Satan Cholesterol: It’s Still Bad, but Its Image Is Increasingly Complex

BOSTON — Cholesterol, long the Great Satan of American health, is getting another look.

The accepted wisdom that everyone should get a cholesterol check and try to lower their cholesterol is no longer quite so clear. Don’t break out the cream cheese yet, however.

While the longstanding doctrine that made high cholesterol a national phobia is the subject of surprising new scientific findings, the experts are unlikely to say any time soon that cholesterol is good for you.

And when all is said and studied and done, the stuff is likely to re-emerge with a slightly rehabilitated, if more complex, image.

There’s little doubt that high cholesterol causes heart disease. And when cholesterol levels fall, so does heart attack risk. But a disconcerting new series of reports hint that lower cholesterol may not necessarily translate into longer life.

Perhaps the most surprising new finding is the suggestion that cholesterol might not matter much for women. This finding is hotly contested. But it is just one among others that nibbles at or complicates accepted cholesterol dogma.

Among other recent findings:

* Men and women with cholesterol under 160--long considered an especially healthy level--have worse death rates than those with higher cholesterol.

* Lowering cholesterol levels through low-fat diets may do less good than many thought.

* Too much iron in the blood may significantly raise the risk of heart attacks.

* Vitamins that prevent oxidation may block cholesterol’s harmful effects.

Just what health-conscious people should make of these new pieces in the heart mosaic is also debatable.

Airing such uncertainties in public makes some experts uneasy. They fear people won’t understand that science is messy, with false starts and wrongheaded conclusions. Consensus emerges only as the data pile up, often after much chewing and arguing.

“There is an awful lot of science that isn’t ready for prime time,” said Dr. John LaRosa of George Washington University. “What, if anything, low cholesterol levels mean in terms of disease causation is uncertain. I don’t agree that it is anywhere remotely near the point where we want to make public policy based on it.”

That policy is the domain of the federal government’s National Cholesterol Education Program. It urges adult Americans to get a cholesterol check every five years and to reduce consumption of cholesterol and fat, especially saturated fat. It also suggests doctors consider prescribing cholesterol-lowering drugs for patients with high cholesterol.

Some experts have long felt uneasy about this broad-based approach. The latest evidence confirms their suspicions.

“I think the national campaign went overboard,” said Dr. Paul Meier of the University of Chicago. “We do have evidence sufficient to encourage people to eat less hard fat, although I’m not enthusiastic about monitoring one’s cholesterol unless there is a reason to do so, such as having had a heart attack.”

However, leaders of the cholesterol education program, while conceding the new evidence deserves follow-up, say it does not come close to outweighing the mountain of evidence of cholesterol’s hazards.

“The general exhortation for people to keep their cholesterol low is in place, supported by many scientific bodies,” said Dr. James Cleeman, the program’s coordinator.

If there is one cholesterol recommendation that seems solidly supported even by skeptics, it’s avoiding saturated fat, the hard fat found primarily in animal foods, such as cream and meat. Saturated fats clearly seem to raise blood cholesterol levels. And they and other kinds of fat contribute to obesity, which shortens life.

Support for some of the other recommendations is less than unanimous, especially in light of a report in the September issue of Circulation, a journal of the American Heart Assn.

Until now, many smaller studies have demonstrated a clear link between cholesterol and heart disease. But they were too small to prove lowering cholesterol extends life.

To examine this point, statisticians pooled the findings of 19 studies involving a total of 523,737 men and 124,814 women. This meta-analysis combined numbers so large that researchers could look at the relationship between cholesterol and death from all causes, as well as heart disease, cancer and other illnesses.

As expected, they found a strong link between cholesterol and death from coronary heart disease. Men with cholesterols above 240 were 69% more likely to die from the disease than those with cholesterols between 160 and 200. Women with high cholesterols had 56% higher death rates than those with moderate levels.

Other findings were less expected. The death rate from all causes among men with cholesterols over 240 were just 14% higher than those with moderate levels.

Perhaps the biggest surprise concerned women. As in men, those with cholesterol under 160 had a 10% higher risk of death from all causes. Yet there seemed no benefit to keeping cholesterol in the moderate range. In fact, the death rate of those with cholesterol over 240 was 3% less than those with levels between 160 and 200.

“This is blown all out of proportion,” contends Dr. William Castelli, head of the long-running Framingham Heart Study in suburban Boston. “Do you want me to believe that something big is being missed? I don’t think there is.”

He and others note that women in the study were under age 70, when heart attack risk is greater.

Some also suspect that those with very low cholesterol levels had higher death rates because they already had diseases that caused their cholesterol to drop. So their low cholesterol was a result--not a cause--of the disease that killed them. The study’s defenders say this is unlikely, because even five years after their cholesterol was initially measured, people with low cholesterol still were dying at a higher rate.

Among those who believe the evidence is powerful enough to tone down the national anti-cholesterol campaign is Dr. Stephen Hully of UC, San Francisco.

No gadfly, Hully sat on an advisory panel that drafted strategy for the program. However, in an editorial in September’s Circulation, he called for major changes in the war on cholesterol:

* Stop trying to lower everyone’s cholesterol. A cholesterol-lowering diet may be harmful for the 6% of middle-aged adults with cholesterol levels already under 160.

* Stop giving cholesterol-lowering drugs to people who have high cholesterol but no signs of heart trouble. The treatment might cause as many deaths as it prevents.