The Cardiologist Who Stopped Prescribing Statins Explains the Real Cause of Heart Attacks | Dr. Aseem Malhotra - ENCORE

27:11It's like you need to treat one person to get one person better. Or maybe if they have a resistant antibiotic, it's two. Or we take paracetamol for a headache is like one in two so it's like two two people one will get their headache completely but with a statin you have to treat 89 people for five years to prevent one heart attack yeah so it's actually so so i know this stuff inside out um so if you've had a heart attack already let's take the high risk group you have to treat 83 people over five years for one to have their life saved or life prolonged right okay and for preventing a further heart attack, 1 in 39.

27:45Now, most people around the world, Marco, prescribe statins are not in that group. They are in the either low risk - 75%, right? Yeah, exactly. Low risk or what we call high risk primary prevention. Now, the benefits of a statin over a five-year period in that group, at best, is 1 % in preventing a non-fatal heart attack, a non-disabling stroke, okay but without prolonging your life by one day

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30:15so essentially if you if you've never had a heart attack and you have high cholesterol and you take a statin yeah it won't prevent you from it won't prevent one single death it will prevent a heart attack. If 100 people take it, it'll prevent one heart attack. So 99 people taking it for five years will have no benefit. So this again comes back to, now this is just my opinion. It's like, oh, is Asimov Hotchur just cherry picking statistics here? 2009, Gerd Gigerenze, the director of the Max Planck Institute for Health Literacy in Berlin. This is the same institution that Einstein taught and trained in.

30:51Brilliant guy. He wrote in a WHO bulletin 2009, is an ethical imperative for every doctor to understand the difference between absolute risk reduction, numbers needed to treat, and relative risk reduction. And he said to protect patients from unnecessary anxiety and manipulation. So in other words, I paraphrase this, if you have that information, and again, most doctors are not trained this way, Mark, this is a problem, you should use it and tell patients, this is what I do. And a patient comes in, it's like, should I take a statin or not? I say, well, let me empower you with the information and tell me what you think.

31:22Most patients with a 1 % thing think, hold on a minute. I don't think that's that great, doc. And then they'll say, well, is there anything else I can do? And of course, you and I are empowered with understanding lifestyle, right? So this is how we should be practicing medicine. But Mark, one quick thing is that I didn't just talk about this. I wrote about it. And I even got this in front of every Royal College president in the UK saying that the British Medical Journal were doing this campaign against too much medicine. They're talking about informed consent by use of NNTs. We need to launch a campaign because overprescription is a big problem.

31:53We know there's a big problem with side effects. We know that one estimate suggests that prescribed medications is the third most common cause of death after heart disease and cancer globally because of side effects. It didn't take long for me to convince the Royal College presidents. I was an ambassador for the overall academy of Royal Colleges at the time and to say that we should have a joint campaign with the BMJ. So I then wrote a paper as lead author, had the chairman of the General Medical Council, the chairman of the Medical Colleges on that co-author paper to say, okay, this is a campaign we can get and change medical education, change postgraduate medical training.

32:22and we got that it's in the media it was a big news story bbc all of the news front page of british newspapers campaigns obviously need to be sustained but what happened is of course if you engage in true informed consent with patients most patients will choose less treatments now who's going to suffer from that the drug industry they in my view it's very clear it's not a conspiracy this is clearly how they do business and this is what they want to do is they want to um they engage in a tactic called opposition fragmentation anyone that threats threatens their bottom line, they will do smearing, they will do all these things behind the scenes.

32:55There's a whole documented history of that. If you Google me, you'll find many groups that are attacking me, like the American Council on Science and Health, which sounds great, but it's actually a front group for pharma, big food and big ag that think trans fats, pesticides, smoking, and glyphosate are all healthy for you. I'm like, okay. And they come up to sound very erudite and smart. So you've experienced it, Mark, right? Oh my God. Yeah, right. Science-based medicine, American Health and Science and Health. I mean, Quack Busters, Quack Watch. I mean, I've been there all through it. You get it.

33:26I totally get it. And actually, I find a badge of honor, you know? It is. Well, no. So actually, in a way, it is. Although you've got to grow a thick skin, right? Because, you know, one of the lessons in public health advocacy done by, written, a great paper written by Simon Chapman, who took on big tobacco in Australia and talks about his 38-year career in taking on big tobacco. He says, as soon as your work threatens an industry or an ideological cabal, because also about this is about mind. It's not just about money. It's about indoctrination in the brain. Right. As soon as your work threatens an industry or an ideological cabal, you will be attacked, sometimes unrelentingly and viciously.

34:02So you have to grow a rhinoceros hide. Yeah. Right. So for me, what happened after that is there was I kept pushing this message, but they then behind the scenes, Royal College of Physicians, I think, funded by farmers, some scientists funded by farmer, started making complaints. to the academy of medical colleges where i was one of their ambassadors for seven years right to say this guy's got his own agenda he's exploiting people for his own agenda he's trying to make money off all all nonsense and and that was so relentless that they then um in 2018 i got an email from the the new chair of the royal colleges saying that the campaign that i had started or was that they had took on and instigated that i was no longer part of that because of of stuff that I apparently said publicly on statins, even though everything in the newspapers that was written about statins for me was coming from medical journals and I was a very strong advocate for informed consent.

34:54But again, this is what - Don't confuse me with the facts. My mind's made up. Well, exactly. So this is what they do. And of course it does have its personal toll. And then it culminated coming back to where we started is that because we were having an effect, Mark, and of course you're absolutely doing the same thing. One of my inspirations, right? Revolutionaries, Mahatma Gandhi. And one of his quotes, which I love, is, you know, and he took on the system. I mean, he got British colonialists out of India. I mean, almost single-handedly. And he says, first they ignore you. Britain was bigger than the pharma companies.

35:25Oh, it was. Absolutely. I mean, America was founded on anti-corporate sentiment taking on the British East India company, right? It was a big corporate tyrannical system. And now we've come back to the same problem right now. But what he said was, first they ignore you, then they laugh at you, then they fight you, then you win. So when you're getting attacked, you're over the target and you're getting closer to winning. But you have to, it's tough. It's tough. So essentially this interesting legal case that we started out with has sort of indicated that you and your colleagues were speaking truth to power.

35:59So let's get into the details here because everybody's listening going, yeah, well, my doctor checked my cholesterol and my LDL was high and they recommend a statin. And like we said it's the number one prescribed drug in the world yeah uh 75 of the prescriptions are for preventing heart attacks if you've never had one it's called primary prevention and there's very weak data to show that that actually works especially for women especially for over a certain age yeah there is benefit for people who've had a heart attack no doubt um it's not like taking antibiotic for a strep throat but there is a benefit and and let me sort of unpack how you came to go from being a trained cardiologist who basically swallowed the gospel to one who understands and has looked at the literature and has come to a different conclusion.

36:48Because it's not just that you're anti-drug or you're anti-medical care, anti-the system. You're for the truth and for science and for an objective look at the facts. So the question I have is, how did you go from being a trained cardiologist who believed in statins to one who started to question statins to one who's come to understand that our approach to cardiovascular disease might be a little bit misguided and we'll talk about what the right approach should be later but i i kind of want to start with unpack unpack the science for us because yeah everybody listening has no one's heard if their cholesterol is high to take a statin sure and statins cause side effects which they do for a lot of people probably 20 get some muscle damage or some symptoms or increase the risk of diabetes.

37:31You know, we'll talk about that data. There's still a huge drive in our society for prescribing these and globally. Yeah, absolutely. So my interest in this came from really looking at the initially the obesity epidemic. So 2004, WHO announced it as an epidemic. You know, by 2010, I was in nine years qualified as a doctor. I was specialist registrar in my cardiology training. I was seeing more people this viscerally i'm very sensitive to how to put it suffering around me if you like but also seeing my colleagues under more stress in the system i was like hold on a minute this if we carry on down this trajectory the whole healthcare system is going to collapse we want to even manage people acutely if they are ill right i never thought that would happen and and ultimately that one of my two of my own pay two of my parents both basically died because of failures in the system because the system's under so much stress, right?

38:25Never predicted that would happen. But that's where I started from. And when I looked into the issue of obesity, you know, I concluded that one of the root causes, Mark, if not the main root cause, was this flawed hypothesis that we should have low-fat diets to prevent heart disease. Food industry exploited that. Increasing sugar intake, increasing refined carbohydrate intake, it became quite clear. There was a clear correlation between that change in guidance in the late 70s in the US and early 80s in the UK when the obesity epidemic started to then take its trajectory down the wrong way. Yeah.

39:00And I covered a lot of this in my book, Eat Fat, Get Thin, which we sort of unpacked the whole history of how we got this low-fat craze and led to this high sugar starch craze that then led to this dramatic rise in obesity, which now, of course, we're treating with another drug, the GLP-1 agonist, and just hepatite and some glutide or Zempic and Majora. It's kind of crazy, right? You just kind of flipped it upside down. Oh, absolutely. So when I looked at that, I started looking at the data and spending years and months and years looking at it and looking at different bits of data, I was able to put it all together.

39:28And I wrote a piece in the BMJ in 2013 called Saturated Fat is Not the Major Issue. I read it. That's how I first came across it. Yeah. And that got a lot of attention, right? It was international news and British news and CNN International and whatever, you know, because obviously suddenly you've got a cardiologist busting this myth that we think butter has been bad for our cholesterol. But when I did that, okay, so what I looked at the data and it was very clear there was no clear association with saturated fat consumption and heart disease. So if that's true, and we know saturated fat raises LDL cholesterol, that means LDL cholesterol can't be that important.

40:00And if LDL cholesterol or total cholesterol isn't that important as a risk factor, how do statins work? But I knew statins had a separate effect to low cholesterol, which is their anti-inflammatory and their anti-clotting. And I knew this even, it's well known within cardiology circles. I trained as an interventional cardiologist, and that means keyhole heart surgery, stents, for example, patient comes in, we didn't even check their cholesterol. Maybe some of the thinking was the lower the better, which we'll come on to as well. So it doesn't matter what their cholesterol starting from, the lower your cholesterol, the better.

40:28And in fact, 2011, our cardiologist, one of the editors, I think, of the American Journal of Cardiology wrote an article, which I mentioned in my book, A Statin-Free Life, which was entitled, It's the Cholesterol Stupid, right? And what did he say in that? He said, you can be an obese diabetic smoker that doesn't exercise sounds crazy but as long as your cholesterol is low enough you're not gonna get heart disease that's like like really so okay i had to unpick that and and and what i what i also then did moving forward from 2003 so that's how i got down this track realizing that our obsession with ldl lowering has been you looked at the saturated fat literature and you weren't impressed and data showed that it didn't both observational data and randomized controlled trials.

41:12No benefit in lowering it, no association, nothing. And when you look at all the data, so that was the first sort of bit that I was like, okay. And some might even have been protective, like some of the dairy fat. Well, we know now, yes, there is some suggestion that dairy fat could be protective, absolutely. So there's all that. And then coming back to the LDL hypothesis - By the way, you're not alone on this. I mean, there was a major paper published by Darsh Mazafarian from Tufts and others looking at butter and actually showing that there really It wasn't evidence that it wasn't wrong. So Mark, this is what's interesting.

41:42That article I wrote, because it creates such a, you know, a lot of headlines and backlash or whatever else, that's when people like Darius started looking at this again. So it was all really from the back of that BMJ piece. It all came together. So then everybody's like, you know, and at the time I was writing just a commentary, which was peer reviewed, but I could have got it wrong. I could have. But I was like, you know what? There's enough here for me to provoke the thoughts. And then it all got proven that, you know, what I'd written had validity, right? Which is good. But the other aspect of this, if we go back and you mentioned cholesterol.

42:13So is high cholesterol a risk factor for heart disease? And is LDL a cholesterol risk factor for heart disease? So you have to go back to square one, right? So these are the framing of studies that started in Massachusetts in 1948 and went over decades looking at thousands of people where a lot of risk factors emerged for heart disease, whether it's diabetes, high blood pressure, smoking, for example. And cholesterol. And high cholesterol, right? So you go and look back at the Framingham studies and just to summarize it without complicating the situation too much, William Castelli is a cardiologist and he published, he was a co-director of Framingham.

42:50And in 1996, he published in one of the cardiology, major cardiology journeys, a summary of Framingham, specifically looking at LDL cholesterol. Let's just look at LDL because that is the so-called bad cholesterol. And he said from framing them unless your ldl was above 7.8 millimoles which by the way i think in your units is probably 250 or 300 250 probably i think maybe we can look it up and calculate but let's just say for argument's sake around 250 which is very very high by the way it absolutely had no it was useless as a predictor for coronary ldl ldl now why is that when you correct for triglycerides and hdl okay which by the way is a more important predictor of heart disease ldl loses its significance completely so then if that's true and i'm saying that means ldl isn't really a risk factor for heart disease and i believe with everything i know now that to be the case okay let's let's unpick every part of it does lowering ldl cholesterol from diet or drugs but more specifically drugs because they're the most potent ways of lowering ldl cholesterol whether it's PCK9 inhibitors, whether it's statins, whatever.

43:58Is there a clear correlation? Is this dogma true that the lower the better? So myself and two cardiologists did a systematic review of the totality of drug industry-sponsored trials, by the way, and some diet trials, but many drug industry-sponsored trials, all of the randomized control trials on cholesterol-lowering drugs, statins, PCK9, blah, blah, blah. Was there a clear relationship as you lowered LDL in low-risk and high-risk patients mark okay over 30 studies yeah was a relationship with lowering ldl and preventing cardiovascular events no even in high-risk patients even in high risk it's nonsense it's nonsense so the question then is why do we also really believe so does that mean but then i said well of course statins have a role they do have a benefit from the from the rct data which is small because i knew already they're anti-inflammatory and anti-clotting so it's nothing in my view.

44:47Listen, I could be proven wrong here, but the evidence at the moment looks very clear that there is no consistent relationship, right? It's definitely not a clear relationship. So even if it's a weak relationship, Mark, let's just argument say, let's say there is a weak benefit in learning LDL. What else is going on and what else are you ignoring, right? What else does statins do that cause insulin resistance? Say one in a hundred people get type two diabetes because of statins. One in two. One in a hundred. One in a hundred. Yeah, one in a hundred. So about one to two percent, but one in a hundred.

45:18Some studies say one in 50, right? We'll get type two diabetes because of the statin. Probably reversible still, but not ideal, right? If you're on a statin drug. The second thing is, look at the whole patient coming in. We have the illusion of protection. We have patients I used to see coming in and they thought, my cholesterol is low. I can go and eat at McDonald's. It's fine. And they're getting more and more of a weight, more insulin resistant. They're increasing their cardiovascular risk. They're not told the statin is going to give them a 1 % benefit, i.e. more likely than not they're not going to benefit.

45:46So you could imagine that concept that the overall net effect of the way that statins are prescribed and the dogma around them, in my view, has been negative and has actually been one of the main reasons why we have got this pandemic of chronic disease. Because we've overemphasized an index on LDL cholesterol and forgotten everything else. Absolutely. Right. Because there's a drug for it. It was interesting to me, if there was a drug for insulin resistance that worked really well, and we have metformin, but it's eh, and it fixed insulin resistance, you know, everybody be prescribing it. But we don't even diagnose it in most people because we don't have a drug for it.

46:24And it's stunning to me that, you know, I was talking to the lab director at Quest Laboratories. I said, what percent of your tests you get that come in are measuring insulin, which is, I think, one of the most important things you need to know about your... biomarkers. And he was like less than 1%. And it's part of why I co-founded this company, Function Health, to really look at a deep biomarker set around cardiometabolic risk factors, including insulin, including L-P-little-A, including something called ApoB, which I want to talk to you about. Not just your total LDL, HDL, and triglyceride levels, but also particle number, particle size, inflammation markers, all the things that are often missed, but that are much better at giving you a holistic picture of your cardiovascular risk, and then you know where to intervene.

47:09And in one of the studies that was so interesting to me was actually from, I think, Scotland or Ireland was where they looked basically at a series of patients who came into an emergency room with a heart attack. And they did glucose tolerance tests on everybody who came in with a heart attack. And they found that two-thirds either had diabetes or prediabetes who had a heart attack. That that was really the big driver. Now, there's a subset of people have familial lipid disorders, inherited genetic lipid disorders. And those people probably need to be treated more directly. But for the majority of people out there who are obese or have prediabetes or metabolic dysfunction, which is basically in America, 93 % of Americans, that's what's driving probably most of the heart disease, not butter or saturated fat or LDL elevations.

47:56Well, something else to throw into the picture, right? So you can make the argument, okay, Dr. Mahatra, you're saying there's no consistent relationship. There may be a benefit. Why not just lower your LDL? Okay. So 2016, and the reason we did this, me and a number of international scientists looked at, we decided to do a systematic review of observational data looking at people over 60. Was there a relationship with LDL, cholesterol, and heart disease? And the reason we did this, by the way, is another thing that was interesting from framing, which wasn't well publicized, is that when, after people hit 50 years old, as their cholesterol dropped, their mortality increased.

48:29So we thought, okay, is there something, you know, because for it to be a risk factor for heart disease, it should be consistent really across all age groups and both sexes, right? For mortality. For mortality. Yeah. But even for heart disease as well, right? That's a good point. So we looked at, was there first of all, any association if you're over 60 with LDL cholesterol and heart disease, right? We found none. Okay. Interesting. but what was surprising was there was an inverse association with ldl cholesterol and all-cause mortality in other ways statistically if you're over 60 the higher ldl the less likely you are to die so what's the reasoning for that well something that's been forgotten or missed or not discussed cholesterol is has a very vital role in many functions in the body including you know brain the brain hormone production but also the immune system and it's likely that that's where the protective benefit comes because older people are more vulnerable to dying from infections and we also know there is an association i'll use this word an association right can't say it's definitely causal between low cholesterol and cancer again it's probably related to the immune system yeah i mean i think i think which is very interesting this data though is and i'll just push back a little bit is it's observational data and the data like from the hawaii studies show that you know the you're older and you had higher cholesterol you know you're more likely to live longer than if your cholesterol is lower yeah but it may be because the people have low cholesterol all are malnourished, have cancer, and other reasons.

49:51So let me push back on that. So we counted for that. And we found actually, no, when you count like time lag, you go back five or 10 years. No, it's not. That does happen. But no, it's independently, it does seem to be an issue.

50:10Okay, so you sort of looked at all the data, and you came up with this very kind of contrary opinion, which is that LDL isn't all it's cracked up to be, that statins work a little, but not for the reasons we think, meaning they lower inflammation and they may have other properties that may benefit. So we don't even know what called this, pleiotropic effects. So they, for example, they induce nitric oxide synthase, which dilates your blood vessels and reduces inflammation and helps your lining of your blood vessels, all that's protective. And so it may be a stabilizes plaque, it may help in those ways, but it may not be the LDL lowering effect.

50:45In fact, Paul Ritger from Harvard, I remember he published a trial, I think it was the Jupiter trial, where they showed that if you had a high LDL but didn't have any inflammation, you didn't have that significant a risk of having heart disease. But if you had a high level of inflammation, high LDL, you had a much higher risk. So it was the inflammation that was really driving the heart disease. And that was really the seminal paper. It was in the New England Journal of Medicine over 20 years ago. I remember reading it by Paul Ritger and his crew that really laid out how heart disease is not a plumbing problem.

51:14It's an immune problem. 100%. It's a chronic inflammatory process exacerbated by metabolic risk factors or inter-resistance. And I wrote an editorial - Metabolic risk factors, by that you mean problems with your blood sugar and insulin - Inter-resistance. And pre-diabetes, yeah. 100%. And actually we published an editorial with two cardiologists I did in British Young Sports Medicine in 2017, which was a very long title, but it got a lot of publicity and there were more than a million downloads, which was saturated fat does not clog the arteries. coronary artery disease is a chronic inflammatory condition which can be effectively managed with lifestyle changes that was the title of this thing but it's all there people it's free access people look it up and read it but we talk that we've overdone the thing and it wasn't just dr malhotra his opinion being controversial the two my two co-authors were both editors of medical journals and cardiologists louise redberg editor of jama total medicine and pascal meyer editor of bmj open art why is this not getting more play why why is still the dogma and the orthodoxy that if you have a high LDL, you take a statin.

52:12Do you want my honest answer, Mark? Yeah. I mean, I know doctors are usually very good-hearted, very smart, well-intentioned, don't want to hurt their patients, try to do what's in the best interest of their patients and follow the science. So why are they not hearing about this? Okay. So let's go to the root cause of the problem, even in society today. What's the big issue in health? We have commercial distortions of the scientific evidence. Who is behind that and who has more power and control over medical education, medical training, the media than ever before? Big corporations, in this case, big pharma.

52:50And the level of this control and power, Mark, has got to a level where it can be very easily and rationally, not in an inflammatory way or overplaying it as being tyrannical. What also happens with these big corporations and the way they exert their power is that they want to avoid conflict, right? They want to avoid the truth coming out. So there's a debate and discussion because ultimately people like myself, like you, who are obsessed with the truth, who want to get it out to help patients, when we speak and act from a place of integrity and truth, it has a very powerful resonance with people.

53:29And it can very quickly destroy all these other dogmas that people have created because of that power, that the truth has. They want that conflict to remain latent, to remain hidden. So that, you know, Noam Chomsky says the general public doesn't know what's happening and they don't even know that they don't know. That's right. Right? So a lot of these doctors, and I agree, are well-intentioned, but they don't, they're living, you know, in many ways, they're living, they're climbing up the wrong wall to success when it comes to helping patients. Because it's a drug companies that are really calling the shots.

53:58Yeah. So we are under a situation of tyranny. And the reason I call it tyrannical is because there are doctors that know this Mark, there are a few doctors that kind of know this, but then they're less, they're afraid to speak out. And only a minority of the doctors that know what's going on will then speak out. That's hard. I mean, listen, you know, I practice medicine. I've seen patients, you're busy. Like I literally had to lock myself in a room, you know, download every paper on this, read it carefully myself, synthesize it all, try to make sense of it. And it's still confusing. And I wrote a whole book about it.

54:25And I said, you know, call you fat, get thin. And I think it's still hard. So the average doctor doesn't have time to kind of do that. They kind of take get face value what they get taught in their training and they try to look at the evidence the best they can but also they're looking at sort of biased evidence that is published completely absolutely and then of course there's a psychological side of it as well because as human beings you know they say changing one's mind is one of the most you know emotionally traumatic things a human being can go through right and that's where you need humility right um john kenneth calbraith the canadian american economist said face with the choice between changing one's mind and proving there's no reason to do so, almost everybody gets busy on the proof.

55:02Yeah. So for the medical profession, we need to have also more humility. I mean, one of the interesting, like there's a great YouTube channel called After School, which I watch a few times. It's brilliant. It goes through like ancient wisdom and philosophy and psychology. And it says, one of the titles, you should look this up, Mark. You'll love it. Why do intelligent people believe stupid things? and the answer is and well because um our intelligence evolved not for seeking objective truth but more about belonging to a tribe you know for personal gain whatever else so what is what do we need to break out of that there are two characteristics in the human being that are most important for you to think outside the box and be willing to change your mind and not being afraid of it.

55:49One is humility and the other one is curiosity. So ultimately it comes down to character. And we've got a system over the years that has become more and more corporatized, right? You have in America, sadly, you know, and I consider this my, honestly, I'm, you know, I, I consider America my second home. So I have a lot of love for America and the American people because I have relatives here and I've been here a lot, but you have now the highest healthcare expenditure in the developed world over$4 trillion with the worst health outcomes. Oops. Right. So, so, so what's happened is, you know, because of all of this situation around corporate capture.

56:26So, you know, the counter, of course, from a philosophical point of view is living a life in darkness has no meaning. Yeah. And we need to get people out of the, of this darkness to understand the root of the problem. And then we can then start making solutions. And you have to think about it. You have to take time to think and learn. I mean, John F. Kennedy said, we enjoy the comfort of opinion without the discomfort. of thought. And I think it's hard to kind of sort through it all. I mean, I found it very hard. You know, I just sort of reflect back on some of the data that I uncovered as I was sort of researching this.

56:57And it was just one very large study showing that it was, I think, 231 ,000 people in 541 hospitals that had had a heart attack. And it was looked at over a six-year period, and they looked at cholesterol lipid levels for everybody. They found that 75 % of people who had a heart attack had, quote, a normal LDL under 130, which is what's considered normal. 50 % had optimal levels under 100. 17 % had super optimal levels under 70. But what they did found was really interesting. And again, it confirms this whole metabolic hypothesis of heart disease, that it's really related to mostly insulin resistance, that those with low HDL and high triglycerides, which goes along with small dense cholesterol particles were much at a higher risk of having a heart attack.

57:50And so, in fact, the average HDL in that group was 39, which is, should be ideally over 50. And the average triglycerides was 160, should be probably under a hundred, ideally under 70. And it didn't really seem that, that LDL was really the driver. It was the triglyceride to HDL ratio. It was the triglycerides and the HDL. And it was what is what we generally call an atherogenic lipid profile, which is not just about the total number of cholesterol or the LDL number. It's about the quality of your cholesterol, which is the size and number of the particles. And the smaller dense particles are the ones that are more putting you at risk.

58:34And those are the ones that are caused by sugar and starch, not fat. In fact, fat actually improves the size of your lipid particles. Yeah. No, fascinating. And it makes sense. But also, interestingly, something else that I came across in the last few years, which you'll find fascinating, Mark, and I don't know if you know this. David Diamond, who's a cholesterol researcher, published a paper. I can't remember which journal it was in very recently. And they looked at the primary prevention randomized control trials done obviously by the drug companies and secondary prevention trials. And subgroup analysis found, So these are people with statins who had either a high risk of a heart attack or had a heart attack.

59:06In the patients in the trials that had normal triglycerides in HDL, no benefit at all from statins. Think about that. So if you're triglycerides in HDL, we're good. Even people who've had a heart attack. There was no benefit from the statin at all, which fits with what you just said. And it's kind of interesting because you get the benefit in some ways of inflammation protection, but you also get increased insulin resistance. You do. And of course, we haven't even talked about side effects, and that's another issue, right? So if you look at, you know, to try and explain why there's no reduction in cardiovascular mortality, even if we accept the four-day increase over five years in high-risk patients, one of my explanations is this.

59:42In the real world, at least 50 % of patients prescribe statins, even in high-risk groups, will stop taking it within a couple of years. And when you do surveys, most of them say they felt they got side effects. Muscle fatigue, muscle pain, brain fog, erectile dysfunction, and how prevalent. That's a big one. Well, how prevalent is that? And you look at the data and it's mixed, but anything from, in my experience, anything from 20 to 50 % of patients at some point, I've had patients who took statins for 20 years and then get side effects for 20 years. And then they got side effects and it gets better when you stop the statin.

1:00:13So they're very prevalent. I wouldn't say they were serious or life-threatening, but the question I ask the patient always, does this interfere with your quality of life? And it's very simple. You know that as a person. It's a very subjective answer, yes or no. If it does, we need to do something about it. Because listen, we're all going to die at some point. What we want to live our lives in the best health we can for as long as possible. Right. That's the most, in many ways, that's probably more important than our longevity. Right. It's having good quality of life. So that is something that I address with patients as well.

1:00:44So you're going to sort of see how many argument and argue the other side. Yeah. How would you argue against yourself for this? Because, you know, I've had these conversations with cardiologists, with experts, and they're like, listen, the data is just so strong about statins. And there's no question that they lower risk and there's no question their benefit. And yes, there are side effects that can cause mitochondrial injury, can cause muscle pain, it can cause insulin resistance, but the trade-off is worth the risk. And the data is so prevalent and so strong and so clear that we should all be taking steps.

1:01:20I think, you know, the arguments have been made on interpretations of the evidence, trust in the evidence, and different bits of evidence. So all I can say, Mark, for me is that we all have our biases. And you could argue that I have a bias because I have an obsession with lifestyle and I'm a foodie and I started cooking when I was 16. I was taught by my dad. And, you know, one of the reasons I got annoyed or pissed off in the hospital and got into this whole, my campaigning started about hospital and, you know, why are we giving junk food to patients? Because I also, as a doctor, was like frustrated.

1:01:53I can't get any healthy food anywhere. That could be my bias. Fine. But, and I accept that. One of the things I do myself, and I think the reason I've been through a process where I've had to change my mind several times on saturated fat, on sugar, on low-fat diets, on statin prescriptions, on cholesterol, on something more recent and more controversial, which we're not talking about, is you have to have an element of humility. But when I do that, my analysis myself, I try and counter my own arguments and then try and find a way of a nuance. I can't really see a strong counter argument and I'm not saying this from a place of hubris um because okay let me get let me give you one argument so so if and this is a hypothetical if statins didn't have side effects or they were almost non-existent I could actually say put them in a water supply because even if you know there is a concept in medicine you got to treat the many to benefit a few so let's just say that they save lives in I don't know on average say one in 300 people are going to live longer because of statins, right?

1:02:55It's for public health. Yeah, for public health. So, you know, put in the water supply, you know? Give to 3 billion people, we're going to have, you know, you're going to save one in 300 of those 3 billion, you know, whatever that is. It's a lot of people. It's a lot of people. It's tens of millions of people, at least, not hundreds of millions. So you could make that case. But that isn't true, though. That's just simply not true. Yeah, if there were no side effects. So I am very for, you know, and that is an argument that has been put forward. And the issue about - Because there's marginal benefit.

1:03:26Yeah. But I'm saying that if you, it's a public health intervention that doesn't have any downside. But if it doesn't have any downside, that's fine. Then go for it. Put it in the water supply. But unfortunately it does. And that's simply just not true. So therefore you then have to then talk about, you know, and some of the doctors come from a mindset, Mark, where they don't even, they, and this is a different school of thought. But I don't agree with it. it's not about agreement. I mean, okay, maybe it's my opinion, is that they think that there should be an old school paternalistic practice of medicine.

1:03:55Doctor knows best, patient do what I say. That's right. It's not working so good anymore. I'm about shared decision-making. I'm about explaining to patients a way that's, you know, that empowers them, that it's a more equal relationship, you know? And that's fine. Maybe it's a philosophical disagreement, but that's the stance I'm going to take. And I'm prepared to die on that hill. I think that's right. I mean, I think, you know, we, we, we, we have to sort of look at this at a high level, like any tool. There is a use for statins. There's a use for the PCSK-9. There's a use for the new CTP drugs that are coming out.

1:04:31There are people who benefit. And, and I don't think it's heterogeneous. I think we have to sort of, and I, I've noticed this as, as sort of the doctor has been doing this for 40 years. Not everybody's the same. Saturated fat is fine for most people, but not for some people. Yeah. Right. Sugar can be tolerated more by some people, but not by others. I just came back from Utah and was in the Native American reservation, the Navajo reservation. It was just staggering to see the amount of obesity. And when you look at 150 years ago, there wasn't a single overweight Native American, period. And why?

1:05:03It's because metabolically, genetically, they're different. So I think I'd love to sort of explore who might benefit from these drugs. Because there's a class of people, we refer to them as lean mass hyper-responders, or people like you and I, maybe who are athletic, who are fit, who may actually have an adverse response to increased saturated fat in the diet, or who might have a family history of lipid disorders and actually have some genetic issues, which I do in my family. So how do you sort of handle those? Yeah, so I deal with those actually quite regularly. So interestingly about the saturated fat, I think you're right, Mark.

1:05:40there are definitely a subgroup of people who have very high saturated fat intake. Actually, it does affect their insulin resistance or make their triglycerides go up. And in fact, there was a paper done by, I think his name's Ronald Kraft, if I'm not wrong. Ron Krauss. Ron Krauss, sorry, Krauss, you're right. And he showed there was an abnormal effect on lipids if your saturated fat consumption in obviously certain groups of people was more than 18 % of your total calories, right? It's still very, very high. But again, you're absolutely right. That might happen with a certain subgroup of people.

1:06:09I've seen, for example, a patient on a carnivore diet who actually had something like that. And when they reduced their saturated fat intake, their lipid profile got better. That's all they changed. So I agree with you. There are going to be a subset of people. What do you do with FH, the people with the familial hyperlipidemia? So let's just lay it out for people, right? And I think there's more than just that one subtype. There's many different types of genetic lipid disorders that I think we're just starting to figure out. There are, but you talk about APOB and lipoprotein little A, which are all these other extra markers of risk that are added in.

1:06:41Basic teaching in medical school, certainly what I teach medical students and junior doctors, don't organize a test unless it's going to change your management plan. Because what's the point? So you create unnecessary anxiety, for example, for some people. Now I get it. People may want to know, and if that's what they want to know, that's fine but you know the and we'll come on to management as well if you're not going to add in a stat in or whatever else and okay maybe those people need to be more extreme in the lifestyle maybe that's a reason to do it saying you need to be like instead of meditating for 30 minutes a day i want you to meditate for an hour right no fine i mean maybe that's what the best we're going to offer them right yeah yeah to to keep the risk down so we we've got to just be a little bit careful about how we about ordering these tests and then but thinking a little bit more about okay is it going to change anything?

1:07:30And am I just going to give this patient unnecessary extra anxiety? And I'm, listen, I'm a doctor. Doctors are the worst patients. I probably have a party because my dad was the same. I have moments of being a hypochondriac and I know on the receiving end, like, you know, tests that are done that didn't need to be done. And then I'm like, okay, what does this mean? And you're going down a rabbit hole. So you've got to think about that as well, right? In terms of if you haven't got a clear solution, then don't order the test. I'm not saying don't do the test, but I just want us to think about that a little bit.

1:08:00It's true. We learned that in medicine. I'm not sure I have the same view because I think that the more data you have, the better you can make sense of what's going on. And I think there's a movement towards this deep phenomics. I've had Jeremy Nicholson in my podcast, Lee Roy Hood in my podcast, and they're about more data and dense dynamic data clouds of information from your biomarkers, your metabolome, your microbiome, your genome, your transcriptome, that all teach you about sort of subtle changes that may not represent a disease today or they don't have a drug treatment today, but that if you left untended would ultimately lead to a disease or - But it may not.

1:08:38Or may not. But I'd rather know if my insulin is going up over 10 way before I get diabetes. No, I agree. So 100%, I agree. There are definitely certain, yeah, so I think there's a nuance there again. There are certain things where we know, okay, there's a very likely benefit here of you getting your insulin down, et cetera. I think some of the other biomarkers, it's still in a certain uh you know um area but again mark you said that okay you're a guy and this is if i was having a conversation with you and it's your preference of values you want the data that's your preference and values i want to know more and more and more and that's fine mark i'm going to help you and let's do all these tests for you yeah somebody else comes in you know and then suddenly they come back and the thing is i see this this is what happens with the whole cholesterol hypothesis right i've got patients coming to me for second opinion as a cardiologist i do you know international consults and virtual and whatever else all around the world.

1:09:26And I talked to them and I just started to tell me what's been going on. And they've been living in absolute fear of death for months. And some of them break down in tears when I just say to them, listen, I've just done a cardiovascular risk here. Your LDL cholesterol is so-called high, but it's not an issue and you're fine. And your risk is only 2%. And you can just see a sigh of relief and say, doctor, thank God. I've been going around thinking that I'm... Then that's again, misuse, not good use of maybe numbers or statistics. I've been going and thinking that I've got in the next five years, there's an 80 % chance I'm going to die of a heart attack.

1:09:58I'm like, no, it's 2 % in 10 years, right? So there's also that as well. So I do think we need to think a little bit carefully on it. But coming back to FH, FH affects familiar hypolipidemia, genetically very high cholesterol, okay? 50 % of men and 70 % of women, right? With FH, untreated, big numbers, will not develop premature heart disease. But 30 % of women will, and 50%, which is a lot, Even before maybe 50 or 60, we'll get heart disease. So I did actually a review paper with a number of international scientists as well. And we published it in BMJ Evidence-Based Medicine. And we thought, okay, that's interesting.

1:10:3450 % of men with FH, familiar with hyperlipidemia, very high LDL, don't get heart disease. And 50 % do. Is there anything we can find that's different between them that highlights the subgroup? Like, what is the difference between them? First thing, was it the LDL? Is the LDL higher in those ones that get heart disease versus the ones that don't? No difference at all. ah that's interesting it can't be the ldl then what is it well we found and this is a mark you're going to like this one of the um lipoprotein little a was higher than the one that dropped heart disease so fh you should look at a lipoprotein little a definitely that gives them a high risk but what's most promising and interesting is when you correct for insulin resistance yeah right it or their level of risk of heart disease for fh patients almost comes back to someone who's completely healthy it's only slightly higher so what were the two two markers normal waist circumference and low insulin yeah now how do you get there diet right cutting out the sugar processed foods refined carbs that's right and it rapidly so this is amazing so i could so what i do with those patients is i go through that with them now if i think they're actually the high low per protein little a and they're probably a high risk i say listen the statin benefit is there it's small but why don't we do a halfway house high dose statins are more like to give you side effects let's do a low dose statin let's do the lifestyle the lifestyle is most important for you and i go really hard on that with them including the diet the exercise and actually the the one that i think isn't discussed enough and you know it comes out in my my documentary film um which is called first do no farm p-h-a-r-m not f-a-r-m all right how do you how do you find that um we it's released online at the moment and you can download it for for $10.

1:12:12Um, and it's, uh, the website is no farm film.com and the reviews have been, you know, pretty extraordinary. No farm, no farm film.com. P H A R M P H A R M. Okay. Yeah. Yeah. Yeah. No farm film.com. Um, we screened it in, in the lesser square Odeon in London, which is the most famous cinema in the world. Seven 90 people came. It was invite only, but sir, Brady's really good feedback screened it to doctors, uh, integrated mental health conference in Washington, DC, really amazing feedback there and so far you know we're getting reviews that are giving it sort of 9.7 out of 10 which is great i'm proud of that but most importantly mark it is a it is in my view this film uncovers um literally how we have got this pandemic of chronic disease both with big pharma and big food capturing we've got you know medical knowledge we've got very credible experts for meds to the bmj we go into some dark stuff in there just how many people have been killed by research fraud, but we also give people hope with the lifestyle stuff.

1:13:08And one of the most interesting things I discovered in the film or in my research is that for me, pushing the boundaries on heart disease is also the next phase is can you reverse the blockages of coronary artery disease? And the only, there's not a lot of research out there. We know, of course, Dean Ornish did his trial many years ago, but the reversal was very, very, you know, listen, at least very least it stabilized coronary disease, but it was like one or 2 % in terms of blockages. Cardioles in India for 20 years has been reversing heart disease to the level where, you know, one of his papers that he published showed a 20 % reduction within two years.

1:13:42Of the narrowing of the artery. 70 % became 50, 50 became 30. So he did it through this healthy lifestyle program. It was a, there were devout Hindus, hundreds of patients, right? High fiber vegetarian diet, because they Devahindu is fine. Two 30-minute bris walks a day, and then something called Rajyoga meditation. When he did a deep dive analysis into what caused a reversal, the only independent factor for reversal of heart disease was 40 minutes of Rajyoga meditation a day. I went to India and I thought, is this true? Is this real? Let me look at the angiograms on myself. I trained in this stuff.

1:14:16I know this stuff inside out. It was unbelievable what I was seeing. I was seeing those patients. I was seeing the angiogram reports. There was clear reversal. In some patients, there was a complete 100 % occlusion that then opened up. So I think it's because you've turned down the chronic inflammation by getting on top of the stress, but it wasn't just about breathwork and meditation. This comes into something that we are dealing with right now in society, which is a crisis of morality. It was a spiritual transformation. These people changed their mindset. They became less materialistic. They became more spiritual.

1:14:48They thought how to reduce their anger. He got them into the ashram with their wives, for example, the men and vice versa to talk about why were they getting more angry? Like, how is your relationship? What's going on with your work? It was a real spiritual transformation that reduced probably the stress. And I think that probably has a scientific basis because we know chronic stress increases chronic low-grade inflammation. We've talked about heart disease being a chronic inflammatory process. You turn down the inflammation and the body can heal. The body has a capacity to heal itself. So kind of in wrapping up, you know, kind of what I'm hearing is that statins have a role, but they're not all they're correct up to be.

1:15:26Just know, are they right for you? Are you being told the absolute benefit is? And then what do you think? Like, you know, do you want to take it or not? And that you have critiques of the way the research was done and how the studies sort of sort and sifted through the statistics to show the benefit. Yeah. How it's reported as relative risk versus absolute risk. So if you get a risk reduction from 3 % to 2%, that's a 30 % risk reduction. Sounds great, but it's really a 3 % to 2%, right? It's 1%, yeah. 1%. And, you know, there are flaws in the ways in which a lot of these studies are done. So could you sort of, for some of the big data that you kind of critique, can you sort of unpack that a little bit?

1:16:07Because I think we didn't dive deep enough into that. I want people to understand, this is not just sort of a heretical opinion, but this is after looking at the way these studies were designed, the way they were done, what the data actually show. So when they do the randomized trials where you're trying to compare two groups, which are the same, and you're trying to get, show a benefit of an intervention. What's reported in the results often underestimates, massively underreports the side effects because what the drug companies do, control how the trials are designed, how they're conducted. Think about that.

1:16:36They're only interested in profit, not looking after you. So they will try and design the trials to maximize ultimately the sales of the drugs. They have what we call a pre-randomization run-in phase where they get these volunteers who are interested in being in the trial and for six weeks for example one of the trials the heart protection study a third of the patients thousands of patients were removed before the trial began because of so-called non-compliance in other words they got side effects so imagine they take the people out with side effects at the beginning and then they only start the trial once they've taken the people out with side effects who get them early on and then report and then so that's probably one of the reasons they're massively underreported the side effects it's i'm sorry uh mark you know it's fraud i'm sorry it's fraud and let me be definitive about how i describe that what's the definition of fraud deliberate deception in order to make money i'm sorry that's the way i interpret it yeah this is fraud yeah yeah right the system is fraudulent so some of the independent studies also show benefit yeah um well the independent studies that have been done have shown very little benefit but i i agree that i think there is a small benefit but the question then is you also look the side effects issue and the independent studies have never been able to get hold of the raw data as well on statins.

1:17:47The totality of evidence around statins, the raw data has never been independently evaluated for side effects. So we still don't know the true side effect profile. In other words, what we know is what's published, not what's actually been tracked because pharmaceutical companies don't have to release that data and they hold it. They hold it. And then you think the regulators are going to be able to ask for it and look for it. They rarely do that. Well, they have it, but they don't publish it, which is interesting to me that the FDA does this because if you probably dig far enough and deep enough, you can find it online or through the FDA databases.

1:18:19But it's not in the literature because they're not published. But the pharmaceutical company has to report all that data before a drug is approved. They can't cherry pick what they provide the FDA, but it's not published. And the FDA doesn't do a good job of saying, hey, yeah, this is what they published, but all this other stuff shows that it really didn't work that way. Well, what they often give the FDA, Mark, is curated information from tens of thousands of pages of clinical study reports on patients in the trial. So the FDA normally doesn't go and then reanalyze it. They just trust what the drug industry, their summary results.

1:18:49And then the other issue is, of course, the financial conflicts of interest. 65 % of the funding of the FDA in the US comes from big pharma. 86 % of the funding in the UK of the MHRA comes from big pharma. And this is a problem. They don't want to bite their hand at feet to them. So there's a huge conflict. Does this explain why it seem that the American College of Cardiology and the American Heart Association still recommend statins for people with high LDL for primary prevention, meaning if you've never had a heart attack, which is 75 % of the prescriptions, you know, um, is it because they're captured too?

1:19:16I think it's a combination of factors, but yes, I think at the root of it is flawed science, dogma and money. And then even if people know there's an issue, um, they're afraid to speak out because they're worried about their jobs. But if we're all doing this collectively, it's going to be a complete, pardon my language, a shit show for healthcare. And that's why we are where we are in America right now. So it's time to, you know, uh, you know, I think, um, I love this phrase. I know this is not a political podcast and it shouldn't be, but a good friend of mine and good friend of yours is Robert Kennedy Jr.

1:19:45And I love the fact that he's come out with this, make America healthy again. I think we should all get behind that. Yeah. It's been co-opted unfortunately. And you can't. Trump campaign. Well, no, but you can't make America healthy again until you remove commercial distortions of the scientific evidence. And that, unless that is addressed head on, we're not going anywhere. Okay. I want to say that again. Commercial distortions of the scientific evidence. Unless you correct that, you won't fix There's actually a paper, I'm going to link to it in the show notes, called The Commercial Determinants of Health, talking about the data on how multinational corporations like pharma, food, and ag companies subvert public health and privatize profits.

1:20:19And it's a WHO report that's sort of partly published, but also coming out in a much, much bigger report. And it's going to be interesting when that hits, because we talk about the social determinants of health, but this is really how the industry is driving it. And just the American Heart Association alone receives$192 million a year from food and pharma companies. Right? Crazy. Mind-blowing. It's mind-blowing. How can we trust their being independent with their information? Come on. I mean, people need to just, you know, wake up, wake up. And you're not telling everybody who's on a statin to stop it.

1:20:54You're not telling them anybody. Let's get better informed. Get better informed. Yeah. Read the data. I wrote an article years ago called Fat, What I Got Wrong and What I Got Right, which goes through a lot of this data. It was published about eight years ago. But still, I think there's more and more data coming out all the time. And I think they can check your books. Where do they learn more about your work and what you're doing? How do they understand how to dig in a little bit more? Let's very quickly on that. I love the fact you brought up commercial determinants of health. There's a definition in public health because I talk about this as well.

1:21:24So just so people understand what that means, strategies and approaches adopted by the private sector. to promote products and choices that are detrimental to health. That's the definition of commercial determinants of health. I have evolved that. And in fact, referencing The Lancet, because Richard Horton, the editor, came to one of my lectures, and I've said that the way that drug companies, big corporations, conduct business, not individuals within it. I'm not pointing at individuals who work for them. As legal entities, the way they conduct their business actually fulfills the criteria for psychopaths.

1:21:53Oh, wow. No, but this comes from Robert Hare. They're immoral, not immoral, right? forensic psychologist Robert Hare behind the original DSM criteria of psychopathy defined them in the book Corporation. He said, so what does that mean? Callous and concerned for the safety of others, incapacity to experience guilt, repeated lying and conning others for profit. So there's another one to throw in there. Maybe next time. Psychopathic determinants of health is my new term. So this is the root of the problem. And of course, downstream effects, we know what's going on. So yeah, people can, I've got a website, drasim.com.

1:22:24I think, to be honest if they want to get an overview of this it's a one hour 50 minutes it's an educational tool um please go and download first do no farm from nofarmfilm.com um and if you want to read about statins in particular but we cover this in the film a little bit the whole drama of statins which is quite interesting um my third book is called a statin free life and i think that really breaks down all the cholesterol stuff and the statin stuff and the lifestyle stuff as well yeah so in summer you're not anti-science or anti-drug or anti-pharma you're just for pro-health real I'm pro-ethical evidence-based medical practice.

1:22:59There you go. So it's really been an amazing conversation. I could talk to you for hours. Unfortunately, we have stuff to do. And I encourage people to dig deep into the scientific work you published, which is where I first came across your work in the British Medical Journal or BMJ, as they call it now. And your books, your films. and you're kind of a tireless advocate for a contrary opinion that is really advocating for a better approach to understanding nutrition health and and making informed choices as opposed to just swallowing hook lung and sinker the dogma that we're all taught in this society which is that the only path to success in medicine is through pharma and and i am not anti-pharma i prescribe drugs regularly.

1:23:45However, I want to prescribe the right treatment for the problem. Yes. And because all we have in our toolkit as physicians is a prescription pad, that's all we know how to use. Yeah. Where diet and lifestyle work far better and are far more effective at achieving the same or even better results than drugs. And if there was a drug that could, you know, instantly reverse diabetes or fix insulin resistance or prevent heart attacks. With no side effects. With no side effects. Yeah. I would do it. But, you know, I've never seen anything work as Well, as food, when applied in the right dose, the right medicine for the right duration.

1:24:20100%. And I think people don't understand that about food. It's not like, oh, food is medicine. It's some hippie-dippie term. It's actually very precise. Just like you need to know the drug. You need to know the pharmacology. You need to know the dose. You need to know the frequency. You need to know the duration of a drug that you're prescribing for a particular condition. You need to know the same about food. That's how nuanced and detailed it is because food is full of tens of thousands of molecules that regulate every single aspect of your biology. And understanding how to leverage that tool for healing is profound.

1:24:48100%. And Mark, another point before we finish is that, which you've just raised, is that these pills for chronic disease rarely improve your quality of life. They may affect a blood marker. They may reduce your risk to some degree in the long term. But lifestyle changes come without side effects, by and large, and they improve your quality of life. Well, there are a lot of side effects. You feel better. You have more energy. you sleep better, better sex drive, less depression, you know. So all the side effects are good ones. Fat point, fat point, positive side effects. If you love this podcast, please share it with someone else you think would also enjoy it.

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