The Fat Doctor Podcast

Robin's Story

• Dr Asher Larmie • Season 5 • Episode 16

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In this episode, I explore the journey of Robin, a 45-year-old art teacher navigating a high cholesterol diagnosis and the frustrating world of weight-centric healthcare. Through their story, I break down the actual science of heart disease risk factors (spoiler: weight is the least of your concerns), explain the difference between primary and secondary prevention, and reveal how the medical establishment's obsession with numbers obscures more important social determinants of health. I also dissect the evidence (or lack thereof) for dietary and lifestyle interventions, highlighting how medication decisions should be based on informed consent, not fear.

This episode asks: What if doctors treated us as whole people instead of just collections of numbers?

This week's journal article is:  Ras, Rouyanne T et al. “LDL-cholesterol-lowering effect of plant sterols and stanols across different dose ranges: a meta-analysis of randomised controlled studies.” The British journal of nutrition vol. 112,2 (2014): 214-9. doi:10.1017/S0007114514000750 

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Hello, everyone and welcome to episode 16 of the Fat Doctor Podcast. It is Wednesday, April 23rd. I'm your host, Dr. Asher Larmie. Yeah, we're still alive, and that counts for something, doesn't it? It's been an interesting few months, hasn't it, folks? And I'm sitting here trying to just carry on, you know, finding Nemo when Dory's just like, "Just keep swimming. Just keep swimming." It's going around in my head every single day. Because, here I am about to record a podcast all about a fictional character named Robin. For those of you who've been paying attention for the last few months, every month I come up with a new character, and I try to give them a gender neutral name and gender neutral pronouns, so that everybody who listens in can possibly relate to what's going on. So I'm going to be talking about Robin and their high cholesterol. And part of me is just like what? What's the point? Who cares about cholesterol? Having high cholesterol is one of those things you need to worry about 10 years in the future, 20, sometimes even 30 years in the future. Who's to say that we have 30 years in the future? But I'm willing to remain optimistic until I know otherwise. I'm just gonna just keep swimming. That's what I'm gonna do. I'm going to talk about Robin today. Robin's delightful. I made them up so of course they are. 45 years old. High school art teacher. Just because why not? I think a lot of my characters are teachers, but just because hardworking, right? And chose art, not physics - art teacher, delightful, lives alone with a cat, a rescue, 19 years old, seen better days, but still plodding along. I love them already. They were diagnosed with PCOS (polycystic ovary syndrome) back in their thirties. Otherwise, fairly well, no real concerns. A history of migraines every so often which anyone who's ever experienced a migraine knows sucks, so they manage, they manage, and they've got them under control, and they very rarely see a doctor about it, because, quite frankly, they're fat, and they don't like going to see the doctor, so they stay away where possible. But they had to go in for a medication review, and when they did they were forced to have some blood tests. Have some blood tests, or you can't get your medication. Anyone else experiencing this now, when you just kind of like, you know, you can go in for migraines, and you're told, "Well, I would check your blood pressure and your weight, and your cholesterol and your A1C and yada yada yada." So they did it. They didn't want to do it. They really didn't. But medication was being held hostage, so they did it, and they did their blood tests. And then they got this message, saying, "Please speak to the doctor about your blood test results," and of course they panicked and avoided it for a couple of weeks, and then was just like, "Yeah, but it can be something really bad. So I better do it." So they finally made an appointment to speak to the doctor, and they had a phone call with the doctor, and the doctor was like, "Oh, you've got high cholesterol." And there was a sort of like, "Oh, okay, whew!" Could be worse. High cholesterol I can manage, you know. I'm not dying. I've not got cancer. It's okay. But the doctor wasn't as relieved to be honest. The doctor was quite concerned, because cholesterol is high, and Robin has a family history of cardiovascular disease of heart disease. In particular, their father, who had a heart attack at the age of 55. Now to be fair, their father was a smoker, and perhaps had a bit of an issue with alcohol, to put it mildly, had a very stressful job, didn't really take good care of himself, and so no one was surprised when he had his first heart attack at 55. But there it is, you know, that is a concern. And so Robin's doctor rightfully said, that increases your risk of heart disease. And now you've got high cholesterol, and you've got a history of PCOS, and you're fat. So if you don't do something soon, you're gonna die. That was a couple of episodes ago. Lose weight or die. So Robin understandably was concerned, and didn't want to die. And too young to be thinking about it - 45 for goodness sake, and was told by their doctor, "You need to go on a diet," and to be fair, the doctor was very sneaky about the way that they presented it. It wasn't like "you need to go on a diet to lose weight" because Robin had come to a stage in their life when they realized they'd done pretty much every diet out there, and they'd never managed to successfully lose weight, and they were fed up of being told to go on a diet again. So if Robin had been told "just lose weight," they may well have been like "no thanks," but this was presented slightly differently. This was a "change your diet in order to prevent a heart attack." Lose some weight in order to prevent a heart attack. That's a little bit different. Now, isn't it? So? Change your diet. If you change your diet you'll lose some weight, and if you lose some weight you won't have a heart attack. That was the way it was presented to Robin, and Robin didn't want to have a heart attack. Robin didn't want to go the way of their father, so they had a go, and they didn't do the weighing and the measuring, because they were done with that that was no longer an issue for them. But they did follow the guidelines in this leaflet they were given all about a cholesterol-friendly diet, you know, a heart healthy diet, and there was all these rules. You should be having 5 portions of fruit and veg a day, which everybody knows you should be having legumes and lentils and beans at least 3 times a week, or whatever it was, and oily fish twice a week, and you should use olive oil and avocado oil, and you shouldn't use these oils, and you should switch to this, and you should change that, and you should add this and not do that and take away that. And then there was all this stuff about low fat, but also low carb and low everything. So it was just basically vegetables and lean protein was all that was allowed. And this wasn't Robin's alley. These weren't the kind of foods that Robin wanted to eat. They made them feel very miserable eating these foods that they were allowed to eat, and it felt very diet culture, very weight lossy. And even though Robin was trying to step away from diet culture, and had successfully divorced diet culture in the years prior to this, this was different. This was a heart healthy diet. This was not about weight loss for Robin. This was about doing something for their heart, and so they worked hard, tried hard, you know. I'm going to say "good" for the most part - "good" in speech marks, because, of course, there's a lot of nuance when we talk about what is good and what is bad when it comes to your heart. But they did what they were told, good, obedient person that they were, and about a year later had to go in for a follow up. 6 months, a year. It was probably meant to be 6 months. It was a year before they actually went in, had another blood test and cholesterol numbers hadn't really changed - pretty much the same as they were. Now, Robin hadn't had a blood test for years prior to that, like I said last time they'd really seen a doctor was when they were diagnosed with PCOS in their early thirties. They hadn't needed blood tests. Migraine was a long standing thing, and they just had this prescription that was refilled more often than not. It just so happened that the last time they needed that prescription, they saw a very overzealous, fresh new doctor, who was very interested in lifestyle medicine. And so that was how they ended up going down the route of the blood test. So now they have had 2 high cholesterol results. And when I say high, I mean, like, you know, borderline high. It wasn't terrible. It wasn't 10 times the normal value. It was just slightly higher than one would expect for a 45 year old, and poor Robin's doctor was furious this time, was absolutely cross, gave Robin a good telling off. "Look clearly, you haven't been trying hard enough. You haven't been following the rules because you've not lost any weight." And when Robin explained, "Well, actually, I wasn't trying to lose weight. I was just trying to follow the diet. I wasn't actually trying to lose weight" then the doctor was like, "Oh, you don't want to lose weight," and Robin was like, "No, I don't really want to lose weight." "Oh, why don't you want to lose weight?" "Oh, well, I don't believe in weight loss. I don't believe that it's particularly beneficial." Immediately labeled the non-compliant patient. "Don't you care about your heart?" And Robin knows and says out loud to themself, "I try really hard." And it's terrible, isn't it? Here I am, a trans non-binary person, really messing up the pronouns for a fictional character. But sorry I'm trying to get it right. Just goes to show it's never easy, anyway. They say "Every time I go to the doctor, no matter what is wrong with me, the prescription is always the same. Lose weight." PCOS - lose weight, migraine - lose weight. What does weight have to do with migraine? Well, lifestyle - lose weight. And now, of course, cholesterol is a big one - lose weight, lose weight, and when their doctor told them initially that they had high cholesterol, and gave them this big lecture, and explained that the LDL cholesterol, the "bad" cholesterol, was very high, they really automatically felt like they'd failed a test, you know, like they were being graded on some kind of scorecard, and they were failing. And now that they tried the healthy diet, and nothing has happened, that's double fail now, and they are non-compliant and clearly doesn't care about their health or their heart, or is just waiting to have a heart attack as far as their doctor's concerned. And so the doctor is now like, "I think you need to take statins," statins, cholesterol lowering tablets, and basically without really looking up from the computer, tap, tap, tap, tap, tap, tap, tap, tap, tap, tap! "Here's a prescription. Off you go," and that was the end of that. And so Robin leaves the doctor's office with a prescription for Atorvastatin 20 milligrams, not really sure that that's what they want to do, but of course, still really worried. Still, at the back of their mind "I don't want to have a heart attack," and they know that diets don't work. But this isn't dieting. This is something different. This is lifestyle changes. This is about managing cardiovascular risks. This is very different from dieting, and so they're kind of stuck. On the one hand, they don't trust their doctor as well. They shouldn't. They have not been given enough information to make a decision about whether or not to take statins, and when they try googling it. Of course the information is really heavily weight-focused and stigmatizing, and so that's not particularly helpful. Don't know who to trust. Don't know what to do. One hand it feels like, "Well, I should just take a tablet. Then why am I even thinking about this?" But, on the other hand just feels really like, "Why can't I find a doctor who will treat me like a whole person as opposed to just a number on their computer, who's more interested in me as a human being than they are at my cholesterol levels." And that's a very all too familiar feeling for me as well. I often feel that way. You know, people are always worried about my cholesterol. I want them to shut up, but that's because I know about cholesterol, anyway. I don't blame Robin, I really don't. And I wonder if you're listening to this, and you're like "Oh, that sounds a bit familiar." It might not be cholesterol - might be blood pressure. It might be A1C. It might be your CRP. It might be something, some blood test, some measurement. What did I call it last time? The moral measuring stick, or something? I do love me some alliteration. We're so obsessed with these numbers and measuring and comparing ourselves based on these numbers. So if I were Robin's doctor, if only - if I were Robin's doctor, here's what I would do. The first thing I would do when I met them, and I had this cholesterol test in front of them is, I say, "Look, I'm not particularly worried about this" - bit of reassurance. It's not anything really to worry about, and just to let you know before we start, having high cholesterol, I would explain, "This has nothing to do with what you did or didn't do. You didn't do anything wrong. You couldn't have prevented it. This is nothing to do with you. It's just one of these things that we found and knowing about your cholesterol is important to a degree, because it's one of the several factors or risk factors for heart disease. And that's something that you'd be considering in the future. You're very young, chances are you have a very low risk of heart disease at the moment. But we're thinking about, you know, 20-30 years in your case in the future. That's what we're thinking about. But look, we've seen it now, and I know that you're particularly anxious because you have a dad who had a heart attack at the age of 55." So the first thing I would do after reassuring them that it's not their fault is, I would actually calculate their risk. Just really easy, because there's a calculator. And if you work in the UK, you don't even have to go to the calculator. The calculation is automatically done for you. This is like a little box over here, and it just tells you what the risk is. That's really helpful. What is the risk of you having a heart attack or a stroke in the next 10 years? That's what it tells you, and you can look at that risk, and you'd be like, "Well, I know exactly what your risk is now." Is it an accurate calculation? No, it's not 100%, but it's a good guesstimate Ballpark figure, and I can tell you, without actually having to do the calculation for this fictional character, that Robin's risk is going to be something like 3 to 4%, maybe less, 2%, 2 to 3%. Really, really low. Robin doesn't have any significant risk factors for heart disease. But Asher, Robin is fat. Yes, correct, which is not a significant risk factor for heart disease. But Asher, it is. No, it's not. It's not actually. It's actually one of the least important risk factors for heart disease out there. Migraine is a higher risk factor than weight. So if you were to compare 2 Robins, one is fat and one is thin, there's really no different. We're talking about point 5 a percentage point, if that, whereas with migraine it's more like 0 point 7 percentage point. Again, it's not like a massive difference, but migraine's still higher. So is having a history of rheumatoid arthritis or kidney disease or high blood pressure, or diabetes, or being a smoker, being on antipsychotics, taking regular steroids, having a history of erectile dysfunction, a lot of things put you at a higher risk of cardiovascular disease. Weight is right at the bottom of the list, so I can tell you that Robin's risk is low because I made them up. They don't have any of these risk factors. They've got migraines. Their risks are slightly higher, but I'm not worried about it. I'm not worried about it at all. In fact, I can give Robin very much a thumbs up. And this is really important when we're having this discussion to have a conversation about the difference between what we call primary and secondary prevention when we're doing preventative medicine. Primary prevention is when we take a group of people that have not had a particular condition. So when it comes to primary prevention of heart disease, that's a group of people who don't have any heart disease. They've not had angina or a heart attack, or a stroke, or any other cardiovascular event. So their risk is actually low. If you've never had heart issue before, your risk is low. If you have had a cardiac event before, then your risk is higher, much higher. Chances are if you've had one, there's some kind of process going on inside, and we call it atherosclerosis, and if you've had one, chances are you will have another one, and that's why we tend to act quite swiftly. That's secondary prevention. You've had a cardiac event. Now we're trying to prevent another one. So when we give you treatment to lower your cholesterol, whatever that is, and we'll talk about that in a moment. But when we give you treatment it's going to reduce your risk. Let's say it reduces your risk by 25%. If your risk is high, if your risk of having another event, because you've had one already. You've had a heart attack like, let's just talk about Robin's dad for a moment. He has a heart attack at 55, right? At that point in time, his risk of having another heart attack is high. So we want to bring that risk down. Let's say, treating his cholesterol reduces that risk by 25%, and his risk is, let's make his risk 60%. Very high risk. The chances of having another heart attack in the next 10 years - 60%. It's theoretical. I just made that up, came up with that number just because it's simple math. So if I'm going to reduce his risk down by 25%, then I take his risk from 60% to 45%. It's quarter, right? Simple simple maths. I can't show my working because this is a podcast. Now let's say, going back to Robin, their risk is 4%. I think it's lower, but let's just say it's 4%. Now, I reduce their risk again by a quarter, by 25%. Now, it's gone from 4% to 3%. Do you see the difference? There's a massive difference between 60% and 45%. But there's a tiny difference between 4% and 3%. That's why primary and secondary prevention are very, very different. So in Robin's dad's case, there's no question. I'd be treating their cholesterol absolutely no question. In fact, I mean, obviously he has the right to refuse treatment, but I would be a very negligent doctor if I didn't prescribe it. But in Robin's case it's totally different. And so when we're talking about these numbers, we have to be like, well, what does the number actually mean? It's just a theoretical number. These, what is normal and what isn't normal. These are very arbitrary cutoffs. I mean, like, we just decided, this is normal, this is normal. And, by the way, the goalposts keep changing, same with blood pressure, cholesterol, A1C, all of them. The goalposts keep changing. We keep making it sort of lower and lower. So more and more people have quote unquote high cholesterol now than they did 20 years ago, because we keep shifting the goalposts. And then you've got to ask yourself, why? Why are we shifting the goalposts? Good question. Maybe we'll talk about that in a moment. So I would not treat Robin as a collection of numbers that I see on my screen. I would treat them as a human being, and I would calculate their risk for them to reassure them that their risk was very low, and then I would talk about the options for treatment, because I don't want to tell Robin what to do. I want to give Robin a chance to decide for themselves. In fact, that is my job to provide the information, the pros and the cons, the benefits, the risks, the long term implications, so that they can make an informed choice. They can make an informed decision. It's called Consent, People. It's a rather important part of my job. And so I would tell them the following things. First of all, dietary changes have not been proven to be effective in preventing heart disease. The end. There is literally no evidence that it works. It just doesn't. It doesn't work. There are no dietary changes - I don't care whether you do your 5 veg a day, whether you have your fiber and your this - it doesn't work. It just doesn't. Plenty of studies out there, that have shown that after 6 months any benefits have disappeared within a year. Nothing to talk about. So yeah, maybe you might be able to reduce your cholesterol in the first few months. Most more often than not you can't. But even if you can, it's not going to last, and even if it did last, it wouldn't make a difference to whether or not you had a heart attack 10 years down the line. The evidence is there people, or the lack of evidence is there, I should say. So dietary changes have never been proven to be effective. So why are we recommending them? I could not tell you. Again, that's a good question, isn't it? If there's no evidence, why are we still recommending them? I don't get it. I'm not saying that any of these things are wrong. 5 fruit and veg a day sounds very sensible to me. Oily fish. All that stuff. I'm not saying it's bad. I'm just - why are we recommending them as doctors? Not our job to recommend treatments that don't work. So it's weird to me that we do. But anyway, I would tell them diet changes not a thing. I would explain that weight loss has absolutely no benefits when it comes to cardiovascular risk. In fact, weight cycling causes harm, and that includes increasing the risk of heart disease in the long term. So don't weight cycle because it's bad for your heart. It's been shown over and over and over again. So I would explain that weight loss is definitely not the solution, that actually dietary changes aren't. I would talk a little bit about plant sterols and stenols. These are the kind of things that you can buy like the spreads and the drinks and stuff that possibly have been shown to reduce your cholesterol a little bit. You could try that, and there are other things that you can try like, movement has been shown to reduce your cardiovascular risk. Small amount, very small amount. But it's not a bad thing. Stress reduction, sleep management, all of that stuff. But to be honest, I would explain to them, "Look, you can do all of these things, and it's not going to make much of a difference. If we really want to treat your cholesterol, and if we really want to reduce your risk of heart disease, then we have to start you on a medication." And so I would discuss the pros and cons of the medication. So the pros are it reduces your risk of heart disease by 25%, roughly, between 20 and 30 ballpark, 25%. And then these are the side effects. And actually, I got some information about side effects of statins. By the way, statins are these drugs that we're prescribing nonstop to everybody, and I don't think everybody should be taking them. However, I also don't like the fact that doctors are very ill-informed when it comes to the side effects. The first thing anyone says is, "What are the side effects of statins?" The first thing we say is "muscle aches, muscle cramps," and that has been shown in many an observational study. However, when you look at all of the randomised control studies, you'll find that there is really no difference between the number of people complaining of muscle pains in the treatment group and in the placebo group, really no significant difference, depending on what study you look at. Maybe a very small difference. But muscle cramps are not as common as we think they are, and there appears to be a placebo effect here. So this kind of reputation - you take a statin, you're going to get muscle cramps. I wonder how much of that is placebo as opposed to actual, because the studies seem to suggest that there's not. We don't talk about the other side effects that are quite common - gastrointestinal side effects up to 5%. We never talk about that - diarrhea, vomiting, feeling sick. It can give you headaches, which is really important to know if you suffer from migraines. I'm not saying don't take it. I just think you need to know that there's a possibility that it can give you headaches. It's rare, less than 5%. But it's still a risk. I say rare, I'll say rare. That's not rare, but it's less than 5%. There's a good chance you won't have headaches, but still there are some studies that show possibly some brain fog - people talking about brain fog. So if you're perimenopausal, and that's already a problem for you, then brain fog is not ideal. And that's another thing to be aware of. When we're talking about medications, I always say to my patients, "Look, you can start a medication and stop it at any time," and in most cases, after a day, that's it, 2 days, 3 days, I mean, it's not going to stay in your system. That's not the case for every medication, but for most medications. So if you want to start on medication, see how you get on with it, and then if you don't like it, you can just stop it. Alternatively, you cannot take the medication, and that is okay, too. But I just want people to know the facts. That's all. I want to allow them to make an informed choice, and I really don't see why that's challenging in any way. That's just - I was having this conversation with a client the other day when we were talking about doctors and how a doctor just doing their job, basic job, which is, you know reassurance, validation, calculating risks, talking about presenting information, allowing people to make an informed choice, stuff like that. This is not extra. This is not extra stuff. This is not extra credit. This is just basic. This is what is expected from a doctor in every single patient consultation as written down, and explicitly directed. And we've been told this from the day we started medical school. It's written into our code of conduct, into our ethics - this is what we're supposed to do. It's just be nice. Do what's in your patient's best interest. Don't do any harm and make sure they're able to consent to something - autonomy. All that jazz, be fair. And that's just basic medicine. I don't get it. It's so sad. But fat people have got to the stage where, if you get that just basic standard care, it feels like such a relief, such a joy, something to celebrate about. "You won't believe it. My doctor actually gave me some information before prescribing me medication" - like we're supposed to be grateful for that. No, no, no, that's just what they're paid to do, not extra credit. Well, I don't know what extra credit is, but it's not that. And so we have this kind of situation where doctors, the medical establishment - doctors have made it so that standard of care is so poor and so far removed from what it should be, that even a tiny hint of kindness like "my doctor didn't lecture me about weight loss. Wow! That was amazing." No, if you said you didn't want to be lectured about weight loss, then that's not amazing at all. That's just standard care. It's infuriating for me. So, on the one hand, I'm telling a story about a fictional character called Robin, who's got this relatively minor issue of having high cholesterol. Like, really? What's the big deal? I was thinking to myself, is it interesting enough? Do I need to make it more interesting? But actually, I just want to get down to the basics, get down to the most simple. This is what doctors should do. I'm not saying anything that, you know, I'm not reinventing the wheel. This is just what you're supposed to do and the fact that your doctor isn't doing it is a real problem. We're going to move on to the section in the podcast where I tell you how everything you've been told about weight loss is a lie when I like to look at a study and just share some information about it. Just, you know, for those who like that kind of thing. And I picked one that is relevant today. It's really again, this is quite basic. I was like, "Oh, is it good enough? Is it okay? Is this enough?" But yeah, I'm going to go with it. The study is "LDL cholesterol-lowering effects of plant sterols and stanols across different dose ranges: a meta-analysis of randomized control studies." So a meta analysis at this point in time is when we take all of the studies that we can find. And then we basically group all the data together and then draw some conclusions which is really useful, because if one study shows something that's helpful. But if 10 studies show the same thing, that's even more helpful, isn't it? So they did a meta analysis of the plants, sterols, and stanols. These are basically plant byproducts that look a lot like cholesterol, and they bind to the cholesterol receptors in your gut, so that when you take them, instead of cholesterol being absorbed into the system, they get absorbed into the system as well, and so they are supposed to have cholesterol-lowering properties, and some of you might hear this and go, "Well, that makes a lot of sense." Here are some facts you probably are not aware of. 80% of the cholesterol in your body is synthesized by your body in the liver. Only 20% is consumed in your diet. So obviously to start with, that's not particularly helpful, right? Because the majority of cholesterol doesn't even come from our diet. The other thing you have to know, and this never really gets talked about: cholesterol is massively important for your health and wellbeing. You need cholesterol to survive. You cannot live without it. It is a fat, it is a lipid. Lipids are necessary to maintain the structure of cells. They're important for hormones. They're important for testosterone, estrogen, cortisol. All of the hormones require cholesterol to make them, to synthesize them, or lipids, I should say. They're important when you turn them into vitamin D when exposed to sunlight. It's really important. The brain uses 25% of the total cholesterol content in your body. Your brain is a very small organ, only about 2% of body weight but small but mighty, I should say, and it needs a lot of cholesterol, so you need it. You can't live without it. You need it in your diet. And also, even if you don't get it in your diet, your body is able to synthesize it, which is great, and cholesterol binds to proteins, so lipids, the fats, binds to proteins to form lipoproteins - lipid protein, you know. In fact, I actually think doctors have been shipping things longer than everyone else. I mean, we're quite good at taking 2 things, putting them together and creating a name. So lipoproteins they can be low density or high density, low density lipoprotein - LDL. High density lipoprotein - HDL, very low density lipoprotein - VLDL. And so when you get your lipid panel back, and that's what it says, it says LDL, HDL. So LDL stands for low density and HDL for high density. Low density takes the lipids from the liver to the cells, and HDL takes the lipids away from the cells, which is why we think LDL is bad and we think HDL is good. But those of us who have actually looked at the research, especially the newer research that's come out in the last 10-15 years, know that's way more complex than that. In fact, there's a lot of stuff going on, a lot of stuff going on that you're just like, "I never even heard of that until I researched it today." So this was a bit of a side trek. But my point is that cholesterol is not inherently bad, and that we don't really know why cholesterol is linked to heart disease. But we do know that it is. We know that fatty plaques in our blood vessels can block the blood vessels and can cause a heart attack, a stroke, etc, but it's really freaking complicated, and it's not as simple as "you have too much fat in your blood, therefore you can have a heart attack." That's not how it works. So just putting that all out there. And you know, "Oh, you got to take this. You've got to take that. You've got to try this. You've got to try that." Okay, plant sterols. There is some evidence for it, and they found that an average intake of 2 grams of plant sterols which, by the way you can't just get from eating plants - it's way too much. You have to use one of the products that can basically reduce your cholesterol. Anywhere like 2 grams, if you're having 4 grams, which is really high, it can reduce it by about 12%. Possibly. But an average was about 7 to 8%. So it has some impact. Cholesterol lowering drugs - up to 30%, possibly more, depending on the drug. These much lower. And of course you've got to buy these products, right? Like you have to go and spend money on them. And that might explain why this meta-analysis found 124 randomized control trials. I looked at that. I was like, no, not 124. That's wrong, that is incorrect. No, no, it was 124. There are some conditions where I struggle to find like 3 randomized controlled trials, and there are 124 for cholesterol-lowering yogurts and drinks, and spreads, that you put on your toast - 124, which just says a lot, doesn't it about medical research? They're not even that impressive. There are 124 RCTs. Why? Because they were funded by the people who are trying to sell them to you. And so when we talk about lifestyle changes, when a doctor says "I want you to make some lifestyle changes, I really think you need to make some lifestyle changes," you need to ask yourself a few things. The first thing is, is this going to cost me anything? In the case of plants, sterols and stenols, yes, it is. You're not getting them on prescription, and even if you have to pay for your prescriptions in most cases. But you've got to pay physically, financially, you have to pay. And of course you have to ask yourself, are there any side effects? Is this actually going to harm me in any way? If I had fewer resources, would I be able to afford this? Is this something that's being marketed to certain people with certain number of resources? That's problematic, isn't it? Capitalism. Yay. Is it sustainable? Is it pleasant? Do I actually like these yogurts and spreads, or are they gross? Because, I suppose if they taste good and you can afford them, there's nothing wrong with that. But if they don't taste good, and/or you can't afford them, why get into a place of financial hardship?

These are the kind of things you need to be asking yourself. So anyway, I hope you found this study helpful. The reason I wanted to share it was, I just wanted to point out that there are 124 randomized control trials, including in this study, with very little to impress upon us the benefits. And yet there will be some people who are waxing poetic about these plant sterols - some people, not that many, but there's money to be made, isn't there? And that says everything that you need to know about medicine. So I got a question for the ask me anything portion of this podcast episode. "I was told that weight loss would improve my knee pain. If anything has made it worse. I feel cheated. What did I do wrong?" That was the gist of the question. It's a much longer question, and oh, I feel you! I feel you! It never fails to amaze me how doctors put all these kind of conditions in place. "If you do this, then this will happen. If you lose weight, your knee pain will get better," and in fact, they don't just say, "if you do this," they say, "if and only if you do this, your knee pain will get better." It's the "if and only if" that really bugs me because they don't give you options. They don't say, "If you do this or this, or this or this, your knee pain will get better," which in of itself is problematic because it's not true. "Evidence shows that this may improve your knee pain" - that's reasonable, but not "if you do this, this will get better." I mean, come on now, you can't predict the future, and you've got to stop putting these kind of conditionality in place because it's not true. But "if and only if" - and that's the thing that really bugs me. "If and only if you lose weight, then your knee pain will get better. If and only if you maintain a healthy diet, then you won't have a heart attack. If and only if you keep your cholesterol level under this level, you won't have problems." In the long term you'll live longer. That's not true. And it's problematic, because what happens is, if it does happen, you do have a heart attack or your knee pain gets worse, or you develop diabetes, whatever it is - they told you that was going to happen, and it does happen. Then you will blame yourself. "It's because they said if and only if I did this, and this happened so obviously because I didn't do it properly, or I didn't try hard enough." It's really problematic, because it shifts all the responsibility off the people who are actually responsible. It shifts the responsibility of the people who are in charge of maintaining access to healthcare, who are in charge of dealing with the real problematic social determinants of health like clean air, clean water, safe housing, income inequality, access to education, social isolation - all the really important factors that actually have a massive impact on our health. Responsibility has shifted from them because we don't talk about social determinants of health. "If and only if you eat 5 portions of vegetables a day, then you won't have a heart attack" makes it so that if I have a heart attack, it's because I didn't eat my 5 portions of fruit and vegetable a day, not because my doctor was stigmatizing me, and I was afraid to go and see them, not because of the income inequality, not because of the fact that I have financial instability, I'm having to work 2 jobs. Thank you very much, capitalism. Not because of the fact that I'm not getting enough sleep, not because of any of these things. It's just because I didn't eat my 5 fruit and veg a day. It's just because I wasn't thin enough. It's just because I didn't work hard enough to lose weight. It's just because I didn't care about myself enough. So I can just blame myself, and the doctor can blame me. The doctor gets to shift off, "It's nothing to do with me. It's not because I didn't treat you properly. It's because you didn't try hard enough." That's not true. That is not true. So I think we need to divorce ourselves from conditionality. That's something that I'm learning to do. I've spent a lot of time in therapy, as you can probably tell, and I've heard this catchphrase before. Divorce yourself from conditionality. The "if and only if" does not apply to medicine. Literally, medicine is the least - it's like sometimes saying being a doctor is a bit like being a meteorologist, you know, like I can look at a screen and show you all this about air pressure and point to things and be like, "This front is moving in here. And that means it's going to rain, and this is not going to rain." At the end of the day, I can be wrong 9 times out of 10. No one's going to do anything about it, because you can't really predict the weather. I mean you can, but you can't, right? And meteorologists always get things wrong all the time. They say it's going to rain, it doesn't rain. They say it's not going to rain, and it does rain, especially if you live in Scotland. Just carry an umbrella around, because you never know. Not that we carry umbrellas around, because we're Scottish, and we're hardy. But you know what I mean. I think doctors are the same, like we can look at the numbers and point at things and graphs and evidence and "cold front coming in." But at the end of the day we don't know, we don't know, and we certainly don't know enough to be able to say "if and only if you do this, this will happen." We certainly have no business telling you, friend, that if and only if you lose weight, your knee pain will get better. I'm not surprised you feel cheated. I'm not surprised you're angry. I would be, too. You didn't do anything wrong. You asked, "What did I do wrong?" Nothing. You did nothing wrong. Your doctor failed you. Society failed you, but you did nothing wrong, and so I don't know what the solution is. I don't know how to fix your knee pain, because I don't know you well enough, but you could always book a consultation with me if that's something that you want to do. But yeah, it's bullshit, isn't it? It's real bullshit and makes me mad. All right, that's all I've got time for today. Listen, if you liked what you heard, and if you're interested in finding out more about cholesterol, about heart health, if you go to the No Way website, noway.org, you go and click on the button that says free resources. There is an entire resource, one for heart health, and a separate one for cholesterol. There's one for blood pressure. There's one for prediabetes. There's one for diabetes, there's one for non-alcoholic fatty liver disease, there's one for osteoarthritis. There's one for idiopathic intracranial hypertension, etc. So go and have a look. It's completely free, and there's no gimmick. I'm not trying to sell you anything. You don't have to sign up. You don't have to do anything. It's just there. I'm putting these things out there because I want people to have access to information that isn't stigmatizing. It's based on facts. And I'm not putting anything out there that I haven't researched in great detail beforehand. Some of you might be like, "Show me the research." Fair enough. You have every right to ask that, and I will show you all the research if you join one of my masterclasses. I'm not giving it away for free, people. I do actually need to make some money. And so I do have masterclasses that you can join. If you're a member of the masterclass membership, then you get access to every single one of my masterclasses, including the one on blood pressure, etc. And this one on cholesterol, which came out last week. But obviously that's behind a paywall. If you are interested, also, I talk a lot about this in the book that I'm writing, and the book is called "No Way: Everything You've Been Told About Weight Loss is a Lie," and it will be out next year, hopefully by this time next year fingers crossed. And I write a chapter a month, so if you can't wait for it, and you want the information here and now, you can support me and have the benefit of reading this book before anyone else gets to by joining the No Way membership. So there's the masterclass membership. There's the No Way membership. And also, I have my online community, my lovely group of people. We're all hanging out on Discord. We are talking about this all the time. You get to ask me anything you like, and I have clinic hours once a week where you can come and say, "Hey, Asher, this is my cholesterol level, and my doctor says that I need to do this. What do you think?" And I will tell you the answer. So there's that, and of course you can book a consultation with me if you fancy a one-to-one consultation wherever you live in the world. I'm here to be your weight-inclusive doctor. You're like "I wish I had a weight-inclusive doctor." I am one. I can't be your personal doctor, because obviously I can't practice around the world and I'm not doing that locally either, but you have the benefit of my 20 years of expertise. You have the benefit of all the knowledge I have surrounding weight-inclusive care, all the conditions that I have researched to death, all the guidelines that I have read through, and all the papers that I have critically appraised. You get all of that. You get my diagnostic skills. You get my care and compassion and sense of humor and validation and all that jazz. Book a consultation with me through my website. All the links are in the show notes. Next week I have a special guest, and I think I might leave it as a surprise. I haven't recorded the episode yet. Once I've recorded the episode, then I can be chill about it. But I haven't recorded it. I am recording it tomorrow, though, and I'm really excited. Getting ready for mental health awareness month. Listen! A lot of you came to me, came back to me like last month was like, "I know, it's autism awareness month. But we have issues with autism awareness month." And I agree. I agree with these issues. I agree with the issues surrounding mental health awareness. I hate the way that mental health has become commodified now, and has become a way of selling stuff to you - absolutely hate it. Also think it's really important to talk about. And so why not do it? Why not talk about mental health? And we're going to talk about that in particular, about trauma and medical trauma, and how that impacts us. So that's the theme for next month, May. And so our next podcast guest will be kind of queuing that up for us. Thanks for listening. And I will see you next time.