Table of contents
0:00 – 2:07 – Introduction and outline of talk
2:08 – 3:58 – What is evidence-based medicine (EBM)?
3:59 – 9:40 – Case study: heart disease, diet and statins
9:41 – 12:23 – Causes of coronary heart disease and metabolic syndrome
12:24 – 16:29 – Statins: benefits, side effects and health statistics
16:30 – 25:18 – Conflicts of interest in science
25:19 – 27:23 – Are statins falling short?
27:24 – 38:06 – Recent developments in Dr Malhotra’s campaign
Summary
Dr Aseem Malhotra is a renowned cardiologist, working in the NHS and leading the campaign against excess sugar consumption in the UK. He speaks regularly at national and international events on matters of heart disease, obesity and diabetes. As a strong believer in evidence-based medicine, he questions existing paradigms that may not hold up to high standards of proof, such as the role of dietary fat in causing heart disease and the effectiveness of statins in preventing it. He urges the healthcare community to be more open and knowledgeable about scientific data. This talk was given at the Public Health Collaboration conference 2019 at the Royal College of General Practitioners in London.
Dr Malhotra begins the talk by defining evidence-based medicine (EBM). He says that in order to practise EBM, three things need integrating: individual clinical expertise (of the healthcare professional), the best available clinical evidence (from published literature) and the patients’ expectations and values. He states that, since evidence changes over time, if practitioners do not keep up, they are selling their patients short.
Moving on to a case study, Dr Malhotra tells the story of one of his own patients, a 55-year old airline pilot who became overweight with an abnormal cholesterol profile, and eventually had a heart attack, despite following what he thought was a healthy diet. Some time later, the patient reported feeling poorly in general. After doing some research, he decided to stop taking his statin, which was one of multiple drugs he was taking. Following this, he felt much better. Around the same time, he began eating a low carb diet and, 3 months later, he had improved his weight, waist circumference and cholesterol profile substantially. Following this, he made the decision to stop all of his medications which Dr Malhotra, following a consultation, supported him in doing.
Dr Malhotra then goes into cholesterol as a risk factor for heart disease. Providing evidence as he goes, he shows that total cholesterol is a very poor predictor of heart disease on its own, whereas the total/HDL cholesterol ratio is a much better measure to use. Dr Malhotra explains that the main risk factor for heart disease is actually insulin resistance.
A major issue in healthcare, according to Dr Malhotra, is the use of misleading health statistics. Benefits of drugs are often reported as relative risk reductions (RRR), as opposed to absolute risk reduction (ARR) and numbers needed to treat (NNT). This can lead to an overestimation of the effectiveness of these drugs by patients and professionals alike. For example, a drug that reduces the 4-year risk of suffering a stroke from 28 in 1000 to 15 in 1000 could be said to have either a relative risk reduction of 48% or an absolute risk reduction of 1.3%. This translates to an NNT of 77, meaning that 77 people would need to take the drug for 4 years in order for one stroke to be prevented.
To make things even more confusing, Dr Malhotra explains that some publications use ‘mismatched framing’, which displays benefits of treatments as RRR and side effects as ARR in order to make treatments seem more effective and / or safer. Evidence suggests that a third of articles in the Lancet, BMJ and JAMA, which are all high-end medical journals, between 2004 and 2006 used mismatched framing.
Moving on to the subjects of conflicts of interest and biased research, Dr Malhotra brings the discussion back to statins. He recounts how he was challenged by an Oxford Professor on his views on the effectiveness of statins, and how his own publication could have been retracted due to this backlash. In a media investigation following this, it was found that the Professor had several financial conflicts of interest regarding statins.
Continuing with the topic of financial conflicts of interest, Dr Malhotra explains that pharmaceutical and medical device companies have a duty to their shareholders to make a profit and are not required to provide the best available treatment to patients. He then reads through a list of ways in which published research can become biased.
Dr Malhotra uses an extreme example to show just how bad the consequences of academic malpractice can be. He presents the story of a Dutch researcher who manipulated data on beta blockers, which some estimates suggest may have resulted in 800,000 excess patient deaths. Dr Malhotra opines that academic malpractice such as this should be a criminal offence, which it is currently not, with the offending researcher in this case being merely fired.
Returning again to the backlash he has faced for speaking his opinions on diet, medication and health, Dr Malhotra recalls how he was pilloried for advocating a low carbohydrate way of eating with his book, The Pioppi Diet, which heavily influenced MP Tom Watson to lose weight and put his type 2 diabetes into remission.
In the final part of his talk, Dr Malhotra talks about how one can be a public health advocate in the face of adversity, while recounting recent developments in his own campaign. He finishes by making the point that one of the best ways we can move forward is by empowering patients to make informed decisions.
If you would like to see more from Dr Malhotra, you can view his previous PHC talks here:
2018: Lessons in public health advocacy
2017: Too much medicine and the great statin con
