London - This is a story about cholesterol: a story that affects me, you and the people you love. It's not a simple story, but it is an important one. And it starts in February of this year, when I had some routine blood tests and my GP called me to discuss the results.
“It's your cholesterol,” she said in that distracted, doctorish way. “It's very high - 7.4 - so you'll need to see the nurse and we might have to put you on statins.”
Gobsmacked, I spluttered a reply and hung up. Statins! For a 43-year-old, fit and healthy man. Not just that, but a health writer, who a couple of years ago wrote about the profound effect observing a triple bypass had had on me, and my determination to exercise well, eat better and generally do everything in my power not to end up on under that heart surgeon's knife.
Even more ironic, I now combine writing with practising as a wellbeing coach, advising clients how to manage their stress and improve their mental/physical health. All in all, not too good.
I visited the practice nurse, who took my blood pressure - fine, thank God - and calculated my “cardiac risk”. This combines various factors, such as whether you smoke, your age, weight, blood pressure, family history - and, of course, cholesterol level - to determine your risk of cardiovascular disease in the next decade. Happily, my risk was low, because, apart from the dodgy cholesterol, I was in good shape.
The result? I was given the standard NHS advice: drastically reduce my intake of saturated fat, especially fatty meats, dairy products, biscuits, chocolate and cake . “Try that for three months and, if your cholesterol score doesn't improve, we'll put you on statins,” the nurse announced, breezily.
As a diehard foodie, I was bereft at the idea of giving up my beloved bacon and brie, and more than a little scared. Despite my low cardiac risk, the fact that my father died of a heart attack in his early sixties has always played on my mind - for all sorts of reasons - but now I wondered, would I be next? Determined to allay my fears, I set out on a journey of discovery to find out all I could about my fatty nemesis.
That journey, as you'll see, had many twists and turns, but let's start with the conventional view.
Cholesterol is a fatty substance found in the blood, which is present in some foods (such as eggs, liver, kidneys and prawns) but mainly produced by the liver from fatty foods such as the aforementioned meats and dairy products. We need cholesterol, because it plays an essential role in various bodily functions - especially cell formation and hormone production - but too much of it can increase your risk of cardiovascular disease. It's carried around the body by proteins, and the combinations of cholesterol and these proteins are called lipoproteins. These are divided into “bad” LDL (low-density lipoprotein) and “good” HDL (high-density lipoprotein). The theory goes that LDL - of which I have rather too much - is harmful, while HDL is protective.
So cholesterol is measured both in terms of units called millimoles per litre of blood and, within that, the balance between LDL and HDL.
“The UK average is around 5.5,” says Ellen Mason, senior cardiac nurse at the British Heart Foundation. “Once you get to about 8 you might well have familial hypercholesterolaemia, an inherited condition that needs treating with statins. With a score of 7.4 you're in a grey area, because you have higher cholesterol than average but not quite high enough to suggest a genetic cause.”
If not genetics, then what? Looking back over the last year, two things stood out. First, because of a nasty injury, my normally vigorous exercise regime bit the dust. And second, I got serious about cooking, spending most weekends baking cakes with my son. And what makes those cakes so delicious? Vast amounts of flour, eggs, sugar... and butter. Lots and lots of butter.
“Well, exercise does increase your HDL levels,'“ observed Mason, “and it sounds like you do need to reduce the animal fats in your diet. But it's the long-term build-up that matters - the cholesterol and other fatty deposits collecting on the wall of your arteries.”
This is why doctors take cholesterol so seriously, because the conventional cholesterol hypothesis goes like this: high-fat diet plus sedentary lifestyle equals high LDL levels in the blood, blocked arteries and cardiovascular disease/stroke. In terms of treatment, if you can't manage your cholesterol through diet and exercise, you have to take statins every day for the rest of your life (once you're on them, you stay on them). And those statins lower your blood LDL to safe levels.
One problem: I dislike taking medication. Having spent more than a decade writing about health, I have developed a profound suspicion of pharmaceutical companies and their products. Time and again these corporate giants suppress studies that do not support the efficacy of their drugs, while funding and publishing the studies that do.
Oh, by the way: Simvastatin is now the UK's most prescribed drug, earning its manufacturer billions of pounds a year. And a review of previous studies, published this January by the respected Cochrane Collaboration, claimed that healthy people derive no benefit from taking statins. The review found no evidence to justify the use of statins in people (like me) at low risk of developing heart disease.
Hmm, time for an alternative view. Dr Malcolm Kendrick is the author of The Great Cholesterol Con (John Blake Publishing), which argues that everything we think we know about cholesterol is wrong. And he is no kooky health “guru” - Dr Kendrick has been a GP for more than 25 years, worked with the European Society of Cardiology and writes for leading medical journals.
“If you look at overall mortality - what you die of and how long you live - there is absolutely no evidence that people with higher than average levels of cholesterol die younger. In fact, most of them live longer,” he says.
During the course of our interview, he keeps saying things like this. I feel like Alice tumbling down a rabbit hole to land in a world where everything is upside down and back to front. “If you ask the experts how lipoprotein gets through the lining of the arteries, they can't really explain it,” adds Dr Kendrick.
“These are very large molecules, which simply cannot penetrate the protective walls - so the first stage of the 'cholesterol causes cardiovascular disease' hypothesis is unexplained.”
He goes on: “Also, why does Switzerland have the highest level of cholesterol in Europe but the second-lowest level of heart disease? Or look at the Japanese, who in the last 50 years have eaten 200 per cent more saturated fat than they did, whose cholesterol levels have gone up from an average of 3.9 to 5.2, but their rate of heart disease has fallen by 50 percent?”
Even more controversial is Dr Kendrick's view that, not only does high cholesterol not cause cardiovascular disease, but lowering it with statins is “completely and utterly stupid”. He believes (and quotes large-scale, long-term study after study to back this up) that the mainstream medical community craved a simple solution to a complex problem and, rather than working with the body's “wonderful repair mechanisms,” we now use a pharmaceutical sledgehammer to crack a nut.
Although Dr Kendrick agrees that cardiovascular disease and stroke are caused by plaque build-up in, and therefore damage to the arteries, he argues that this is not caused by cholesterol, but rather multiple factors including high blood sugar, the stress hormones cortisol/adrenaline, cell damage, insulin resistance and age - so there is no single, simple cause. And the solution? He emails me a to-do list of 16 strategies, including “daily meditation/relaxation; avoiding fructose/diet drinks; stopping smoking; ensuring that you're not bullied at work; and exercising - walking is best”.
Oh, and I should never take statins nor worry myself by getting my cholesterol levels checked.
Deeply confused now, I turned to Dr Devi Nair, consultant chemical pathologist at the Royal Free Hospital, London. Having politely declined to discuss Dr Kendrick's view, like Ellen Mason she argued equally convincingly that cholesterol does cause cardiovascular disease and stroke. “And especially if someone has familial hypercholesterolaemia [FH], this needs treating with diet, exercise and statins.”
Dr Nair acknowledges that statins are powerful drugs, which you should only take if necessary. But she argues that people with FH definitely need statins; as do those with diabetes or people who have already had a stroke or heart attack. And if you are obese, or just have high levels of abdominal fat, your triglycerides (another type of fat found in the blood) are also likely to be high, which needs treating with a high-dose omega-3 fish oil, or fibric/nicotinic acid.
So, the $64,000 question: who do I believe and what will I do about my high cholesterol?
Honestly, I'm not sure. I wish I could wrap this up neatly, but both sides of the cholesterol debate make compelling arguments. If you are concerned, you should certainly talk to your GP - but then investigate all the evidence and make up your own mind.
Because I have a low cardiac risk, I won't be taking statins any time soon. I remain unconvinced that, in my situation, I need to take a powerful drug that can have nasty side effects such as muscle pain/weakness. I will restart my exercise regime and reduce the saturated fat in my diet - I'd like to lose some weight anyway, so it can't hurt. I will also stop worrying, because that just stresses me out and raises my blood pressure, which everyone agrees is a bad thing. And I will keep researching the subject. It seems my cholesterol story has only just begun.
Heart health: what should you do?
* If you're a smoker, give up - this is the single most important thing you can do to protect your heart.
* Do 30 minutes of cardiovascular exercise (jogging, cycling, brisk walking, football, Zumba...) at least three times a week.
* Take an omega-3 fish oil supplement every day. If your cardiac risk is high, this needs to be prescribed by your GP, not an over-the-counter supplement.
* Manage your stress and anger. Chronic stress and hostility have both been linked with an increased risk of cardiovascular disease.
* Go easy on the booze. Drinking more than the recommended weekly amount (21 units for men, 14 for women) raises your blood pressure, which in turn puts your cardiovascular system under increased strain.
* Practice daily mindfulness meditation, a research-backed relaxation technique that reduces stress and blood pressure. - The Independent