Dr Kendrick has produced a very readable book, almost conversational in style, in which he dissects the evidence on which current thinking on heart disease is based. The non-medical public will have little difficulty in following the text, as all basic concepts are clearly explained. Medically trained readers will either be entertained by his writing, or be irritated by it. For example, ‘Run for the hills, hide your children’ he says, ‘here in all its terrifying glory is a saturated fat’. But this book is a triumph of substance over style. For Dr Kendrick makes no statement without supplying a reference, almost always from a peer reviewed journal, and often from one of the major heart disease trials, all of which feature in the book.
The diet–heart hypothesis is dissected first, with a history of the evolution of the hypothesis and the evidence (or otherwise) behind it. WHO figures for 1998 round off the chapter, showing the seven countries with the highest saturated fat consumption having far lower rates of heart disease than the seven countries with the lowest consumption.
Cholesterol is the main theme. Increased mortality with low cholesterol is shown in various studies, and familial hypercholesterolaemia, when looked at in more depth, is shown to be poor evidence of the danger of cholesterol. Plaque formation is analysed, and the difficulty in demonstrating any plausible way in which lowering LDL cholesterol could remove cholesterol from plaques drives Kendrick to incredulity.
There are other themes in the book, but perhaps the most immediate issue for those of us prescribing statins is the lack of evidence, according to Kendrick's detailed analysis of the trials, of any benefit to men or women in primary prevention in terms of overall mortality, and of any benefit to women even in secondary prevention. For men with established disease, increased survival of a few days per year of taking the drugs is acknowledged, but Kendrick does not accept that this is anything to do with lowering cholesterol. He gives evidence of harm from these drugs, which he feels is greatly underestimated.
The scientific method of Karl Popper is cited, whereby any good scientific statement or theory should be disprovable. The single black swan among a 1000 white swans is sufficient to negate the statement that ‘all swans are white’. When Kendrick has presented all his evidence, he creates a powerful image of cholesterol experts clustered round a rather threadbare white swan, with a large flock of black swans flying overhead blocking out the sun.
Malcolm Kendrick says he has great difficulty in finding any expert or researcher who does not depend for his reputation and/or income on pharmaceutical companies, and furthermore that the companies increasingly design the trials and decide on the presentation of the results. He does not go so far as to express the hope that none of the large pharmaceutical companies is also a manufacturer of polonium 210, but it is clear that he feels his views are unpopular in some quarters.
This book should make us all uneasy. For those of us who lack the time or mental energy to check all of Kendrick's work, it would be helpful to know that Sir Michael Rawlins had a copy and was preparing either a rebuttal or a recantation of NICE advice.
- © British Journal of General Practice, 2007.
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