Betrayal by Bias
This is going to be a pretty obvious statement at this point, but we have a crisis of expertise in this country. It has been so easy to amplify your voice in recent years that anyone, regardless of background experience, can say anything, and a lot of people out there will believe it. These influencers can have financial conflicts of interest (they’re being paid by a supplement company to promote a supplement) or intellectual conflicts of interest (they’re famous for a certain opinion and would lose their fame if that opinion was wrong), and you may have no idea that what you are reading or listening to is really a commercial.
In an ideal world, you would have a question about something, and then research the topic, analyze the data, and come up with a conclusion. You would then choose a plan of action based on that conclusion.
Nowadays, people seem to choose what they want to believe first and THEN search for evidence that supports that point of view. It doesn’t matter that when you look at the totality of research, it may lead you in a different direction. In the current world, we ignore things that don’t line up with our preconceived notions, and focus only on data points or stories that support what we wanted to believe from the beginning. We no longer look at the totality of evidence or experience, just the small bit that supports what we want to believe.
Now this may sound like the beginning of a political blog, but it really isn’t.
You might then ask: How does this relate to the heart and heart disease prevention?
I’ll share a little bit about me first: I haven't been a vegetarian or vegan all my life. It wasn’t something that I was “raised to believe in”. I came to it naturally, over time, in the course of my career as a cardiologist. As I read more and more about cholesterol and inflammation and heart disease and strokes, I learned about the lifestyle patterns that were associated with better health. My wife was vegetarian, and trust me, I would have loved for her to have been wrong about her diet: I enjoyed grilling burgers and eating chicken tacos. But as I kept up with heart-related research over the years, it became increasingly clear that if you looked at the totality of evidence about how to prevent heart disease, it pointed towards eating a more plant-based diet. So I made the change myself. I didn’t come to this conclusion and then cherry-pick studies that supported my choice. I didn’t think “because I like eating burgers, I want to find evidence that allows me to keep eating them”.
The reason I am writing this blog at this time is because of the recent KETO-CTA trial, which made headlines around the world. GlobalNewsWire reported “New research from The Lundquist Institute finds ketogenic diet-induced high cholesterol does not predict heart disease.” Fox News reported “'Shocking' study challenges conventional beliefs about heart health and cholesterol.”
So what was this ground-breaking study that evidently changes everything that we believe about cholesterol and heart disease?
The recently published KETO-CTA trial was a research study that took 100 hand-picked people that had been on ketogenic diets for 5 years and tried to see the effect of this diet on blockages in their hearts. These study subjects had an average age of 55 yrs old and were specifically chosen because they were “lean mass hyper-responders”, meaning that they were thought to be in good health and had extremely high cholesterol levels because of their diets. What do I mean by “extreme”? The average LDL was 253, and the average total cholesterol was 355. These values are worse than >99% of the general population of this country. The participants were hand-picked in that they were on no medications and had NO other medical issues: no high blood pressure, diabetes, insulin resistance or anything. In order to be in the trial, they had to have LDL ≥190 mg/dL, HDL ≥60 mg/dL, and triglycerides ≤80 mg/dL This group is of course NOT representative of the general population. The researchers evaluated the hearts of the research subjects using a Coronary CT Angiogram, which is a special "CAT" scan that can see inside the blood vessels that deliver blood to the heart muscle. The participants had this test performed at the start of the study, and then again after 1 year.
What did the authors report? Using the advanced cardiac imaging, the researchers reported that ApoB and LDL-C (markers of “bad” cholesterol) were NOT associated with changes in plaque levels in the heart’s arteries or with baseline heart disease over a one-year period. Instead, existing plaque levels seemed to be a better predictor of future plaque accumulation. Meaning that if you don’t already have plaque, you don’t need to worry about your cholesterol levels at all, even if they are exorbitantly high. One of the authors of the report stated: "This population of people — metabolically healthy with elevated LDL due to being in ketosis — are not automatically at increased cardiac risk simply because their LDL is elevated.”
Of course this made headlines: it was published in a highly respected “peer-reviewed journal”, lending the conclusions weight and importance. Media outlets around the world reported on this study, and the authors amplified their findings on social media, podcasts and interviews.
So we now have a study that actually looks at plaque and apparently showed evidence that extremely high bad cholesterol wasn’t related to plaque progression. This seemed to have upended decades of thought and research.
When I read this study at first, I wondered if my approach to health, and the approach I have recommended to patients for years, was completely wrong. I wondered how it would be possible to eat a meat-based diet and experience extremely high cholesterol levels and have no ill effects on the heart?
But of course, there’s the rub: their conclusions were wrong, and the headlines were worse.
It turns out that what the research actually showed was that ALMOST ALL of the 100 participants had an INCREASE in soft plaque. 96 out of the 100 participants experienced progression of soft plaque! And when compared to likely similar healthy populations in other studies (this study was so poorly designed that they didn’t include a “control” group of their own), the amount of increase in soft plaque was almost 4x higher in the ketogenic diet eaters compared to the healthy populations. After just 1 year!
In fact, this amount of plaque growth is similar to what would be seen in a much “higher risk” cohort of patients with diabetes or multiple risk factors.
But even though this was the “primary endpoint” that the researchers planned to look at, they didn’t report this result in the paper and buried it in “the fine print” (a supplemental appendix). Instead, they focused on a made-up measurement called “total plaque score” which was rated as small, medium or large. And they reported (correctly) that no one in the trial moved from small to medium total plaque, or medium to large. This was what brought on the headlines: Regardless of cholesterol levels, the participants didn’t exhibit an increase in their average “total plaque score”. But these were healthy men with an average age of 55yo, followed for just 1 year. We shouldn’t expect that they would have had such a change in plaque that they’d jump from one category to the next. And their own research clearly showed that people moved WITHIN those categories: for example from the low end of the “small plaque” group, to the higher end. So while the participants didn’t necessarily increase from small to medium plaque score (or medium to large), if they were followed for more than 1 year, they likely would have.
The authors in this research group are people who for years have created careers selling people on ketogenic diets. They actually raised money to fund this trial from crowd-sourcing in a Facebook group that is dedicated to ketogenic diets. They clearly wanted to prove that ketogenic diets are healthy. They had financial AND intellectual conflicts of interest. They promoted the trial on social media BEFORE the results were even known, telling everyone that it was going to confirm that ketogenic diets were healthy. And then they were all over the media in the last 2 weeks touting the results.
So what did they do? They settled on a conclusion in advance, and then ran a trial to try to find the data points that supported their conclusion. Instead of having a question and seeing where the data took them, they already “knew” the result they wanted. And so when the data didn’t agree, they buried it and tried to find some data points that would support what they wanted to believe.
Which brings me back to the original point of this blog. This whole fiasco is a great example of why no one trusts anyone anymore. This was research published in a well-respected journal, and it ended up being propaganda more than anything else. So who really is an expert anyway? Who can really give you trustworthy direction on how to be healthy anymore?
When people come to see me and start arguing that carnivore or keto diets are actually healthier, I try to point to the wealth of experience that proves that idea incorrect. From observational trials to randomized/controlled clinical trials to “evidence” from evolution (the shape of our teeth) to simple human experience: If you look at the healthiest populations on the planet right now, the ones who live the longest and best are eating predominantly plant-based diets. And that is why I do, too.
And at Wisconsin Cardiology Associates, we recommend to our patients the interventions and behaviors that we would use for our family, or ourselves. The funny thing is that now I actually have this research from these keto influencers that supports our approach: keto diets and high cholesterol levels lead to increased soft plaque!
At Wisconsin Cardiology Associates, we counsel our patients to aim for a healthy, plant-based diet, emphasizing fruits, vegetables, beans, lentils, whole grains and nuts. Have questions about the best way you can prevent heart disease? Call us and make an appointment for a consultation.
Our clinic is open and we are accepting new patients
