Book Reviews • Buchbesprechungen

If you have already harbored some doubts about the veridicality of the hypothesis that cholesterol causes heart disease and that statins are useful medications, here is the book for you. It will convert those doubts into security. If you have no doubts whatsoever, you should read this book, not to convert yourself, but to take in the perspective of those who have spent a lifetime working and studying this topic and who, for whatever reason, have arrived at quite different conclusions than the mainstream. This book is a collection of articles of who might be termed the ‘cholesterol skeptics’ that have been assembled by Uffe Ravnskov – one of the co-authors to whom the book is meant as a tribute – into THINCS, the International Network of Cholesterol Skeptics (www.thincs.org). As the foreword by Paul J. Rosch, the editor, explains, it was originally intended as an invited special issue for the journal ‘Expert Review of Clinical Pharmacology’. When the papers were assembled, only a small number passed the journal’s peer review process; the rest was rejected. So the editor and the authors decided to publish their own book, since the reviewers or the editor seemed to not have invited back amended versions. One is not surprised about this, once the material starts to unravel. It indeed completely contradicts the mainstream opinion. Had I been a reviewer of that special issue, I would have sent back some of the papers for editorial amendment in writing, style, grammar, cohesion, but only very few of them. The rest appears to be in good shape. These papers tell a troubling story, which I shall compress here. It is a story of collective neglect of contradictory data, being blinded by conflicts of interest and following along the broad road of funding and publishing success, against obvious mistakes and contradictions. The story the book has to tell, briefly, is the following: The so-called diet-heart hypothesis, meaning that the rising figures in incidence of cardiovascular disease and death from heart disease are due to an increasing cholesterol level in the food, was wrong from the beginning. The lipid hypothesis, whereby cholesterol is a causative agent for atherosclerosis, was ill founded, and already in 1957 one would have had the chance to see that and change course. Therefore, all following attempts at verifying this hypothesis failed, but these failures were ignored because the idea had become mainstream and powerful agents from the food industry were funding research and influencing policies. Attempts at lowering cholesterol through drugs did not make it better. The early studies were likely either flawed or a huge publication bias veiled the lack of effect that became obvious in more recent studies with more rigorous methodology. Where effects are visible, they are very small, and the benefits do not outweigh the widespread side effects that are largely neglected, underreported, or not associated with statin use. A little vignette may illustrate this. One of the single most important studies in the whole drama is Ancel Keys’ famous ‘7 countries’ study [1]. He states: high cholesterol might be one of the factors that drive increasing cardiovascular mortality. For, if one looks at a graph from his study correlating fat availability (which later became fat consumption) with cardiovascular mortality, a very close correlation can be observed. This graph was one of the single most influential graphs in this discussion. The problem with it is: it was actually forged, scientifically speaking. The study examined 22 countries, and when the data of all 22 countries were plotted, the correlation vanished into insignificance. This information was known since 1957, when a team of statisticians used Ancel Keys’ data to demonstrate the problem of cherry-picking data to one’s liking and other methodological problems [2]. In other words: the knowledge of the falsity of the correlation of cholesterol scores and heart disease mortality is as old as I am, yet no one took it into account. In my view, this is one of the largest scandals in modern medical research, as it had such huge reverberations both in medical practice and in directing research interests and funding streams.