How Ideas That Are Not True Become Facts - part 2 of 3


dr_malcolm_kendrick_m.d._134by Dr. Malcom Kendrick, M.D. 
Author of The Great Cholesterol Con

‘I know that most men, including those at ease with problems of the greatest complexity, can seldom accept even the simplest and most obvious truth, it be such as would oblige them to admit the falsity of conclusions which they have delighted in explaining to colleagues, which they have proudly taught others, and which they have woven, thread by thread, into the fabric of their lives.' Leo Tolstoy.

The exceedingly tight connection between what scientists believe, and their sense of worth, and status, explains the angry vehemence with which new ideas are rejected. Indeed, the level of rage that has been directed at me from time to time, has forced me to conclude that when you criticise the ideas of a scientist, you are, effectively, attacking them - and they will lash out at you. Their ideas are as jealously protected as if they were their own kith and kin. In some cases, more so.

The best book on this complex and fascinating subject, and the lengths we are prepared to go in order to protect our ideas, and thus ourselves, is ‘Mistakes were made, but not by me,' I recommend everyone in the world to read it. That is, if they want to try to understand themselves a little more, and why they act as they do.

Of course, the flip-side to the rage and anger with which people can react when their ideas are challenged, is the ease with which certain ideas are accepted...when a man finds a conclusion agreeable he accepts it without argument. (In order not to be considered sexist, I think women do this too).

At which point, in a slightly roundabout way, I shall return to the female sex hormone hypothesis, and why it was so rapidly, and unquestioningly, accepted. Back to heart disease.

Virtually since research began into this area, it had been noticed that women have higher cholesterol levels than men. Despite this, younger women (women aged under about sixty five), had much lower death rates from heart disease. Around three to four times less in most countries, although the exact figure varies considerably, from twenty times less, to one and a half times less (Brazil, by the way).

Now, if you believe that a raised cholesterol level is the most important causal factor for heart disease, then this represents a rather inconvenient fact. Shouldn't women actually be at higher risk?

It is true that women generally smoke less than men - not in all countries - but most, and this can explain some of the difference. However, if you plug female and male risk factors into a risk calculator, there is still a vast chasm that cannot be explained by the traditional risk factors: age, smoking, blood pressure, diabetes, LDL / cholesterol levels. In short, on the face of it, women appear to contradict the cholesterol hypothesis.

When confronted with a possible contradiction, or 'refutation' such as this, you have a number of different choices. You can call it a paradox, you can ignore it, or you can try to explain why it happens. (You could also accept that your hypothesis is wrong).
Calling something a paradox is a method that has been used to explain away many apparent contradictions about heart disease. 

As a method it explains nothing, but it does have the advantage of placing an issue on the top shelf, far away from prying eyes. 'Oh yes, that, don't worry about it, an explanation will turn up....' However, if no explanation does turn up, at some point you are going to have bring the paradox down off the top shelf, dust it down, and explain it. But calling it a paradox does buy time.

The second choice is to ignore the issue altogether, which is more common than you might think. In this particular case, ignoring the issue takes two forms. The first is to add ‘male or female sex' to the risk factor calculator as a variable. Once you have done this you can simply divide the male risk by three, or four, or whatever the difference happens to be in your own country. So you can re-calculate the risk for women, without ever having to address the issue of why it is so different.

Changing the risk calculator is all very well, and it works - if you don't think about it too hard. However, as with declaring something to be a paradox, you are always left with the uneasy sense that you have not really solved the problem, merely concreted it over. At some point the green shoots of doubt will find the cracks, and emerge once more. ‘But why do you have to divide by three, or four, to calculate the risk for women?' Said the ghost of Christmas future. ‘Why....why....why....'

There is also another, rather more complex method of ignoring the issue, which is being increasingly used. This is to use the lifetime risk of dying of heart disease. It goes something like this. In the end we are all going to die of something, and a large number of us will die of 'cardiovascular disease (CVD).' As it turns out, in the end, about as many women as men die of cardiovascular disease. Fewer younger women than older women. So, if you choose to calculate 'lifetime risk of CVD' then there is no real difference between men and women.

Using this method of determining risk, you can state that women are not actually protected by anything. Why... because over a lifetime, they are just as likely as men to die of heart disease. Of course this says nothing about the age at which you will die. Yes, I know. Think about that for too long, and you will go mad.

How else can you explain away the difference in heart disease between men and women? You could use my preferred explanation which would be to state that the ‘cholesterol hypothesis' is wrong. This certainly works. It also explains the French paradox, the Swiss paradox, the Greek (Crete vs. Corfu) paradox, the Japanese paradox, the Asian paradox the.....( no room for all the paradoxes here).

Sorry, that was a moment of madness. No-one was ever going to use the explanation that actually fits all the facts. Everyone was, and is, far too wedded to the cholesterol hypothesis.

In the end, the best way to explain away the difference in heart disease risk between men and women is to establish a reason why women are ‘protected.' And the best place to start is to look for some significant biological difference between the sexes, to see if this may be the cause of the gap in rates of heart disease.

The most obvious biological difference between men and women is their sex hormones. So this seems a reasonable place to start. Could female sex hormones, via some complex effect (undetermined), explain the vast gap in heart disease rates? Answer.....possibly. Well, possibly seemed to be good enough for most people. And so, with the fair wind of ‘we really want to believe this' filling its sails, the good ship female sex hormone sailed off.

Given time, lab based research in rabbits became proof of an effect in humans. The accelerating rate of heart disease after the menopause became proof - so long as you didn't actually look at the curves too closely. Studies on extremely healthy women who took HRT ( hormone replacement therapy) and developed less heart disease became proof. Gradually, all of this shaky evidence was welded together. Possibly transformed into probably; probably became 'fact'.

The only thing that surprises me about this whole sorry saga is that the HERS study ( The Heart and Estrogen/Progestin Replacement Study) (1) (and others) were actually accepted. I thought they would be dismissed as being poorly designed, not using the right dose of hormones, no measuring the right outcomes, etc. etc. This is what normally happens to studies that disprove fondly held hypotheses.

For a while the HERS study, and others in this area, gave me hope that all incorrect scientific dogma can eventually be overturned by the facts. Unfortunately the cholesterol hypothesis appears impervious to such puny weapons as contradictory evidence. Like a monster from a nineteen fifties sci-fi movie, it consumes contradictory evidence and grows ever more powerful.

As a side note, now that the sex hormone hypothesis has gone, what factor is thought to protect younger women against heart disease? Interestingly, this seems to be a question that no-one is much interested in answering anymore. It sits on the top shelf, gathering dust. It can't be explained by sex hormones, or cholesterol levels, or any of the traditional risk factors.... I suppose it is a, you guessed it, a paradox.

Anyway, the more that I have researched heart disease the more I have come to recognise that the sex hormone hypothesis was not some strange anomaly. It was just the first of literally hundreds of unproven 'facts' that are now widely accepted about heart disease. They all sound highly plausible. But when you track them back you realise that they all have one thing in common, which makes them instantly suspect. They are what Karl Popper described as ad-hoc hypotheses.

'Ad-hoc hypotheses - that is, at the time untestable auxiliary hypotheses - can save almost any theory from any particular refutation. But this does not mean we can go on with an ad hoc hypothesis as long as we like. It may become testable; and a negative test may force us either to give it up or to introduce a new secondary ad hoc hypothesis, and so on, ad infinitum. ...moreover, the possibility of making things up with ad hoc hypotheses must not be exaggerated: there are many refutations which cannot be avoided in this way, even though some kind of immunizing tactic such as ignoring the refutation is always possible.' Karl Popper. (The problem of demarcation).

When I first read this, I wasn't quite sure what he was talking about. Surely scientists don't just make things up, then claim they are true. How little I knew. In reality, the world of heart disease research has now become jammed solid with ad hoc hypotheses. And more are created on an almost daily basis. Green leaf tea, anti-oxidants, omega-3 fatty acids, coffee, genetic protection, excess iron, excess copper, or too little copper, etc. etc.

Dr. Malcolm Kendrick (MbChB MRCGP) M.D.
Dr. Kendrick has worked in family practice for twenty years.
He has specialized in heart disease and set up the online educational website for the European Society of Cardiology.
He is a peer-reviewer for the British Medical Journal.

How Ideas That Are Not True Become Facts - part 3

1. http://www.nhlbi.nih.gov/new/press/18-1998.htm

November 2011 

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