Framingham flip flop

If you went through the copy-paste-enlarge gyrations to be able to read the yellowed clipping taped on to the back of my Framingham study booklet you know that Dr. Kannel, the head of the Framingham study at the time, didn’t mince words about the association of serum cholesterol with heart disease. His strong statements came, strangely enough, as a ‘clarification’ to the report published under his name showing no such association.

See Dr. Kannel’s remarks in an enlarged section of the yellow clipping below.


Just in case you can’t read it, let me tell you what Dr. Kannel said.

A number of blood lipids have been implicated in coronary disease, but none more substantially than the blood cholesterol content. That blood cholesterol is somehow intimately related to coronary atherosclerosis in no longer subject to reasonable doubt…[my italics]

Now contrast this statement by the Director of the Framingham Heart Study at the time of the yellow clipping (1970) to the following statement by his successor, Dr. William P. Castelli:

Most of what we know about the effects of diet factors, particularly the saturation of fat and cholesterol , on serum lipid parameters derives from metabolic ward-type studies. Alas, such findings, within a cohort studied over time have been disappointing, indeed the findings have been contradictory. For example, in Framingham, Mass, the more saturated fat one ate, the more cholesterol one ate, the more calories one ate, the lower the person’s serum cholesterol.

Hmmm. Was Dr. Castelli drunk or on dope when he said this? And he didn’t say it. He wrote it in an article published in the prestigious Archives of Internal Medicine in 1992 when Dr. Castelli was the head of the entire Framingham operation. A little different from the above quote from Dr. Kannel based on the same data.

A curious thing about this quote is his use of the word ‘disappointing.’ In science, one is supposed to be searching for the truth, not trying to prove a bias. How can scientific data be disappointing unless they don’t conform to one’s preconceived notion?

And it just gets curiouser and curiouser.

Recently Dr. Kannel was one of three authors of a paper published in the American Journal of Cardiology discussing the search for the lab test of blood lipids that would prove the most sensitive as a risk factor for coronary heart disease (CHD). Presumably, since Dr. Kannel’s name is on the paper, he approved and agreed with what was written, which is indeed interesting in view of his statement 36 years ago in the yellowed clipping.

The thrust of the paper is that the best indicators of increased risk for CHD are elevated total cholesterol/HDL cholesterol and/or elevated LDL cholesterol/HDL cholesterol ratios. What the paper has to say about total cholesterol levels and LDL cholesterol levels is indeed illuminating.

An excerpt:

Because of a continuous graded influence of total and LDL cholesterol on coronary heart disease (CHD) development, and a substantial overlap of the distributions of the lipids in cases and noncases, it is not possible to select a critical lipid value that separates potential CHD candidates from the rest of the population. The lack of a clear demarcation of high-risk coronary candidates based solely on LDL cholesterol values indicates the need to consider dyslipidemic risk in the context of the associated lipids and the burden of other risk factors.

What Dr. Kannel is now saying 36 years later is that it is not possible to select a total cholesterol or LDL cholesterol value that separates those who are at risk for CHD. In other words, there is no point at which total cholesterol or LDL cholesterol levels tell who will or won’t develop heart disease. Now go back and look at what Dr. Kannel said in the yellowed clipping. Quite the change, I would say. And he was so sure back then. It looks like his own data back in the 1960s confirms what he is finally coming around to admit today.

But, he isn’t just rolling over. No way.

He and his co-authors are futzing with the data to figure some way to salvage their unwavering belief that somehow blood fats are involved in the development of heart disease.

What did they come up with? A few more excerpts:

At any specified total/HDL ratio level, only a suggestion of an influence of the total or LDL cholesterol level was discernible and was more evident in women than in men.

However, at low ratios, there appeared to be no discernible influence of either total or LDL cholesterol.

The total/HDL ratio appeared to predict CHD equally well at low and high total cholesterol values.

It appears that when the total/HDL or LDL/HDL cholesterol ratio is favorable, the level of the lipids that compose the ratio on CHD risk has little influence.

What does it all mean. According to the new, less authoritative Dr. Kannel and partners total cholesterol levels and LDL levels don’t mean squat as long as the ratios of total cholesterol/HDL or LDL/HDL are low. Which, means, of course, that it is HDL that matters because a high HDL reduces the ratio.

Let’s take this analysis a step further. What drives HDL up? A few things. Exercise. Alcohol in moderation. And–drum roll, please–fat in the diet, particularly saturated fat. So, I’ll leave you to draw your own conclusions.

One of the crushing blows to proponents of low-fat dieting has been the realization that although reducing fat in the diet typically reduces LDL levels a little, it reduces HDL levels a lot, leading to higher ratios. The second blow came when it was discovered that the lower LDL levels generated by the low-fat diet were composed of many more small, dense LDL particles, the very ones believed to cause heart disease.

Now comes the rechristened Dr. Kannel telling us it doesn’t matter a flip what our LDL levels are as long as we have low ratios.

In reading and authorizing comments to be published on this blog over the past year I can’t tell you how many people have written telling me that their doctors want to put them on statins because of elevated cholesterol or elevated LDL levels when their HDL levels are extremely high. I guess most doctors have been brainwashed that a total cholesterol over 200 or an LDL cholesterol over 120 is in need of treatment no matter what. This paper should put that idea to rest. Problem is, will they read it?

All these docs writing all the statin prescriptions for nothing more than elevated cholesterol or LDL levels need to do the John Kerry and flip flop the way Dr. Kannel did. At least they won’t be putting people with HDL cholesterol levels of 100 at risk for liver disease, muscle pains, and rhabdomyolisis. Let’s hope they figure it out.

Please note: I reserve the right to delete comments that are offensive or off-topic.

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12 thoughts on “Framingham flip flop

  1. Thanks. I e-mailed the link to my sister and excerpted a paragraph. I’m spending Thanksgiving with her and her hubby and my dad and I’m trying to explain to her why *I* need to eat low-carb. She eats pasta and everything and has great cholesterol and everything else and just dosn’t “get” that I can’t eat the way she does. :-p I’ve been trying to explain stuff by e-mail. I gained A LOT of weight at her wedding last year and don’t want a repeat of that at Thanksgiving.

    BTW, off topic, but the magnesium suggestion was great! I have been cheat free for 7 weeks when I normally only last 4 or 5. It really blunts the cravings.

    Hi Victoria–

    Hang in there over Thanksgiving and be tough.

    I’m glad the magnesium worked for you.



  2. I’m definitely marking this article for use if and when the argument comes — that is, when I go back to my doctor in December to show off what should be an astoundingly (to him, anyway) reduced a1c, and hopefully similarly improved cholesterol — if he sees it that way. Anyway, I’ll be going prepared to just stomp my foot and refuse statins period, after what I’ve read from both you and Dr. Bernstein. So thanks for that! I was wary already, but it’s so much better to know WHY.

    Hi RFS–

    Good luck!



  3. Good stuff about the ratios.

    I noticed that most life insurance companies — who are chiefly concerned with mortality — only seem to look at ratios when deciding who they will insure, and for how much, on the basis of their blood work.

    Hi Walt–

    You’re right. Best place to look for what is valid are at the policies of those standing to make or lose money.



  4. speaking of HDL, you should check out today’s interview with the great “scientist” Dr. Ornish, he trots out his “garbage trucks” theory again. Yeah. Right. Uh-huh.
    I think we should come up with a name for the small dense LDL- how about “tiny assassins?” or “little daggers?”

    Hi mrfreddy–

    Ah, yes, the old garbage truck theory. It’s the last refuge of the ill informed.



  5. Another great post, Dr. Eades. Keep up the great work.

    BTW, do you know of any resources where one can find a low carb/paleo/cholesterol skeptic doctor, or are they just way too rare of a breed?



    Hi Neal–

    I know a few here and there. Where are you located? If I don’t know someone in your neck of the woods maybe someone else reading these comments will.



  6. Victoria:
    You are in a difficult position, however sometimes “tough love” can win out and forgive me if I am stepping out of line here on Dr. Mike’s blog.

    My father was an alcoholic and was very abusive verbally. However, I did not cut him out of my life and to make a long story short could figure out the reasons why he was the way he was. One day, when he started on one of his rampages swearing and yelling at my mother, me, my son, my sister (or anyone else), I would calmly tell him that I was leaving and would leave whenever he started yelling because it upset me and was a bad influence on HIS GRANDSON. The first time I didn’t hear from him for 2 weeks because he was so insulted by my comment. Then he invited us over more regularly. I calmly reminded him about the yelling a few more times until it stopped completely, in my presence anyway.

    Maybe it would be good to try a version of that on your family. Calmly tell them that you cannot join them in festivities until a lot more low-carb options are available and the reasons why. But it’s up to you.

  7. So what are good numbers and ratios for our cholesterol? I just got a letter from my dr. telling me to watch my cholesterol, it was 242 total and my good cholesterol (HDL?) was 68. It was a form letter with my numbers written in, I know he doesn’t pay much attention to what the pharma. Co’s tell him it should be.

    Hi David–

    The rule of thumb is that a good TC/HDL ratio is one below 4, which, according to that calculation, yours is.

    I don’t look at that ratio much, preferring instead to use the Triglyceride/HDL ratio, which I like to see somewhere under 5. Most of our patients on low-carb diets stay around the 2-3 range.



  8. Uh… huh? Regarding Total Chol / HDL ratio, Doc said:

    “I don’t look at that ratio much, preferring instead to use the Triglyceride/HDL ratio, which I like to see somewhere under 5. Most of our patients on low-carb diets stay around the 2-3 range.”

    Unless I have lost my mind, on your forum, there is a sticky thread with recommended lipid ratios and Tri/HDL should be

    Hi Bill–

    Was there more to this comment?


  9. A message from Holland. I really like reading articles on your site. A lot easier to read too compared to some literature I got from the library 😉
    I had a small stroke in May 2005 – due to a migraine attack – and all the neurologist could find was a slightly elevated cholesterol level. Further scanning proved no clogging of the arteries whatsoever. However, I was instantly put on statins which did lower my cholesterol levels within a week or so. So I thought I was done. When I asked my physician if I could stop taking the statins now the levels were ok, I was told I was to keep taking them for the rest of my life. Suffering from bothersome side-effects like head-aches and total loss of energy, I tossed the pills that same day.
    Then I read the book by Uffe Ravsnkov and some other articles and I started to ‘see the light’. So now I’m trying to ‘behave’. I have to admit I don’t excercise as much as I should, but I will, I promise 😉
    Meanwhile, a discussion has started over here about the ‘forces’ steering us into drug use and so called cholesterol lowering products like margerine (health advisory instances heavily sponsored by pharmaceutical industries for instance); there was even a representative of the European counsil on the TV this evening stating there will be a formal inquiry into this matter.
    Well, enough ranting from The Lowlands, regards,

    Hi Richard–

    Thanks for writing.  You should take a look at a book available in Europe by Malcolm Kendricks titled The Great Cholesterol Con.  It may help you get even more clarification on the statin and fat issues.



  10. Old thread, but just had to write. You said:

    “The rule of thumb is that a good TC/HDL ratio is one below 4, which, according to that calculation, yours is.

    “I don’t look at that ratio much, preferring instead to use the Triglyceride/HDL ratio, which I like to see somewhere under 5. Most of our patients on low-carb diets stay around the 2-3 range.”

    I’ve been LCing since around 1998. In 2002 I had my blood work done. TC/HDL was 2.71, and Triglyceride/HDL was .99. In 2005 I had it done again. TC/HDL was 2.82 and Triglyceride/HDL was .85.

    Pretty good, huh, for someone who’s killing themselves eating all the saturated fat!

    Pretty good indeed!

    Keep it up.



  11. When my doctor put me on Lipitor I had a 260/45 ratio. When I gave up my low-fat diet, my HDL has zoomed to 69. Now I have an explanation! Thank you.

    However, being on Lipitor my total number is now low. How can I convince my doctor to take me off Lipitor since the total number is being skewed lower and we don’t know what the total number/ratio would be without the Lipitor influence?

    Thanks for considering.

    I don’t know how you can persuade your doc to take you off Lipitor. He/she has probably bought the drug company promotions hook, line and sinker. Maybe you should copy the post on Statin Panic and take it to your physician, though I doubt that it would make a lot of difference.

    Good luck.