Dr Aseem Malhotra: We need a healthy dose of lifestyle medicine

I recently saw a woman in her early sixties who was terrified because her GP had told her that her cholesterol was high. “Congratulations,” I said. “That will probably help you live longer.” She left smiling. It is little wonder she had been scared. For decades,governments have issued “low fat” dietary advice, while consumption of sugars and refined carbohydrates has soared. The result has been twin epidemics of type 2 diabetes and obesity – and a bloated medical bill to match. The time has come for an urgent overhaul.

There is no association between so-called “bad cholesterol” and cardiovascular disease in the over-60s. In fact, if you consider all causes of death, the trend is for fewer deaths the higher the cholesterol. One explanation is that cholesterol is involved in immune system protection against potentially fatal gastrointestinal and respiratory infections and possibly even cancer.

So while there is a risk of higher cholesterol in the development of cardiovascular disease, official insistence on lowering it by drug or diet as an end in itself has been entirely misplaced. As Dr John Abramson from the Harvard School of Public Health points out, cholesterol is one of the most vital molecules “and to think you can radically pull this out of the body and not have consequences is ridiculous. It’s such bad science.”

Even the American scientist Ancel Keys, architect of the original study that identified consumption of saturated fat as one of the major drivers of heart disease, changed his tune, noting three decades after his study that “I’ve come to think that cholesterol is not as important as we used to think it was.” But the dietary guidelines that his research led to, and the multi-billion-dollar cholesterol-lowering drug industry, remain in place.

The truth is that the most important risk factor for heart attacks in young men is insulin resistance. It’s implicated in the development of high blood pressure and is also a precursor to type 2 diabetes. Why do most people not know about this? Perhaps because the solution to dealing with it is simple, cheap and dramatic.

Only last week I saw a woman in her late sixties who was diagnosed with type 2 diabetes a quarter of a century ago. She had been on insulin injections for the past 17 years. But recently, after reading reports that type 2 diabetes is a condition of carbohydrate intolerance, she changed her diet. “What did you stop eating?” I asked her. “Bread, rice, and sugar,” she answered with a beaming grin. “But now I can enjoy eating cheese and butter again.” She no longer requires her 80 units of insulin.

The management of type 2 diabetes has been upside down for decades. The perception is that it is a chronic, irreversible condition. As such it is treated with drugs that cost hundreds of millions of pounds, and which marginally reduce the complications of kidney problems, eye and nerve disease, but have no impact on heart attacks, stroke or death. Furthermore, side effects of these medications contribute to 100,000 emergency room visits a year in the US alone.

How many patients are explicitly given this information? Too few. Instead, as the BMJ pointed out in 2013, the drug industry’s business plan for diabetes is “recruit tame diabetologists, [and] massage them with cash ”.

When doctors have to make clinical decisions based upon biased information corrupted by commercial influence, we cannot claim to practice ethical medicine. When I wrote an article pointing out that it was wrong not to tell patients that inserting a heart stent for stable angina does not prevent heart attacks and prolong life, I received a supportive email from a colleague. “Many interventional cardiologists would privately agree with you but find your message in public uncomfortable,” he wrote. “There’s a whole industry of people whose livelihoods are dependent on invasive cardiology.”

Perhaps the most sobering conclusion about medical research was reached by John Ioannidis, professor of medicine and health policy at Stanford University. He concluded, in a paper published more than 10 years ago, that most published medical research is likely to be false. “The greater the financial interests in a given field,” he noted, “the less likely the research findings are to be true.”

It was Ioannidis who, in a separate analysis, compared exercise with drugs in the treatment of heart disease, rehabilitation after stroke, treatment of heart failure and prevention of type 2 diabetes. The benefits were similar. In a documentary film I’ve co-produced (The Big Fat Fix, thebigfatfix.com) we discover why, in the tiny Italian village of Pioppi, average life expectancy remains close to 90. A combination of eating well with the right type of exercise and stress reduction is not only a powerful treatment of chronic disease; it may also slow down the ageing process.

It is time for our healthcare systems, like the NHS, to incorporate this lifestyle medicine. Not only is it cheap, but it also comes without side effects. Good health does not come out of a medicine bottle. As the heart transplant surgeon Christiaan Barnard said: “I have saved the lives of 150 people from heart transplantations. If I had focused on preventive medicine earlier, I would have saved 150 million.”

Aseem Malhotra is a NHS cardiologist and member of the board of trustees of the King’s Fund

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Graham