The Cholesterol Con–Where Were the Doctors? Part I

After the stock market bubble burst, the New York Times asked: “Where were the analysts? Why didn’t they warn us?”

To be perfectly honest, this was a somewhat disingenuous question. As experienced financial journalists understood all too well, the analysts plugging the high-flying issues of the 1990s were employed by Wall Street firms raking in billions as investors bet their nest eggs on one hot stock after another. It really wasn’t in their employers’ interest for analysts to tell us that their products were wildly over-priced.  When a small investor wades into the financial world, there are two words he needs to keep in mind: “caveat emptor.”

But physicians, I firmly believe, are different from the folks employed by Merrill Lynch. (I don’t mean to knock people who work at ML. I am simply saying that they have a very different job description.)  When consulting with your doctor, you should not have to be wary. You are not a customer; you are a patient. And your physician is a professional who has pledged to put your interests ahead of his or her own.

This brings me to the question I ask in my headline: during the many years of the Cholesterol Con—where were the doctors?  When everyone from the makers of Mazola Corn Oil to the Popes of Cardiology assured us that virtually anyone could ward off heart disease by lowering their cholesterol, why didn’t  more of our doctors raise an eyebrow and warn us : “Actually, that’s not what the research shows” ?

No doubt, you’ve heard about the recent Business Week cover story, “Do Cholesterol Drugs Do Any Good?", which blew the lid off the theory that “statins”– drugs like Lipitor, Crestor, Mevacor, Zocor and Pravachol — can cut the odds that you will die of a heart attack by slowing the production of cholesterol in your  body and increasing the liver’s ability to remove L.D.L., or “bad cholesterol,” from your blood.   

It’s true that these drugs can help some people—but not nearly as many as we have been told. Moreover, and this is the kicker, we don’t have any clear evidence that they work by lowering cholesterol.

Although medical research suggests that statins can definitely benefit one group—men under 70 who already have had a heart attack–researchers are no longer convinced that the drugs stave off a second attack by lowering the patient’s cholesterol. The drugs do lower cholesterol, but that is not what helps the patient.

In other words, researchers are questioning the bedrock assumption that
high levels of  “bad cholesterol” cause  heart disease.  “Higher LDL
levels do help set the stage for heart disease by contributing to the
buildup of plaque in arteries. But something else has to happen before
people get heart disease,” Dr. Ronald M. Krauss, director of
atherosclerosis research at the Oakland Research Institute, told
Business Week.  "When you look at patients with heart disease, their
cholesterol levels are not that [much] higher than those without heart
disease," he added. “Compare countries, for example. Spaniards have LDL
levels similar to Americans’, but less than half the rate of heart
disease. The Swiss have even higher cholesterol levels, but their rates
of heart disease are also lower. Australian aborigines have low
cholesterol but high rates of heart disease.”

“Current evidence supports ignoring LDL cholesterol altogether," Dr.
Rodney A. Hayward, professor of internal medicine at the University of
Michigan, told Business Week’s reporter.

In recent years, researchers have begun to suspect that statins help
patients, not by lowering cholesterol levels, but by reducing
inflammation. If this theory is right, “this seems likely to shunt
cholesterol reduction into a small corner of the overall picture of
heart disease,” the Guardian reported four years ago

And if the key to statins is that they reduce inflammation, it’s worth
keeping in mind that this is what other effective heart treatments like
aspirin and the omega three fatty acids found in fish oils, garlic  and
Vitamin E do—at a much lower cost and with far fewer side effects.

But hold onto your hats, I still haven’t gotten to what is most
shocking about the cholesterol story.  What raises my blood pressure is
the knowledge that Business Week’s scoop isn’t really “new” news.” With
all due respect to Business Week, which showed real courage in putting
the story on its cover, and to its author, John Carey, who did a superb
job of explaining the medical research, the truth is that medical
researchers have been questioning the theory that widespread use of
statins to lower cholesterol will  save lives for many years.

You can find the research questioning the benefits of statins in  medical journals like Lancet (2001) and BMJ (2006), as well as in reports from medical conferences (“Tales From the the Other Drug Wars,” 1999). 

Occasionally, doubts popped up in the mainstream press and then disappeared.

Five years ago, veteran healthcare blogger Matthew Holt pointed to a BMJ article suggesting that stains might be no better than aspirin. That same year, Holt raised pointed questions regarding the risk of taking statins, including possible memory loss.”

Nevertheless, the very next year, the National Cholesterol Education
Program at the U.S. National Heart, Lung and Blood Institute issued new
recommendations that drastically lowered the threshold for statin
therapy. According to its 2004 report, people at a moderately high risk
of developing heart disease (with LDL cholesterol levels between 100
and 129 mg/dL) should be offered statins—even if they have no previous
history of heart disease. Statin therapy also should be recommended to
very high risk patients, the panel said, even if  their LDL levels are
as low as 70. NCEP declared that the recommendations applied to both
men and women, regardless of age.

The bottom line: NCEP was urging millions of Americans to go on statins.

Not everyone agreed, recalls Merrill Goozner, editor of “GoozNews,”
a top-drawer investigative healthcare blog.   In 2004, a few months
after the new guidelines came out, a coalition of more than 30 academic
physicians and researchers, inspired by Dr. John Abramson (author of Overdosed America: The Broken Promises of American Medicine),  decided to write a letter to the National Heart Lung and Blood Institute (NHLBI).

Goozner, who does research at the Center for Science in the Public
Interest, organized the group. The letter “outlined all the evidence,
which was there in published clinical trials for anyone who cared to
look,” Goozner recalls, and concluded that while statins, “may lower
cholesterol in people at low risk and even many sub-groups at moderate
risk of a heart attack . . . there was no evidence that the drugs
actually saved lives.”

How could this be, if statins lower the risk of heart attack, at least
for some people?  Preventing a heart attack does not necessarily mean
that a life is saved. In many statin studies that show lower heart
attack risk, the same number of patients end up dying, whether they are
taking statins or not. “You may have helped the heart, but you haven’t
helped the patient," says Dr. Beatrice Golomb,
an associate professor of medicine at the University of California, San
Diego, and  co-author of a 2004 editorial in The Journal of the
American College of Cardiology questioning the data on statins. "You
still have to look at the impact on the patient overall.” 

“The letter we sent to the NHLBI also called for an independent panel
to review the evidence,”  Goozner notes, “since the NLHBI panel that
made the recommendations had been dominated by physicians with ties to
statin manufacturers.” Indeed, the National Institutes of Health later
admitted that eight of the nine experts on the panel had received
financing from one or more of the companies that make statins.  (None
of the panelists had publicly disclosed their ties to manufacturers
when they made their recommendations.)

Just how much “financing” were the panelists receiving? According to the LA Times,
from 2001 to 2003 Dr Bryan Brewer, a leader at the National Institutes
of Health,  and “part of the team that gave the nation new cholesterol
guidelines in 2004” had accepted “about $114,000 in consulting fees
from four companies making or developing the cholesterol-lowering
drugs.

But “this is relative peanuts compared to Dr P. Trey Sunderland III, a
senior psychiatric researcher at the NIH, who took $508,500 in fees
from Pfizer, Inc. whilst collaborating with them, and endorsing their
drug [Lipitor],” says Dr. Malcolm Kendrick, who is a member of The International Network of Cholesterol Skeptics (THINCS)– a growing group of scientists, physicians, other academicians and science writers from various countries.

Dr. Abramson, who is a clinical instructor at Harvard Medical School,
charges that the study that accompanied the updated 2004 guidelines
“knowingly misrepresented the results of the clinical trials that they
supposedly relied upon to formulate their recommendations.  The problem
is that the experts claimed to rely on scientific evidence, but they
act as if empowered to ignore the evidence when it is not consistent
with their beliefs.”

This is a serious allegation. Keep in mind that statins are the most
popular drugs in the history of human medicine. World-wide sales
totaled $33 billion in 2007. More than 18 million American now take
them.

Nevertheless, “medical research suggests that only about 40 percent to
50 percent of that number are likely to benefit,” says Abramson.  “The
other 8 or 9 million are exposed to the risks that come with taking
statins –which can include severe muscle pain, memory loss, sexual
dysfunction — and one study shows increased risk of cancer in the
elderly– but there are no studies to show that the drugs will protect
these patients against fatal heart attacks.”

Abramson can cite many studies to support his claims. But first, he stresses that statins can help some people.

“Statins  show a clear benefit for one group,” he says: “People under
65 who have already had a heart attack or have diabetes. But even in
these very high risk people, about 22 have to be treated for 5 years
for one to benefit.”

What about middle-aged people who are not diabetic and have not had a heart attack?  A 2006 study
published in the Annals of Internal Medicine that focused on seven
trials involving nearly 43,000 middle-aged adults concluded that statin
use did not cut their chances of dying from heart disease.

Is there any benefit for this group? “If they are high risk, statins
can be beneficial to people under 65 who haven’t had a heart attack,
but 50 such men have to be treated for 5 years for one to benefit.” says Abramson.
“The other 49 will not be helped.  The problem is that we can’t know
who is going to be the 50th man,” he adds. And all 50 will be exposed
to the side effects.

Older adults have little to gain. The drugs don’t help people over 70
even if they have elevated cholesterol levels, according to a report in the Journal of American Cardiology.

Finally, “there is no evidence of any benefit for women who don’t
already have heart disease or diabetes,” says Abramson.  According to a
2004  article published in the Journal of the American Medical
Association which reviewed all trials in which women with high
cholesterol had been randomly assigned to take a cholesterol-lowering
drug or a placebo, there was no evidence that statins prolonged women’s lives or cut their chances of dying of heart disease.

An editorial published in the Journal of the American College of Cardiology came to the same conclusion
though there does seem to be a risk that women  on statins develop
memory loss so severe that their  relatives may begin shopping for a
nursing home.

Memory loss that can mimic Alzheimers is the second most common side
affect for people taking statins, right after muscle pain, according
to researchers at the University of California at San Diego. For a
number of years, they have been running a randomized controlled trial
examining the effects of statins on thinking, mood, behavior, and
quality of life. Separately, the UCSD researchers have been collecting
anecdotal experiences of patients, good and bad, on statins.

"We have some compelling cases," Dr. Beatrice Golomb, the study’s lead
researcher, told the Wall Street Journal. “In one of them, a San Diego
woman, Jane Brunzie, was so forgetful that her daughter was
investigating Alzheimer’s care for her and refused to let her baby-sit
for her 9-year-old granddaughter. Then the mother stopped taking a
statin. ‘Literally, within eight days, I was back to normal — it was
that dramatic,’ said Mrs. Brunzie, 69 years old.”

According to the Journal, “Doctors put her on different statins three
more times. ‘They’d say, “Here, try these samples.” Doctors don’t want
to give up on it,’ she said.’ Within a few days of starting another
one, I’d start losing my words again,’ added Mrs. Brunzie, who has gone
back to volunteering at the local elementary school she loves and is
trying to bring her cholesterol down with dietary changes instead.”
Returning to Goozner’s story, did the letter his group wrote to the
NHLBI in 2004, spark public discussion about the new cholesterol
guidelines?   No. “We released the letter to the press, but the
mainstream of the national press ignored us,” Goozner recalls.       

In 2008, Goozner is happy to see the statin controversy hit Business
Week’s cover– though he can’t help but wonder, “Where were these guys
three years ago? Now, call me a cynic, but why does my perverted mind
think to itself as I watch this coverage: Yeah, now we hear, just when
the world’s best-selling drug [Lipitor] is about to go off patent.” 

I suspect Goozer is right. It would have been much harder to publish this story a few years ago.

But there also was a trigger that probably helped spur the Business
Week investigation. Last month, Merck -Schering/Plough released a
long-awaited study revealing that Vytorin, an expensive combination of
two drugs designed to lower cholesterol, brought no added benefits for
patients suffering from heart disease.

The two cholesterol-lowering drugs were Zocor, which is a statin, and,
Zetia, which is not. When combined, the two drugs did drive cholesterol
levels much lower. But the clinical trial offered no evidence that the
two cholesterol-busters were more effective in reducing heart attacks
than Zocor alone.  This raises an obvious question: is cutting
cholesterol levels really the key to avoiding heart attacks?

The results of the study helped buttress the strong suspicion that
insofar as statins like Zocor  do help anyone with heart disease, the
beneficial effect has little to do  with lowering cholesterol levels.
Meanwhile, Zocor is now available in a generic form that can be
purchased for less than $6 for a 30-day supply. By contrast, the new
combination, selling under the brand name Vytorin, was fetching more
than $100 for a 30–day supply. In 2006, the drug brought in $1.5
billion with sales climbing 25% in the first half of 2007 to over $2
billion, according to IMS Health.

Naturally, Merck and Schering/Plough, who were marketing Vytorin  in a
joint venture,  were shy about reporting the results of the clinical
trials. It was only when they were threatened with a Congressional
investigation that they made the results public on January 15—more than
a year and a half after the clinical trials were completed.

The day after the drug-makers released the news, the American Heart
Association rushed to their defense, declaring that the study was too
limited to draw conclusions about Vytorin’s ability to reduce heart
attacks or deaths compared to Zocor alone. The AHA advised patients not
to abruptly stop taking Vytorin without consulting with the doctors who
had prescribed it.

The New York Times, to its credit, was quick to respond, noting that
“what the [American Heart Association] did not note in its statement  .
. .  was that the group receives nearly $2 million a year from
Merck/Schering-Plough Pharmaceuticals, the joint venture that markets
Vytorin.

When I return to the saga of the “Cholesterol Con,” in the second
installment of this post, I am going take a closer look at the American
Heart Association—and others who stood to gain by persuading  Americans
of the absolute link between high levels of cholesterol and heart
disease. 

It is a story that begins long before Pfizer and other drug makers
invented statins. And it explains why so few American doctors stood up
and questioned the widespread use of drugs like Lipitor.

The belief that cholesterol causes heart disease wasn’t just a theory.
It became a matter of faith, brought to us by a motley group that
included food companies advertising margarine and corn oil, the
American Heart Association, and doctors who joined the bandwagon. At
first the American Medical Association resisted—but soon it too
capitulated.  Finally, when the American College of Cardiology signed
on, it became very difficult for physicians to speak out.

At that point, anyone who questioned the cholesterol connection could
easily be painted as “reckless”—a doctor willing to put thousands of
lives at risk by encouraging patients to question what had become the
Holy Grail of cardiac care.

63 thoughts on “The Cholesterol Con–Where Were the Doctors? Part I

  1. GRRRRRRRRR this is frustrating, I have all but been screaming this in my practice and am well known for taking many of my new patients off statins!!!! I have seen people die from these meds who I knew didn’t even need to be on them!! I want to pull out my hair. There is no pleasure when my popular title goes from “cynic” to “foresighted” nobody benefits from that. This is all about $$$. When will we all wake up and realize in order to have just, quality, equitable medical care we must, must, must remove money from the equation!!!

  2. The implication seems to be that financial rewards for investigators has led to misleading (or even fraudulent) data being promoted.
    The question I have is, what is the experience in countries with national health care plans? The economic incentives to over prescribe should be different as should the pressures on individual physicians.
    So is the over use of statins strictly a US phenomena?
    If it is not then what are the factors that lead to over use elsewhere? I think one of the problems with drugs which only show benefit when measured against large populations is that physicians really don’t know what to do in individual cases.
    If a person fails to have a heart attack was the drug regimen the reason or just happenstance? Even if treatment was restricted to those in the groups statistically most likely to be helped, what to do when faced by a specific person remains an art not a science.

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  4. Physicians are in a pickle when these controversies emerge, but the drumbeat of standard medical theory states that the lower the cholesterol, the better. If you do not place your patient on a statin, and he/she has a heart attck or sudden death, then you can find yourself questioing whether your decision was the right one. Could you have prevented this event with a statin? Worse yet, you could be open to litigation from some angry family or patient who will undoubtedly get an expert witness to say you did not fulfill the standard of care.
    I would also point out that most of the studies you refer to use mortality and/or cardiac events as their endpoints, but speak little to quality of life and functional ability of the patient. Medicine has gotten very good in the past few years at salvaging patients after a heart attack or stroke, but many may end up with debilitating congestive heart failure or paralysis. What about these endpoints for study?
    There is no doubt in my mind that in the 25 years in practice, something we are doing to patients with cardiac disease has greatly improved the chances of survival. Rarely do I witness the patient that has one heart attack after another till their heart become too weak to pump. Something in the concotion of medications we use must be having a positive effect. This post heart attack patient is the area where the evidence is most strong for using statins. But the questions posed are good ones as to whether we have extended the boundries of treatment to groups where the risks outweigh the benefits. This remains to be shown and it may take several years till we have a clear answer to this question. Till then, it requires a careful conversation with the patient about the existing controversy.

  5. Bravo Keith, but there is no question we are using these medications way outside of proven benefits, i attended the renal failure of an 82 y/o woman and her family (note she had never had an MI or a storke and was on a statin by one of my colleagues). I stopped statins in a 32 y/o woman who had a mildly elevated cholesterol w/o other risk (note she got pregnant two months later). I have story after story. I do agree that they are of GREAT benefit to a particular population, but I believe excellent marketing of weak studies to overworked doctors has lead to thier pervasive, over misuse. In regard to litigation, again BRAVO, jurys and courts use standard of care not EBM, which is worse the sin of omission or comission?

  6. I went off lipitor 6 years ago after being on it for one year. I and my family have high cholestrol, about 300 and up. I noticed the strange side affects, looked at my family and decided that cholestrol reduction was bull.
    My Doctor, who is very good, always tries to persuade me to go back on them. I have read enough to know that its the C reactive protein that is the best indicator and mine has actually come down from 0.5 to 0.3. I understand that a person with low cholestrol has a 50% higher chance of a massive heart attack than does a person with high cholestrol. Additionally, I drink milk and I have read that milk drinkers have half the rate of heart attacks than do non milk drinkers.
    This brings me to my main concern that you can’t trust all the information you get from the orthodox medical profession. I started eating lots of eggs,butter and meat about 5 years ago and provided I stay away from sweets and eat a reasonable amount of carbs, my weight stays in a low range even though my cholestrol stays near 300.
    I am trying to reduce my blood pressure without using drugs but every attempt has failed so far. I than have to stop my execise program until the pressure goes down to a reasonable level before restarting strenuous excercize.
    I do not trust the medical profession for much of their advice concerning both cholestrol and high blood pressure because I believe they have been mislead by the drug companies and so called expert panels.
    However even I am captive to the blood presure drugs for now since the alternatives are too risky.

  7. I’ve researched the Cholestrol “myth” for several years. What your primary care physician will not tell you is that the ratio is just as important or more than the LDL and the HDL. The overall Cholestrol count is useless, according to cardiologist. Your ratio should be 4.0 or less. I have a very high HDL and my LDL is over 100, but my ratio is 3.1. You will not hear this from a family physician. Be sure and know what the ratio is with your HDL and LDL. Also, my overall count with my HDL is excellent. FYI..my overall cholestrol is 162…imagine that, but my ratio is 3.1 and my HDL is 76. Don’t listen to the crap they sell you…research!

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  9. The “ratio” has pith my curiosity. Many people have come to believe that all cholesterol is bad, yet cholesterol is needed to form important hormones and perform other vital cell functions. The truly bad cholestrol (LDL) clogs arteries. The good cholestrol (HDL), works like a drain cleaner for arteries.
    For years, my old (and very trusted) family physician (God rest his soul) would look at my cholestrol and was mindful that my LDL was somewhat high. However, he was also mindful that my HDL was somewhat high too, and sent me on my way.
    I had two ederly parents that where patients of physicians that thought the world of statins. For all the good they were supposed to be, the statin drugs had become quite problematic for them. It started with rhabdomyolysis (severe muscle breakdown). It could eventually lead also to liver disorder and kidney failure, and I didn’t even want to think of the next level (death). Yes, I had them both taken off. For my dad, maybe it was too late. For my mom, she’s still cooking (figuratively) at 93.
    I wholeheartedly agree with the notion that one of the problems with drugs which only show benefit when measured against large “populations” is that physicians really don’t know what to do in “individual” cases. This is especially true with cancer drugs. At least with cancer drugs, there is a solution to that misnomer, but the powers that be in cancer medicine would think otherwise.

  10. individual cases are how I practiced medicine, I would talk to and educate the patient on what I knew about statins (or any med) how the information is weakened through extrapolation and we would make a decision together, you never really “know” what to do when you first walk into that exam room, this is the “art” of medicine.

  11. maggie,
    Doctors “let this happen” because who are we as little community physicians to challenge the recommendations of the big smart important “experts?” If we challenge the money influenced guidelines, even if we have the evidence at hand, we still don’t have the reputation and influence of the big name specialsits telling us “what the evidence shows.”
    The guidelines become the standard, and unless they change, the standard is the standard. Ignore it at your own risk. Start rating docs based on how many patients meet the guidelines, then the fun really starts.
    NCEP had a vigorous response to the CSPI letter, thought I’d post the link for those interested.
    http://www.nhlbi.nih.gov/guidelines/cholesterol/response.pdf

  12. I responded more completely on my blog, click my name.
    Look, I’m a medical student and so not yet an expert but what I do see in the comments above is the idea that docs are ‘keeping things’ from people or ‘won’t tell’ people things or are marching to some ‘drumbeat’.
    Statins aside–and I think this article raises some great questions–doctors are not some monolithic army of robots. We tend to say similar things partly because guidelines are starting to be a measuring stick for ‘quality’. A family doc that takes people off statins may well be ‘reminded’ of their use or measured on LDL numbers by their HMO.
    Your average doc, IMHO, is doing their level best to help you. They give you the best advice they know, and they practice medicine every day. Are they always right? Of course not! But we’re not trying to fleece you.
    I DO think pharma has an undue influence. I took the No Free Lunch pledge that I would never accept drug company education or funding, and I haven’t, and I won’t. That said, statins still have their place, I think. Overused? maybe. Side effects? Sure. But it’s not a conspiracy or a plot.

  13. Thank you all for your comments–you’re raising interesting points.
    I’m traveling–in Texas to give a talk. But I’ll
    get back to you, this week-end, if not earlier
    mm
    P.S. A health tip to avoid
    mental stress. If you can
    possibly avoid air travel, do so.

  14. Thank you all for your comments–you’re raising interesting points.
    I’m traveling–in Texas to give a talk. But I’ll
    get back to you, this week-end, if not earlier
    mm
    P.S. A health tip to avoid
    mental stress. If you can
    possibly avoid air travel, do so.

  15. Maggie-
    Don’t you see our own fallacy here?
    “If they are high risk, statins can be beneficial to people under 65 who haven’t had a heart attack, but 50 such men have to be treated for 5 years for one to benefit.” says Abramson. “The other 49 will not be helped. The problem is that we can’t know who is going to be the 50th man,” he adds. And all 50 will be EXPOSED to the side effects.
    How many of the 50 actually get significant side effects? That’s the fair comparison because, like those who benefit, we don’t know who they will be. Number Needed to Treat vs. Number Needed to Harm is the first step of a correct comparison. You then also must compare the magnitude of the benefit or harm.

  16. The use of clinical trials to establish prescribing guidelines for evidence-based medicine is highly criticized because such trials have little relevance for the “individual” patient in the real world, the individuality and uniqueness of each patient.
    There is also an inherent conflict of interest when organizations that provide guidelines for treating a disease also receive funding from corporations that benefit financially from the recommended treatment.
    In medical situations – particularly life or death – one must make judgements based upon preponderance of available evidence as opposed to proof beyond reasonable doubt.
    If respectible Journals (the ones that fail to adhere to guidelines on conflict of interest) won’t publish all articles because they have a lock-up on information, don’t lay blame on its critics.
    The problem is not lousy doctors, it’s a lousy system.

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  18. Saturday Morning/Friday Nite Links

    Skiing again in the morning. Okemo this time, and I am about to head up there for the weekend. Not a particularly challenging mountain (a family mountain for sure), but closer, and with the loan of a friend’s condo and today’s snow, some go…

  19. I read the Business Week article, and it raised some valid points, such as that the number needed to treat (NNT) for primary prevention with statins is high (this is also true of many other drugs). However, I think it’s important to look at individual risk. Let’s say someone has no symptoms of heart disease but their risk of a heart attack is estimated at > 20% over the next ten years (this is considered “high risk”). Taking a statin could lower their risk by 30% or so. They could also lower their risk by taking low-dose aspirin and fish oil, getting regular exercise, and controlling any other modifiable risk factors they have. I think that person’s doctor should discuss the pros and cons of statin therapy with them and the person should make their own decision whether or not to take a statin.
    Regarding the Business Week article, a couple of quotes in it are misleading. The quote from Dr. James K. Liao (“Cholesterol lowering is not the reason for the benefits of statins.”) is either incorrect or taken out of context. What he meant is that cholesterol-lowering is not the *only* reason for the benefits of statins. He confirmed this with me in a e-mail and it is stated in a number of things he has written. Statins are thought to work partly through lowering LDL and partly through other effects generally known as “pleiotropic effects.” This is pretty well accepted among cardiologists. For example, statins have been shown to improve endothelial function; ezetimibe (Zetia, and a component of Vytorin) has not. Fichtischerer et al., Differential effects of short-term lipid lowering with ezetimibe and statins on endothelial function in patients with CAD: clinical evidence for “pleiotropic” functions of statin therapy, European Heart Journal (2006) 27, 1182-1190. Landmesser et al., Simvastatin Versus Ezetimibe: Pleiotropic and Lipid-Lowering Effects on Endothelial Function in Humans, Circulation 2005;111;2356-2363.
    In addition, the quote from Dr. Hayward is taken out of context. When he said “current evidence supports ignoring LDL cholesterol altogether,” what he meant was the following:
    (1) Overall cardiovascular (CV) risk is what is important to know;
    (2) Knowing something about a person’s cholesterol level, along with their other risk factors, is important in assessing CV risk; and
    (3) If two patients have the same CV risk level, they should get approximately the same benefit from a statin, regardless of their LDL level. He is also of the view that total cholesterol & HDL gives you better information on CV risk than LDL. Although not everyone agrees with Dr. Hayward’s views, he does *not* saying cholesterol levels should be ignored.
    I also take issue with the presentation of the case discussed at the beginning of the article. Martin Winn, we are told, has chest pain when bicycling uphill, which might be angina. His doctor puts him on a statin. In the next paragraph we are told that Winn “didn’t actually have angina.” Um, how does Dr. Wright know this? Were there tests performed to determine whether or not Winn’s chest pain was angina? After all, men with angina are at higher risk of a heart attack than men without angina. In addition, there *are* statin trials showing lower total mortality in middle-aged men with hypercholesterolemia who have not had a heart attack. The West of Scotland trial comes to mind. In addition, many people would prefer to avoid having a heart attack or stroke even if they don’t end up living longer.
    I don’t consider myself a statin booster. I’m not on one myself, because I’m not at high risk of a heart attack. But let each person consider both the risks and benefits, and then make an informed decision. Does this always happen? No, but that’s true of many therapies in medicine.

  20. Thank you all for your comments.
    Marilyn, waltdougherty,Dr. Matt, Dr. Rick, Gregory:
    Let’s begin with the question of whether bad cholesterol causes heart disase.
    I’m going to be writing a second post on this issue, but let me say here that what the doctors I have spoken to are telling me is that “bad cholesterol” is NOT a major factor in causing heart disease.
    See Dr. Krause’s quote in my post above. it’s key.
    This doesn’t mean that statins don’t lower cholesterol. They do. But that the evidence now suggests that this isn’t how they help people with established heart disease avoid a second attack. We think that statins work by reducing inflammation–just as aspirin does.
    Pls re-read what I say about the Vytorin study. The drug-makers didn’t want to release it because it really undermines the idea that statins reduce the chances of a heart attack by reducing cholesterol. When they cominbed two choleseterol-lowring drugs, they were sure that they would be more effective than one cholesterol-lowering drug.
    But they weren’t. Why not?
    The original Framingham studies (that I will talk about in my next post) showed that “bad cholesterol” was only a “marginal factor” in causing heart disease.
    But the word “marginal” was forgotten as food manufacuters and the American Heart Association began promoting the idea of low cholesterol foods.
    I realize that this is hard to believe–but this is what doctors who have no financial interest in the drugs are now saying. And this is what some doctors in other countries have said for a long time.
    Re-read my post and note the fact that there are large populations with high levels of bad cholesterol, and little heart disease. There are also groups with low levels of bad cholesterol and high rates of heart disease. This has puzzled doctors for a long time. Now we think we understand why: bad cholesterol just isn’t that important in causing heart disease.
    Marilyn-I’m interested in the fact that two of the doctors in the Biz Week article were quoted out of context. This is a serious charge. If true, Biz Week would have to print a correction–but I haven’t heard anything about a retraction.
    On the other hand, I wouldn’t be suprised if doctors quoted might not be experiencing “sources remorse.” I can only imagine the mail, phone class and e-mail they are getting from outraged colleagues who genuinely believe that statins work by lowering cholesterol.
    All I can say is that before publishing this post, I sent it to the doctor I quote most frequently (Abramson from Harvard) to make sure I had both the facts and the details right. He made a couple of small, but useful suggestions. And he sent me an e-mail after the post came out, saying how much he liked it.
    This is just one doctor’s opinion–but he has spent quite a bit of time studying this subject. And he’s not a quack. I’ve also now read quite a few studies by doctors and scientsts saying the same thing (and I cite them in the post.)
    In any case, I’m sure this will continue to be a controversial subject. But at least the dogmatic insistence on statins as the major cure-all for heart disease has been called into question.
    Robert Feinman–you raise a very good question about other countries.
    Statins have caught on world-wide, but, from what I have read statin use is significantly higher in the U.S. than in most other places, and there have been many more
    outspoken critics of the statin theory in other countries.
    When I was doing research for my book, Money-Driven Medicine, back in 2003, I had gotten wind of the skepticism in the U.K. And as a former financial reporter, I knew statins were being hyped on Wall Street.
    So I began asking doctors. Most scoffed at the skeptics. But not all. The head of cardiology at one of the most prestigious
    academic medical centers in the U.S. told me “Doctors in the U.K. think we’re nuts when we talk about cholesterol causing heart disease–and I think they’re right.”
    He practiced what he preached. I heard him tell a patient scheduled for a by-pass in a couple of weeks not to worry about eating ice cream.
    He was an older doctor, not at all slick, and struck me as very intelligent. (He was also worried about stents–that they were being overused and that the risks that they would become disloged were being ignored. This was back in 2003–before we began reading articles about the risks of stents.) But he
    didn’t want to be quoted in my book about cholesterol. He didn’t become the head of the cardiology dept. at a major academic medical center by putting himself in the center of controversies. I don’t mean this as a criticism. But it was clear that he was a very discrete, pretty private person.)
    In this country, cardiologists who have spoken out about cholesterol have found it very hard to get published, are viewed as
    “fringe people,” etc.
    Marc: You raise a very good question about risks.
    If fifty people are exposed to the risks, how many actually are hurt?
    It’s tough to answer. In one place, I read that approxmiately 2% of patients on statins suffer serious side effects. The author pointed out that 2% is a small share–but given how many people are on statins, this is a large number of people. (And 2% is also the share of people who saw any benefit from statins in the example I gave.)
    Moreover–and this is important– many times
    people on statins who complain of side effects are ignored. Gregory’s parents, for example, may have suffered side effects, but if their doctors “thought the world of statins” they probably didn’t pay too much attention, believing that the benefits were so great that they outweighed the side effects.
    I know a doctor at Kasier in California whose elderly father lived here in Manhattan and went to 4 or 5 specialists complaining about severe muscle pain. None of them suggested that he go off statins.
    When his son, who is a family doctor, heard about his complaint, he immediately told him to go off statins. It worked. The son couldn’t believe that none of the New York doctors (including his cariologist) told him that this is a known side effect of statins that can become very serious.
    So, as Dr. Matt and others on this thread have commented, one has to weigh risks and benefits with the individual patient in mind.
    The good thing is that this controversy is likely to make doctors more aware of the risks–and more likely to explain these risks to patients. Then, if
    patients start experiencing side effects they will know what’s going on.
    For what it’s worth, a doctor put my husband on statins a few years ago. He has never had any symptoms of heart disease, but his cholesterol was moderately high. After a few months, my husband stopped taking them becuase he “just didn’t like the way they make me feel.” (He’s extremely healthy, in touch with his body, and wary of taking drugs. He’s also the sort of person who is more likely to listen to his body than to his doctor. Good doctors respect this–especially since he’s not overweight, his diet is excellent, etc.)
    Keith– Yes, it does seem that for some people, statins really are helping as “part of the concoction of medicines that we use” in reducing heart disease. As I said above, we now think they do this by reducing inflammation.
    You are also right that the endpoints in these studies are fatalities. And there certainly is something to be said for statins reducing heart attacks and other symptoms of heart disease that undermine quality of life (even if they don’t reduce fatal heart attacks.)
    We need more disinterested studies to better understand the actual benefits.
    Aspirin has also proved very useful for many people. (We really need a head to head study comparing aspirin to Lipitor. My husband, who gave up statins, takes a baby aspirin every day.)
    Aaron, pcb and other doctors on this thread–
    I do believe that most doctors are doing their level best to give their patients the best treatment possible. And I also understand why the average doctor can’t override a consensus among the supposedly “best” most esteemed cardiologists int he country.
    When I ask “where were the doctors?” I’m really blaming the doctors who have a huge influence over medical opinion–the ones who write in the major journals, are interviewed by the New York Times, the Wall Street Journal etc.
    Why didn’t more of these experts step forward? I don’t think it’s entirely about money (though this clearly was a factor for some of the most vocal statin-supporters), but it also was a matter of not wanting to deal with the inevitable attacks that would follow.
    The politics of American medcine can be vicious–in part because there is so much money at stake.

  21. Here is the abstract for a recent article by Dr. Liao.
    Pleiotropic effects of statin therapy: molecular mechanisms and clinical results
    Chao-Yung Wanga, Ping-Yen Liua and James K. Liao,a
    aVascular Medicine Research Unit, Brigham and Women’s Hospital and Harvard Medical School, Cambridge, MA 02139, USA
    Available online 14 January 2008.
    Statins inhibit the enzyme 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase, which is required for cholesterol biosynthesis, and are beneficial in the primary and secondary prevention of cardiovascular disease. Most of the benefits of statin therapy are owing to the lowering of serum cholesterol levels. However, by inhibiting HMG-CoA reductase, statins can also inhibit the synthesis of isoprenoids, which are important lipid attachments for intracellular signaling molecules, such as Rho, Rac and Cdc42. Therefore, it is possible that statins might exert cholesterol-independent or ‘pleiotropic’ effects through direct inhibition of these small GTP-binding proteins. Recent studies have shown that statins might have important roles in diseases that are not mediated by cholesterol. Here, we review data from recent clinical trials that support the concept of statin pleiotropy and provide a rationale for their clinical importance.
    Glossary
    AKT/PKB and FOXO
    This term refers to serine-threonine protein kinase Akt (protein kinase B) and its downstream target forkhead transcription factors. It is an important regulator of cellular growth, survival and senescence.
    Caveolae
    Caveolae refers to approximately 50–100 nm invaginations of the plasma membrane in terminal differentiated cells. Caveolin is the principle protein of caveolae. Caveolae have important roles in endocytosis, oncogenesis, uptake of pathogenic bacteria and signal transduction.
    Isoprenylation
    This term refers to post-translational modification of proteins with isoprenoids. Isoprenylation of proteins is important for protein trafficking and compartmentalization.
    Neointima
    This term refers to vascular remodeling within the internal elastic lamina formed by a thickened layer of vascular smooth muscle and inflammatory cells. Formation of neointima occurs in response to vascular injury.
    Reactive oxygen species, NADPH oxidase and p67phox
    Reactive oxygen species refers to oxygen-derived free radicals. They are formed mainly through three processes: (i) they are a byproduct of cellular respiration, (ii) they are synthesized by dedicated enzymes such as NADPH oxidase or myeloperoxidase and (iii) they can be formed by ionizing radiation injury. The cytosolic protein p67phox is a component of NADPH oxidase.
    Trends in Molecular Medicine
    Volume 14, Issue 1, January 2008, Pages 37-44
    Notice that the abstract states that most of the benefits of statins are due to cholesterol-lowering.
    Here’s something quoting Dr. Hayward:
    http://www.eurekalert.org/pub_releases/2006-10/uomh-hls100206.php
    Narrative Review: Lack of Evidence for Recommended Low-Density Lipoprotein Treatment Targets: A Solvable Problem, Rodney A. Hayward, MD; Timothy P. Hofer, MD, MSc; and Sandeep Vijan, MD, MSc
    Annals of Internal Medicine, 3 October 2006 | Volume 145 Issue 7|Pages 520-530.
    Or you can ask him yourself. That’s what I did.
    That doctor who said it was OK to eat ice cream was talking about *dietary* cholesterol and/or saturated fat. That’s totally different from *serum* cholesterol.
    The ENHANCE study says nothing about the benefits of statins, since the two groups were on the same dose of simvastatin. The study was designed to test if there was an additional benefit to adding ezetimibe (Zetia, a component of Vytorin) to simvastatin. It did not show a benefit, although Merck/Schering-Plough still have 3 ongoing studies that will provide a more definitive answer.
    In any case, the idea that a drug that lowers LDL (or raises HDL) may not be beneficial is not exactly new. Take torcetrapib, the Pfizer drug that raised HDL and lowered LDL. Unfortunately, it also killed people.
    I agree that LDL as a cause of heart disease is sometimes overhyped. But let’s not throw the baby out with the bathwater.
    Getting back to ezetimibe, there are studies that show that although ezetimibe lowers LDL, it does not appear to have the same pleiotropic effects as statins. Landmesser et al., Simvastatin Versus Ezetimibe: Pleiotropic and Lipid-Lowering Effects on Endothelial Function in Humans, Circulation 2005;111;2356-2363. Fichtischerer et al., Differential effects of short-term lipid lowering with ezetimibe and statins on endothelial function in patients with CAD: clinical evidence for “pleiotropic” functions of statin therapy, European Heart Journal (2006) 27, 1182-1190.

  22. Maggie, I didn’t know if you know this but finding out the percentage of side effects of a medicine is pretty much impossible. When someone has a significant side effect there is a form to be filled out by the doctor, a copy goes to the manufacturer and I think one goes to the FDA. The problem is that we are busy and most of us only fill it out for significantly severe side effects (the one I filled out was due to a death from statins) but who is to say what is “significant” if I filled one out everytime I changed a medication due to side effects I would probably have filled out three a week! granted we would have a better picture of side effect profile but….when are we supposed to do this???? You can get one of these forms from your local hospital pharmacist, check it out.

  23. I’d also like to bring to your attention the fact that evidence for the benefits of vitamin E and garlic in heart disease is very weak. For example:
    Arch Intern Med. 2007;167:1610-1618.
    A Randomized Factorial Trial of Vitamins C and E and Beta Carotene in the Secondary Prevention of Cardiovascular Events in Women
    Results From the Women’s Antioxidant Cardiovascular Study
    Nancy R. Cook, ScD; Christine M. Albert, MD; J. Michael Gaziano, MD; Elaine Zaharris, BA; Jean MacFadyen, BA; Eleanor Danielson, MIA; Julie E. Buring, ScD; JoAnn E. Manson, MD, DrPH
    Background Randomized trials have largely failed to support an effect of antioxidant vitamins on the risk of cardiovascular disease (CVD). Few trials have examined interactions among antioxidants, and, to our knowledge, no previous trial has examined the individual effect of ascorbic acid (vitamin C) on CVD.
    Methods The Women’s Antioxidant Cardiovascular Study tested the effects of ascorbic acid (500 mg/d), vitamin E (600 IU every other day), and beta carotene (50 mg every other day) on the combined outcome of myocardial infarction, stroke, coronary revascularization, or CVD death among 8171 female health professionals at increased risk in a 2 x 2 x 2 factorial design. Participants were 40 years or older with a history of CVD or 3 or more CVD risk factors and were followed up for a mean duration of 9.4 years, from 1995-1996 to 2005.
    Results A total of 1450 women experienced 1 or more CVD outcomes. There was no overall effect of ascorbic acid (relative risk [RR], 1.02; 95% CI, 0.92-1.13 [P = .71]), vitamin E (RR, 0.94; 95% CI, 0.85-1.04 [P = .23]), or beta carotene (RR, 1.02; 95% CI, 0.92-1.13 [P = .71]) on the primary combined end point or on the individual secondary outcomes of myocardial infarction, stroke, coronary revascularization, or CVD death. A marginally significant reduction in the primary outcome with active vitamin E was observed among the prespecified subgroup of women with prior CVD (RR, 0.89; 95% CI, 0.79-1.00 [P = .04]; P value for interaction, .07). There were no significant interactions between agents for the primary end point, but those randomized to both active ascorbic acid and vitamin E experienced fewer strokes (P value for interaction, .03).
    Conclusion There were no overall effects of ascorbic acid, vitamin E, or beta carotene on cardiovascular events among women at high risk for CVD.
    Trial Registration clinicaltrials.gov Identifier: NCT00000541
    Author Affiliations: Divisions of Preventive Medicine (Drs Cook, Albert, Gaziano, Buring, and Manson and Mss Zaharris, MacFadyen, and Danielson), Cardiovascular Medicine (Drs Albert, Gaziano, and Buring), and Aging (Drs Gaziano and Buring), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; Department of Epidemiology, Harvard School of Public Health, Boston (Drs Cook, Buring, and Manson); Veterans Affairs Boston Healthcare System (Dr Gaziano); and Department of Ambulatory Care and Prevention, Harvard Medical School, Boston (Dr Buring).
    The jury is still out on the cardiovascular benefits of garlic, if any.
    http://seniorjournal.com/NEWS/Nutrition-Vitamins/2007/7-02-26-GarlicDoesNot.htm
    Aspirin has both risks and benefits. Hundreds of people are hospitalized and some even die every year from taking aspirin. Low dose aspirin can only be recommended where the benefits outweigh the risks.

  24. Interesting drmatt brought up about reporting the side effects of drugs. Reports of serious injuries and deaths that may have been caused by prescription drugs skyrocketed between 1998 and 2005, according to a paper published in the Archieves of Internal Medicine.
    Details buried deep inside the paper showed that the increase was largely explained by reports from manufacturers. And those reports were mainly about side effects not already described on drugs’ labels. Reports directly from doctors and pharmacists, as well as reports from drug companies of side effects already on drug labels, rose much more slowly. Imagine that?
    The study’s lead author, at the Institute for Safe Medication Practices, feels the bigger issue is that the FDA’s problem-ridden Adverse Event Reporting System isn’t a systematic measure of how often drugs really cause side effects. Doctors aren’t required to report drug side effects into the system, and it’s estimated that fewer than 10% of all adverse events ever get reported.
    Daniel Carlat, a professor at Tufts Medical School, has critized the FDA as being too lax about monitoring drug safety. The chore of teaching doctors how to practice medicine has been handed to the pharmaceutical industry. As a result, dangerous side effects are rarely on the curriculum.
    And there is the transformation of continuing medical education into an enterprise for drug marketing. Most states require that doctors obtain a minimum number of credit hours of continuing medical education each year to maintain their medical licenses.
    Not so long ago, most of these courses were produced and paid for by universities and medical associations. But this has changed drastically over the past decade. Because pharmaceutical companies now set much of the agenda for what doctors learn about drug, crucial information about potential drug dangers is played down, to the detriment of patient care.

  25. Gregory, Dr. Matt and Marilyn–
    Gregory & Dr. Matt–
    That’s a very good point about how little we know about how many people
    suffer side effects.
    Of course if we had
    electronic medical records, we would have a data-base. Rather than sending in a report each time a patient suffered side effects, perhaps a
    doctor could check a box next to the part of the patient’s medical record where he had noted the side-effect, recommended a change in medication, etc–and by clicking that box, that section of the EMR would automatically go do the FDA (or whatever disinterseted party was collecting the data).
    Gregory– I agree, the way that drug-makers have taken over so much of continuing medical education is disturbing.
    Marilyn–
    There are, as you know, many studies on statins, what lowers cholesterol, what good it does or doesn’t do. . . Clearly we need more much more disinterestedc research in this area.
    But
    it’s also quite clear that
    statins have been overprescribed and that “bad” cholesterol is not a major cause of heart disease.
    I could cite studies publisihed in medical journals as you have in your comment, but most of the people reading this list are not doctors and so I don’t want the discussion to get bogged down in a level of detail that not everyone can easily follow.
    Ultimately, competing studies reveal that many of these questions are unresolved.
    But I do appreciate the time you have taken to produce this evidence, and I will look at these studies myself. .

  26. “. . . it’s also quite clear that statins have been overprescribed”
    They are both overprescribed and underprescribed. Overprescribed for primary prevention and underprescribed for secondary prevention.
    “‘bad’ cholesterol is not a major cause of heart disease”
    There are many causes of heart disease, known and unknown, modifiable and unmodifiable. LDL levels happen to be modifiable, so they get a lot of attention. In addition, statins lower risk regardless of baseline LDL. I don’t care if you call elevated LDL a “major” risk factor or a “minor” one. Clearly it’s a risk factor. No one is saying it’s the only one.
    “I could cite studies published in medical journals”
    Then why don’t you? Inquiring minds want to know.
    “but most of the people reading this list are not doctors and so I don’t want the discussion to get bogged down in a level of detail that not everyone can easily follow.”
    What a ridiculous, condescending comment. You make unsupported statements and then decline to cite any evidence for fear of confusing people. I find that insulting.
    “Ultimately, competing studies reveal that many of these questions are unresolved.”
    There’s always things that are unknown, things that are uncertain.
    The fact is, you didn’t do enough research before you wrote your post, and it shows. Better luck next time.

  27. Now it’s getting very interesting, drmatt bringing up about reporting the side effects of drugs. Is he psychic?
    The WSJ’s Health Blog posted that their Anna Wilde Mathews reported FDA’s new plan to bolster oversight of drugs already on the market. The plan was announced to FDA staff in an email. Blogee, Scott Hensley thinks that this is the latest response by FDA to years of criticism about its handling of drug safety issues.
    http://blogs.wsj.com/health/2008/02/26/fda-says-safety-first-for-drugs/#comments

  28. Marilyn–
    I have had a complaint from a reader (who, as it happens, is a doctor) about your comments.
    Apparently, he has spotted you on other blogs–using other pseudonymns.
    He said that he recognized you by your style when you “unloaded a deluge of meaningless references when she cannot cobble together in a cohesive and persuasive original content based upon logic and the issue at hand. Then she has to use bully tactics and unjustified discrediting.”
    The goal seems to be to undermine the blog–perhaps for political reasons. . He concludes by saying:
    “Trying to read someone slicing and dicing and dissecting every sentence you write is borig. The point by point, line by line, tit for tat rebuttal style is indeed fundamentalism, with the guiding principle of Quackwatch people.”
    This is what I was getting at when I said that I didn’t want to get bogged down in a “Here’s my journal article which says the opposite of your journal article” war of words.
    Rather than contributing to the thread, you are interrupting it with a diabtribe that is not interesting (or even comprehensible) to most readers.
    Please refrain from this style in the future.

  29. Marilyn Mann is not a pseudonym. It is my real name.
    Maybe I feel strongly about this subject because my daughter has heterozygous familial hypercholesterolemia and would be at risk of an early death if it weren’t for statins.
    My husband has also been told he is at high risk of a heart attack. He is also on a statin.
    I agreed with you that statins are overprescribed for primary prevention. But because I dared to disagree with some of the other things you said, you accuse me of “fundamentalism” or of pursuing a “diatribe.” I respectfully disagree.
    If you post something on the internet, and open it up for comments, you have to be ready for people to disagree with you. If that offends you, then you are in the wrong business.
    Please ask your friend to contact me directly to discuss the situation. My e-mail is mannm@comcast.net. My phone numbers are (202) 551-6813 and (301) 520-5488. I would be glad to discuss the matter with him at his convenience.
    Have a good evening.

  30. I just want to add that I am curious about what your friend thinks my political leanings are. I’m a liberal democrat. This is my first time reading your blog, so I’m not even familiar with your political views.
    I’m no apologist for the drug industry, if that is what he/you are thinking.
    I am not familiar with the “Quackwatch people” he is referring to so I can’t comment on that. If “Quackwatch” is an organization, I am not a member of it.
    I would be curious to know what the pseudonyms are that he attributes to me. I am wondering whether those other posts are mine or not.

  31. Marilyn–
    First, I’m very sorry about your daughter, and am glad to know Marilyn isn’t a pseudonymn.
    I don’t mind when people
    disagree with me. I do mind when they try to derail or stop the discussion and this is what the other reader (who I don’t know personally, just on this blog) was complaining about.
    Listing a string of journals articles isn’t helpful. Most people don’t have the time (or the access) to look them all up. If you had read this blog for a while, you would know that when people cite evidence they explain–in clear English, free of jargon, that everyone can understand. They explain any technical terms. They provide a URL so that someone who does want to look at the article can do so.
    The fact that I was the only person on the thread who responded to your comments should tell you something.
    As for the truth of what I have said here, and what Business Week printed,– as you know there are doctors who agree with the Business Week article. And there are doctors who agree with my post. (See, for example, http://www.Kevinmd.com, which lists it as one of the best health posts of the week.)
    Finally, on this blog we try to avoid hostility and saracasm. ( You wrote: “What a ridiculous, condescending comment. You make unsupported statements and then decline to cite any evidence for fear of confusing people. I find that insulting. . .
    The fact is, you didn’t do enough research before you wrote your post, and it shows. Better luck next time.”
    In fact, I have done a great deal of research on this topic–and asked a doctor who specializes in this area of reserach to fact-check the post before I put it up.

  32. Marilyn–
    First, I’m very sorry about your daughter, and am glad to know Marilyn isn’t a pseudonymn.
    I don’t mind when people
    disagree with me. I do mind when they try to derail or stop the discussion and this is what the other reader (who I don’t know personally, just on this blog) was complaining about.
    Listing a string of journals articles isn’t helpful. Most people don’t have the time (or the access) to look them all up. If you had read this blog for a while, you would know that when people cite evidence they explain–in clear English, free of jargon, that everyone can understand. They explain any technical terms. They provide a URL so that someone who does want to look at the article can do so.
    The fact that I was the only person on the thread who responded to your comments should tell you something.
    As for the truth of what I have said here, and what Business Week printed,– as you know there are doctors who agree with the Business Week article. And there are doctors who agree with my post. (See, for example, http://www.Kevinmd.com, which lists it as one of the best health posts of the week.)
    Finally, on this blog we try to avoid hostility and saracasm. ( You wrote: “What a ridiculous, condescending comment. You make unsupported statements and then decline to cite any evidence for fear of confusing people. I find that insulting. . .
    The fact is, you didn’t do enough research before you wrote your post, and it shows. Better luck next time.”
    In fact, I have done a great deal of research on this topic–and asked a doctor who specializes in this area of reserach to fact-check the post before I put it up.

  33. Maybe most of the people reading this blog “are not” doctors and don’t like to see discussions get bogged down in detail.
    I certainly don’t like the concept of having anyone make a pronouncement as to what constitutes “truth.” Medical science is no different than any other type of science. Truth is generally an imperfect work in progress. Evidence-based medicine is an attempt to fix “truth” in concrete, in many cases ossifying what should more properly be a work in progress.
    I believe Maggie would not want to turn this into a Jerry Springer-style blog. What do attacks and detours have to do with the subject being discussed?
    If someone thinks they have information on the subject being discussed, they should post that information and leave attacks in the drawer.
    I personally read this blog because of the more civil nature of discourse. I feel it is patently unfair for someone to attack anyone else’s thoughtful opinions or information which may not meet with the personal opinions of someone else.
    The most interesting discussion is the honest difference of opinion.

  34. Maggie,
    I think this may be more a question of style than anything else. I’m used to posting on usenet groups, like sci.med.cardiology, where people routinely post abstracts and where the discussion is fast and furious.
    If I ever post on your blog again, I’ll keep your helpful hints in mind.
    Also, I’m an lawyer, and you know how obnoxious lawyers are!
    Best regards,
    Marilyn

  35. Marilyn–
    I agree–I think our problem was mainly a matter of style. You’re accustomed to a differnt kind of blog.
    But I really hope you keep commenting here. You
    clearly are very knowledgable and care passionately about healthcare.
    These are the commenters I most value. It’s just that commenting here tends to be less of a
    “fast and furious argument,” and more of a conversatoin designed to bring everyone
    in while in coming to a betternunderstanding of our health care system and what we need to do to fix it.
    I’m a former college teacher, and so I tend to think of a good blog as a good seminar. It’s an interactive learning experience. Ideally, commenters talk across the table to each other–not just to me. And they’re interested in helping each other navigate a very, very difficult topic–how we can improve health care in America.
    I truly do hope that we hear from you again.

  36. So, do any of you doctors ever step back and think about these things, and wonder if they arent being done on purpose?
    This is 2008, so where are all these ‘advances’?
    Why are we sicker now than in the 70s?
    Maybe your foundations and authorities dont have the same goals as the goals they advertise?

  37. Terry–
    Thanks for the head’s up on RSS–
    I e-mailed the person who oversees our computer system and this was her reply:
    “I just took a look at Health Beat and all of the feeds are working correctly– I verified Firefox in PC/Mac; Internet Explorer on PC; and Safari in Mac.
    So, right now, everything is working fine with a variety of browsers and on both macs and pcs.”
    Is it working for you now?

  38. As one who uses a statin, I guess it
    is reasonable to share my observations and opinions.
    I have had high cholesterol since I was in my early 30’s. I am now almost 55 years old. it took a while to find a medication my body would/could tolerate. After several years I changed Docs, and the new doc took me off the statin. I could not afford to take what she wanted to replace it with so I went without for about 5 years. In those five years I could actually feel the change in my body as the cholesterol began to build up again. After we thought I had a heart attack in 2004 (I didn’t) my doc agreed to put me back on what I knew would at least “help”…
    Ok…now here is the catch. Had I known in my early 30s what was happening inside my body, as a result of an internal/unconscious stress response due to early (interpersonal) childhood trauma, causing a “fight/flight/freeze” over-production of cortizol (in simple terms -cholesterol ), I wouldn’t have waited 20 plus years to deal with the internal stuff (treating the stress disorder, and learning natural ways to allow my body to “unfurl” from its “frozen” place) instead of just treating “symptoms” and covering up all the stuff one needs to “uncover” and go through, to change internal the relationship/response.
    So…what do I mean by all this? I agree that there is a big gap in the information we get. For example medical doctors treat high cholesterol, and psychiatrists treat “stress disorders”. Most/many docs aren’t even trained to connect the biochemical/neuro-biological dots.
    I am not sure it is anyone’s “fault” though. We don’t live in a society which embraces an interdisciplinary/intersubjective approach to much. In one corner, science may be busy looking at a problem, and in the other corner, religion (for example) may be looking at the same problem, but, typically, they aren’t talking to one another, and they aren’t often delving into each other’s methodologies for obtaining information. In many instances, as some people here have pointed out, it simply is not encouraged.
    Things can change, though, and in some cases they are. Some very influential MDs have shifted their focus to the study of psychology and the human brain. The combination has the potential to create a very powerful voice in this very industry.
    Although Marilyn (sorry if I didn’t spell your name correctly) may have been a little personally impassioned when she first wrote, I feel that at the heart of her comments she has a point. Opinions are wonderful and we all need to have an avenue for being more able to both articulate and to “hear” about new information, without the jargon that higher education tends to bring to (especially a subject like this — so a blog like this is perfect.
    Ultimately, though, I am not sure those bigger, stronger, voices which/who are needed to be the driving force behind the kind of change that is being proposed here, will do more than “glance” at material that doesn’t provide sufficient references which can be used to propel the forward motion of this kind of argument.
    This is not to say I didn’t enjoy the blog, and the comments, or that I don’t agree with the nature of its general purpose. I just caught myself wondering if it can manage to do both things.. provide a place of congenial conversation for the average-person and also be the vehicle for moving healthcare out of it’s currently entrenched position? Might there be a way to bridge that gap?
    Thanks for the good read and the opportunity to share a bit.

  39. As one who uses a statin, I guess it
    is reasonable to share my observations and opinions.
    I have had high cholesterol since I was in my early 30’s. I am now almost 55 years old. it took a while to find a medication my body would/could tolerate. After several years I changed Docs, and the new doc took me off the statin. I could not afford to take what she wanted to replace it with so I went without for about 5 years. In those five years I could actually feel the change in my body as the cholesterol began to build up again. After we thought I had a heart attack in 2004 (I didn’t) my doc agreed to put me back on what I knew would at least “help”…
    Ok…now here is the catch. Had I known in my early 30s what was happening inside my body, as a result of an internal/unconscious stress response due to early (interpersonal) childhood trauma, causing a “fight/flight/freeze” over-production of cortizol (in simple terms -cholesterol ), I wouldn’t have waited 20 plus years to deal with the internal stuff (treating the stress disorder, and learning natural ways to allow my body to “unfurl” from its “frozen” place) instead of just treating “symptoms” and covering up all the stuff one needs to “uncover” and go through, to change internal the relationship/response.
    So…what do I mean by all this? I agree that there is a big gap in the information we get. For example medical doctors treat high cholesterol, and psychiatrists treat “stress disorders”. Most/many docs aren’t even trained to connect the biochemical/neuro-biological dots.
    I am not sure it is anyone’s “fault” though. We don’t live in a society which embraces an interdisciplinary/intersubjective approach to much. In one corner, science may be busy looking at a problem, and in the other corner, religion (for example) may be looking at the same problem, but, typically, they aren’t talking to one another, and they aren’t often delving into each other’s methodologies for obtaining information. In many instances, as some people here have pointed out, it simply is not encouraged.
    Things can change, though, and in some cases they are. Some very influential MDs have shifted their focus to the study of psychology and the human brain. The combination has the potential to create a very powerful voice in this very industry.
    Although Marilyn (sorry if I didn’t spell your name correctly) may have been a little personally impassioned when she first wrote, I feel that at the heart of her comments she has a point. Opinions are wonderful and we all need to have an avenue for being more able to both articulate and to “hear” about new information, without the jargon that higher education tends to bring to (especially a subject like this — so a blog like this is perfect.
    Ultimately, though, I am not sure those bigger, stronger, voices which/who are needed to be the driving force behind the kind of change that is being proposed here, will do more than “glance” at material that doesn’t provide sufficient references which can be used to propel the forward motion of this kind of argument.
    This is not to say I didn’t enjoy the blog, and the comments, or that I don’t agree with the nature of its general purpose. I just caught myself wondering if it can manage to do both things.. provide a place of congenial conversation for the average-person and also be the vehicle for moving healthcare out of it’s currently entrenched position? Might there be a way to bridge that gap?
    Thanks for the good read and the opportunity to share a bit.

  40. As one who uses a statin, I guess it
    is reasonable to share my observations and opinions.
    I have had high cholesterol since I was in my early 30’s. I am now almost 55 years old. it took a while to find a medication my body would/could tolerate. After several years I changed Docs, and the new doc took me off the statin. I could not afford to take what she wanted to replace it with so I went without for about 5 years. In those five years I could actually feel the change in my body as the cholesterol began to build up again. After we thought I had a heart attack in 2004 (I didn’t) my doc agreed to put me back on what I knew would at least “help”…
    Ok…now here is the catch. Had I known in my early 30s what was happening inside my body, as a result of an internal/unconscious stress response due to early (interpersonal) childhood trauma, causing a “fight/flight/freeze” over-production of cortizol (in simple terms -cholesterol ), I wouldn’t have waited 20 plus years to deal with the internal stuff (treating the stress disorder, and learning natural ways to allow my body to “unfurl” from its “frozen” place) instead of just treating “symptoms” and covering up all the stuff one needs to “uncover” and go through, to change internal the relationship/response.
    So…what do I mean by all this? I agree that there is a big gap in the information we get. For example medical doctors treat high cholesterol, and psychiatrists treat “stress disorders”. Most/many docs aren’t even trained to connect the biochemical/neuro-biological dots.
    I am not sure it is anyone’s “fault” though. We don’t live in a society which embraces an interdisciplinary/intersubjective approach to much. In one corner, science may be busy looking at a problem, and in the other corner, religion (for example) may be looking at the same problem, but, typically, they aren’t talking to one another, and they aren’t often delving into each other’s methodologies for obtaining information. In many instances, as some people here have pointed out, it simply is not encouraged.
    Things can change, though, and in some cases they are. Some very influential MDs have shifted their focus to the study of psychology and the human brain. The combination has the potential to create a very powerful voice in this very industry.
    Although Marilyn (sorry if I didn’t spell your name correctly) may have been a little personally impassioned when she first wrote, I feel that at the heart of her comments she has a point. Opinions are wonderful and we all need to have an avenue for being more able to both articulate and to “hear” about new information, without the jargon that higher education tends to bring to (especially a subject like this — so a blog like this is perfect.
    Ultimately, though, I am not sure those bigger, stronger, voices which/who are needed to be the driving force behind the kind of change that is being proposed here, will do more than “glance” at material that doesn’t provide sufficient references which can be used to propel the forward motion of this kind of argument.
    This is not to say I didn’t enjoy the blog, and the comments, or that I don’t agree with the nature of its general purpose. I just caught myself wondering if it can manage to do both things.. provide a place of congenial conversation for the average-person and also be the vehicle for moving healthcare out of it’s currently entrenched position? Might there be a way to bridge that gap?
    Thanks for the good read and the opportunity to share a bit.

  41. I think my heart disease is not a result of my colesterol or diet or fitness as they are all resonable for a 50 yr old. I think it is because of the stress of 30 yrs of marriage to a nagging selfish woman combined with as many years of a nagging selfish boss. Mens hearts failing them out of fear is the simple explanation.

  42. I had 3 heart attacks in Dec. all atypical. A 99% blockage was found and I now have a stent VAD. I had no symptons, high total Cholesteral, high Triglycerides. I am a diet freak and health nut, love exercise. I refused statins due to the side effects, I am a 75 y/o female, no smoking, no drinking, no drugs. HOWEVER!!!! I AM TOTALLY CONVINCED MY PROBLEMS STARTED WITH THE REMOVAL OF MY GALL BLADDER FEB 2005. Prior to this my angiogram showed 0% placqing. After this surgery I still experience daily pain in the liver area. January 2007 showed 50% blockage in the LV and in December 2007 99+% blockage resulting in my new stent (which I am not thrilled about and suffered w drug reaction (pain & inability to breathe) for about 6 weeks. HAS ANY RESEARCH BEEN DONE IN THIS AREA? I BELIEVE TOO MANY GALL BLADDERS ARE REMOVED WHEN THE SITUATION COULD BE RESOLVED WITH SOME KIND OF NATURAL FORM OF TREATMENT. We are to quick to accept meds and diagnosis from MD’s and although I trust my body more than the MD’s, I dropped my guard and went along with the surgery I did not want. Stupid? Yes, and now I also have diabetes, heart disease and gross placqing in my left brain. WE NEED RESEARCH ON REDUCING PLACQ. Dr. T

  43. Janice N. Thaxter, I think EDTA chelation is good for ridding the heart of plaque.

  44. I want to thank you for this Maggie. Although I know everything in here and in fact have been part of getting this information into the press, I can’t think of another writer who has pulled it together as cogently as you have.
    Regarding your post about a doctor contacting you privately: I assume you Googled and did an AMA search on this physician’s name? How rare that this professional has time on his hands to read blogs, form intricate character analysis of posters over a period of time, and then privately contact you with a synopsis of his hours and hours of internet study.
    Wow. There is no doctor shortage in the U.S.

  45. Julia, Janice, LT3Y, RS,
    Julia, I do there will be more interdisciplinary work in
    medicine exploring mind/body problems–though it has been a long time coming. This is probably because the profit motive has so distorted priorities.
    Researchers in the private sector tend to focus on problems that they can hope to solve in a relatively short period of time (a slight variation on a drug we alrady have,for example), package and sell.
    We need to put more money into govt research and, most of all, we really need more academic scientists doing research for the sake of expanding knowledge–scientists are not dependent on funding from for-profit companies.
    Of course that means that universities would need to reward these scientists (with tenure, respect and enough funding to do their work) even though they weren’t bringing in outside money.
    As for the blog, most of the issues we focus on are not that technical. Even in the case of cholesterol, this is a subject that many people are interested in and can follow. (The post was picked up by http://www.alternet.org, a general interest alternative online newspaper that covers a wide range of subjects. There, a 109 people have commented–many of them people who have bad experiences with statins.
    On this blog we often have comments from doctors,but the majority are able to express what they know in plain English . . .
    LT3Y– Thanks much. When I
    get e-mails from people they are usually people who
    have been reading my posts for a long time, here and elsewhere . .
    RS and Janice–Someone who
    I respect very much is a big fan of chelation. He’s an older man (actually fought in WW II)and in very good health, so it certainly doesn’t seem to have done him any harm, and he firmly believes it has done him a world of good.

  46. There has been a proliteration of doctors posting to articles such as yours. Whether or not they are doctors is debatable.
    Some years ago Monbiot wrote about his investigation into Monsanto putting paid infiltrators on boards where activists shared information about actions. That’s also being done by non-agro pharmaceutical companies.

  47. My blood cholesterol was well over 300 and came down 100 points because of Simvistatin. Statins are hard on the liver but my liver tests showed just fine and I take the smallest dose. A person taking statins needs to be checked periodically by a doctor and get blood tests regularly.

  48. Statins are sheer poison, they destroy pretty much everything good in the body inc. the appetite. Why so many people and doctors have been sold this rubbish I don’t know. Surely the alarm bells go off when “statins cure diabetes, statins cure dementia, stains cure pneumonia. When’s this going to end. Kd.

  49. All this is really a concern. I’ll just bring up two sons and try to ensure that they eat properly. In order to find the right diet you can always use Google or watch video seminars on youtube.

  50. In response to Ralphie:
    Yes, I do think about these things, all the time; it’s my job. I quite literally agonize over starting any one of my patients on a medication about every 15 minutes. I wish I had more time to expound (and I’m not saying this for dramatic effect at all), but I have too much work to do tonight to reply in more detail. But, please be assurred that many medical folks have deep concerns about statins and other pharmaceuticals as well! [And, thank you for the wonderful blog Ms. Mahar. Keep up the good work!]
    Curt Haugen, PAC (Internal Medicine)

  51. In my personal experience I believe that Statin drugs do more harm than good. When my doctor told me that my cholesterol was a few points over normal she immediately prescribed drugs. There was no conversation about diet or exercise. Doctor’s are programmed to immediately pull out the prescription pad. After being on them for a month or so I experienced muscle pain which is one of the side effects. My doctor’s recommendation to help alleviate this was yet another drug. After some research on my part I brought it down to normal by making some easy changes to my lifestyle. You can learn more on how to accomplish this with an article I found at http://bit.ly/cy3PWW

  52. Thank you all for the interest and many provocative comments.
    I do think that many doctors think carefully about whether or not to prescribe statins. Statins seem to help some people. At the same time, good doctors listen to what their patients say about side effects.
    That said, I’m impressed by how many patients have decided to take themselves off statins, becuase they don’t like the side effects.
    This post has been reprinted in mnay places, and I’m alway surprised by how many patients write in to say that they decided to go off statins.
    Since this is an old thread, I’m only going to respond to the most recenr comment (assuming that people who commented a few months ago won’t be checking back)
    John–
    First, thanks very much for the link.
    And I do think that if a doctor is very quick to prescribe medication, a patient might want to ask about alternatives.. . “Are you saying that I absolutely should take this drug; or that it is probably a good idea; or that it might be a good idea?”
    Older patients, in particular, might want to say “I’m already taking (4,5, 6, 7, 8) medications, and don’t really want to become a walking pharmacy (SMILE). That’s why I’m asking why this one is absolutely necessary . . .”

  53. The doctors in this country are doing their patients a more harm than good by prescribing these poisons to the masses. If you are concerned about your cholesterol levels the best way to lower them is with some rather simple lifestyle changes. You can learn how easy this can be at http://bit.ly/cy3PWW

  54. I had all of the classic muscle pains listed in statin side effects documentation. My doctor said it was because of coQ10 and vitamin D deficiency from the statins. She recommended StatinHelp (www.statinhelp.com) that is sold on Amazon. It has really helped with the muscle pains. Statin side effects are never really discussed by the doctors. I found out two years into treatment when I mentioned needing something for back and leg pain to her. By then I was taking 10-15 advil per day to function. Thankfully she was a runner who believed in vitamin supplements.

    I did go off statins for a while. It took weeks for muscle issues to go away and I had other strange cramp like issues during the period. I went on a vegan diet but my cholesterol went back up so back on crestor. I’ve considered Lipitor also.

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