The cholesterol controversy

Risk factors for stroke? Hypertension, smoking, cholesterol, heart problems, positive family history, maybe adipositas, ethanol.

There is, however, a slight problem with this list – cholesterol. It turns out that the evidence for the following things is not really impressive:

  • that high cholesterol is a risk factor for stroke
  • that low fat or low cholesterol diet helps reducing risk for stroke
  • that lowering cholesterol is generally helpful for stroke risk

[One can argue that, yes, statins have been shown to reduce stroke (albeit with a very high NNT), but then we have all been told that statins are so very pleiotropic that maybe their antiinflammatory or other properties reduce stroke much more than their cholesterol-lowering properties.

Bear in mind that the evidence for statins (and all other cholesterol lowering drugs) in primary prevention is less than weak, as this metanalysis and a Cochrane analysis shows. Remember that statins might even lead to (discovery of) diabetes.]

The above list of arguments against the so-called cholesterol hypothesis (invented in the 1920s and highly publicized since the 1950ies) is raised by cholesterol agnosticians such as

As so often in history, it is quite difficult to separate the crazy from the serious critics of contemporary science. Myself, I am not too convinced of all the megatrial hype that the statins brought with them and, in general, I don’t like NNTs of > 100, because I know that being a good physician has a NNT of about 5. I am not (yet) an outspoken critic of the cholesterol myth but recommend being conscious and follow the discussions – remember hormone replacement therapy! Still I follow the guidelines recommending a statin for any stroke/TIA patient, even the young ones.