A notification email was sent to Dr. Chris Palmer–a psychiatrist at Harvard who investigates the use of ketogenic diets for mental health issues–for a claim that LDL is not an independent risk factor for cardiovascular disease, below:

Dr. Palmer is an accomplished and very nice man, and I regret having to send him this notification email, but it is for exactly that reason that I do so: Dr. Palmer justifiably has a lot of clout, so misinformation coming from him that may substantially harm patients at risk for cardiovascular disease is important to try to counter. Having a notification email sent in turn allows for him to respond and argue his case before the entry is “officially” listed on the Unresolved List, thereby providing accountability on my end and an ability to clarify or reverse harmful claims on his end. Dr. Palmer requested that his contestation be made public; correspondingly, it will be included in this post.

This blog entry will document our exchange on the question of whether LDL is an independent risk factor for cardiovascular disease, and what the important clinical implications are of this question.

The original notification email

The original notification email is as follows:

Dr. Palmer’s response

Dr. Palmer’s entry in the contestation form reads as follows:

My Tweet was the following: “AND… metabolic syndrome does NOT include high LDL. There’s a reason for that. The science does not support this as an independent risk factor for cardiovascular disease.”

It is indisputable that LDL is NOT included in the definition of metabolic syndrome. There’s a reason for this. As a sole, independent risk factor, it is NOT sufficient to predict risk. However, it is used widely in people already at high risk, such as those with diabetes, and as secondary prevention in those with pre-existing cvd. Here’s a systematic review of statins in primary prevention, which acknowledges this controversy. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6500096/ Additionally, my tweet did NOT mention statins, I said LDL. It’s well known that statins reduce levels of inflammation, which might independently lower risk for cvd apart from LDL levels.

Plain and simple… my tweet pointed out that LDL is not part of the definition of metabolic syndrome. If you disagree with the science and those who define metabolic syndrome, that’s your problem with them, not me.

Please let me know when you remove me from your libelous list.

My response

Dear Dr. Palmer,

In the contestation form, you wrote the following:

My Tweet was the following: “AND… metabolic syndrome does NOT include high LDL. There’s a reason for that. The science does not support this as an independent risk factor for cardiovascular disease.”

It is indisputable that LDL is NOT included in the definition of metabolic syndrome. There’s a reason for this. As a sole, independent risk factor, it is NOT sufficient to predict risk. However, it is used widely in people already at high risk, such as those with diabetes, and as secondary prevention in those with pre-existing cvd. Here’s a systematic review of statins in primary prevention, which acknowledges this controversy. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6500096/ Additionally, my tweet did NOT mention statins, I said LDL. It’s well known that statins reduce levels of inflammation, which might independently lower risk for cvd apart from LDL levels.

Plain and simple… my tweet pointed out that LDL is not part of the definition of metabolic syndrome. If you disagree with the science and those who define metabolic syndrome, that’s your problem with them, not me.

Please let me know when you remove me from your libelous list.

The part of your tweet about metabolic syndrome, specifically, “AND… metabolic syndrome does NOT include high LDL. There’s a reason for that,” was not the reason that your tweet was flagged for the list.

Your tweet was flagged because of this sentence: “Science does not support this [LDL] as an independent risk factor for cardiovascular disease.” Therefore, I will address the part of your message that addressed this part of the tweet. Again, specifically, you wrote:

As a sole, independent risk factor, it is NOT sufficient to predict risk. However, it is used widely in people already at high risk, such as those with diabetes, and as secondary prevention in those with pre-existing cvd. Here’s a systematic review of statins in primary prevention, which acknowledges this controversy. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6500096/

The existence of legitimate controversy in clinical medicine re: primary vs. secondary prevention with statins is not sufficient to support your claim that LDL is not an independent risk factor for cardiovascular disease. All the controversy about primary vs. secondary prevention with statins is about is whether those who have had not had cardiovascular events benefit from statins or not. It is not about whether LDL is an independent risk factor in cardiovascular disease.

In fact, many people without cardiovascular events for whom primary prevention is controversial will have metabolic syndrome. And some people with cardiovascular events for whom secondary prevention is not controversial will not have metabolic syndrome. The controversy about primary vs. secondary prevention is not about whether or not LDL causes heart disease in people who do or do not have metabolic syndrome, and the paper you linked does not address this question.

A section of separate paper does address precisely this question, at least in the context of statins:

Screen Shot 2020-12-19 at 4.02.55 PM.png

Link: https://jaoa.org/article.aspx?articleid=2093916

The above paper gets at the heart of our disagreement. Our disagreement is about whether those who do not have metabolic syndrome should be concerned about elevated LDL levels. I believe that that is the practical question that is the basic context for our disagreement. And the evidence seems to suggest that they should–at least in the context, as you pointed out, of secondary prevention. It seems, to restate the above paper, that people with elevated LDL benefit from statins regardless of whether they have metabolic syndrome.

There is no good evidence that I am aware of that not having metabolic syndrome completely abrogates risk from elevated LDL, or that LDL lowering does not. If you find such evidence, please share it with me.

You wrote:

Additionally, my tweet did NOT mention statins, I said LDL. It’s well known that statins reduce levels of inflammation, which might independently lower risk for cvd apart from LDL levels.

I agree that statins also reduce inflammation and that this might be an important mechanism through which statins work. However, the relevant issue is whether LDL lowering is necessary in people with elevated LDL without metabolic syndrome, i.e. whether statins, the first-line drug to reduce CVD risk, should be prescribed; although I suppose it would be right to say that another issue is whether diet should be changed, so perhaps our disagreement cannot be reduced to whether statins should be used. In that respect, I think my jumping to a discussion about statins may have been premature. Still, the question as to whether LDL confers additional risk for CVD absent metabolic syndrome remains relevant, and the most I think we can agree on is that it may not (for all practical purposes) in the context of those without history of CVD.

Finally, you wrote:

Plain and simple… my tweet pointed out that LDL is not part of the definition of metabolic syndrome. If you disagree with the science and those who define metabolic syndrome, that’s your problem with them, not me.

I want to clarify that is not the only thing that your tweet pointed out, and if it was, your tweet would not have been flagged.

I admire the work you are doing with the ketogenic diet and mental health, and I hope you can continue studying that intervention for that purpose in greater depth. I am confident that there is probably a strong link between nutrition, physical health, and mental health. However, I worry about the potential harm done to people who might be persuaded by statements such as yours that LDL is not a real problem for heart health and who might subject themselves unnecessarily to elevated risk by foregoing interventions that will reduce their blood LDL levels. Your entry will not be added to the Unresolved List for at least another 30 days to give you the opportunity to respond further. If you still believe that the above is scientifically inaccurate, I will be happy to continue discussing.

My concern, like yours, is for the welfare of patients and the public.

You requested that your contestation message be made public. I will therefore post your contestation message along with my response to my blog and tag you on Twitter. If you change your mind, please send me an email, and I can remove it.

Sincerely,
Kevin Bass

Conclusion

It is my hope that by making exchanges like these public, accountability can be increased and public education on some of the substantial issues can take place.

Kevin

UPDATE:

Dr. Palmer also recently made the following tweets:

My response:

And this one:

These are fine. LDL definitely is an independent risk factor for CVD in people without pre-existing CVD; but some have argued that it just hasn’t been shown convincingly that reducing via statin therapy reduces risk of CVD without pre-existing CVD. However…

The part below is just false. LDL lowering in folks with pre-existing CVD where all else is normal in fact does improve outcomes.

I discuss this at length in my post (above), but here is the link and passage that is relevant to this claim, again:

Link: https://jaoa.org/article.aspx?articleid=2093916

One wonders what @ChrisPalmerMD‘s motivation is here. If he wants to dispute whether primary prevention reduces risk, he is on solid enough ground and can make that case with plenty of evidence to call upon to support him.

But saying that LDL is not an independent risk factor when metabolic syndrome is not present is false; and it is not true that LDL lowering in people without metabolic syndrome with pre-existing CVD will not see benefit. They absolutely will, and suggesting that they might not is a disservice to patients and public health.

Matthews et al. estimated the health effect of a short period of negative media coverage of statins: between 2000-6000 excess cardiovascular events.

The only legitimate controversy here is whether statin therapy improves outcomes in primary prevention (without pre-existing CVD). Everything about metabolic syndrome is speculative and not supported by any clinical trial evidence that I am aware of.

I would like to conclude by pointing out that this comment with respect to libel is unnecessary and inaccurate.

Libel consists of statements that are defamatory and false. My statements are scientifically accurate and some of Dr. Palmer’s are false.

Kevin



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