Cape Town sports scientist Prof Tim Noakes calls statins ‘the single most ineffective drugs ever invented’, yet they are also the most prescribed drugs on the planet. US family physician Dr Jeffry Gerber is a little more diplomatic. Gerber was one of the expert panel of speakers at the first international low-carb, high-fat summit in Cape Town. His topic was ‘Cholesterol, OMG!’. He  believes that as doctors understand more about cholesterol’s real role in the  body and that lowering cholesterol isn’t always so smart, statins will stop fattening drug companies’ bottom lines. Here he talks about the ‘statistical noise’ around cholesterol, diet and heart disease. – MS
Today, I have Denver’s Diet Doctor talking to me, Dr Jeffry Gerber. He is a board-certified family physician in the US. Dr Gerber the topic of your talk at this rather unique (for South Africa) convention was “Cholesterol OMG”. Why OMG?
I thought it was a really, catchy and attractive title to make people light up and realise that there were some issues related to this non-standard diet and concerns about cholesterol, cardiovascular risk, and health. Traditionally, dating back even to the days of Dr Atkins, there was an observation with some people going on low carb/high fat diets, that their LDL cholesterol would go up.
And the Atkins diet would kill them?
The Atkins diet would clog their arteries and kill them because of heart attacks and strokes.
That’s the diet-heart hypothesis. Does cholesterol cause heart disease?
I think that it is there. It plays a role, but the idea is that there’s a shift in the thinking. When we go back and look at the history, the history has really, been driven based on cholesterol therapy and to lower cholesterol. There are two components to it. Firstly, you have the diet-heart hypothesis: eating saturated fat in a diet raises cholesterol and leads to heart attack and stroke. When you look at the trials over the last 40 years, what we see in those trials is basically statistical noise. These trials were set up to prove that there was a causal relationship between the consumption of saturated fat and heart disease, and they definitely don’t prove that.
That is so sobering, that for 40 years people all over the world have been given the wrong advice by their doctors, dietitians, and other nutritionists.
You can say it that way. I’m one for diplomacy.
I thought you’d be.
That tends to be my way. Sometimes I’ve been applauded (or not applauded) for being such, but the idea is that it’s the best information they had at the time. Back then, we did see that there were indeed some issues related to heart disease. Smoking was a factor. Maybe that played into it. There was an attempt to improve the health of our country post World War 2. Now, what we’ve come to realise is that based on those guidelines, we came out with the 1977 George McGovern report in the US and  shortly thereafter in 1980, the Federal Guidelines for America. Then the NIH came up with the guidelines based on that, so we ran the experiment for 30 to 40 years, and we see a rise in heart attack, stroke, and diabetes.
Based on that observation, unless you can find another cause, the dietary guideline to reduce saturated fat and replace it with sugar and carbohydrates doesn’t appear to be working and there is perhaps some relationship. What has led us to look at it is science’s advances. The idea is that you’re not being a good scientist if you refuse to accept new ideas and to be open.
Just to explain again, I am a primary care doctor and I focus on general health, but I’ve learned about proper prevention through nutrition, something that we didn’t learn in medical school. We were busy learning everything else and then, they just told us what to do,s and we didn’t have time to investigate. I have always been open to the idea of thinking outside of the box.
I see that very recently, the US Government’s Dietary Advisory Committee has apparently pardoned cholesterol. In that same report, it still demonises saturated fat. It says cholesterol’s no problem but saturated fat is. Isn’t that odd?
Firstly, regarding that recommendation that they’re going to remove any restriction on dietary cholesterol – it’s about time. In fact, dating back to Ancel Keys, there was never any evidence to support that anyway. If you follow the logic, the next step may be to address saturated tape but unfortunately, with red tape and government policy, it’s really hard to bring about change. Perhaps it’s a little battle that’s been won. It’s a step in the right direction but it’s going to take baby steps. We’re not going to see change overnight.
I hope it doesn’t take 40 years before the American Government says it’s okay to eat saturated fat. Do you tell your patients it’s okay to eat saturated fat?
Yes, very much so. I would define it more as natural fats, and so the idea is that there’s a shift in thinking. The shift in thinking is that cardiovascular disease, in which, I’m most interested is not necessarily a disease of cholesterol calamity or bad cholesterol. That’s just one marker.
What is causing the heart disease epidemic?
The paradigm shift is that cardiovascular, atherosclerosis are complicated metabolic processes, and we know  this brings the idea of inflammation and oxidative stress into it. It’s not necessarily about the quantity of cholesterol, but rather the quality of cholesterol. Now we start to look at the ratios and particle size, and it brings us back to the root cause, which is diet. We start manipulating the macronutrient ratios and we see the cholesterol ratios change in favourable ways, where the HDL goes up and the triglycerides go down.
Big Pharma isn’t interested in those ratios because they don’t have the medication to address it. When you look at it from a nutritional approach, you see those numbers improve. Ratios and particle size improves, which also suggests that nutrition is favourable, inflammation is favourable, and this may be suggesting that we look at inflammatory markers such as insulin and haemoglobin a1c. All these things are taking us in a different direction and saying: “Hey, it’s not necessarily cholesterol itself, but these factors that are having an adverse effect on inflammation and oxidative stress.”
What is this new paradigm going to do the statins industry?
That’s a great question. I’m actually bold enough to address that. The second component that has really been driving the statins industry and this cholesterol hypothesis is what I like to call the lipid hypothesis.  Statins had come out in 1987 when I was just finishing up at my medical school. The idea is that introducing medication to artificially reduce a risk factor like LDL cholesterol was going to somehow, reduce cardiovascular risk. It turns out that there may be a small benefit, but when you actually look at the evidence, this is where we find some major problems.
Is this about numbers needed to treat?
Yes, very much so. Typically, the pharmaceutical industry does a great job of reporting relative risk. Relative risk is a great statistical number when you’re looking at populations , but when you and I would be interested in knowing our specific risk, we want to look at the absolute risk reduction (the number needed to treat). I’m rather transparent with my patients in at least, trying to discuss and make them understand the difference between relative risk and absolute risk.
When you look at absolute risk reduction for primary prevention (meaning an individual who doesn’t have any documentation of cardiovascular disease if you were to give them a statin), the risk reduction is about one in 150. This means that you’d have to put 150 patients on Statins for five years to prevent one cardiovascular event. When you look at it from that perspective, it’s minimal. It doesn’t even effect mortality.  It doesn’t make you live any longer.
Prof Tim Noakes, who is the co-host of this conference, has called statins the single, most ineffective drug ever prescribed. Yet, it is the most prescribed drug on the planet. Would you agree that it is the most ineffective drug ever prescribed? Are you going to be diplomatic again?
Professor Noakes is the best part of this conference. I’m so happy that I made the decision to make the trek here and to actually, personally meet Professor Noakes, hear him talk, tell his story, and to see the passion. Sometimes, when you’re in a very visible position (as he is), it has to become a battle.
That’s putting it mildly.
I have the privilege perhaps, of being under the radar – just being a primary care doctor in the State of Colorado.
You are Denver’s diet doctor, though, so it’s a little bit above the radar?
I guess I’m coming out of that radar, especially after attending this conference and presenting. We may find that to be the case. I believe that statin therapy will go away. In fact, the day after I gave my presentation, a famous independent cholesterol researcher, Dr Uffe Ravnskov, had just released a paper (published in the Expert Review of Clinical Pharmacology journal) with Dr David Diamond of the University of South Florida that basically, repeated what I had talked about in my story that the pharmaceutical industry was exaggerating the benefit of statins. It wasn’t any new information – just kind of, repeating.
Statins have a role to play in very well-defined circumstances. Now the focus is turning more and more to diet and nutrition. What diet do you recommend to your patients?
The main thing is looking at what diet specifically addresses, which is inflammation and oxidative stress. It changes the whole ball game and it appears that it started out with simple trials and just helping patients lose weight with these low-carb, high-fat diets. We have 25 well done RCT’s and some observational studies.
RCTs are the gold standard of scientific research?
They are the gold standard but they can be done poorly as well. Everyone says: “We have our CTs (controlled trials),”,but when you actually look at our CTs again, the difficulty is feeding trials. How did they report what the people ate? Did they look at the quality of the macronutrient and the micronutrient? When you put them together, for the majority of them, they are at least able to document that there was statistically significant difference.
Some of the arguments is that some of the diets (and I actually agree in these RCT’s) weren’t as high in fat as we would define them in terms of ketogenic. They were more like a Mediterranean diet, which is not as bad. Working in the trenches, I find that you have to find specific diets for specific patients.
That’s a key message, which is coming out of this congress. There’s no one diet, one size, which fits all. There does seem to be agreement on some key elements, that low carb is the way to go. Are you, in effect, saying that carbohydrates are a major source of health problems in the diet?
Yes, especially the sugars. The refined process grains are the big ones. Again, I look at common themes. Most people agree that sugar and refined process foods are bad. That’s great. There are some themes out there.
How low carb do you tell people to go?
It depends. If you have a type 2 diabetic patient, beyond the metabolic syndrome, and overweight, they clearly do best on a low-carb, high-fat, ketogenic diet. That has been the observation in our clinical practice repeatedly. The high in saturated fat diet is metabolically favourable for them because it regulates the blood sugars and it controls their appetite.
Part of it is that there’s some metabolic advantage to eating that much fat, but many times, patients actually feel so filled up that they eat less. They’re therefore eating fewer foods and calories are reduced, so those are some of the benefits. Then we have patients who actually, aren’t as insulin resistant. You refer to them as insulin sensitive, but not insulin resistant. There are several ways to describe it. Unfortunately, we see this in women – that metabolically, their numbers look fairly normal and yet, they have a weight issue. Insulin still plays a role, but there may be a certain degree of genetic variation in populations. For those patients, we still like the idea of them eating high fat diets.
With the diabetics, a ketogenic diet could be 70% to 80% fat. That’s probably the best thing for them. With these patients (the women), a low-carb, high-fat diet is not a bad idea. They can actually lose weight on virtually any diet, but you have to think a little bit about the quantity and the calories. Working in the trenches, we have challenges.
Another theme in this congress is the quality of the saturated fat. What kind of saturated fat foods do you recommend?Â
I am very fond of organic, pastured, and grass-fed animals.
What is it you who said “happy foods” or was it Steve Phinney?
That sounds like Ann Childers, my wonderful colleague. When we address quality of food, we actually don’t have all the answers regarding it. If a patient is type 2 diabetic and they need to lose a lot of weight, and they’re maybe going on insulin or something like that, I think the appropriate intervention is just to get the macronutrient/fat content high. Get them on a path and once they have some success, we try to clean up the diet so we look for high quality sources of natural fats. That comes from grass-fed animals, Kerry Gold butter. You have it here. We have it in the States. It tastes great. For myself, we enjoy the organic, vat pasteurised, low heat, pasteurised, non-homogenised cream.
What do you have for breakfast?
I don’t track my diet, but I was asked to be part of an experiment several months ago, so I had to track it. I used one of the online apps. Presently, I’m averaging 65% fat in my diet. My favourite breakfast is eggs cooked in different fats or bullet-proof coffee  (coffee with butter or other saturated fat) by itself.
Have you ever had a weight problem? You don’t look like you have.
Thank you very much. Personally, I struggled. My discovery was through several things. Back in the late 1990s, my patients and family members challenged me to try these non-standard diets, so I lost about 20kgs. I’ve kept that off. My energy has come up and I feel great.
You look really good. Your skin looks good. You have bright eyes.
I’m 54.
It’s amazing. The doctors I’ve met who are very strict low-carb, high-fat all seem to be 10, 15, or even 20 years younger. I would have put you at much younger.
Well, thank you. I’ve always had that youth gene. You could easily attribute it to the diet, but let’s just say it’s maintained my youth.
Have you come across any opposition from your peers for advocating low-carb, high-fat?
Not too much. We had a story where I’d gone out to a small community in Colorado. I was invited to give a talk about nutrition and there was an older cardiologist (a great doctor, but rather entrenched in the traditional thought mode). I had presented this to the staff. He really wasn’t aware of the content and he wasn’t very happy. We had a discussion at the end of the lecture. When he went to his office, he was a bit more civil. The point that I remember most is that he said to me: “Dr Gerber, what if you’re wrong?”  I looked at him and I said, “But doctor, what if you’re wrong?”
Do you think that in 40 years’ time, we might look back and say: “What were we thinking to tell people to eat all this saturated fat?”
Or not to eat it… Looking back, it’s not to eat it. Firstly, in 40 years’ time, we might look back and say… yes we fixed nutrition. I think statins will be a thing of the past in 10 years or sooner.  The do play a small role right now, in patients who have already had cardiovascular events, although not much. The absolute risk reduction is not the panacea of statins, even in that situation. Statins are going away. Right now, they block innovation. I joke in my lecture about if Hamlet were to ask the question it would be: “To statin or not to statin?” There are natural therapies. What I like to do is blend modern medicine with more natural therapies. Modern medicine is wonderful, especially when you’re sick but we have to find a way to use it appropriately.
It’s integrative medicine?
Yes. It’s functional, integrative medicine. What we try to do is bridge that gap. Right now, there’s a big hole and we try to find a happy middle. We will look back. I just think it’s going to take a little bit of time. Hopefully, we’ll see some change.
