Cholesterol denialism

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For the polar opposite fallacy, see dietary cholesterol.

Cholesterol denialism is a form of pseudoscientific denialism that asserts that high blood LDL cholesterol levels do not increase the risk of cardiovascular disease. A related idea known as statin denialism holds that statin usage does not reduce the likelihood of cardiovascular disease. Proponents claim that statins should be avoided because they are sold by Big Pharma and cause adverse side effects. It is promoted by carnivore diet and LCHF conspiracy theorists and has a presence on social media platforms such as Twitter.

Cholesterol and statin deniers claim that saturated fat has wrongly been demonized by medical scientists and is healthy for dieting in very high quantities. They say that there is no link between LDL-c and total blood cholesterol levels and the risk of cardiovascular disease.[1] This view is contradicted by scientific evidence and has been described as bad science and dangerous.[1]

The leading advocates of cholesterol and statin denialism are associated with The International Network of Cholesterol Skeptics (THINCS). They have been accused of "cherry-pick[ing] the scientific literature to find studies that support their theses, ignore the flaws in those studies, and ignore the vast body of literature that contradicts them."[2] Statin denialists are known to exaggerate the side effects of statins and utilize scaremongering tactics.[3]

Global deaths attributable to high LDL-C increased from 3 million in 1990 to 4.4 million in 2019.[4] Disability-adjusted life yearsWikipedia (DALYs) attributable to high LDL-C also increased from 69.7 million in 1990 to 98.6 million in 2019.[4] In 2021, the World Heart Federation reported that elevated LDL-C contributed to 3.8 million CVD deaths.[5]

Criticism from the medical community[edit]

Cholesterol and statin denialism is not taken seriously by the medical community. Poor adherence to statin therapy is linked to significantly increased risk of cardiovascular events and death.[6]

In 2017, cholesterol denialist Aseem Malhotra and colleagues published an article which disputed the link between blood cholesterol levels and occurrence of heart disease. The authors also suggested that "stopping statins may paradoxically save more lives".[7] The article was criticized by the medical community. Cardiologist Tim Chico commented that "high cholesterol has been proven beyond all doubt to contribute to coronary artery disease and heart attack […] to say the cholesterol hypothesis is dead is simply incorrect."[8]

Cardiologist Steven E. Nissen, has described statin denialism as an "internet-driven cult with deadly consequences."[9] He has also written that "we have abundant scientific evidence demonstrating that treatment of high risk primary prevention patients substantially reduces the risk of cardiovascular morbidity." Whilst acknowledging that statins, like other drugs, have adverse effects, "the benefits are so well documented that every effort should be made to encourage use of these drugs in appropriate patients."[10]

Professor of Medicine and Epidemiology Rory Collins has compared statin denialism to flat earthism, he has noted "the claims that blood LDL cholesterol levels are not causally related to cardiovascular disease (which is really in the same realm as claiming that smoking does not cause cancer) are factually false."[1]

James Stein, a Professor of Cardiovascular Research has stated that "many lives have been lost or impaired because of statin non-compliance."[11]

In 2019, a joint editorial was published in the top cardiovascular journals around the world to warn people about the medical misinformation of statin denialism found on social media.[12][13][14]

"But they're measuring the wrong things!"[edit]

Blood levels of LDL cholesterol (the "bad" cholesterol correlated with heart disease) are typically calculated by measuring total blood cholesterol (in mg/dL in the U.S. and mmol/L elsewhere), subtracting the measured amount of HDL cholesterol, and further subtracting a constant fraction of the measured blood triglycerides.[15]

While this is good enough for most people, cholesterol denialists aren't most people. They'll claim that it's the ratio of LDL cholesterol to HDL cholesterol, not the absolute amounts, that matter, and therefore cholesterol doesn't cause heart disease. They'll claim that the triglyceride-to-cholesterol ratio isn't always constant, which screws up the calculation for LDL cholesterol levels, therefore cholesterol doesn't cause heart disease. They'll claim that it's the LDL particle count (LDL-P), not the LDL cholesterol level (LDL-C) that matters, therefore cholesterol doesn't cause heart disease.[16] They'll claim that there are two kinds of LDL cholesterol molecules -- large and fluffy, versus small and dense -- and that therefore cholesterol doesn't cause heart disease. I think you can see the pattern here.

Current consensus[edit]

There is a strong medical consensus from clinical trials and human Mendelian randomization studies that LDL-C is causally related to atherosclerotic cardiovascular disease, and that lowering LDL particles and other ApoB-containing lipoproteins as much as possible reduces cardiovascular events.[17]

By 2012, many clinical trials had been done.[18] The Cholesterol Treatment Trialists' Collaboration confirmed the LDL-C hypothesis after examining data from 26 trials involving 170 000 participants. According to their meta-analysis:

Further reductions in LDL cholesterol safely produce definite further reductions in the incidence of heart attack, of revascularisation, and of ischaemic stroke, with each 1·0 mmol/L reduction reducing the annual rate of these major vascular events by just over a fifth. There was no evidence of any threshold within the cholesterol range studied, suggesting that reduction of LDL cholesterol by 2–3 mmol/L would reduce risk by about 40–50%.[19]

In 2019, the European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS) stated that the "LDL-C hypothesis" is no longer a hypothesis, it is an established fact:

Several recent placebo-controlled clinical studies have shown that the addition of either ezetimibe or anti-proprotein convertase subtilisin/kexin type 9 (PCSK9) monoclonal antibodies (mAbs) to statin therapy provides a further reduction in atherosclerotic cardiovascular disease (ASCVD) risk, which is directly and positively correlated with the incrementally achieved absolute LDL-C reduction. Furthermore, these clinical trials have clearly indicated that the lower the achieved LDL-C values, the lower the risk of future cardiovascular (CV) events, with no lower limit for LDL-C values, or ‘J’-curve effect... Human Mendelian randomization studies have demonstrated the critical role of LDL-C, and other cholesterol-rich ApoB-containing lipoproteins, in atherosclerotic plaque formation and related subsequent CV events. Thus, there is no longer an ‘LDL-C hypothesis’, but established facts that increased LDL-C values are causally related to ASCVD, and that lowering LDL particles and other ApoB-containing lipoproteins as much as possible reduces CV events.[17]

The above is supported by current textbooks on lipidology. For example, Clinical Lipidology: A Companion to Braunwald's Heart Disease (third edition), published in 2024 states:

The first and most relevant update presented in the 2019 guidelines concerns the old concept of an “LDL-C hypothesis,” which is now replaced by the established causal role of elevated LDL-C levels in ASCVD. Besides this causal role, genetic studies have introduced the concept of exposure time, revealing that LDL-C also has a cumulative effect on the risk of ASCVD9, a longer-term exposure leads to a greater retention over time of LDL particles (or, more generally, proatherogenic apoB-containing particles) in the arterial wall. Thus, the overall effect of LDL-C level on ASCVD risk is determined by the combination of both plasma levels and time of exposure.[20]

Cholesterol denialists are either unaware about any of these scientific developments or ignore all of the modern research from clinical trials and human Mendelian randomization studies.

List of notable cholesterol denialists[edit]

See also[edit]


  1. 1.0 1.1 1.2 1.3 1.4 Butter nonsense: the rise of the cholesterol deniers
  2. 2.0 2.1 2.2 2.3 2.4 Statin Denialism
  3. The Movie “Cholesterol: The Great Bluff” Is an Exercise in Denialism
  4. 4.0 4.1 Global Burden Attributable to High Low-Density Lipoprotein-Cholesterol From 1990 to 2019
  6. Lansberg et al 2018. Nonadherence to statins: individualized intervention strategies outside the pill box. Vasc Health Risk Manag 14: 91–102.
  7. Demasi, M; Lustig R. H; Malhotra A. (2017). "The cholesterol and calorie hypotheses are both dead — it is time to focus on the real culprit: insulin resistance". The Pharmaceutical Journal doi:10.1211/CP.2017.20203046.
  8. Expert reaction to new report on statins and the cholesterol hypothesis
  9. Nissen SE. (2017). "Statin Denial: An Internet-Driven Cult With Deadly Consequences". Ann Intern Med. 2017 Aug 15;167(4): 281-282.
  10. Nissen Calls Statin Denialism A Deadly Internet-Driven Cult
  11. Dr. James Stein Speaks Out Against "Statin Denialism"
  12. Editors-in-chief of major cardiovascular journals claim medical misinformation puts “lives at stake”.
  13. Hill JA, et al. Medical misinformation: vet the message!. European Heart Journal - Cardiovascular Pharmacotherapy 5 (2): 62-63.
  14. Medical Misinformation: Vet the Message!. List of the journals that have published the editorial.
  15. LDL-Cholesterol – The “Bad” Cholesterol Explained, Sigurdsson, Doc's Opinion, 24-Mar-2019
  16. The Diet-Heart Myth: Why Everyone Should Know Their LDL Particle Number, Chris Kresser, 17-March-2019
  17. 17.0 17.1 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk: The Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS)
  18. The Lipid Hypothesis
  19. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170 000 participants in 26 randomised trials
  20. Treatment Guidelines Overview: European Society of Cardiology/European Atherosclerosis Society Guidelines Treatment Guidelines Overview: European Society of Cardiology/European Atherosclerosis Society Guidelines
  21. Tim Noakes called a 'cholesterol denialist'