MONICA, Oh MONICA, Where Art Thou?
Jun 2013 30
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Regular readers will know I'm no fan of nutritional epidemiology. This is where researchers gather up a bunch of people, give them a diet questionnaire every few years and pretend this is an accurate representation of their daily diet, then record who suffers or dies from whatever disease they are supposedly studying.

One routinely reads headlines and articles claiming "New study shows red meat causes cancer!" or "whole-grain cereals lower heart disease risk", but when you source the study this allegedly life-saving revelation came from, invariably it was an epidemiological project. This is despite the fact that epidemiological studies can't even begin to "show" that red meat/eggs/full cream milk/yellow Smarties/pickled gherkins cause heart disease, cancer, diabetes or any other ailment.

Nutritional epidemiological studies can't prove diddly, because they are manifestly inadequate to detect anything other than statistical associations. They cannot, I repeat cannot, establish causality. The first rule of good science is association does not equal causation. Unfortunately, this rule is routinely ignored in this day and age where health authorities prefer to dredge supportive data from epidemiological studies, having well learned over the years that randomized clinical trials have the annoying tendency to thoroughly demolish their most cherished beliefs.

And so we have the prevailing trend nowadays in which researchers, health authorities and other so-called 'experts' discuss the findings of epidemiological studies as if they were physiological fact.

Epidemiology's Biggest Wank of All

The cholesterol theory of heart disease - the same contradiction-riddled theory that dominates modern CVD prevention attempts, that gave us cholesterol-free but cancer-causing omega-6-rich vegetable oils, utterly ineffective low-fat diets and toxic cholesterol-lowering drugs that wreak havoc upon muscles, tendons, nerves and even sexual organs - was built upon epidemiology.

More specifically, it was built upon the back of one of the most pathetic and selective epidemiological exercises conducted in the very spotted history of humankind. I'm talking, of course, about the Six Countries study by Ancel Keys. This was the 'study', published in 1953, in which Keys took the data for six countries, plotted them on a graph, and was able to show a wonderfully linear and positive association between national fat consumption and CHD mortality[1]. Other researchers tried to point out that data was actually available for 22 countries at the time and that Keys had simply handpicked the ones supporting his preconceived thesis[2]. At a 1954 conference in Geneva, the Minnesota cherry-picker - by now used to getting his own way - was stunned to find his ideas were met with much skepticism. British professor George Pickering interrupted Key's presentation to ask in calm, understated James Bond-like fashion:

"Professor Keys, would you be kind enough to cite for us the principle piece of evidence that you think supports this diet-heart theory of yours?"

At this crucial moment, Keys, not usually at a loss for words, was caught off guard. His long-time friend and collaborator Henry Blackburn recalled: "...Ancel fell into a trap, he made a mistake; he cited a piece of evidence and they were able to destroy it. Instead of citing 'well, this theory’s based on a body of evidence that we’ve seen here and here from the clinic, from the laboratory, and from comparing populations', he didn’t make his case. He cited a piece--destroyed."[3]

So when Keys presented his cherry-picked hogwash to a panel of top heart surgeons and researchers from around the world, he was almost laughed out of the room. But it didn't matter; back home in the USA, Keys' connections, his domineering manner, and his burning desire to avenge his humiliation in Geneva allowed him to worm his way onto the American Heart Association's nutrition advisory panel, and his diet-heart hypothesis eventually became official policy.

The world has never been the same since.

Before I talk a little more about Keys and his absurd 'research', I want to share with you, my dear readers, a conversation I recently had with one of the studliest creatures the world has ever known. A man whose square jaw, rippling muscles, inhuman chest-to-waist ratio, thick bull-like neck and glowing golden coat sends bitches into instant heat, causing owners of female dogs to sense something is terribly amiss and tremble with fear from as far as 100 metres away.

I'm talking, of course, about my dog Ramone. A few days ago, I was sitting at my computer and looked over at him, only to see him looking right back at me with an unmistakable expression on his face. Drawing upon the finely tuned mental intuition that develops between a dog and his master, I could tell instantly he was wondering why I was tapping away and staring at this stupid screen instead of goofing around with him outside. And so I called him over for a little father-son chat:

Life According to Anthony, as Told to Ramone the Studliest Dog in the World

"Come here buddy and let me explain something...

[Sound of paws traversing tiled floor]

Humans, Ramone, are freakin' insane. Well, not all of them. I mean, the Ramones were pretty damn cool, which is why I named you after them. And you know I've got your back, along with the rest of the family. But the bulk of humanity, my canine sofa-hogging friend, is just one big crapshoot. Humans long for leadership, tend to flock to authority figures, and will believe the most unlikely bullshit so long as it comes from an 'official' and 'respected' source. Here, let me give you a hypothetical example so you'll understand where I'm coming from:

Imagine if that grumpy pitbull called Lex from up the street one day came up with this idiotic idea that bones caused canine heart disease (CHD). To support his theory, he plots six countries on a graph that shows as national bone consumption rises, so too does CHD. He ignores the other sixteen countries whose data refute his theory, but despite his fraudulent methods he still gets his screwball theory published in The International Journal of Dogshit, and while you and Kermit and Indy and the rest of your doggy buddies conclude this is one pitbull that's completely lost his marbles, a bunch of toffy poodles in white coats eventually get together with Lex and form a 'consensus' that dog bones do indeed cause CHD. Never mind that dogs have been happily chewing away on bones ever since there were dogs, and therefore have thoroughly developed the necessary genetic machinery to enable you guys to efficiently process whatever nutrients you extract from bones.

Heck, researchers even do a bunch of clinical trials clearly showing no increase in canine heart disease nor overall mortality among dogs randomized to chew bones every day. In fact, some of these trials show a lower mortality rate among the bone-chewing dogs! But by this point the CHA (Canine Heart Association) has been formed and they're making a fortune selling "Heart Licks" to manufacturers of 100% animal-free vegan-friendly dog bones.

When proponents of Lex's theory complain that many dogs simply will not or cannot give up chewing on real bones, a company called Pfurzer promptly brings a new bone-blocking 'wonder' drug to market called Poochastatin. Not to be outdone, Bristol Meyer Rover promptly releases Woofastatin, followed by FidoSmithKline who gain FDA approval for a slow release version called Droolastatin. Before you know it, there are more statins on the market than fleas on Lex.

But investigative journalists do a little digging and find out that statins are toxic drugs whose official side effect rates have been dramatically under-reported. They also discover that the CHA is really run by high-flying cats who receive hundreds of millions of dollars each year from drug companies and vegan-friendly dog bone manufacturers, but no-one seems to be listening. Your fellow dogs, in what appears to be a collective state of trance-like stupidity, start believing the sham. You, Indy and Kermit try and make them see sense, but you're promptly written off, most ironically, as a bunch of "quacks" and "cherry-pickers".

Now, Ramone, I know by the way you're looking at me that there's no need for me to go on. Yep, you dogs would never fall for such crap. You dogs are pretty straightforward, no-bullshit creatures. You can tell if someone is full of shit simply by sniffing them. You don't form governments to oppress and spy on your fellow dogs, you don't sell drugs to each other's kids, you don't commit genocide and wipe out thousands of your own kind on a daily basis, you don't spend thousands on brand name bollocks and useless gadgets in order to impress each why on Earth would you be dumb enough to believe a perfectly natural food you've been eating for thousands of years with much success has suddenly become unhealthy?

But that's exactly what humans do, buddy.

No, I'm not kidding.


 Ramone-portraitComing soon: Ramone's Guide to Pulling More Chicks Than a Rock Star: Why Being Buff and Just Plain Friggin' Awesome Beats Corny Lines, Expensive Cars & Neck Tattoos Every Single Time!

Yep, us humans could learn a lot from dogs. But sadly, after some 15,000 or so years of hanging out with man's best friend, pretty much all we've picked up from them is how to mount our partners from behind.


Look, nothing against the doggy position, it's a time-honoured favourite that has undeniably bought much joy to mankind. And womankind, too. But maybe if we started emulating dogs in other ways, such as doing a little more sniffing around before embracing every oddball theory our industry-sponsored health authorities try to impose upon us, we might be in a much better place. A place where we can largely avoid heart disease by natural, safe methods instead of relying upon low-fat pseudo-foods, dubious vegetable oils, and toxic drugs with side effects that include muscle and tendon damage, sexual dysfunction, mood disturbances and more.

Which brings us back to the late Ancel Keys.

People often say you shouldn't speak ill of the dead. But there does exist a sub-clause allowing exceptions to this rule if the dead person in question was an egotistical, megalomaniacal asshole whose actions caused massive and irrevocable harm to humankind.

Which is why, for example, no-one except the most devoted Neo-Nazis get upset when you talk about what an asshole Adolf Hitler was, and why no-one except the most devoted low-carbers get upset when you post irreverent and rather hilarious film clips depicting the fanatical Fuhrer as a tubby ketotic diet failure. You know, like this one (nice work Señor Green hahaha):

Ancel's Ego versus Public Health: Ancel Won

Ancel Keys is a man whose fraudulent and ego-driven behaviour brought irrevocable harm to mankind. Granted, his shenanigans have helped make oceans of money for drug companies, heart associations and vegetable oil manufacturers, but I think you'll agree public health should take precedence over profiteering any day.

Remember the Geneva conference where Keys was flabbergasted to find that, unlike back home, the participants did not hold him and his absurd theories in gushing awe? According to Blackburn, Keys was "so stung by this event that he left the Geneva meeting intent on gathering the definitive evidence needed to establish or refute this Diet-Heart theory"[4].

"He got up from being knocked to the ground and went out saying, 'I’ll show those guys,' and designed the Seven Countries Study"[3].

The Seven Countries study was to be Ancel "Screw You George Pickering!" Keys' revenge on all those who doubted him. Sadly, millions of innocent people would suffer in the process, falling victim to the useless preoccupation with animal fats and cholesterol that would proceed to distract the world from the real causes of CVD.

The Minnesotan bully immediately went about organizing a 'real life' version of his Six Countries study, this time adding an extra country. Unlike 6C which was purely a paper exercise, 7C was a prospective study that involved recruiting groups of men in various countries, surveying them about their diet and checking their cholesterol levels, then recording coronary and all-cause mortality over the subsequent ten years.

As with the garbage Six Countries study, 7C also featured nations hand-picked by Ancel Keys (Finland, Greece, Italy, Japan, Yugoslavia, Netherlands, U.S.A.) that just happened to show a correlation between saturated fat intake, cholesterol levels, and CHD mortality.

Well, at least that's how the study was reported. And continues to be reported by people who should damn well know better, but whose reliance on the cholesterol sham for a salary thoroughly blinds them to the bleedingly obvious.

Those who aren't hopelessly blinkered by the cholesterol bollocks and who've bothered to look at the 7C data for themselves will come across some rather interesting findings.

In 7C, the lowest cholesterol levels were found amongst the Japanese, who experienced a far lower incidence of coronary deaths than the U.S. and Finland, the two countries with the highest mean serum cholesterol readings. Which, of course, would tend to support the cholesterol thesis. However, the lowest rates of heart disease in the entire study occurred amongst the residents of Crete, in Greece, whose average cholesterol levels were positioned right between the middle of the two extremes. The Cretans, in fact, were the healthiest participants in the entire study, experiencing the lowest death rates not just from heart disease, but all causes.

The Cretans had an average serum cholesterol of 202; across Greece, on the island of Corfu, cholesterol levels were 198, yet coronary deaths were five times higher than those seen in Crete.

Correlation shmorrelation!

In Crevalcore and Montegiorgio, two different districts in Italy, mean serum cholesterol levels were identical, yet death rates from heart disease were 2.5 times higher in the former than the latter.

In Rome, Croatia and the Netherlands, serum cholesterol also showed no relationship with CHD mortality. As with saturated fat, cholesterol levels within nations were not a reliable indicator of heart disease risk[5].

It was the same with diet. Inside countries, cardiovascular mortality varied widely between regions, despite similar dietary habits and risk factors. In Finland, CHD deaths were four times higher in Karelia than in Turku, even though similar diets were consumed in both regions. In Greece, Cretans experienced a far lower incidence of CHD than residents of Corfu, despite similar saturated fat intakes. ECG readings also showed no correlation between diet and heart disease risk. Importantly, unlike the clinical diagnosis, which was conducted by local doctors with varying degrees of competence, all electrocardiograms were analyzed in the American study center.

Despite these findings, Ancel Keys - ever the shameless bullshitter - claimed his study showed that low cholesterol levels and a low fat intake, especially from saturates, reduced heart disease risk.

It showed no such thing, but that didn't even begin to stop his hopelessly biased findings being embraced by an orthodoxy that was both desperate for some kind of theory that explained the puzzling prevalence of CHD and also increasingly aware of the massive commercial potential conferred by the diet-heart hypothesis (manufacturers of n-6 polyunsaturate-rich cereal and nut oils were the first industry benefactors of this hypothesis, a role the drug companies subsequently and gleefully took over when it became evident saturated fat restriction was an outright failure in preventing CHD).

Keys got his revenge, but the rest of us still don't have a cure for heart disease. Despite some six decades of what essentially constitutes a collective and highly irrational phobia of cholesterol and animal fats, and despite the best efforts of drug companies to manipulate 'therapeutic' cholesterol targets so that as much of the public as possible can be pushed onto statin drugs, CVD is still as prevalent as ever and still remains the  number one killer in the Western world.

Heck, the shifty bastard even moved to Italy, a country where monounsaturate-rich olive oil rather than polyunsaturate-rich sunflower and corn oils reigned supreme, and where surgically trimming the fat from your meat was such a foreign behaviour it was likely to raise questions about your sexual orientation. While the rest of us separated our egg whites from the yolks, drank watery skim milk, forced down mouthfuls of fartaceous whole-grains, and laced our salads with tumour-inducing amounts of linoleic acid, Ancel Keys privately ate like an Italian and lived to be 100 years old.

Moral of the Story: If you're an anti-cholesterol shill who wants to live to a ripe old age, practice not what you preach.

It worked for Ancel.

MONICA, Oh MONICA, Where Art Thou?

Unlike 6C, 7C cost a lot of money, involved 'real' people and a huge assembly of researchers, giving it the veneer of a worthwhile research project. And by ignoring the intra-country results, de-emphasizing Crete and instead wanking on about the low rates of CHD in Japan and the high rates in USA and Finland, the cross-country results could be made to look supportive of the cholesterol hypothesis of CHD.

But there is a more recent study that also compared ten year mortality rates both among and within various countries, and cannot even begun to be twisted in such a manner.

Which, I might add, is why most of you have never even heard of it.

The MONItor trends in CArdiovascular diseases (MONICA) project is without question the largest study into the relationship between 'risk factors' and cardiovascular disease ever conducted on this here planet. Born in the early 1980s, MONICA was a collaborative effort involving thirty-two centers in twenty-one countries around the globe, monitoring a whopping ten million men and women aged between 25-64 years for a period of ten years.

Read that again folks: 10,000,000 people, followed for ten years, in 21 countries around the world. That is a humungous study.

But I'm betting almost all of you who've not read The Great Cholesterol Con or The Cholesterol Myths have never heard of it. For some strange reason, MONICA doesn't even begin to get the same kind of attention awarded to famous but much smaller projects like Seven Countries or Framingham.

Why is that, do you think?

Monica-Bellucci_3I couldn't find any pictures of "The MONICA Project", but I did come across this picture of "MONICA BELLUCCI" so I posted that instead. I hope you don't mind. If you do, you probably eat too much soy.

After all, you'd think such an important and massive study would deserve pride of place in any discussion examining the epidemiological relationship between animal fats, cholesterol and heart disease. With over ten million participants, MONICA is a big girl who absolutely dwarfs over anything that came before her. Even when a bunch of researchers whose writing committee was made up of people who made their living working for an outfit that receives funding from drug companies and the British Heart Association (who in turn receives generous 'donations' from drug companies) conducted a meta-analysis involving data for some sixty-two non-MONICA prospective epidemiological studies, the total number of pooled subjects still amounted to only 1.24 million.

Needless to say, if I was putting together a paper on the epidemiological relationship between cholesterol and heart disease in prospective epidemiological studies, MONICA would be first on the list.

However, let's pretend for a moment I made my living promulgating the cholesterol hypothesis and worked for an outfit that received money from cholesterol drug manufacturers. Let's pretend I was quite fond of the cholesterol theory because, hey, it put a roof over my head, clothes on my back, and a nice, highly-tuned Lotus in my garage. In this circumstance, it would be a real bummer for me to have to include MONICA in the meta-analysis. And so I might just conveniently modify my exclusion criteria on rather inane grounds so that, lo and behold, MONICA no longer meets the eligibility requirements. Or I might just flat out ignore her and hope no-one notices.

Why would I do this?

Because MONICA, the most MASSIF cardiovascular epidemiological study in the history of humankind, completely failed to support the cholesterol hypothesis. The highest cardiovascular mortality was observed in Central and Eastern Europe, despite the fact that these regions exhibited blood cholesterol levels and dietary saturated fat intakes similar to those seen in Western Europe and the U.S.A.[6]. Central and Eastern Europe did differ from the West in other important ways; the intake of dietary antioxidants from domestic and imported fruits, vegetables, nuts was substantially lower, while struggling economical and political systems gave rise to greater psychological stress. Alcohol abuse was also widespread in the Eastern bloc countries[7].

And so while MONICA was a huge disappointment for lipid hypothesists, it does throw out a few important clues for the non-dogmatic as to what some of the true contributors to CHD might be.

Cross Country, Intra-Country

When you compare the relationship between cholesterol and CHD among different countries, as MONICA did above, you are performing what is known as an ecological comparison. Ancel Keys' initial bad joke, the Six Countries study, was an ecological comparison. His Seven Countries study, as we saw above, examined not just international (ecological) but intra-national cholesterol levels and CHD mortality.

So too did MONICA.

Sorry folks, still can't find any pictures of "The MONICA Project", damnit.

And like the 7C study, MONICA also found a disconnect between cholesterol not just at the ecological level but also at the intra-national level.

In Italy, for example, mean serum cholesterol levels among those aged 35-64 declined in Friuli (FRI) residents but rose among the folk in Brianza (see Figure G46 on page 205 of this MONICA paper). According to the cholesterol thesis, CHD should have dropped in Friuli but risen in Brianza (BRI).

But the cholesterol thesis is utter bullshit. Which goes a long way to explaining why CHD mortality declined to similar degrees in both populations during the same period these cholesterol changes were recorded. Lung cancer, total cancer, stroke, total CVD, and overall mortality similarly declined in the two locations (see Table 1 here).

Now, if I was a lipid hypothesist, I might call this the "Italian Paradox", which is another way of saying "I have no clue how to explain this glaring contradiction to my cherished beliefs".

If I was a lipid hypothesist and was tempted to do this, I would also need to create a "Swiss Paradox". In the Vaud/Fribourg (VAF) region of Switzerland, cholesterol levels slightly declined while Ticino (TIC) saw the greatest rise in mean serum cholesterol levels in the entire population. Again, this should have resulted in a sharp disparity in CHD mortality, but coronary mortality declined to a similar degree in both populations (see Figure G22 on p. 181 of this paper).

Thankfully, researchers have already dreamed up a "French Paradox" to describe the 'puzzling' observation that the French eat a diet rich in animal fats yet have much lower rates of CHD than most other countries. Again, this observation is not at all puzzling to those aware of what complete garbage the cholesterol hypothesis is, but those who aren't may well like to again apply the paradox tag to the fact that in France, cholesterol levels rose significantly in Strasbourg (STR) but slightly declined in Toulouse (TOU). Once more, despite this allegedly 'atherogenic' change in the former, it experienced a similar decline in CHD mortality to the latter.

And then there was the "Swedish Paradox". Mean blood cholesterol hardly changed in Northern Sweden (NSW), but dropped by 0.5 mmol/l in Gothenburg (GOT). Despite this, coronary mortality declined to a greater degree among men in Northern Sweden compared to Gothenburg, and to a similar degree among women.

I could go on and on, but I have a rather energetic pooch here yearning to be taken outside for a lengthy stroll. If you want to find more "paradoxes" of your own, feel free to keep searching through Fig G46 here and Fig G22 here.

But I think most of you will have gotten the point by now. Not only is epidemiology highly flawed, but it must be cherry-picked selectively by those who would have us believe the nonsensical fairy tale that is the cholesterol hypothesis of heart disease. MONICA, the most massive epidemiological CVD study of all time, does not afford the anti-cholesterol crowd such an opportunity, so despite its massive stature it is simply ignored.

Epidemiology's One Redeeming Feature

I will reiterate once more: Epidemiology is terribly inferior to tightly controlled clinical research, and the modern-day habit of awarding findings from the former similar status as the latter is an absolute disgrace.

But epidemiology isn't totally useless. While 99% of the nutritional epidemiology polluting our journals is time- and tax money-wasting pap designed to support a preconceived agenda, every now and then epidemiology does detect statistically robust relationships that are worthy of further investigation in the clinical setting.

And lo and behold, the MONICA finding that cholesterol levels were unrelated to CVD mortality, while dietary intake of antioxidant-rich fruits and vegetables was, has indeed been strongly supported by a number of randomized clinical trials.

We'll talk about those trials the next time we meet. Until then, au revoir.


  1. Keys A. Atherosclerosis: a problem in new public health. Journal of Mount Sinai Hospital, 1953; 20:  118-139.
  2. Yerushalmey J, Hilleboe HE. Fat in the diet and mortality from heart disease. A methodological note. New York State Journal of Medicine, 1957; 57: 2343-2354.
  3. No author listed. Health Revolutionary: The Life and Work of Ancel Keys. Available online:
  4. Dunn Gifford, K. Introduction to the 2003 Conference on the Mediterranean Diet, Jan 12-14, 2003, Boston, Massachusetts.
  5. Keys, A. Coronary heart disease in seven countries. Circulation, 1970; 41 (Suppl 1): 1-211.
  6. No authors listed. Ecological analysis of the association between mortality and major risk factors of cardiovascular disease. The World Health Organization MONICA Project. International Journal of Epidemiology, Jun, 1994; 23 (3): 505-516.
  7. Ginter E. Cardiovascular disease prevention in eastern Europe. Nutrition, May, 1998; 14 (5): 452-457.


Anthony Colpo is an independent researcher, physical conditioning specialist, and author of The Fat Loss Bible and The Great Cholesterol Con. For more information, visit or

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