Since when did bad cholesterol become good? This week!

If there's one thing that has been a constant in medicine since forever (or more accurately, since the pervasion of fast food all over the planet), it's that nasty eleven letter word - cholesterol. Basically, from the day you hit 21 years old, the warnings and measurements begin, along with the doom and gloom message that what you eat is what is going to kill you. It's about as popular a message as talking about retirement savings plans to recent college graduates - which quite rightly goes in one ear and out the other most of the time. 

However, while saving for retirement at 25 may be a debatable question, if not total anathema, for many, the end result of wolfing down too many cholesterol-laden goodies is all around us and the stats on the number of people dying of cardiovascular disease or heart attacks speaks for itself. Smoking and being sedentary in combination with excessive daily intake of fatty cholesterol is a modern day death sentence; one that is seemingly guaranteed to come knocking at the door, demanding payback. 

The pharmaceutical industry took the cholesterol problem to heart and invested huge amounts of money trying to solve the problem, chemically, not least because as humans we are almost pre-programmed to ignore the doctor's advice pretty much most of the time. We want to have our cake and eat it too, quite literally, so the dream is that we can stuff our faces with a daily dose of goodies, but the pill we take lowers our cholesterol in spite of it. Hence the discovery of a drug class that has pervaded society to almost the same extent as fast food, such that the name itself is known to many - we are of course talking about statins.  

Statins became tremendously successful blockbuster successes, and in fact Pfizer's Lipitor (Atorvastatin) became the best-selling pharmaceutical in history back in 2003, with the other major brands doing extremely nicely whether in second or fifth place. Statins are a goldmine and deservedly so; it is unquestionable that they have played a major part in eroding heart disease as a death sentence and extending people's lives well beyond what was possible before their discovery. 

Having said all of the above, it came as quite a surprise this week to hear on various national news services, both online and in broadcasts, that "cholesterol is no longer a concern". This is to be the take of both the US Departments of Health & Human Services (HHS) and Agriculture (USDA). What? How come? Well, there has been a striking shift in policy seemingly out of the blue, as officials announced that warnings about high cholesterol diets are no longer in the US government's draft dietary guidelines for Americans. The big and burning question is - why?!

Until this week, the government's take on the matter was that people should restrict themselves to a maximum of 300mg of cholesterol a day, thereby reducing the build-up of fatty deposits in the artery walls that is the hallmark of atherosclerosis, which in turn is a major cause of heart attack and stroke. However, there has just been a sharp left turn, with the direction changing into one focused not on how much cholesterol is in your stomach, but rather, how much is in your blood.

According to the USDA, "available evidence shows no appreciable relationship between consumption of dietary cholesterol and serum cholesterol", they said in a new statement. This is an extremely radical take on the issue, clearly emphasising that the key critical measurement is how much bad cholesterol (LDL) is circulating in your blood, almost irrespective of what is in your diet. For sure, it does address the genetic component of elevated cholesterol, in that some people can eat eggs and cheese every day with no effect while others who eat an egg once a week have cholesterol problems. 

The draft report, which was put together by 14 renowned key opinion leaders in medicine, nutrition and public health is available online at "health.gov/dietary guidelines"- but it is still strictly a draft until a 45 day response period has passed. The report will be discussed at a meeting (open to the public) in Bethesda, Maryland on March 24th, after which any changes will be incorporated into it and it becomes official HHS and USDA language.

As one cardiologist commented, the committee "clearly is trying to dispel the idea that cholesterol matters", and indeed the committee themselves state clearly that "cholesterol is not a nutrient of concern for overconsumption." This is in total contrast to what has been taught not only in medical school but also contrary to the message we have been getting from our doctors for decades. As much as I understand the nuance that it is how much cholesterol is in our blood that matters, I feel that the message is a potentially dangerous one or one that can be conveniently misinterpreted. There are concerns other than atherosclerosis associated with a high fat-high cholesterol diet and I think that fact should be underlined more heavily. 

Although the committee does stress the need to lower saturated fat in our diets (while worrying less about cholesterol), the sound bite that's making the news is that we no longer have to worry about cholesterol. Nevertheless, cholesterol and saturated fat often come hand-in-hand, so telling people not to worry about cholesterol may create the false feeling that they can now eat whatever they want with no worries. To a scientifically less sophisticated public, cholesterol more or less equates with fat anyway, so no worries over cholesterol may equate with no worries about fat - period. 

In any case, the pharmaceutical world won't wince too much at this report, because a new focus on serum cholesterol does not impact the future of statins as that is where they exert their effect, unlike agents which prevent cholesterol absorption from the stomach, for example. So statins will survive, and it is the upcoming release of the much-touted PCSK9 inhibitors that threatens to punch a hole in their market dominance, not this report. CVS Health Corp is already at work to limit the cost of this new class of drugs, for their estimate of around 15 million people who may utilise them at an annual cost of $7-12,000 per person per year.

If you do the math, you can see that fighting cholesterol is very big business, and both Amgen and Sanofi-Regeneron stand to reap handsome rewards as the first two out of the gate with FDA-approved PCSK9 inhibitors. Amgen was first to file with the FDA but the purchase of an FDA priority voucher from BioMarin means that Sanofi-Regeneron can catch up after having filed. It is expected that decisions on both drug candidates will be forthcoming this summer, and after that you can expect the cholesterol wars to kick into another gear and rack up huge earnings for those who invested heavily in them. 

Who knows, maybe we are approaching a day where concerns over cholesterol will truly be relegated to something in our past, and we get to eat burgers and fries and fish and chips as often as we want. I hope so, but in the meantime, I guess I will be good and take the baked potato instead of fries with my steak tonight - unless those new-fangled cholesterol fries are also about to hit the market?!

PS - there's more good news in the report for us coffee lovers also - it now transpires that up to five cups a day may actually be good for you, after all. So on that note, I am off to grab a large mug of Dante's Infernal Dark Roast that just arrived from far-off fields. Happy Sunday, all!

Preying for predators - it's the key to survival!

  

I watched a fascinating documentary on the weekend about the African savannah, a grassland ecosystem that is home to the most diverse variety of hoofed mammals in the world. This exotic terrain is typified by hardy trees and shrubs and rolling grasslands that are the mainstay of the herbivore diet of the animal population living there, and it sprawls across some 25 countries in Africa. 

As natural as it may be to some (biologists), it never ceases to make me smile at how delicate even such huge ecosystems are, and how the balance between life and death can depend on factors that are not that obvious at first glance. As much as various species such as elephants and rhinoceros are always in danger of extinction at the hands of poachers, it is unquestionable that it is the presence of a very unnatural species there - mankind - that has had the greatest impact on the savannah. 

The predator-prey relationship is a fundamental to evolutionary biology and is how we got to where we are today; but we both impact it and insist on messing with it in ways that are generally destructive and upset the natural balance of things. To wit, the ongoing issue since the sixties of grassland erosion and gradual desertification of what were once fertile grounds thriving in what are warm, tropical wet-dry seasons. 

This desertification is disastrous not just to the indigenous species living there such as zebra, elephant, black rhinoceros and giraffe, but also to the cattle being grazed there today by Masai farmers. The savannah ecosystem works by nature of the trees and shrubs being rather sparsely spread out, such that abundant light and water reaches the ground facilitating cultivation of a slew of plant life that ultimately sustains not only the herbivores, but also scavengers and decomposers, and the feared carnivores that ultimately control the animal population beneath then in the food chain.

Decades ago, the policy was clear - conservationists actually culled elephant herds in particular because of an apparent overgrazing problem that was believed to be at the root of the observed desertification. The thinking was that due to huge herds of large mammals such as elephants trampling through the savannah, they were actually destroying their own pastures due to overpopulation. In terms of our negative impact on this situation, the key problem perceived by experts was that mankind was killing too many predator carnivores on safaris or via poaching, and this was the root cause of grassland erosion. 

However, the result of that misperception was that after many years of culling elephant herds to manually control their numbers, rather shockingly, it appeared that reducing elephant numbers had been of basically no benefit whatsoever, and man replacing lions and other big cats as top-of-the-food-chain predator did not work - clearing of the grasslands continued as before. So what the hell was going on?

It took some real out-of-the-box thinking and a load of observation to figure out why reducing large animal populations didn't do the trick, and in fact it was not the number of elephants that was causing grassland erosion, it was the fashion in which they were grazing and moving that was at the bottom of it all.  A real bright spark had a brilliant light bulb moment and hypothesised that it was natural selection (by animal predators) that was key; not unnatural selection by two-legged ecosystem-destroying human predators. 

Thus, large herds of animals freed of the normal level and fear of aggressive carnivores kind of became, well, too relaxed and stress-free. So what happened? Evidently, they sort of spread out and just grazed to their heart's content, enjoying long warm afternoons on the "lawn" and rarely having to rush off anywhere. A holiday from those evil carnivores, in effect. Well, whaddya know, it lead to more desertification. 

It turns out, just as the bright spark hypothesised and proved by testing it on cattle on his own grazing lands, that such relaxed and abnormal elephant behaviour hurts the environment. When predators or human herders reappeared, the animals would be relaxed and grazing one minute, then upon the growl of a few big cats, the herd bunched closer together and upon attack would stampede as a collective to escape the mauling that awaited them. 

So what, you say? Well, this thunderous trampling of the ground over compact areas actually has somewhat of a ploughing effect, exposing topsoil and trampling dead plants and grasses into the soil, along with faeces and urine and other "fertilizers", which, along with the work of decomposers, provides serious nutrients to the ground resulting in new plant growth over coming seasons. 

Therefore, the very thing that was thought to cause desertification was in fact grassland's salvation - and it all came down to the presence of predators around them - just not for the reason suspected! As much as we know about biology and evolution, we continue to be educated by it in action. It was not the removal of elephants by carnivore kills that was needed to save the grasslands, it was the herd's behaviour in the presence of that predator that changed everything! Incredible, huh?

There are a couple of lessons here, the most obvious of which is that we can never underestimate the power of natural selection and evolution, and how delicately the existence of so many apparently insignificant components of an ecosystem are actually intertwined together; in this case that comes all the way down to the critical role insects such as termites and scavengers play in fertilising and maintaining an ecosystem populated by huge mammals. 

Perhaps the most important lesson, not only in the African savannah but also in the modern jungles of the business world, is how the presence of predators is actually a good thing. Yes, there will be a few who will get eaten alive as part of the natural selection process, and I would argue that this is something that should happen more often in business - not less. Those who are under-performing should be weeded out and replaced with stronger candidates, not moved sideways endlessly, having learnt little and contributing even less. If you ain't essential to maintenance of the ecosystem which you live and work in then selection should dictate your fate. I mean, look at what happens to even grasslands when the population is allowed to wander aimlessly! 

The major single problem I see in business today is the shuffling around of the same set of local names in some kind of circle of incompetence, from one position to another, and one job to another, never appreciated enough to keep around for long, but always being given the reference needed to get the next position - i.e. to get rid of them. There is no more lethal (pardon the pun!) combination than a weak performer and a weak/weaker manager who is incapable of doing their actual job. This is how people mistakenly become overly (overtly?) cocky and begin to feel they have a right to their job, not that their continued existence in it has to be actually earned. Whether the value being created is by fertilizing grasslands or making the company lots of money is irrelevant - the outcome has to be a beneficial one, for all. 

In business and at work, in total analogy with the carnivores and the herbivores, a perceived threat or competitor or even office enemy is not so much a danger to your continued survival; rather, it is a positive, and it should impact your behaviour in a way that is more beneficial to the ecosystem you exist in. We all need to not get too comfortable in our padded swivel chairs in the office and the boardroom, and having our behaviour tweaked by the ongoing presence or proximity of a "predator" actually can keep us at the top of our game. 

I am convinced that many of those who reach "job for life" status become both bored and less productive; we actually need challenge to be "alive". In analogy with the elephants, it's not being eaten by a lion that benefits the ecosystem most - it is the mere presence of that carnivore and the fear of being eaten alive that modifies the herd's behaviour - beneficially. In other words, we need (more) competitors and predators in our life science ecosystem, not less, and if you don't want to compete then step out of the jungle and if you can't stand the heat then get out of the (jungle) kitchen. Both apply! 

Who would have thought that a weekend documentary about African grasslands and the daily struggle to survive could make me think of the city and its business jungle? Well, you know people, we are still animals after all and as advanced as we like to think we are, it is incredible how similar to animals we often are - particularly when threatened or in the face of stiff competition for rather slim pickings. It's a jungle out there my friends, quite literally, so - back to work!

From having it all, to throwing it all away - literally - in mere seconds!

Unless you've been off on an island somewhere, you probably ran into Superbowl Sunday last weekend, somewhere, and that was emphasised by the statistic that an estimated >110 million Americans (alone) watched the big game. It broke all records and made television history in the USA, and this time at least, the game actually lived up to all the hype and produced a heart-stopping finish that gave a shocking 28-24 victory to the New England Patriots over the Seattle Seahawks. 

The devastating thing about professional football is that a game can literally go back and forth for four quarters with one team leading close to the end of the game, and with even mere seconds on the clock and knowing use of the sidelines and timeouts, the trailing team can get to the end zone and produce a win. It seems unquestionable that psychology often plays more than a little part in these things, and occasionally, it may even be the deciding factor. 

In the last minute of this game, as shown in the video above, wide receiver Jermaine Kearse makes an out-of-this-world juggling catch that theoretically ended the game right there and then. It might not seem that amazing when watched in slow motion but during that moment, but I am pretty sure no one in that stadium thought it was anything but an incomplete pass, and clearly neither did the commentators. Just as everyone was looking away and waiting for the next play, the guy managed to bump or touch the ball as many as five times before getting hold of it and making it a complete pass. 

You only have to look at the face of New England QB Tom Brady to get an idea of what it feels like to have one of the biggest prizes in professional sports yanked right out of your hands, at the very last second. Brady thought it was all over at that very moment, and frankly, it should have been. The Seahawks went from being within a minute of losing the big game to being only 60 seconds and one run by Marshawn Lynch from winning it - all in a heartbeat. 

The insane and devastating reality was that in the end that exceptional play by Kearse didn't matter, apart from having it on his record. A few seconds later, Russell Wilson (Seahawks QB) threw the victory to New England; but even that throw was less inexplicable than the coach's call that ordered it. The pendulum swings in heartbreaking fashion in life as well as in sports, and it was rookie Malcolm Butler who this time was on the receiving end of not just redemption but actual glory. He was the New England player covering Kearse when he made that catch, and he was the hero who intercepted the throw (seconds later) that ended the game. 

I couldn't help but feel that amongst all the agony and the angst, and the guts and the glory (depending which coast one came from), there were some valuable lessons for all of us inside that high-tension, adrenaline-fueled furore:

• It's an old adage, but it's totally true - it ain't over till it's over. Just prior to that massive play by Kearse, New England probably thought they had it. Only a minute to go, and 40 yards out, the Seahawks were trailing, and it's possible that some of the Patriots could already taste the champagne waiting on ice in the locker room - a few seconds later and Tom Brady's blood-drained face told a very different story. 
• As tempting as it is to take an eye off the ball for a second and bask in the moment, the game isn't over and anything can happen - as it did. It's pretty much the same in business, and until the deal is closed, it's best to keep your mouth shut and your eye on the ball, until the touchdown actually occurs.  
• Sometimes it's pure psychology that works against you, and just as you begin to breathe a sigh of relief late in the game, and turn away for a mere nanosecond, it's in that nanosecond that all hell breaks loose. In life and career it's about staying power, and those with a major focus on the daily details while keeping an eye on the bigger picture and the longer term are usually those who make it in the end.
• Looking at it in the inverse way, if we put ourselves in the position of the Patriots in the last minute of that game, facing what looks like certain defeat coldly in the face - there should be widespread panic, right? Well, yes, maybe, hidden inside. But one thing they got totally right was the belief that even in the face of imminent loss, it's still not lost (yet) if the game is not actually over. Giving up is never the option, and if you worked your backside off to get somewhere in life, then you should fight to the last minute to try to stay there or stave off a defeat. 
• Facing what appeared to be by then a certain win, the Seahawks did take their eye off the ball at a life-changing critical moment, and paid an enormous price. It actually did a great disservice to the acrobatics of Kearse mere seconds before, whose heroics were all for nought in the end. Why they chose to throw, that close to their goal, and with the Sherman tank known as Marshawn Lynch left holding nothing is not just beyond me, but beyond basically everybody.
• You know? When it comes to psychology, sometimes we can overthink things and be our own worst enemy. As a coach, this can be a potentially destructive trait, trying to be too smart and more worried about out-thinking the opposition than using the tried-and-trusted tools and weapons at your disposal. Thus it was for Pete Carroll who inexplicably ignored the most potent weapon in his arsenal, and instead took a huge risk at the wrong time - the victory suddenly falling through his fingers like sand as the ball was stolen out of his receiver's hands. 
• It was a brutal, crushing moment on one of the biggest stages on the planet, and Patriots fan or not, one couldn't help but empathise with Carroll at that exact moment. We have all lost a big game in life, literally or metaphorically, and we have all looked back retrospectively and asked what if, or said I should have done this or could have done that.  We got in the way of ourselves, and lost a big one. 

In the case of Pete Carroll, well, he has been around the block, a few times, and he is a consummate pro, so there were no visible tantrums, tears or trauma, and we all respect him for that. Having said that, one of the biggest lessons we try to learn whether it be sports, business, career and life, is - learn from your mistakes and do not repeat them. Given that he should have been through this before, only time will tell whether he is to be forgiven for getting in his own way and overthinking this one.

Well, I didn't realise that I had that much to say about the Superbowl, but it's surprising how we can be in the midst of some great entertainment and yet still that left brain starts to draw lines and parallels between the war being fought on the field, and the war going on in business and life. It is all about competition, of sorts (even if that competition is with ourselves), and how we react to the good days and bad, and the wins and the losses. 

Coming back from a loss is the flip side of the coin, yet it is the side that is most educational for us and where we (and others) learn the most about who we really are. Ask any successful (even some of the famous ones!) entrepreneur and there's one thing they all seem to more or less agree on - failure is an essential part of the learning process and of the winning process - no one gets to the top of the tree without losing sometimes. The key is what you learn and take away from even a miserable failure, and then what you do with that knowledge and experience.

On that note, I can say that I have learnt from my failure to get my weekly blog written during the big game due to too much noise, commotion and emotion, and subsequently only succeeded in getting it done by retiring to a cosy brick-walled corner by a crackling fire with no distractions. One small victory at a time, people - we can't always be in the Superbowl or Dante's Inferno!