The article “Ditch pills to beat heart disease” was published on the front page of Daily Express this week. It builds on the statements of doctor Aseem Malhotra and his controversial book, the Pioppi Diet, a single case-study and seems to have no basis in science what-so-ever. The article not only offers health advice that runs contrary to medical consensus, it also actively encourages sufferers of cardiovascular disease to stop taking their medication.
Doctor Aseem Malhotra believes that cholesterol levels are not a factor in cardiovascular diseases. He urges heart patients to ditch their medication and rely totally on a specially devised diet and his lifestyle advice in order to improve their condition. What is the major problem with this advice? Though it comes from a legitimate doctor, a cardiologist, the advice isn’t based on anything that would even remotely pass as ‘evidence’ in the medical community as it is anecdotal in nature.
A distinct lack of balance
Immediately in the Express article, we are informed that Dr Aseem is basing his advice for heart patients to stop taking statins, medicines that have a proven track record and have been shown to lower cholesterol in numerous double-blinded studies, solely on one case-study.
In addition to this Aseem makes several claims in the article, that are not referenced or supported in any way. When Aseem does offer a reference it is not linked and is done so in such a vague way that the study is extremely difficult to find. Also, many of the claims Aseem makes can be countered very easily.
Take for example:
“A global campaign over 40 years to lower cholesterol has failed to curb heart disease. In fact, research published in 2016 revealed that in people over 60, cholesterol not only had no association with heart disease but protected against an early death, probably through its crucial role in the immune system.”
Just because the campaign’s to reduce cholesterol have failed to reduce heart disease, it does not immediately follow that cholesterol is not a cause of heart disease. Another explanation could be that the campaigns have not been entirely successful. Or that the success they have had has been offset by worsening diets and the fact that people are living longer.
Dr Aseem makes his case that heart patients and others with high cholesterol should ditch their medication and the advice of their doctors based solely on the success of his diet with one subject, a former pilot, Tony Royle. The Express informs us that Tony shed three stone by ignoring his doctor’ dietary advice and ditching his medication for Aseem’s Pioppi Diet.
Aseem boldly states:
“Here was a man who suffered a heart attack after following what we now know to be unscientific government dietary advice but made an informed decision to dramatically change his diet and stop the cocktail of drugs he was prescribed after suffering debilitating side-effects,” Aseem continues “Now his health has never been better. We have to keep reminding ourselves that good health rarely comes out of a medicine bottle.”
This is a doctor advising the sick that medicines do not improve health. He also has the gall to refer to the medical community’s health advice (as it is the medical community that influences governmental health policy) as “unscientific“. Does Aseem really expect us to accept that a multitude of peer-reviewed studies and associated meta-analysis are less scientific than a single case-study?
Professor Sue Bailey, a psychiatrist who serves in a non-executive capacity on Manchester University’s NHS board, adds insult to injury by adding:
“Doctors don’t always know best and shared decision-making should be given top priority in patient management.”
I’d argue that when it comes to health, yes ‘doctors’ do know best. Unless that doctor is basing their health advice on a single case-study and a book he himself co-authored, as Dr Aseem Malhotra is.
If you were in any doubt about this article’s bias at this stage, its conclusion may well settle that for you. In a rather extraordinary show of partisan status, the article’s writer hands the conclusion over to Dr Malhotra to pen. Perhaps unsurprisingly, this is the section in which the most unsupported claims are made and Aseem’s book is promoted the most vigorously.
Don’t underestimate carbohydrate’s role in a healthy lifestyle
Whilst it’s certainly true that a healthy lifestyle should be encouraged and certainly plays a part in reducing the risk of cardiovascular disease and this overall approach can include reducing carbohydrates, Aseem’s Pioppi Diet pushed in the book of the same name, involves the virtual elimination of carbohydrates from the diet with no focus on also cutting down on fatty foods.
Does a low-carb, high fat-diet sound familiar to you?
It should. This is the Atkins diet reborn.
The elimination of carbs in this way is directly against the advice the vast majority of doctors and dietitians who consider carbohydrates an important part of a balanced diet. Anyone concerned about the health disadvantages of carbohydrates can switch to whole grain and minimally unprocessed alternatives, which are generally healthier. Carbohydrates have also been associated with a reduced rate of diabetes in direct contradiction to what Aseem states.
These benefits aren’t something mentioned in the article.
What is mentioned with regards to diabetes, is that statins are known causes of type 2 diabetes. But is this even true?
Overplaying the dangers of statins. Downplaying the benefits
Whilst there has been a multitude of studies that have shown that individuals that take statins are slightly more likely to have type 2 diabetes. Does this mean that it’s conclusive that statins cause diabetes?
Not entirely. That’s because of the old sceptical chestnut “correlation doesn’t equal causation”. The majority of statin takers are already likely to be overweight as the drug is prescribed to reduce cholesterol and high cholesterol is most common in the over-weight. Being overweight is the leading cause of type 2 diabetes. This leads to a situation in which it’s difficult to conclusively state that taking statins led to the occurrence of diabetes.
Observational studies that are used to draw correlations are not suitable to draw conclusions about direct effects as they don’t control for other factors which may lead to illnesses like diabetes. These studies are the ones that are generally the worst represented in the media, as journalists frequently fail to understand this.
Aside from that, the only other connecting factor is the fact that patients who take extremely high doses of statins have been found to have slightly elevated fasting glucose levels. But this is only in patients who already have diabetes.
Contrary to this the article and Aseem himself are very quick to point out that statins don’t actually have as many benefits as the medical community would have you believe. In the article, he states “there is no evidence of a single person suffering a heart attack or dying from not taking statins”. This is quite an odd claim to unpack. It’s almost asking the medical community to prove a negative. It’s difficult to say after the event if a medical intervention would have prevented that preceding event. How soon before the heart attack would the patient have had to begin the treatment? At what dose? Would it have been effective? Does it even make sense to say a person died as a result of not taking a medicine?
The only way to effectively answer the question “do statins prevent heart attacks?” is to look at their effect on known causes of heart attacks. In this case, that’s high cholesterol, which statins have been shown to reduce. They do this by causing the liver to produce less cholesterol. As Aseem refuses the premise that high-cholesterol causes heart-attacks, it goes without saying that he also wouldn’t consider cholesterol reducing measures to be effective in the prevention of heart attacks.
Whilst it’s right to aware of the drawbacks of statins, the fact that they will not work in isolation requiring the adoption of a healthy lifestyle and the fact that like any medication they can have side-effects, advising patients with cardiovascular disease to drop them entirely is deeply irresponsible.
Obscuring the truth
One of the most striking things about this article is that none of the health claims made within it are supported by peer-reviewed studies or journal articles. Tony, the single case -study used in support of the lifestyle change, states that he “did his research” with regards to statins and diet but we aren’t given much of a clue of what sources he used to conduct this research.
The only real hint of a source that we are given here is Dr Aseem’s book Pioppi diet, coauthored with Donal O’Neill, a documentary filmmaker behind several anti-carbohydrate movies. We need to be aware here that advances in medicine are not published in books, they are published in peer-reviewed journals. Aseem likely knows he would never get his theories published in this way as there doesn’t seem to be anything in the way of actual research to back them up.
The findings of the book seem to be entirely based on anecdote. Let’s let the author, Dr Aseem, explain how he came to the conclusions in the book and what leads him to advise sick people to stop taking their medication.
“As I point out in my book The Pioppi Diet, based on the secrets of one the world’s healthiest villages, dramatic improvements in weight, health markers and sense of well-being happen within weeks of lifestyle changes and unlike medications, which have marginal benefits at best, come without side-effects,” Dr Malhotra continues “But the best way to tackle this problem is not by taking a pill but by following a diet that contains minimal sugar and processed carbohydrates, avoiding being sedentary, reducing stress and getting a good night’s sleep.”
Let’s say we accept that taking statins isn’t the best way to tackle cardiovascular disease, that doesn’t mean they can’t help does it?
It’s odd that Aseem mentions the avoidance of a sedentary lifestyle in the Express article, as in the publicity for his book he is quite clear that his diet helps patients avoid exercise. In fact, it’s clear from the book’s description that it also implies readers will be able to maintain a high-fat diet as long as they cut out carbohydrates and follow the book’s advice.
“This isn’t a diet or lifestyle which requires saying ‘no’ to the things you love, or exercising for hours upon end. In just three weeks, The Pioppi Diet will help you make simple, achievable and long-lasting changes to how you eat, sleep and move – changes that all of us, no matter how busy we are, can make.”
Sounds too good be true, doesn’t it?
I know someone who was impressed. Professor Sue Bailey. She’s provided a lovely blurb for the book.
‘A must have for every household and a must read for every medical student and doctor’ Professor Dame Sue Bailey
Professor Bailey is closely involved in the ‘Choosing Wisely’ Campaign, which is referenced in the article we are discussing and seems like a perfectly sensible idea. The campaign’s goal is to create a more meaningful dialogue between doctors and their patients. This certainly shouldn’t be considered a campaign to encourage patients to come off medications, instead focusing on ensuring that they better understand the side-effects of medical interventions and why they are required.
The danger is, that by mentioning that campaign alongside Dr Malhotra’s health suggestions readers may believe that this is the case. They may also be led to believe that Aseem’s book and diet are part of the ‘Choosing Wisely’ campaign, which they explicitly are not.
So what about Pioppi, the village upon which Aseem’s diet is based?
Pioppi is a small village in Italy which has generally been hailed as the home of the Meditteranean diet, it has been celebrated in the past for the health of its 200 residents. This is generally accepted to be a result of the fact Poppi is a rural farming and fishing village. Residents have a diet low in saturated fat. The residents are involved with a life of manual labour from an early age and generally don’t have much access to red meats and other rich, unhealthy foods.
It is entirely consistent with what mainstream science understands is a healthy diet.
Aseem and his co-author are twisting this reputation to claim that it is not associated with fat at all but with avoidance of carbohydrates. It is made abundantly clear in the book that the pair conducted no research in the village other than visiting to sample the local produce for themselves. The claims are at odds with reality as the two most consumed foods in Pioppi are pasta and bread, both high in carbohydrates and foods that the diet recommends giving up entirely.
A familiar hypocrisy
Dr Aseem Malhotra offers one more supportive piece of evidence that we should be ditching the health advice of medical professionals and rely instead on his book and diet. It’s an argument familiar to those with a passing acquaintance with alternative medicine advocates.
“But the science alone is not enough. Multi-billion dollar food and drug industries continue to profit from the flawed science of lowering cholesterol.”
If the science behind lower cholesterol is “flawed” then Aseem, or someone else, should be able to demonstrate it using a peer-reviewed study, that is how science is progressed.
As for the argument that food and drug companies are money motivated, that is true. But when we consider that argument it actually works against Aseem’s claims, not for them. If the food industry could conclusively show that cholesterol is not a factor in cardiovascular diseases they would immediately free themselves from a great deal of legislature. Production costs would decrease significantly and the reduction in advice to eat less would positively affect profits. If drug companies could produce a more effective medication to treat cardiovascular diseases they would also profit from this. Drug companies prosper by keeping customers alive.
The final blow to the argument that drug companies seek to prosper fro the sick is probably to point out that Dr Aseem’s book is available from Penguin press for £8.99. Like companies that manufacture alternative medicines, whilst criticising other companies for their profit-based motivation, Aseem isn’t offering his advice for free.
Finally… Someone who knows what they are talking about
As I was particularly concerned about this article I sent it to someone with actual medical qualifications, doctor Lorraine Smith. Here is her response to the article:
“I think it’s irresponsible reporting. I haven’t read the original articles but I am aware of the choosing wisely campaign which isn’t about stopping all medications but about opening meaningful dialogue between patients and clinicians. It focuses on educating people about informed decision making and understanding risk/benefit. This article seems to encourage people to discontinue all meds and embark on a diet few will be able to stick to based on a single case study. The patient in the case study was obviously highly motivated and changed his diet to lose weight. It will be the weight loss leading to a resolution of his diabetes that means he no longer requires the medication (diabetes being an independent risk factor for heart disease and peripheral vascular disease) however the majority of individuals would not achieve this level of control. The issue is the apparent encouragement to discontinue meds then alter diet rather than the other way round.”
Pretty much what I thought about the article.
It’s disheartening when papers resort to this kind of journalism. This article presents a highly distorted and imbalanced picture of cardiovascular diseases, its causes and its treatment. It suggests the very inaccurate idea that medical intervention can be assessed on the basis of one case study and it is extraordinarily biased. It also further promotes the extremely dangerous idea that the medical profession does not have patients best interests at heart. Allowing the subject of an article to write the conclusion of that article seems to me deeply un-journalistic.