Cancer, heart disease, and smoking

Today the American Cancer Society released figures showing a decrease in cancer deaths in the United States in 2004 as compared to 2003. (See full report here) Says Reuters in its coverage of the announcement:

…the big decrease shows that not only has the death rate from cancer been reversed — but it has been reversed so much that fewer people are dying, even though the population of elderly people, who are most susceptible to cancer, is growing.”Cancer death rates have been declining for a long time. The declines have now outpaced the growth and aging of the population,” Elizabeth Ward, director of surveillance research for the American Cancer Society, said in a telephone interview.

She said a small decline seen in the previous report had grown considerably, showing the trend was real.

Decreases in smoking may be a major factor, Ward said.

I would suspect that the huge decline in smoking is behind this falling off of cancer deaths. Since 1955 the number of males who smoked has decreased by almost 60% and the number of females smokers by 35%. Since lung cancer is one of the most common cancers and is indisputably related to smoking, it would seem reasonable that as people wean themselves from this noxious habit (or never start in the first place), deaths from cancer would be on the decline. And not only are deaths from cancer on a downtrend, so is the incidence of cancer. Looking at the rates of new cancer cases in 1997 and comparing them to those in 2006 (adjusted for population) we find that the incidence of lung cancer has fallen by about 18%. So, it is reasonable to conclude that the fall off in smoking would translate into fewer cases of lung cancer, and it has.

Now let’s look at heart disease. If we look at the American Heart Association (AHA) statistics, we are told of the tremendous decline in death rates due to heart disease over the past couple of decades. Based on what the AHA recommends to reduce the risk for heart disease, we learn that we should eat less saturated fat and cholesterol, reduce our serum cholesterol levels (with drugs, if necessary), reduce our blood pressure, quit smoking, and exercise. Do these things were told and deaths from heart disease will fall even further.

On page 8 (large pdf) of the Heart Disease and Stroke Statistic–2007 Update much is made of studies showing that lowered cholesterol, blood pressure, and smoking greatly reduce the risk of heart disease. The trends for these lifestyle changes are shown in the graph below.

trends-in-cvd-risk-factors.jpg
You can see that cholesterol has plummeted, high blood pressure has been reduced, and smoking is on the wane. Remember this chart, we will come back to it.

So, it appears that the AHA is right. As a country we’re eating less saturated fat, less cholesterol, we’re all taking statins, and many of us have stopped smoking, and it’s paid off because deaths from heart disease have dropped dramatically. But not so fast. All these AHA recommendations are to reduce the risk of developing heart disease in the first place. Since it’s difficult to die from heart disease if you don’t have it, it makes sense that preventing the onset of the disease would reduce deaths from it. Which is precisely what the AHA wants you to believe. Follow our guidelines, they tell us, and you will reduce your risk for heart disease, and, consequently, your chances of dying from it. If you don’t believe us, look at the statistics.

Harkening back to the cancer statistics, remember that both the incidence of cancer (i.e. how many people were afflicted) and the deaths from cancer decreased. From these statistics we can say that fewer people died from cancer because fewer people got it. I’m sure medical treatment improved, but primarily fewer people had cancer.

What about the incidence of heart disease? We know that deaths from heart disease declined significantly, but what about the actual rates at which people are getting heart disease?

Well, that figure is a little tougher to find out. The AHA doesn’t particularly want us to know about the incidence of heart disease; they just want us to know that deaths from it are declining. To find the incidence you have to go to a table called Hospital Discharges with Cardiovascular Disease as the First Listed Diagnosis.

data-on-cvd-hospitalizations.jpg
As you can see the rate of these discharges is increasing. When you correct for the increase in population over the years, the line doesn’t increase as rapidly, but still increases slightly. What does this mean? It means that despite all the decrease in cholesterol levels, all the statin drugs, all the blood pressure drugs, and all the people on low-fat diets, that the number of people developing heart disease hasn’t dropped at all. If anything it has increased.

How can we tell this from this chart? When doctors hospitalize patients the doctors list the disorder requiring the hospitalization first. If someone with heart disease has a car wreck and breaks his femur (the thigh bone), he would be admitted with thigh fracture as his first diagnosis. Ditto for someone with heart disease who develops pneumonia; he (or she) would be admitted with pneumonia as a first diagnosis. The people represented on this chart are people who have been hospitalized for heart disease. It’s probably not the most reliable source for a truly accurate incidence of heart disease statistic, but it will have to do because the AHA doesn’t report anything else. They even tell us not to believe their own incidence statistics from year to year.

Incidence is an estimate of how many new cases of a disease develop in a population in a one-year period. For some disease statistics, new and recurrent attacks or cases are combined.

The incidence of a cardiovascular disease (CVD) in the United States is estimated by multiplying the incidence rates reported in community- or hospital-based studies by the U.S. population. The rates are not computed annually; they change only when new data are available. The estimates were revised to reflect the 2000 U.S. Census. Neither the incidence nor the rates should be compared with those in past issues of the Heart Disease and Stroke Statistics Update.

If we’re still getting heart disease at the same rate, why are deaths from heart disease going down? Easy. Better, more rapid medical intervention. We’re treating it better once we’ve got it, but we’re still getting heart disease at the same rates as before.

We know that smoking, a known risk factor for both heart disease and lung cancer, is on the decline. It would make sense then that the incidence of these diseases should be on the decline as well. And indeed the incidence of lung cancer has fallen by 18%. But the incidence of heart disease is the same despite the drop off in smoking.

What does this tell us? It can tell us a number of things. It could tell us that smoking isn’t really a risk factor for heart disease. (Millions have quit smoking and heart disease incidence hasn’t changed) It could tell us that all the changes that the AHA has recommended–reducing cholesterol (with drugs, if necessary), reducing blood pressure, following a low-fat, low-cholesterol diet–are making us have more heart disease to replace that that has fallen due to smoking cessation. Or it could tell us that something else is increasing the incidence of heart disease to make up for that that has fallen due to fewer smokers.

If you look back at the chart above showing the trends in cardiovascular risk factors, you will notice diabetes on the far right. The chart is constructed poorly in that it doesn’t show the relative rates of increase or decrease of these factors, which would be much more meaningful. If you look at the far left, you can see that high cholesterol has fallen from 33.6 to 17, which represents a decrease of about 0.5. Look again at diabetes and you can see that it is up by a factor of almost 3. And that’s diagnosed diabetes. There are many more cases of undiagnosed diabetes out there than there are of diagnosed diabetes. And there are many more cases of glucose intolerance than there are even undiagnosed diabetes.

It would seem therefore that the reduction in the incidence of cardiovascular disease we should expect to see from the decline in the numbers of smokers is made up for by the increased in people with diabetes.

And remember, diabetes is a disease of too much sugar in the blood, not too much fat. We’ve got a situation in which the heart disease authorities, the AHA, have recommended that we cut the fat in our diets, keep our blood pressures low, and stop smoking to reduce our risk for heart disease. We’ve done all those things, yet the incidence of heart disease hasn’t changed. Why? Because we’ve increased the sugar in our blood. It’s more data showing the lipid hypothesis is flawed while putting another notch in the belt of the sugar hypothesis.

To paraphrase James Carville: It’s the sugar, stupid!

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

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17 thoughts on “Cancer, heart disease, and smoking

  1. Another brilliant post.

    When I saw the news about the cancer decline, I was hoping you would blog about it, and help interpret the statistic. Even better, you expanded the topic to include metabolic syndrome and the way the press is manipulated to perpetuate the low-fat high carb mythology.

    Thanks,
    Richard

    Hi Richard–

    Thanks for the kind words.  It’s interesting that the AHA doesn’t keep it’s old statistics online as the American Cancer Society does.  Makes it tough to find out how the incidence changes over the years.  I wonder why they don’t do that.

    Cheers–

    MRE 

  2. Thanks for linking to your Jan 06 post about the sugar hypothesis. I wasn’t reading your blog back then and missed it, despite reading quite a bit of the archives. You say it so well.

    I have been beating my head against a wall trying to get my mother (64 yo) and younger sister (43 yo) to stop focusing on their high cholesterol, get off statins, and pay attention to their blood sugar instead (maternal grandfather died at 50 of 2nd “coronary occlusion” so that strikes fear of cholesterol and CHD; no one is alarmed that uncle and cousin were diagnosed with T2 DM in recent years or another “young” uncle has MS). Mom is a labor & delivery nurse and has never heard the “truly normal” blood sugar limits I reference. I sent them your post today (and the Jan 06 Sugar Hypothesis) and hopefully your words will sink in, because they are resistant to mine (which aren’t sugar coated, but must be insulin-coated because they sure aren’t docking with their hearing receptors) :-).

    Even if they don’t ever heed the message, I am taking it very seriously for myself and my family. Despite relatively normal weight (thanks to low carb diet the past few years), I have a history of gestational diabetes, so I know I am at risk of T2 DM. After reading about “truly normal” BG levels of 84 or so, quite by by chance, I reviewed my BG tests for the past 10 years and they have almost always been in the high “normal” range of around 100-103 in recent years (during low carb!) to as high as 108 (pre-low carb and pre-pregnancy 11 years ago). The recent A1c of 5.5 (that a new dr ordered to my surprise) does not comfort me, either, with all that I have learned recently as normal is closer to 4.5. So I read Dr. Richard K. Berstein’s The Diabetes Solution, too. None of my FBG levels have caught the attention of any physician I have ever seen (except my 1 hr & 3hr GTT during my pregnancy), so on my own I have started using a glucose monitor again to see what happens after meals. Whoa! Probably not “truly” diabetic yet, but way too close for comfort. And definitely not “normal”. Sticking strictly to low carb has improved post meal and FBG, but not sure if enough. Might be too soon to tell. But no excuse for cheating when my friend bakes cookies anymore! I have a new physician and I will discuss this with him when I go for annual in March. I will have more data of my testing experiments by then.

    Thanks again for all the good information you put out there for us. I just wish more paid heed. The outlook for the nation’s (& world’s) future health prospects is quite alarming.

    Anna

    Hi Anna–

    Thanks for the kind words.

    You might try an extreme carb-restricted diet to see what happens to your blood sugar.  If you eat no or very few carbs your liver makes up the difference.  Sometimes people have a little insulin resistance in their livers, and since insulin is the hormone that shuts down the liver’s sugar production, these folks produce more sugar than they need and run their blood sugar up.

    One of the ways to check how much sugar your liver is producing is to eat a no-carb dinner, nothing before bed, then check a blood sugar first thing in the morning.  If your sugar is up, then it’s coming from your liver.

    Best–

    MRE 

  3. Yea, we know it’s the sugar, but what hope do we have when even the ADA says sugar is ok, high carb/low fat diets are the correct treatment, and too much fat is the cause of diabetes?

    Also of note, I noticed the chart said “short stay” hospitals…is that simply a new name for acute care facilities? or are they only talking about short stays in the hospital, which would set a limit on the # of days, and not take into consideration the people that are inpatient for long stays after cardiac surgery??

    Hi Cindy–

    The ADA couldn’t be more wrong.  And the amazing this is that the more information they have the wronger they get.

    I’m sure these are acute care facilities.

    Cheers–

    MRE 

  4. Wonderful post Dr. Eades. I love this stuff. Anyone who feels the same and hasn’t done so already needs to read Anthony Colpo’s new book, The Great Cholesterol Con. It is full of fascinating findings and spot on interpretations just like this!

    Thanks Dr. Eades

    I’ve just gotten started on Anthony’s book, but what I’ve read so far is terrific.

    MRE 

  5. Am I correct in thinking that the Diabetes establishment’s pushing of high carb diets followed the demonising of saturated fat?

    If diabetics can’t eat sat fat, can’t eat too much protein as we all “know” excessive protein can harm even healthy kidneys, the there’s not a lot else for diabetics to eat except carbs.

    Hi Neil–

    Their entire philosophy is driven by their insane fear of fat. They’ve postulated that fat is bad, therefore any diet but a low-fat diet is going to be high in fat, and, consequently, harmful. The fact that a low-carb diet, which has been shown to be at least as effective as a low-fat diet (and in most cases better than a low-fat diet) in the treatment of diabetes doesn’t hold water with them because they know a low-carb diet has got to be a high-fat diet. They’re so ignorant on the subject that they haven’t even read Yudkin’s early studies showing that that isn’t necessarily so.

    Best–

    MRE 

  6. Dr. Mike, I see you have started a new book that I haven’t even heard of yet. Would mind posting a list of recomended reading for those of us who like to keep up to date but don’t have the time to research titles.

    Thanks!

    Hi David–

    I went back and searched all through the post this comment was attached to and couldn’t find any mention of a new book that I had started.  Did you attach it to the wrong post?  Did I overlook something?  Help.

    Cheers–

    MRE 

  7. Sorry, post number 4 by Daniel Chong talks about Anthony Colpo’s new book. Can’t you just read my mind and know exaclty what I am refering to? My wife seems to think I can so I am glad I am not the only one who can’t.

    Dave

    Hi Dave–

    I see now.  I read the post a half dozen times trying to figure out what book you were talking about.

    At some point I plan to put up a page on the website listing all the books I’m reading with brief reviews.  Like everything else, it’s just a matter of having the time to do it.

    Cheers–

    MRE 

  8. I believe David was referring to you starting to read Colpo’s “The Great Cholesterol Con”, ie what you are reading, not what you are writing. :-)

    Regards,
    Craig.

  9. Lies, damned lies and statistics.

    I worked for 15 years at the Australian Bureau of Statistics. Believe me, you can find statistics to support any theory or point of view you want to espouse.

    You are quite right that it is the incidence of the disease that counts, and it’s no wonder that this particular statistic is being withheld from easy access.

    Hi Odille–

    Yep, statistics on the incidence of heart disease are hard to come by. If you look on the American Cancer Society site, you can see that they list statistics for each year going back some time. So, if you are interested to see what the incidence of pancreatic cancer was in 2001, you can find it there. If you go to the American Heart Association site, you will find the current year’s statistics. You can’t go back to find an earlier year’s stats. If you Google heart disease statistics and 2001 you get taken to the current AHA site. The only way you can compare is to print out the 2001 statistics in 2001, then wait for 2006 and compare. Problem is, as I wrote in the post, the AHA says that the figures aren’t accurate for comparison.

    Makes you wonder why they make these numbers so hard to find.

    Cheers–

    MRE

  10. How does the AHA explain this table that shows the incidence of cardiovascular disease increasing? Is it possible it’s just being diagnosed at a higher rate now than in past decades? Or that it’s being listed as the first diagnosis more frequently? Or that because people are more aware of the symptoms of heart disease, they are going to hospitals more often to be treated?

    I don’t have a medical background and am not really up on this literature, so I’d be interested to hear your opinions on this.

    Hi syl–

    It’s not really a table showing that the incidence is increasing, it’s my interpretation of the hospital data.  The AHA for some reason doesn’t want to make statistics on incidence easy to find.  What they want people to focus on is the decreased death rate from heart disease because it looks like they are doing their job.  But in my opinion their job should be prevention, and if the incidence figures are increasing (or even staying the same) it doesn’t look as if a whole lot of preventing is going on.  And the AHA gets significant funding from the makers of statin drugs, a group that really wouldn’t want the idea made public that heart disease hasn’t been on the decline despite millions being on statins.

    Cheers–

    MRE 

  11. I agree that Anthony Colpo’s book is very good, although quite similar to Uffe Ravnskov’s (sp?) book on the same topic. I started it some time ago but I had to stop because of the tiny, faint print (really, really dense text and little rest for the eyes). I generally have very good eyesight, but even 1.00 power reading glasses didn’t help enough. I suppose if I hadn’t already read Ravnskov’s book, I would have perservered.
    Cheers,
    Anna

    Hi Anna–

    I had the same problem with the softcover book version.  I have perfect eyesight, other than having to wear reading glasses, and I found it tough even with those.  At least for long periods.  Anthony sent me an e-book version that I have been printing off with much larger type.  The book is good and does echo Ravnskov’s book, but it’s worth a read on its own.  One can never get enough anti-lipid hypothesis material.

    Cheers–

    MRE 

  12. Colpo’s book does cover ground that Ravnskov covered but goes way beyond it, too. He not only shows that cholesterol and saturated fat isn’t harmful, he also examines the evidence to show what actually contributes to heart disease and what can be done to prevent it.

    When I first read The Cholesterol Myth by Ravnskov, I was disappointed. He does a great job in destroying the cholesterol myth but the book doesn’t go any further. Anthony’s book picks up that ball and runs with it.

    Hi Ryan–

    Thanks for the info.  I’m eager to read the rest of it as soon as I get the time.

    Cheers–

    MRE 

  13. Statistics on a lot of different things, including death and disease rates are available from the following web site as far back as 1878. Keep in mind that reporting on diseases changes depending on how the disease is defined. It takes a little work to find and compare rates from year to year, but the info is there. Some tables include year to year comparison, and some are arranged by decade; most have demographic comparisons, too. The very earliest data is sketchy, as can be expected.

    http://www.census.gov/compendia/statab/past_years.html

    Hi Martha–

    Thanks for the info.  It will indeed take a little time to pore through all of this.  One wonders why the AHA doesn’t just provide it for heart disease as the American Cancer Society does for cancer.

    Cheers–

    MRE 

  14. Both books have their niche, I feel, Colpo’s is far more in depth and correspondingly more of an effort (worthwhile) is needed to read it. Don’t forget that Ravnskov’s book is older (mine was 2000 edition)so he had less up to date material to work with. Its a lot shorter, which will appeal to some readers. The main thing I submit is that the ‘message’ reaches as many people as possible.

    Malcolm Kendrick M.D. has just had published “The Great Cholesterol Lie” He is a long standing Cholesterol skeptic, he is also a humorous writer.

    Barry Groves (Author of Eat Fat Get Thin) also has a new book out this month called Natural Health and Weight Loss. His writing should be of interest to you, Dr Eades, as well as your readers.

    Hi Neil–

    I know of both of the above authors and have both of their books on order.  So many books, so little time.

    Best–

    MRE 

  15. “I know of both of the above authors and have both of their books on order. So many books, so little time.”

    ++++++++++++++++++++++++++++

    Thought you would, but I couldn’t resist plugging two of my fellow Brits to your readers!!

    Hi Neil–

    I’m glad you did. They’re both good men.

    Cheers–

    MRE