a quick look at this graph from my previous database (for a large graph, please click here). The association between t-C and healthy life expectancy, and thus a pleasant longevity, is very clear. People with high cholesterol live the longest! I just wonder why past researchers completely missed all these "clues" and decided that cholesterol should be bad, instead of being good.

Actually, some of those researchers even decided that some cholesterol is good, and some should be bad (like in the picture above), despite cholesterol in HDL and LDL being the same substance (they’re only playing different physiological roles; can we call this bad science?) and 70% of it being produced (and regulated if we overeat lots of eggs rich in cholesterol) by our own liver. We could ask if our livers are trying to kill some us, or rather constantly protecting us with a healthy substance called cholesterol! After reading this article, I’m pretty sure you’ll know the correct answer!

Source: Integrated nutrition, lifestyle and health database.
For a larger graph, click here.

 

Cholesterol provides immunity and protects against infections

Now back to the cholesterol-mortality database. The "Mean t-C, men (mg/dl), 2005" vs "All cause mortality, age-standardized per 100,000 (2002)" chart, in GIF or PDF formats, which is the main result from my statistical data research on cholesterol mortality, can be downloaded from here (see links below):

Download: cholesterol-mortality.gif (or in pdf/vectorial format)

 

Let’s have a look at this chart in detail. I suggest you print this for easier reading. It represents average mortality data from 164 WHO countries, so from almost every corner of planet Earth. What can we conclude? First of all, total mortality, represented by the blue curve, is a U-shaped curve, just like the MRFIT curve presented in the WHS blog. I’m not completely sure this should be a U-shaped curve because there aren’t too many countries with average t-C above 220 mg/dl to fit this curve (for statistical purposes, average cholesterol values are as good as maximum values because the population mean predicts the number of deviant individuals). The mathematical relation of t-C with mortality is not an exact science, as it depends on several characteristics of the populations, as Dr. Uffe Ravnskov clarifies in one of his papers.

"It is true that high t-C is a risk factor for coronary heart disease, but mainly in young and middle-aged men. If high t-C or LDL-C were the most important cause of cardiovascular disease, it should be a risk factor in both sexes, in all populations, and in all age groups. But in many populations, including women, Canadian and Russian men, Maoris, patients with diabetes, and patients with the nephrotic syndrome; the association between t-C and mortality is absent or inverse; or increasing t-C is associated with low coronary and total mortality. Most strikingly, in most cohort studies of old people, high LDL-C or t-C does not predict coronary heart disease or all-cause mortality; in several of these studies the association between t-C and mortality was inverse, or high t-C was associated with longevity."

Source: High cholesterol may protect against infections and atherosclerosis (Ravnskov).

 

Anyway, those guys in Uruguai, Colombia and Serbia & Montenegro are enjoying their high t-C levels without much higher mortality than most countries in the world. On the other side of the curve, those "healthy" countries with t-C below 200 mg/dl, for whatever reasons, are dying much, much more than colombians are. How is this possible if their t-C is so low and thus "healthy"? They (might) have lowered cardiovascular diseases (CHD) on a low cholesterol but, on the other hand, they are prone to much higher infectious and parasitic diseases. Dr. Uffe Ravnskov explains this in his paper High cholesterol may protect against infections and atherosclerosis. So we can ask, what if higher LDL cholesterol (yes, the "bad" LDL cholesterol) is actually protective against infections and atherosclerosis, and not as bad as we are constantly being told by the "experts"? What if cholesterol has pro-immunity and anti-infectious properties people totally ignore because of this obsessive worry about blood lipids and cardiovascular diseases?

 

Increased infectious diseases linked to low cholesterol

Total mortality is usually subdivided in three main chapters: 

I. Communicable/infectious, maternal, perinatal and nutritional conditions
II. Non-communicable diseases (heart disease and other diseases of civilization)
III. Injuries

For an explanation of the meaning of communicable/infectious and non-communicable diseases, please see the Wikipedia: communicable diseases and non-communicable diseases. The latter can also be called diseases of civilization, or lifestyle/modern diseases. Cardiovascular diseases ("II.G. Cardiovascular diseases"), the major cause of mortality in industrialized countries, are included in this last category and so modern health authorities tend to focus exclusively on these and forget the others, but both are linked by this much misunderstood "nutrient": cholesterol! Their approach is based on lowering LDL (and also t-C)  levels with drugs called statins, which, by inhibiting the cholesterol synthesis, actually manage to reduce cardiovascular diseases (ironically not necesarily by reducing LDL) but, at the same time, also increase communicable/infections diseases, cancer, diabetes, etc. The result is the same total mortality, and we know this because most intervention studies with statins aren’t able to reduce total mortality (on this subject, also see this study). Of course this didn’t happen in the Jupiter statins’ trial, because researchers decided to stop it when the results where most favourable to statins.

In our graph, the most important communicable diseases are "I.A. Infectious and parasitic diseases", which increase as t-C levels decrease below 220 mg/dl, and become very high (5 to 10 times higher) at very low t-C, around 150 mg/dl or less. Under these circumstances, it is legitimate to ask "what if high cholesterol levels have immunoprotective effects that explain observations contradicting the LDL-receptor hypothesis"? And what if "mental stress, physical activity and change of body weight may influence the levels of blood cholesterol and this substance is not dangerous by itself, but may reflect an unhealthy condition, or it may be totally innocent"?

"Many epidemiological and clinical observations are in accord with the laboratory studies. A meta-analysis of 19 cohort studies including 68 406 deaths, found an inverse correlation between t-C and mortality from respiratory and gastrointestinal diseases, most of which are of an infectious origin. It is unlikely that the low cholesterol was due to these diseases because the associations remained after the exclusion of deaths occurring during the first 5 years.24 Also, in a 15 year follow-up study of more than 120 000 individuals, Iribarren et al. found a strong inverse association between t-C (as determined initially) and the risk of being admitted to hospital due to an infectious disease. Statistically significant, inverse associations were found for urinary tract infections, all genitourinary infections and miscellaneous viral infections for women, and for urinary tract infections, musculo-skeletal infections and skin and subcutaneous infections in men. Inverse, but non-significant associations were found for most other infectious diseases. In a similar study of more than 100 000 individuals followed for 15 years, a strong, inverse association was found between t-C and the risk of being admitted to hospital because of pneumonia or influenza, but not for chronic, obstructive pulmonary disease or asthma."

Source: High cholesterol may protect against infections and atherosclerosis (Ravnskov).

 

Updated epidemiological data on communicable/infectious diseases fully support what Dr. Ravnskov says. Have a look at this graph:

Source: Integrated nutrition, lifestyle and health database.
For a larger graph, click here.

 

Patients hospitalized with CHD have lower (yes, lower!) cholesterol

Regarding cardiovascular diseases, the most deadly diseases of civilization, it is very difficult to establish a relationship between them and t-C. They are almost totally unrelated, as you can see from the graph below, and yet health authorities and high level "experts" kept recommending, in the last five decades, that you should keep your t-C levels under 200 mg/dl (and today below 190, even for children) in order to avoid heart disease. Try fitting a curve along those very dispersed data points. Quite difficult, isn’t it? That’s because t-C is a really bad predictor of cardiovascular risk. Many people with high t-C never suffer from heart disease, and many people with low t-C also never suffer from it also. But the contrary may also happen for both groups.

Source: Integrated nutrition, lifestyle and health database.
For a larger graph, click here.

 

As we now see, of course most people with heart disease don’t have "high risk" t-C level. Guess how high their t-C levels are? Well, this is a big surprise to you: their average t-C level (174.4 mg/dl) is actually significantly lower than the average level of most "healthy" individuals (around 200 mg/dl). If you look at the chart you see that red line, which represents "II.G. Cardiovascular diseases". Notice the lower TC is possibly linked to higher cardio mortality. This all makes sense now, doesn’t it? So you now understand that this hypothesis is not complete science fiction, it is actually supported by a very large study by the AHA, based on valuable observational data:

Lipid levels in patients hospitalized with coronary artery disease: An analysis of 136,905 hospitalizations in Get With The Guidelines (pdf)

 

And what about people with genetically decreased cholesterol synthesis, shouldn’t they be much healthier than other "normal" cholesterol people, because their t-C is much lower and so healthier?

Smith-Lemli-Opitz Syndrome

"Much evidence supports the theory that people born with very high cholesterol, so-called familial hypercholesterolemia, are protected against infection. But if inborn high cholesterol protects against infections, inborn low cholesterol should have the opposite effect. Indeed, this seems to be true. Children with the Smith-Lemli-Opitz syndrome have very low cholesterol because the enzyme that is necessary for the last step in the body’s synthesis of cholesterol does not function properly. Most children with this syndrome are either stillborn or they die early because of serious malformations of the central nervous system. Those who survive are imbecile, they have extremely low cholesterol and suffer from frequent and severe infections. However, if their diet is supplemented with pure cholesterol or extra eggs, their cholesterol goes up and their bouts of infection become less serious and less frequent."

Source: The Benefits of High Cholesterol.

 

Healthier t-C range is 200-240 mg/dl

Another question we could ask is which t-C levels are associated with lower mortality? After all, we just want to live longer and don’t really care if we die from a heart attack or in a car accident. Well, I now firmly believe that the most favourable t-C levels, for overall good health and longevity, are in the range 200-240 mg/dl, as illustrated by the statistical data presented in this post and as also referred by Dr. Mary Enig in her article Cholesterol and Heart Disease - A Phony Issue: "Blood cholesterol levels between 200 and 240 mg/dl are normal. These levels have always been normal. In older women, serum cholesterol levels greatly above these numbers are also quite normal, and in fact they have been shown to be associated with longevity." Dr. Enig was 100% right, I don’t know if she had solid data to support the 200-240 values but she certainly knew what she was talking about. I know this totally contradicts what the "experts" say, but please ask those experts about the data sources they used to support their claims. I’m presenting my data here, make sure they also present the data supporting their (wrong) idea that t-C below 190 mg/dl is necessarilly healthier for human beings. IT IS NOT! The big drama in all this cholesterol story is that people worry too much about cholesterol and ignore the real modern poisons: sugars/HFCS, processed foods, high glycaemic cereals/starches, vegetable oils, etc. The truth is your t-C tells very little about your future health and that cholesterol-lowering may even shorten your life!

Source: cholesterol-mortality-chart.pdf (32 kb).

 

Obvious conclusion: "high" cholesterol is good!

Now you understand why I wrote this comment on Stephan’s blog?

"Low cholesterol levels are certainly not good for your health! There is epidemiological data associating lower cholesterol with an increase in impulsive or violent behaviours and some authors even suggest that "low-cholesterol may be a marker for risk of suicide or traumatic death". This is because there might be a link between cholesterol and serotonin synthesis. As we all know, brain cholesterol is essential to cell membranes and have a number of biological functions, so it is no surprise that low cholesterol have a role in the development of neurodegenerative disorders, like Alzheimers. Low cholesterol is also associated with some cancers, namely lung, liver, lymphatic and hematopoietic cancer. There is also the Smith-Lemli-Opitz syndrome and its deformities to remember us of the importance of adequate cholesterol synthesis. Cholesterol is also necessary for the synthesis of Vitamin D and Dr. William Davis reports a strong link between Vitamin D and HDL levels. They get really high with D3 supplementation (http://heartscanblog.blogspot.com/2008/08/vitamin-d-and-hdl.html). Dr. Uffe Ravnskov suggests that high cholesterol may protect against infections and even atherosclerosis (http://qjmed.oxfordjournals.org/cgi/reprint/96/12/927.pdf). For all these reasons, a few doctors are now thinking that "the benefits associated with cholesterol reduction may not outweigh the risks in all patients with hypercholesterolemia. Cholesterol-lowering interventions should be recommended with caution in patients at increased risk of cancer, stroke, and depression".

 

Source: Whole Health Source.

 

With all this infinite (dis)information and the current dogmatic propaganda against cholesterol, you must be very confused. Don’t worry, you are not alone, I’m also very confused about all this. If cholesterol levels are so poorly related to cardiovascular diseases, and most probably are not even causing them (they are probably just a mark for other unhealthy and long established conditions), we could ask "Why does a high cholesterol predict cardiovascular disease"? Notice the word "predict" only means association, that both variables are related, but it doesn’t means one is causing the other, it doesn’t means high t-C, or even LDL, causes cardiovascular diseases (CHD only). Most epidemiologists know that correlation doesn’t imply causation, but most heart health "experts" that say cholesterol is a deadly poison certainly never looked at the existing data themselves, this data you are looking at now. When an hypothesis doesn’t fit the observational data, not just a few marginal data, but some relevant data than contradicts an hypothesis, it is because our hypothesis is totally wrong and then we should abandon it. Here is how Dr. Ravnskov explains the association (not causality, of course) between t-C and CHD:

Why does a high cholesterol predict cardiovascular disease?

"If LDL-cholesterol and (delta)LDL-cholesterol do not correlate with degree of atherosclerosis or with atherosclerosis growth, why does a high cholesterol predict cardiovascular disease? The answer may be that cardiovascular disease is not synonymous with atherosclerosis. A high LDL or total cholesterol may be secondary to uncontrolled factors that promote cardiovascular disease in other ways and cause hypercholesterolaemia at the same time, for instance lack of physical activity, mental stress, smoking, and obesity. It is generally assumed that their effect on cardiovascular disease is mediated through the high cholesterol, but this may be a secondary phenomenon. Physical activity may benefit the cardiovascular system by improving endothelial function, or by stimulating the formation of collateral vessels; mental stress may have a harmful influence on adrenal hormone secretion, smoking increases the oxidant burden; in these all situations the high cholesterol may be an epiphenomenal indicator that something is wrong. This argument also explains why some studies found atherosclerotic growth to be associated with initial or on-study LDL-cholesterol, but not with (Delta)LDL or total cholesterol. If the amount of LDL-cholesterol in the blood were the determining factor, atherosclerotic growth should have been associated with (delta)LDL-cholesterol as well and to a higher degree."

Source:  Is atherosclerosis caused by high cholesterol? (Ravnskov)

 

Final conclusions

Until now, I have a single conclusion from all this: "high" cholesterol is good! From an epidemiological point of view, the most favourable t-C levels, for overall good health and longevity, are in the range 200-240 mg/dl. This obviously implies that the official recommendation to keep t-C below 190 mg/dl doesn’t make any sense at all, because it doesn’t provides any adittional protection from diseases and/or lower mortality. It focus exclusively on heart disease and forgets about other equalliy life threatening conditions. Lower t-C levels are associated with a series of poor health conditions, namely infectious and parasitic diseases.

How many people have their t-C levels in this optimal range? In a brazilian sample of more than 10.000 individuals, with average t-C 222 mg/dl (wow, right on the middle of 200-240!), 35% of them are in the range 200-240 mg/dl. Another 14% are at 180-200 mg/dl and 11% at 160-180 mg/dl. In Portugal, my home country, I estimate, from published data, that the average portuguese t-C should be 215 mg/dl (and not the 202 mg/dl value published by WHO). Most probably, 28% of us are in the 200-240 mg/dl range. About 43% are below 200 mg/dl and 31.7% of the portuguese have t-C above 240 mg/dl. This is not necessarilly bad, perhaps it might even be very good, maybe a marker for "healthy life expectancy"? After all, t-C level is negatively associated with most diseases!

If you want to learn more about these issues, you should read some of the articles linked below and also some of the cholesterol books from my Amazon Listmania. Science is made of disagreement, and Dr. Uffe Ravnskov, the spoksmen of the The International Network of Cholesterol Skeptics provides us with critical insight into how the approaches to the main health issue of our modern society - cardiovascular diseases - are so based in selective science, rely on old/poor epidemiological data and are also completely misguided by pharmaceutical/medical lobbies interested only in selling statins. And these people are converting healthy people into patients, instead of actually protecting them and their families from the diseases of civilization. If you don’t want to be a victim of this insane "health" system, do as Dr. Uffe Ravnskov says: Wake up!

 

Downloads:

Excel database - cholesterol-mortality-database.zip (894 kb)
Graph - cholesterol-mortality.gif (also available in pdf/vectorial format)

 

Suggested articles:

The cholesterol myths (Dr. Uffe Ravnskov)
High cholesterol may protect against infections and atherosclerosis (Ravnskov)
The benefits of high cholesterol (Ravnskov)
Questionable role of saturated and polyunsaturated fats in cardio disease (Ravnskov)
Saturated fat is good for you (Ravnskov)
Retreat of diet-heart hypothesis (Ravnskov)
Is atherosclerosis caused by high cholesterol? (Ravnskov)
Cholesterol lowering trials in CHD: frequency of citation and outcome (Ravnskov)
Diet-heart idea kept alive by selective citation (Ravnskov)
Colesterol references (Ravnskov)

THINCS:

The International Network of Cholesterol Skeptics (THINCS)
Dr. Uffe Ravnskov (THINCS)
Dr. Malcolm Kendrick (THINCS)

Chris Masterjohn:

Cholesterol, you can’t live without it

Also see this:

A collection of anti-’cholesterol con’ links, as requested by Richard Nikoley
Health problems of low or lowered cholesterol levels