Does low cholesterol cause death?

Is the use of cholesterol in mortality risk algorithms in clinical guidelines valid? Ten years prospective data from the Norwegian HUNT 2 study

RATIONALE, AIMS AND OBJECTIVES

Many clinical guidelines for cardiovascular disease (CVD) prevention contain risk estimation charts/calculators. These have shown a tendency to overestimate risk, which indicates that there might be theoretical flaws in the algorithms. Total cholesterol is a frequently used variable in the risk estimates. Some studies indicate that the predictive properties of cholesterol might not be as straightforward as widely assumed. Our aim was to document the strength and validity of total cholesterol as a risk factor for mortality in a well-defined, general Norwegian population without known CVD at baseline.

METHODS

We assessed the association of total serum cholesterol with total mortality, as well as mortality from CVD and ischaemic heart disease (IHD), using Cox proportional hazard models. The study population comprises 52 087 Norwegians, aged 20-74, who participated in the Nord-Trøndelag Health Study (HUNT 2, 1995-1997) and were followed-up on cause-specific mortality for 10 years (510 297 person-years in total).

RESULTS

Among women, cholesterol had an inverse association with all-cause mortality [hazard ratio (HR): 0.94; 95% confidence interval (CI): 0.89-0.99 per 1.0 mmol L(-1) increase] as well as CVD mortality (HR: 0.97; 95% CI: 0.88-1.07). The association with IHD mortality (HR: 1.07; 95% CI: 0.92-1.24) was not linear but seemed to follow a 'U-shaped' curve, with the highest mortality <5.0 and ≥7.0 mmol L(-1) . Among men, the association of cholesterol with mortality from CVD (HR: 1.06; 95% CI: 0.98-1.15) and in total (HR: 0.98; 95% CI: 0.93-1.03) followed a 'U-shaped' pattern.

CONCLUSION

Our study provides an updated epidemiological indication of possible errors in the CVD risk algorithms of many clinical guidelines. If our findings are generalizable, clinical and public health recommendations regarding the 'dangers' of cholesterol should be revised. This is especially true for women, for whom moderately elevated cholesterol (by current standards) may prove to be not only harmless but even beneficial.

Understanding the neurobiology of suicidal behavior

Our current knowledge about the neurobiology of suicide is still limited. Technical limitations and the complexity of the CNS are major obstacles. However, there is evidence for a hereditary disposition to suicide, which appears to be independent of diagnosis. Clinical, postmortem, genetic, and animal studies suggest that serotonin has a central role. The main regions of interest in the CNS have been the dorsal and median raphe nuclei in the midbrain that host the main serotonergic cell bodies and the prefrontal cortex, particularly the ventral PFC, innervated by the serotonergic system. In vivo and postmortem studies indicate serotonergic hypofunction in suicide and serious suicide attempts. This deficiency in turn can lead to a predisposition to impulsive and aggressive behavior, probably due to a breakdown in the inhibitory function of the ventral prefrontal cortex as a result of less serotonin input. In the context of this predisposition and the development of mental illness or other life stressors, the individual is at risk of acting on suicidal thoughts. Such deficient serotonin input into the PFC may arise as a result of genetic, parenting, head injury, and other effects. Identifying psychiatric, social, and environmental predictors of suicide are studied to improve prediction and prevention of suicide. A better understanding of the neurobiology of suicide can help detect at risk populations and help develop better treatment interventions.

Assessing the observed relationship between low cholesterol and violence-related mortality. Implications for suicide risk

Health advocacy groups advise all Americans to restrict their dietary intake of saturated fat and cholesterol as an efficacious and safe way to lower plasma cholesterol concentrations and thus reduce the risk of coronary heart disease and other atherosclerotic disorders. However, accumulating evidence suggests that naturally low or clinically reduced cholesterol is associated with increased nonillness mortality (principally suicide and accidents). Other evidence suggests that such increases in suicide and traumatic death may be mediated by the adverse changes in behavior and mood that sometimes accompany low or reduced cholesterol. These observations provided the rationale for an ongoing series of studies in monkeys designed to explore the hypothesis that alterations in dietary or plasma cholesterol influence behavior and that such effects are potentiated by lipid-induced changes in brain chemistry. In fact, the investigations in monkeys reveal that reductions in plasma cholesterol increase the tendency to engage in impulsive or violent behavior through a mechanism involving central serotonergic activity. It is speculated that the cholesterol-serotonin-behavior association represents a mechanism evolved to increase hunting or competitive foraging behavior in the face of nutritional threats signaled by a decline in total serum cholesterol (TC). The epidemiological and experimental data could be interpreted as having two implications for public health: (1) low-cholesterol may be a marker for risk of suicide or traumatic death and (2) cholesterol lowering may have adverse effects for some individuals under some circumstances.

Influence of dietary lipids on agonistic and affiliative behavior in Macaca fascicularis

The current study evaluates the hypothesis, derived from previous investigations, that alterations in dietary fat and cholesterol influence the social behavior of monkeys. Subjects were 62 adult male, cynomolgus macaques (Macaca fascicularis) assigned originally to an investigation of atherosclerosis regression. This study thus involves a secondary analysis of data derived from an investigation conducted for another purpose. Animals were housed for 14 months' in social groups of five individuals each and initially fed a diet very high in saturated fat and cholesterol to induce coronary artery atherosclerosis. Monkeys were then exposed for 28 months to one of three conditions; (1) a moderately high-fat, high-cholesterol diet and an unstable social environment (in which monkeys were switched among groups monthly); (2) a low-fat, low-cholesterol diet and an unstable social environment; and (3) a low-fat, low-cholesterol diet and a stable social environment. A comparison of animals living in unstable groups revealed that those consuming the low-fat diet exhibited more overt aggression (P < 0.001) and overt submission (P < 0.01) than did monkeys eating the high-fat diet. A second comparison involved only those animals living in stable social units. These monkeys, while consuming the low-fat diet, engaged in more aggression and submission (P_s < 0.05), spent less time in passive body contact or within touching distance (P_s < 0.001), and spent more time alone (P < 0.001) than they had initially while consuming a very high-fat diet. The current investigation is the first on this topic to include measures of social behavior in animals both before and after a reduction in dietary fat. The findings that such a reduction is associated with increased agonism and decreased affiliation may help explain the epidemiologic association in human beings between low or reduced plasma cholesterol concentrations and a high incidence of violence-related mortality. More generally, the data are consistent with the hypothesis that there is a negative feedback adaptation providing for appropriate changes in behavior in response to periodic dietary privation. © 1996 Wiley-Liss, Inc.