Thread by @healthmisinfo

Fact Check

Is inflammation the cause of heart disease, and not cholesterol?

A thread👇

There is better evidence for cholesterol (specifically LDL) as being causative in cardiovascular disease than almost any other theory in modern medicine.

So many lines of evidence converge on the same conclusion that if this theory is wrong, then almost all of modern medicine is also false. A figure from a consensus paper from the European Atherosclerosis Society makes this clear. academic.oup.com/eurheartj/arti…

Indeed, there is a dose-response relationship between heart disease risk and LDL cholesterol levels. This relationship exists entirely independent of inflammation. academic.oup.com/eurheartj/arti…

So why do some health influencers assert that “inflammation, not cholesterol, is the cause of cardiovascular disease”? Because this claim is marketable: it sells skepticism toward the medical authorities.

With excessive costs of healthcare especially in the United States, with the model of rushed, unfeeling healthcare, alienation and resentment toward the medical establishment is common and increasing.

Combine this with a decades-long and continuing increase in social and economic inequality—i.e. the gap between rich and poor—and skepticism toward elites of all kinds, including medical ones, has become widespread.

Plus, high cholesterol is driven by the kinds of things that people love doing: eating a diet low in fiber and high in refined sugar and saturated fat (meat and butter), not exercising, and smoking. And people would rather not be told to stop doing what they like to do.

High cholesterol also “feels fine”. It does not cause any immediate problems. So people question: “do I really have to take a medicine for life to prevent heart disease, when I feel just fine?”

Re-enter the science.

The claim that inflammation causes heart disease also has a kernel of truth. JUPITER, in particular, showed that when people with high levels of inflammation but normal cholesterol still benefit from taking a statin (which has anti-inflammatory effects). nejm.org/doi/full/10.10…

More directly, CANTOS, which tested whether directly reducing inflammation in the body would help prevent and treat heart disease, resoundingly showed that yes indeed, inflammation does play an important role in the development of cardiovascular disease. nejm.org/doi/full/10.10…

Cardiovascular disease is caused by a diversity of different inputs, and these are captured in modern cardiovascular disease risk calculators that doctors use. Some of these include diabetes, high blood pressure, smoking, family history, age, race, sex, and yes, cholesterol.

In the future, inflammation may be added to these calculators. Its full development as an important causal factor is still only recent. A newer diagram shows the relationships between these factors and more. academic.oup.com/eurheartj/arti…

In other words, yes, it is true: inflammation does contribute to heart disease. But so does cholesterol and a host of other known factors.

Cholesterol is not a “firefighter” at the scene of a fire, i.e. of atherosclerosis (driven by inflammation). If it was, then reducing cholesterol would not reduce heart attacks. But it does. Reducing cholesterol reduces fires. So how can cholesterol be a “firefighter”?

So why do these health influencers reduce the story to one of deciding between inflammation and cholesterol? They do this because reducing the story to a dichotomy also allows them to reduce the story to a battle between good and evil.

On the one side, cholesterol, represented by the “establishment”, is wrong, and its proponents are bad or evil. They are trying to hide the truth.

On the other side, inflammation, represented by the “truth-tellers”, is right, and its proponents are good and virtuous. They are trying to reveal the truth.

Do not fall for this simple-minded thinking. Most of these health influencers do not know what they are talking about and are just using this story because it is effective.

This story makes money, helps struggling doctors promote their private medical practices, and sells books. It has almost nothing to do with the science of heart disease.

This thread was created in honor of the following tweet

https://twitter.com/ElieJarrougeMD/status/1429151553571721223