The Clot Thickens

I have enjoyed Dr Kendrick’s talks and books, most notably Doctoring Data published in 2015, which shone a light on how scientific data is often manipulated by the corporate world for the purposes of profit.

On his website ([https://drmalcolmkendrick.org/]) he lays out his stall thus:

“This blog is my best effort at providing some balance to the increasingly strident healthcare lobby that seems intent on scaring everyone about almost everything. Is there a foodstuff that is safe to eat anymore? Is there any activity that does not cause cancer or heart disease?”

Malcolm Kendrick is a GP based in Macclesfield, with a special interest in cardiovascular disease (CVD). His conviction is that the bad cholesterol (LDL) / saturated fat thrombogenic hypothesis is unsound. Casting aside a central tenet of medical wisdom doesn’t make you friends. And, given the profits that have accrued from the sales of statins, more likely to make you enemies.

A quote from the American economist, the late John Kenneth Galbraith comes to mind, “Faced with the choice between changing one's mind and proving that there is no need to do so, almost everyone gets busy on the proof”, and the cholesterol thesis is no exception.

This latest book is an update on The Great Cholesterol Con published back in 2007. Comparing the two, The Clot Thickens is in larger format, and now fully referenced and indexed. A notable addition to his thesis is the role of the glycocalyx, a layer of glycoproteins that line and protect the endothelium of the arteries. First identified in 1970, its importance in competent vascular function will only have emerged since Kendrick’s earlier book.

An alternative “encrustation” hypothesis dating back to 1852, was proposed by Austrian pathologist Karl von Rokitansky (according to Encyclopaedia Britannica, he personally conducted some 30,000 autopsies!). The repair of endothelium damage necessitates clotting at the arterial wall, which repeated over time results in the build-up of hard atherosclerotic plaques. Slivers of these, if dislodged, can result in coronary heart disease and strokes through blocking arterioles downstream.

The fact that cholesterol is not soluble in the blood stream but has to be transported in a lipid is the “fly in the ointment” of the dominant thesis. Yet, cholesterol crystals are present in atherosclerotic plaques, a discovery by Rudolph Virchow of Triad fame, so “from whence?” is the question arising. That LDL is the source stumbles due to the esterified nature of the cholesterol therein, whereas cholesterol crystals require pure cholesterol. The answer is the erythrocytes. In a further twist to the tale, lipoprotein fragments found in plaques are not LDL as believed, but a closely related protein Lp(a) which has an important role in clotting. The robust nature of the clots resulting in atherosclerotic plaques is due to Lp(a) and is problematic in CVD.

Thus, the “encrustation” theory is resurrected. Atherosclerotic plaques arise from damage to the arterial endothelium (plaques are unique to the large arteries and form under the endothelium). But what are the cause or causes of endothelial and glycocalyx damage? The reader now enters familiar territory and as might be expected the following come to the fore:

Environmental factors (e.g. pollution, drugs / alcohol etc.)

Metabolic disease (e.g. diabetes)

Factors impacting the renin-angiotensin-aldosterone system (RAAS) (e.g. hypertension)

Factors impacting the hypothalamus-pituitary-adrenal (HPA) axis (e.g. stress / strain)

Diseases causing vasculitis (e.g. Lupus and Rheumatoid Arthritis)

and so on…

As an interesting aside Dr Kendrick notes that the acute hypoxia seen in COVID-19 results from a vascular inflammation. However, he predicts that the chronic impact may be worse through increased incidence of CVD as a consequence of long term anxiety (strain) from isolation, economic pressures and more.

Part 2 considers the impact on impact on life expectancy of lifestyle choices (though “choice” may be a misnomer) and actions one might take to assure good cardio-vascular health. Beyond some judicious supplementation, as ever the fundamentals of health don’t change. On my shelf I have a number of books from the late naturopath Jan de Vries, who had a busy clinic in Troon, Ayrshire, Scotland, for many years; one is titled Treating Body Mind and Soul each to be respected. Simple!

Dr Kendrick has a certain style of dry humour that runs throughout the book and appeals to me. Likely it keeps him sane. But I am a fellow Scot, so must declare cultural bias.

The cholesterol / saturated fat hypothesis stems from the work of the late Ancel Keys (1904-2004) in the USA. Whilst writing this review I dipped into his story finding a web page with the intriguing title “pulling Ancel Keys out from under a bus”¹. Hypothesis, right or wrong, it seems to me that his Seven Countries Study epidemiological study into CVD, which ran for some decades, was an honest effort. Keys lived to 100 and spent much of his retirement years in Italy (he favoured the Mediterranean diet). Given that the first statins came to market in the late 1980s by which time Keys would have retired, this quote from the article might have validity.

“Misadventures in low-fat eating, to say nothing of low-fat junk foods, cannot legitimately be attributed to any position espoused by Keys over the course of his career. … There is more than one way to eat badly, and if the American public has been committed to exploring them sequentially, blame for it cannot be laid at the door – or now the grave – of Ancel Keys.”

So in conclusion, I would have liked to seen a page or two on the achievements as well as the possible failings in Keys work, but that aside Dr Kendrick’s book is a courageous work, not just in the promotion of sound science but also his highlighting, yet again, of the impending death of science at the hands of corporate interests.

[https://oldwayspt.org/blog/pulling-ancel-keys-out-under-bus]