We need more actuaries in medicine

Actuaries are individuals who use mathematics to assess, among other things, the financial impact of risk and uncertainty. Their critical analysis of data is an essential part of evaluating things like how much our we pay for our insurance premiums and what our pension contributions should be. I was recently made aware of a piece which appeared in the August 2011 edition of Actuary – the Magazine for the Actuarial Profession. Written by actuary Garth Lane and entitled Heart of the Matter, it deftly disassembles many of the cherished beliefs held by the medical profession that related to heart disease and its prevention [1].

Mr Lane starts by skewering original research conducted in the 1950s by epidemiologist Ancel Keys which purported to show a relationship between fat consumption and heart disease in a handful of countries. But as Mr Lane points out, this represented a ‘misuse’ of the data. When we look at the wider evidence available at the time, the supposed relationship between fat and heart disease simply disappears.

Subsequently, the focus was thrown on cholesterol-containing foods. But, as Mr Lane points out, in the late 1990s Ancel Keys himself admitted that “There’s no connection whatsoever between cholesterol in food and cholesterol in blood. And we’ve known that all along. Cholesterol in the diet doesn’t matter unless you happen to be a chicken or a rabbit.”

So, what is the relationship between cholesterol levels and heart disease? Mr Lane points our attention towards a study published in 2009 which measured supposedly unhealthy LDL-cholesterol in almost 137,000 individuals admitted to hospital with a heart attack [2]. 75 per cent of hear attack victims had LDL levels below the recommended threshold of 3.4 mmol/l (130 mg/dl). Yes, that’s right – the majority of people who have a heart attack have cholesterol levels their doctor would be proud of.

Mr Lane goes further when he refers to the fact that in ‘primary prevention’ (people without established cardiovascular disease), statins do not save lives. He also draws our attention to the risk of ‘probably under-reported’ side-effects including liver and muscle damage.

Here’s Mr Lane’s closing paragraph in full: “Statins are not the swallows heralding a summer free of heart disease for everyone. Arguably, if we do not insist on a proper answer to the question of what really causes heart disease then we may unduly medicate millions of people for little benefit at the danger of making a significant number of them seriously ill.”

I wholeheartedly agree with Mr Lane on this, and ask, how come he sees this but the vast majority of doctors don’t? Could part of the reason be that actuaries are trained to take a critical eye data, but we doctors are not (although, we think we are). And could another reason be something to do with money? Some elements of industry, at least in part to swell the coffers, will seemingly contort the evidence to convince doctors that statins are wonder drugs. Actuaries do work that has financial implications too, the difference being that decisions are based on more objective analysis of the facts.

References:

1. Lane G. Heart of the Matter. Actuary. August 2011;28-29

2. Sachdeva A, et al. Lipid levels in patients hospitalized with coronary artery disease: an analysis of 136,905 hospitalizations in Get With The Guidelines. Am Heart J. 2009;157(1):111-117.

8 Responses to We need more actuaries in medicine

  1. Michael Allen 8 September 2011 at 1:20 pm #

    Your conclusion is understandably low key, given that you continue to work in medicine. However, in Vanity Fair recently, two Pulitzer Prize-winning journalists laid bare the corruption and deceit which are endemic in the current drug-testing system.

    http://www.vanityfair.com/politics/features/2011/01/deadly-medicine-201101

    The article was summarised in the New York Times:

    http://prescriptions.blogs.nytimes.com/2010/12/02/6485-overseas-clinical-trials-and-counting/?partner=rss&emc=rss

    It’s worth reading the full article before you take the pills that your doctor thinks will do you good.

  2. Chris 9 September 2011 at 7:00 pm #

    Garth Lane, as you report it, seems to have picked up upon the thrust of the argument adopted and put forward by members of THINCS (The International Networks of Cholesterol Sceptics) whose web presence, member list, and even some email contacts can be found on the web, along with some links to some very interesting articles.

    Author of ‘The Great Cholesterol Con’, Dr Malcolm Kendrick is a cholesterol sceptic and a member of THINCS (incidentally there are two books by the same name but authored by different sceptics).

    Mr Lane may well have trended to becoming cholesterol sceptic himself after reading Kendrick – for the talk-down of the cholesterol ‘faith’ follows the path of reasoning that Kendrick reports. As an actuary I imagine Garth Lane has checked Kendricks argument with a critical eye and found it representational of ‘facts’, or the closest we can get to them.

    Dr Kendricks work put me on to ‘Spacedoc’, Dr Duane Graveline, who has authored books on cholesterol side effects. He should know them, Dr Graveline experienced ‘transient global amnesia’ (memory loss) while on a course of Liptor to lower his serum lipoprotein count (the surrogate measure of serum cholesterol – there IS NO absolute way to measure serum cholesterl). Dr Gravelkine wrote about transient global amnesia in ‘Liptor: Thief of Memory. His latest offering is ‘The Statin Damage Crisis’ and it makes for very sobering reading.

    Cholesterol is crucial to life and to many biochemical actions/interactions that support life and even consciousness. We synthesise about 80% of the cholesterol we need and typically might source around 20% from diet. Since cholesterol is so important to us, since we synthesise so much, and since we are increasingly aware of the bodies ability to self-regulate checks and balances of the biochemicals and their interactions whose complex processes give rise to life as we know it, then you’d imagine the body has systems to self-manage cholesterol in an envelope that is consistent with, or trending to, demand. In other words, in the absence of a complete map of biochemical interactions, and a requisite understanding, that give rise to life we’d be bloody foolish to interfere. Reading ‘The Statin Damage Crisis’ leaves one in no doubt how bloody foolish and I’ll wager Garth Lane has read Graveline.

    Statins do not just act to reduce cholesterol synthesise and then, seemingly as a secondary consequence, reduce the lipoproteins in which cholesterol is transported and which the labs then measure and report back as LDL or HDL. Oh nooooo ….. Statins interfere too high upstream in something called the mevalonate pathway to be discrete in their actions. Statin drugs interfere with 5/6 other biochemical outcomes that are derived from this upstream chemical step that statins act upon. This interference with this crucial step, allied with the consequences of the blocking of the synthesis of these other 5/6 biochemical outcomes and dependencies, predicts symptomatic outcomes associated with statin medication. Put simply, someone in the know can predict statin side-effects. The predicted side-effects tally well with those that actually arise, and as Graveline and certain of his fellow sceptics no doubt ‘thinc’, statin side-effects are probably under-reported. Lane seems to validate such a proposition.

    There is one uncertainty in my mind that I would like to resolve. Those cute little bunnies were fed cholesterol, it is said, but I’d like to be in no doubt whether the cholesterol as isolated and fed to them was in fact cholesterol or ‘oxycholesterol’, the oxidised variant of cholesterol. ‘See, eggs and milk might well contain cholesterol, whereas powdered egg and powdered milk likely contain oxycholesterol and the distinction could be significant. In isolating cholesterol (or refining some cholesterol rich source) to add to the rabbits diet it seems possible that the cholesterol may have become oxidised. It may be pertinent.

  3. Richard David Feinman 9 September 2011 at 8:16 pm #

    Very informative and I thought it was high-enough key. I think that it definitely has “something to do with money?” Although industry is part of the problem, it is NIH money. The study sections will not tolerate dissent and are, in any case, funding each other, sitting on the sam editorial boards and advisory committees. I think that this is where the problem is. “The study was supported by the NIH; the authors reported no relevant disclosures ” is a contradiction in terms.

  4. Michael 9 September 2011 at 11:02 pm #

    Here in the US, where I work regularly, it’s a question of money and convenience.
    Medics subscribe satins because there’s no, or little, chance of comeback in the guise of a legal action from a messed up patient.
    Then the process of recommendation, and related ‘marketing’, also provides big bucks to the medic/practice.
    Recent requirements that force both pharma and medic to identify such income is already reducing the total amounts (squillions) involved, but pharma and their feeders are getting clever in the way financial incentive reaches its destination.
    Recently, when back in the UK, I needed a cholesterol test. The values were above guidelines, so the doctor immediately said that I needed to begin a course of 40mg (40!) statins. No discussion about lifestyle, eating habits, and medical history. Needless to say, I didn’t take him up on his recommendation.

  5. Mark Struthers 9 September 2011 at 11:29 pm #

    The link to Garth Lane’s useful article is,

    http://www.theactuary.com/actuary/feature/2096092/heart-matter

    There is also an added comment to the article from the always excellent Uffe Ravnskov on the extent of the ‘cholesterol scandal’. Of course, a great part of that scandal is the behaviour of heavily conflicted journals like the BMJ … with their ‘ties to industry’ … whether those pharma-industrialists make statins … or vaccines.

    http://www.bmj.com/content/343/bmj.d5147.full/reply#bmj_el_268989

  6. Janet 12 September 2011 at 6:11 pm #

    Re the comment above regarding rabbits being fed cholesterol: as I understand it, the reason it was detrimental to the rabbits was that rabbits never, ever encounter cholesterol (in any form) in their diet in the wild, because they eat only plants, and plants contain no cholesterol whatsoever. (So feeding rabbits cholesterol and then extrapolating the results to humans was just plain ridiculous)

  7. Chris 14 September 2011 at 6:20 pm #

    I agree Janet, feeding an animal upon a diet to which it is not naturally adapted is one possible hindrance to a reliable transposition of results to a human case. It’s one factor that may have confounded Anitchkov (there are alternate spellings) who conducted early experiments on rabbits.

    More recent experiments on animals indicates there is a distinction in outcome between feeding those animals cholesterol or oxidised cholesterol. Dietary cholesterol seems relatively benign whereas oxidised cholesterol appears devastating.

    My curiosity is whether Anitchkovs’ methods were sufficiently sophisticated to ensure the cholesterol fed to his rabbits remained ‘pure’ and did not become oxidised. This could be a second confounding factor,

    More than a decade ago a ‘scare’ did the rounds that the powdered creamer commonly used in vending machine tea and coffee ‘clogged yer arteries’. The concern seems to have waned but I expect it was contemporaneous with the animal experiments that fed oxycholesterol to lab animals and found it to be deleterious.

    Plant sterols constitute a class in which there are about 60 known variants. As with ‘polyunsaturates’ it could be dangerous to assume all variants posses similar properties. Cholesterol is also a ‘sterol’ as the etymology might indicate, albeit one with greater application for animals than for plants.

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