Patrick Holford Claims More People Die, Prematurely, From Cardiovascular Disease Than Actually Die, Prematurely, From All Causes

Patrick Holford on ITV Lunchtime 16 April 2008
Former Visiting Professor Patrick Holford is Head of Science and Education at Biocare. Despite the imprimatur of respectability about these confidence-inspiring titles, from time to time, there are disappointing errors in the content of Holford’s health advice and sales pitches for home tests and the evidence base for supplements. These errors are all the more dispiriting when one recalls that he was corrected about some of them more than two years ago. We don’t mean differences of opinion, we mean verifiable, checkable facts. When Holford persuades people to rely upon his opinion and lend credence to it because he undertakes to do the scientific research and interpret it for them then it seems inappropriate to claim that more people died, prematurely, from a specific cause than actually died, prematurely, from all causes.

The remainder of this post is an elaboration on the theme that Holford has been wrong about this specific topic before and he is still egregiously wrong despite having his errors pointed out to him. He over-states mortality rates in a way that may alarm readers and might be helpful for the sales of home test kits and supplements but does not aid the public understanding of these issues.

Holford claims that:

More people die prematurely from diseases of the heart and arteries than anything else – 250,000 a year…[Holford email June 22 2009, Reduce your risk of heart disease.]

The most up to date statistics are available from the British Heart Foundation‘s annual report.[1] The most recent reveals that there were 198,395 deaths under the age of 75 for all causes in 2006 in England, Wales, Scotland, Northern Ireland and United Kingdom (Table 1.3, 2008 British Heart Foundation statistics report). There were substantially fewer than 250,000 premature deaths yet Holford claims that there were 250,000 premature deaths from cardiovascular diseases in a year.[a] He mis-reports the facts by approx. 500%. In fact, in 2006, there weren’t even 250,000 deaths from all diseases of the circulatory system even if you include all ages: there were 197,767 (Table 1.2, 2008 British Heart Foundation statistics report).

In a later post we will discuss the impact of errors like this on the NHS should Primary Care Trusts and GP practices ever succumb to marketing hype and overlook the evidence-based advice available from Registered Dietitians and start to refer patients to IONistas and BANTers of similar ilk which seems to be the current business plan and focus.[b]

The detail of Holford’s error is given below.

May 2007, HolfordWatch pointed out that Holford had made some arithmetical errors in reporting some frightening statistics relating to coronary heart disease and stroke and using those figures to justify a regime of expensive blood tests and supplements. HolfordWatch ran the calculations and presented the correct figures that were considerably less alarming.

Not only has Holford failed to correct those errors in his existing materials, he continues to repeat them, not only in his marketing materials but his publications. In repeating them, for someone who so regularly upbraids medical and healthcare staff for ‘failing to keep up to date’, he also demonstrates that he is not monitoring the most recent figures despite his self-praise as the interlocutor who constantly monitors health research so that he can translate it for others.

More people die prematurely from diseases of the heart and arteries than anything else – 250,000 a year, half from heart attacks and a quarter from strokes. Yet both of these are largely preventable diseases with highly familiar risk factors, such as poor diet, smoking, obesity and lack of exercise.
The medical treatment
If you’ve just been diagnosed with some form of heart disease – angina, hypertension (high blood pressure), thrombosis, a stroke or heart attack – your doctor is probably unlikely to focus on these risk factors. [Holford email June 22 2009, Reduce your risk of heart disease.]

No. As we pointed out in 2007, Holford had mis-reported the figures from 2004 when he discussed “heart attack and stroke”. When HolfordWatch checked the 2006 British Heart Foundation statistics report we learned that:

CVD caused just under 60,000 premature deaths in the UK in 2004.

Ca. 60,000, not 250,000. There is no room for complacency, but the figures were lower than the alarming ones that Holford stated.

In the spirit of fairness we checked the most up to date figures from the 2008 British Heart Foundation statistics report (that reflects data collected in 2006).

CVD is one of the main causes of premature death in the UK (death before the age of 75). 30% of premature deaths in men and 22% of premature deaths in women were from CVD in 2006…CVD caused just over 53,000 premature deaths in the UK in 2006…

CHD, by itself, is the most common cause of premature death in the UK…About one fifth (19%) of premature deaths in men and one in ten (10%) premature deaths in women were from CHD…CHD caused almost 31,000 premature deaths in the UK in 2006…

Other forms of heart disease cause more than 7,500 premature deaths in the UK each year. In total there were 38,000 premature deaths from heart disease in the UK in 2006 – around one fifth of all premature deaths.

These statistics reveal that there were 198,395 deaths under the age of 75 for all causes in 2006 in England, Wales, Scotland, Northern Ireland and United Kingdom (Table 1.3, 2008 British Heart Foundation statistics report, “all causes” includes not only cancers and respiratory disease but injuries and poisonings). There were substantially fewer than 250,000 premature deaths yet Holford claims that there were 250,000 premature deaths from cardiovascular diseases in a year.

Note that the collator of these statistics does not claim that ‘more people die prematurely from these diseases than any other cause’, only Holford does. The BHF precisely identifies “CHD, by itself, [as] the most common cause of premature death in the UK” (pg. 12). The BHF also defines “premature”, it would be interesting to know if “death before the age of 75” would be most people’s understanding of “premature” when used in the way that Holford does.

That approx 53,000 premature deaths includes the approx. 10,000 deaths from stroke and 38,000 from all heart disease (it is difficult to tease out what Holford understands by “heart attack” and the statistics are not presented in that manner). I have adapted these data from Table 1.3 of the report.

All deaths and deaths under age 75, 2006, UK
All ages  

Under 75

All causes

571,034  

198,395

All diseases of the circulatory system

197,767  

53,324

It is still too many, but there is a noticeable drop in the reported number of premature deaths from CVD between even 2004 to 2006. BHF makes the following observations.

Recent trends in death rates in the UK
Death rates from CVD have been falling in the UK since the early 1970s. For people under 75 years, they have fallen by 40% in the last ten years

Death rates from CHD have been falling in the UK since the late 1970s…For people under 65 years, they have fallen by 45% in the last ten years

Death rates from stroke fell throughout the latter part of the twentieth century. For people under 65 they have fallen by 30% in the last ten years…[pp. 12-13. Bold emphasis added.]

The remainder of Holford’s email contains too many errors or unsubstantiated assertions to cover in this post. However, we would like to point out that the both other considerations and NICE guidelines undercut Holford’s assertion (no matter how caveated with “probably unlikely to focus”) that:

If you’ve just been diagnosed with some form of heart disease – angina, hypertension (high blood pressure), thrombosis, a stroke or heart attack – your doctor is probably unlikely to focus on these risk factors. [Holford email June 22 2009, Reduce your risk of heart disease.]

In the case of a thrombosis, stroke or heart attack, there are probably more immediately pressing issues than your intake of oily fish. A patient may well need clot-busting drugs, blood thinners or surgical intervention to clear blockages. Nonetheless, after the immediate crisis has passed and the patient is stable enough to embark upon rehabilitation, the coronary care team or similar are very interested and involved in diet and lifestyle for secondary prevention of further incidents.

But what about stable angina or hypertension or primary prevention? Are doctors uninterested in diet and lifestyle factors where these are involved?

NICE has provided extensive documentation in support of the recent Clinical Guidelines for Lipid Modification: Cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease.[2] NICE has taken considerable care to state that, aside from age and sex, there are modifiable risk factors such as smoking, raised blood pressure and raised cholesterol that make a contribution to heart disease, particularly in combination. They highlight the need to identify people at higher risk of CVD such as those with heart disease in the family or men with a South Asian (for example, Indian, Pakistani or Bangladeshi) background. They also include social deprivation as a proxy indicator for an increased risk of CVD.

For primary prevention, NICE recommends that people should be prioritised on the basis of an estimate of their CVD risk before a full formal risk assessment. Their CVD risk should be estimated using CVD risk factors already recorded in primary care electronic medical records. Despite Holford’s assertions (for which he gives no references or any substantiation) NICE emphasises that before offering drugs to reduce cholesterol levels, all other modifiable risk factors should be considered and support given to manage them: this includes support for smoking cessation and advice for dietary modification, weight loss (if necessary), lifestyle changes, increasing physical activity levels etc. It also details the additional tests and assessments that should be performed to identify and manage secondary causes that dysregulate cholesterol levels such as thyroid issues.[c]

NICE recommends statin therapy for primary prevention when the individualised risk of CVD is more than 20% over the next 10 years. However, they emphasise that the decision to initiate statin therapy should follow an informed discussion of all an individual’s risks and benefits and should be arrived at jointly between the responsible clinician and the individual.[d]

However, NICE emphasises that the decision to embark on (say) statin therapy for primary prevention should not be taken lightly and is to be advised only for those at higher risk, and to be used in conjuction with other risk-management strategies such as smoking cessation etc..

Compare and contrast the actual premature mortality statistics for CVD with Holford’s assertions. Compare and contrast NICE’s actual guidance with Holford’s assertions. Should PCTs and GP practices really be considering referring patients to nutritionistas[b] who have been trained by people who persist in such errors and who are strongly associated with them? Your grandmother could probably tell you the standard dietary advice for reducing heart risk in-between admonishing you to eat your greens, make time for your friends and get out in the fresh air. So, beyond that, why should PCTs and GP practices consider referring patients to nutritionists who, depending on their qualifications, lack the firm theoretical grounding, experience and exposure to patients that Registered Dietitians have?

HolfordWatch would like to acknowledge some welcome changes in Holford’s emails. They used to be lamentably lacking in nuance and the caveats that one likes to see when dispensing health advice. Now, for whatever reason, they do contain the occasional sentence such as, “do not change any prescribed medication without first consulting your doctor” and “[o]bviously, if you’ve had a heart attack or have very high blood pressure, we’re not suggesting you throw your drugs away”. Of course, in the context of the emails, they may seem a little half-hearted or even CYA to some readers. One slickly-worded section of the same email asserts:

The trouble is these medications all interfere with some aspect of your body’s chemistry and none are necessary if you address the underlying causes of heart disease.

Really? People with (say) familial combined hyperlipidaemia who have been unable to control their lipids even with aggressive diet and lifestyle management might not need these medications? Or people whose heart tissue has been damaged by (say) morbidity associated with a vaccine preventable illness? But – baby steps.

Notes

NB Clinical Guidelines and Evidence Review for Lipid Modification:
cardiovascular risk assessment and the primary and secondary prevention of
cardiovascular disease
(pdf) is the source of the following quotations from the guidelines for notes c and d.
[a] See BHF glossary for descriptions of Cardiovascular Disease and Coronary Heart Disease and stroke. Effectively, CHD is a subset of CVD.
[b] BANT newsletter, June 2009.

A role for Nutritional Therapists in the NHS?
On the 1st April 2009, the vascular checks assessment (VRA) progamme was introduced in several test areas over the UK. This is an ambitious initiative which will offer preventative checks to all those aged 40 -74 to assess their risk of vascular disease (heart disease, stroke, diabetes and kidney disease) followed by appropriate management and interventions. The programme will be slowly implemented and introduced nationwide over the next 3 years.
The objective of this new policy is to promote the prevention or early identification of vascular disease by introducing a universal risk assessment and management programme. Those with high risk will get referred on for services (e.g. exercise or nutrition services). This may be an exciting opportunity as Nutritional Therapy could be included in this intervention in several ways e.g. weight management, lifestyle changes for impaired glucose tolerance, reducing blood pressure, cholesterol and triglycerides.
As well as the VRA, Polyclinics are opening all over the country and larger GP led practices in an attempt to integrate NHS services. The Department of Health says that one of the main challenges facing the NHS is that patients want greater control of their health care and the NHS wants to promote healthy lives. They want to concentrate on personal care for long term medical conditions. The emphasis is very much on quality. This is where Nutritional Therapists can really add value.
One of the problems that we may face is that each PCT interprets policy differently and many GPs are still not receptive to our services. When approaching GP practices we can help with them achieving their QOF targets (Quality and Outcomes Framework for GP practices – http://www.qof.ic.nhs.uk/) as well as giving added value to their practice, monetarily as well as qualitative.
For more information on the VRA go to http://www.improvement.nhs.uk/
vascularchecks

See NHS Health Check for more information about these programmes.
[c] pp. 134-5; Section 6.1.2.

Baseline blood tests and clinical assessment should be performed, and comorbidities and secondary causes of dyslipidaemia should be treated. Assessment should include:

  • smoking status
  • alcohol consumption
  • blood pressure (see ‘Hypertension’, NICE clinical guideline 34)
  • body mass index or other measure of obesity (see ‘Obesity’,
    NICE clinical guideline 43)
  • fasting total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides (if fasting levels are not already available)
  • fasting blood glucose
  • renal function
  • liver function (transaminases)
  • thyroid-stimulating hormone (TSH) if dyslipidaemia is present.

[d] pg. 135; Section 6.1.4.

The decision whether to initiate statin therapy should be made after an informed discussion between the responsible clinician and the person about the risks and benefits of statin treatment, taking into account additional factors such as comorbidities and life expectancy.

References

[1] Steven Allender, Viv Peto, Peter Scarborough, Asha Kaur and Mike Rayner (2008) Coronary heart disease statistics. BHF: London
[2] Cooper A, Nherera L, Calvert N, O’Flynn N, Turnbull N, Robson J, Camosso-Stefinovic J, Rule C, Browne N, Ritchie G, Stokes T, Mannan R, Brindle P, Gill P, Gujral R, Hogg M, Marshall T, Minhas R, Pavitt L, Reckless J, Rutherford A, Thorogood M, Wood D (2007) Clinical Guidelines and Evidence Review for Lipid Modification: cardiovascular risk assessment and the primary and secondary prevention of cardiovascular disease (pdf). London: National Collaborating Centre for Primary Care and Royal College of General Practitioners.

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9 Comments

Filed under Holford, home test, hometesting, homocysteine, patrick holford, supplements

9 responses to “Patrick Holford Claims More People Die, Prematurely, From Cardiovascular Disease Than Actually Die, Prematurely, From All Causes

  1. Wulfstan

    Is this some form of anti-homeopathy? If Patrick Holford states that there are more people dying prematurely from heart attacks and strokes than actually die, prematurely from all causes including cancer, injuries from car accidents, mis-adventure, brain aneurysms etc. then either something is awry with his arithmetic or he has insights that are beyond our knowing (to employ a PoModism that irritates me beyond belief).

    It is approaching a stroke of genius to claim that there are more premature deaths from heart attacks and strokes than there actually are for all deaths from diseases of the circulatory system across all ages.

    It’s a shame Patrick Holford can’t bring himself to acknowledge the improvements in reducing the death rate from heart attacks and strokes. However, I suppose that such an acknowledgement doesn’t help if you need to earn commission from endorsing or selling tests and pills.

    If I needed guidance on reducing CVD risk, I would hope my GP would refer me to an RD. If not, I hope that I would be able to refuse a referral to an practitioner of nutritionism without being apprehensive about being removed from a GP’s list for lack of co-operation.

  2. This is quite depressing. Holford not only getting things wrong, but tediously repetitively so…

  3. How unfortunate that “one of the most inspiring and informative health and nutritional experts at the cutting edge of health transformation” has made such an error.

    • Unfortunate for arithmetic, the ability to interpret simple tabular data, comprehend a well-written, clearly laid out report (both the earlier statistics report and the more recent), science and the public understanding of the multi-factorial contribution of various factors in the aetiology of CVD, risk factors, workable prevention strategies etc.

      Nonetheless, a serendipitous error for any who win commission from selling tests and supplements or who are paid in some way to endorse them.

  4. Any idea where the 250,000 figure came from, or did he just pull it out of thin air (or worse…?)

    • The 250,000 came from a misunderstanding of an earlier version of the report (it’s explained in the linked 2007 post). Holford seems to have failed to distinguish between the total no. of deaths from CVD (all ages) and the no. of premature deaths (before the age of 75).

      The total number of deaths from CVD is a “quarter of a million”; the number of premature deaths that involve CVD is “just under 60,000″.

      As ever, no room for complacency but it looks like improvements are such that the most comparable figure is substantially fewer than 250,000, the report says that there are 197,767 deaths from all diseases of the circulatory system even if you include all ages.

  5. That BANT newsletter is total b***** nonsense. It states that GPs are still not receptive to our services.

    I think I am correct in saying that GPs take a big personal risk if they refer patients to some one not regulated by a statutory body. If something goes wrong they could be guilty of professional misconduct. Rather worryingly BANT have no understanding of the rules or the regulatory framework under which GPs work.

    I’ll see if I can find a link on the GMC website.

  6. Pingback: Patrick Holford, Shark Liver Oil and Walnuts « Holford Watch: Patrick Holford, nutritionism and bad science

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