dr aseem malhotra, honorary consultant cardiologist ...a79444d2-d4fe-466f... · rcp, sir richard...
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Dr Aseem Malhotra, Honorary Consultant Cardiologist, Lister Hospital Stevenage
Academy of Medical Royal Colleges Choosing Wisely Steering Group
King’s Fund – Member of Board of Trustees
“ Half of what you learn in medical school
will be shown to be either dead wrong or
out of date within 5 years of your
graduation; the trouble is nobody can tell
you which half. The most important thing to
learn is how to learn on your own” David
Sackett
Ann Intern Med 1979; 90:85-91 Castelli W. Atherosclerosis 1996;124 Suppl:S1-
S9
Ideal Risk Factor Framingham Heart Study
‘Cholesterol and Disease’ Experts are called ‘Lipidologists’
What do Leading-Edge Experts Say?
One of the USA’s foremost is Thomas Dayspring, MD, FACP, FNLA, NCMP
Clinical Assistant Professor of Medicine, Director of Cardiovascular Education
2) LDLc is a near-worthless predictor for cardiovascular issues*
“The [Total/HDL] RATIO was found to be a better predictor of CHD
than TC, LDL, HDL and triglyceride -- not only in the Framingham Study,
but also in the Physician's Health Study and many other studies.”
- William P. Castelli (Framingham Director)
Lipids, risk factors and Ischaemic heart diseaseAtherosclerosis 124 Suppl. (1996)
S1-$9
Are we giving the wrong dietary
advice on saturated fat? 1970 American Scientist Ancel Keys, 7 countries study- saturated
fat – increased cholesterol- main dietary cause of heart disease.
Change in dietary advice in 1977/1984 – eat less fat and more
carbs! ( <30% fat <10% sat fat)
Food industry exploitation of “low fat” mantra has resulted in diets
high in refined carbohydrates (sugar)
Prevalence of obesity and type 2 diabetes in western population
has rocketed since.
But Selective data. Keys’ observational correlations didn’t appear
so strong when other countries included.
Keys’ received research funding from Sugar industry
But saturated fat increases HDL (good) cholesterol to equal degree and affects LDL large type A particles, wheras small dense type B particles are more atherogenic (responsive to refined carbs)
Little effect on total cholesterol:HDL ratio- a better predictor of CHD events that total cholesterol alone.
Source and type of saturated fat may be important with some suggestion that dairy products may be protective
Re- analysis of unpublished data from Sydney Heart study revealed cardiac patients who replaced butter with safflower oil and margarine containing omega 6 had increased all cause and cardiovascular mortality despite a 13% reduction in total cholesterol
Cambridge MRC/BHF
Rajiv Chowdhury, Samantha Warnakula, Setor Kunutsor, Francesca Crowe, Heather A. Ward, Laura Johnson, Oscar H. Franco, Adam S. Butterworth, Nita G. Forouhi, Simon G. Thompson, Kay-Tee Khaw, Dariush Mozaffarian, John Danesh, Emanuele Di Angelantonio; Association of Dietary, Circulating, and Supplement Fatty Acids With Coronary RiskA Systematic Review and Meta-analysis. Annals of Internal Medicine. 2014 Mar;160(6):398-406.
A meta-analysis of 72 unique studies with over 600,000 participants from 18 countries led by the Cambridge Medical Research Council concluded that “current evidence does not support guidelines that restrict the consumption of saturated fats and encourage consumption of polyunsaturated fats in order to prevent heart disease.” The study raised questions regarding current nutritional guidelines that focused principally on the total amount of fat from saturated or unsaturated rather than the food sources of the fatty acid subtypes. One interesting finding was that the consumption of one particular fatty acid (margaric acid) which is a dairy fat, significantly reduced the risk of cardiovascular disease
Could better dietary assessment
methods help to clarify the
association?
Could better dietary assessment methods help to clarify the
association?
Aim: To investigate the association between saturated fatty acids measured in the blood and
the risk of developing type 2 diabetes (T2D)
Method: EPIC-InterAct StudyLarge case-cohort within the EPIC study
across 8 countries of Europe, with 340,234 adults with stored blood
12,403 incident cases of T2D ascertained16,835 random sub-cohort selected
3.99 million person years of follow-up
Interpretation & Conclusions
Different individual blood SFAs are differentially associated with risk of T2D
Dairy SFA’s inversely associated with type 2 diabetes risk
SFAs are not a homogenous group
Endogenous synthesis of saturated fatty acids associated with increasing type 2 diabetes risk encouraged by dietary starch, sugar and alcohol
Need to discriminate between sub-types of SFAs
Implications – “Take home message”
Need to take focus away from single nutrient (fat, SFA)
Source of the SFA matters
What replaces SFA in the diet matters
○ SFAs are often replaced with refined carbohydrates
- Many low fat products have high sugar content
Place more emphasis on foods and on diet patterns
Place emphasis on healthy diets within healthy lifestyles
Focussing on cholesterol “lowering” has been counterproductive. “who cares about cholesterol lowering if it doesn’t translate into a benefit for patients?” Prof Rita Redberg
Abramson J, Rosenberg H, Jewell N, Wright JM, BMJ 2013;347:f6123 doi:
10.1136/bmj.f6123 (Published 22 October 2013)
Call for retraction
“ there are only one or
two well- documented
(problematic) side
effects” Myopathy and
muscle weakness
occurred in one in
10,000 people he said
and there was a small
increase in diabetes -
Professor Rory Collins
–Guardian, March
2014
Statin controversy Statins – letter to Health Secretary signed by
leading doctors including the President of the RCP, Sir Richard Thompson, past chair of the RCGP, Clare Gerada, Chair of National Obesity Forum David Haslam, Prof Simon Capewell rejecting NICE move to lower threshold to offer treatment. (2014)
Guidance based upon industry sponsored data and several members of the GDG had financial ties to Pharma companies sponsoring statins. Side effects not taken into account including type 2 diabetes. Increased GP appointments –No mortality benefit in the group. No access to raw data
Loss of professional confidence
GPC “In light of the Cochrane review of the
effectiveness of antiviral influenza treatments, the
GPC will request that NICE refrain from
recommending a reduction to the current
treatment threshold for primary prevention of
cardiovascular disease with statin therapy unless
this is supported by evidence derived from
complete public disclosure of all clinical trials' data’
Harvard Researcher Wins Round in Brawl
With Oxford Peer Over Benefits of
Cholesterol Drugs
The verdict is in on a bruising spat between researchers at Harvard University and
the University of Oxford over a paper questioning the value of prescribing
cholesterol- lowering drugs to people at low risk of heart disease.
The decision goes to Harvard—and that’s not great news for pharmaceutical
companies that make the medications.
The dispute began last October, when Harvard Medical School lecturer John
Abramson and colleagues from California and Canada published an analysis in the
BMJ—formerly known as the British Medical Journal—concluding that the
multibillion dollar class of cholesterol- lowering statin drugs conveys no overall
health benefit in low- risk cases.
Armstrong D, BloombergBusinessWeek, August 1, 2014
Statin Usage Survey
statinusage.com
nearly 75% of new users discontinue statins within a year of prescription
1. Side effects were the leading reason why patients stopped taking statins
More than six in ten respondents (62%) said they discontinued their statin due to side effects, with the secondary factor (17%) being medication cost. Only 12% of respondents cited lack of efficacy in cholesterol management as a reason for stopping their medication. On average, respondents who experienced side effects due to their statin stopped after trying two different statins.
Three out of ten respondents experienced side effects of muscle pain and/or weakness, and 34% stopped taking their statin because of these side effects without consulting with their doctor.
Sunday Times Investigation, 18th
September 2016 Sir Rory Collins, a professor of medicine and epidemiology at Oxford
University, led a review into statins, published in The Lancet earlier this month, which found that not more than one in 50 people will suffer side effects.
Collins, who believes millions more Britons could benefit by taking statins, is also co-inventor of a test that indicates susceptibility to muscle pain from them.
The test, branded as Statin–Smart, is sold online for $99 (£76) on a website that claims 29% of statin users will suffer muscle pain, weakness or cramps. The marketing material also claims that 58% of patients on statins stop taking them within a year, mostly because of muscle pain
Royalties from the licensing of the patent can be used to fund university research, but Collins and his co-inventors have waived personal fees.
Boston Heart Diagnostics said it stood by its claims about statin side effects and that they were based on published research. It also cited a US taskforce on statin safety that said randomised controlled trials — such as those used in the Lancet study led by Collins — had “major limitations” because patients with statins intolerance were often excluded.
Nearly Four Dozen RCTs of Cholesterol
Reduction Have Reported No Mortality
Benefit
DuBroff R. Evid Based Med 2017;22:15-
19
Unintended Consequences of
LDL Cholesterol Reduction Statin drugs are prescribed to millions of
otherwise healthy individuals at low risk of CHD.
Statin users mistakenly believe they can eat whatever they want (statin gluttony).
The increased risk of DM with statins may convert some healthy individuals into patients.
The promotion of low fat (high sugar) foods has contributed to the epidemic of obesity and DM that can actually lead to CHD.
The myopic focus on LDL reduction has distracted us from investigating other preventive strategies.
UK: The fat man of Europe?• 2/3 adults obese or overweight
• obesity will double by 2050
• 1/3 children obese or overweight
• Obesity costs NHS £5billion+
↑ ↑£10 billion by 2050
Burden of disease attributable to 20 leading risk factors in 2010
expressed as a percentage of global disability-adjusted life-years
Global Burden of Disease Group. www.thelancet.com 2012 380 2245http://www.telegraph.co.uk/news/health/news/11556593/Sugar-is-to-blame-for-obesity-epidemic-not-couch-potato-
habits.html
Fructose is not glucose
Common wisdom: A calorie is a calorie, and
“Sugar is just “empty calories”
But:
• Chronic fructose exposure promotes liver fat accumulation,
which promotes Metabolic Syndrome (toxicity)
• Metabolic syndrome ( 3 of hypertension, dysglycaemia, increased
triglycerides, decreased HDL, and increased waist circumference
• 66% of those admitted with acute myocardial infarction have
metabolic syndrome with 50% increased mortality or hospital
readmission at 1 year.
Elliot et al. Am J Clin Nutr, 2002
Bray et al. Am J Clin Nutr, 2004
Teff et al. J Clin Endocrinol Metab, 2004
Gaby, Alt Med Rev, 2005
Le and Tappy, Curr Opin Clin Nutr Metab Care, 2006
Wei et al. J Nutr Biochem, 2006
Johnson et al. Am J Clin Nutr 2007
Rutledge and Adeli, Nutr Rev, 2007
Brown et al. Int. J. Obes, 2008
Obese (30%)
Normal weight (70%)
240 million adults in U.S.
Normal weight,Metabolic dysfunction
(40% of 70%)
Obese and sick(80% of 30%)
57 million 67 million
Total: 124 million sick
72 million
168 million
Pioppi; the home of the
Mediterranean Diet
A book that marries the secrets of Pioppi with the latest cutting edge medical,
nutrition and exercise science to bust the myths prevalent in today’s weight
loss, and health industries
Myth busting
The Mediterranean Diet has been wrongly interpreted for decades
Eating fat does not make you fat and saturated fat does not clog the arteries
Cholesterol can be good for you! ( and if you’re over 60 “bad cholesterol” protects you from an early death)
Physical activity and obesity is a myth ( you can’t outrun a bad diet)
Dietary changes is more powerful than any drug for preventing and treating heart disease and type 2 diabetes (which is reversible) and effects/benefits are immediate
“ The preservation of the means of
knowledge among the lowest ranks is of
more importance to the public than all
the property of all the rich men in the
country” John Adams, 2nd US President, 1775.
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