In my work as a doctor I see a quite-steady stream of individuals who are concerned about their cholesterol-levels. Usually, these people are male, quite young (often in their 40s) and have been diagnosed with ‘raised cholesterol’. They are also often fit, healthy, non-smoking and free of diabetes and high blood pressure.
Despite the fact that these men have, generally speaking, very low risk of heart disease, they have usually been urged to ‘get their cholesterol under control’. The usual advice is to take exercise (which they’re usually doing) and eat a diet devoid of butter, red meat and eggs. If these approaches do not work, it is often suggested that they should consider taking a statin.
Part of the problem here is that total cholesterol levels or even levels of supposedly ‘unhealthy’ LDL-cholesterol are not accurate guides to the risk of heart disease or other cardiovascular problems. We know, for example, that the size and density of LDL-cholesterol and/or the number of these particles floating around in the bloodstream affects the damage that this may wreak on the vessel walls. Smaller and denser LDL particles and higher numbers of LDL particles (these things go hand-in-hand) are linked with heart disease but larger, less buoyant and less plentiful LDL particles are not. However, this detail is completely missed by standard blood tests.
However, there is some sense that the tide is beginning to turn regarding what is regarded as good practice with regard to cholesterol management. About a year ago, I wrote this post which highlighted the views of US Professor of Medicine and cardiologist Harlan Krumholz, who pours cold water on conventional cholesterol management. Part of his argument is that treating to get LDL cholesterol levels down to a particular level has never been tested. It’s an example of a common medical practice that is not actually ‘evidence-based’, though my experience is that there are plenty of doctors around who believe it is.
More recently, Dr Krumholz featured in a report in the journal Nature which, again, highlighted some of the problems with conventional cholesterol management. I reported on this here.
A study was published recently which, I think, highlights a need for some shift in doctors’ thinking and practice with regard to cholesterol management [1]. In it, 750 doctors in the US were surveyed, with each being presented with a vignette of 6 hypothetical people. Doctors were asked which of these people they would likely treat with statins over the coming years.
One of these vignettes was a 40-year-old man, with ‘raised’ LDL levels and normal blood pressure (just the sort of person I see quite-often in practice). The authors of the research point out that this man is actually at low risk of cardiovascular disease and very unlikely to benefit from statin therapy. Nonetheless, the great majority of doctors said they would treat this man with statins.
The authors of the study suggest, sometimes, we doctors don’t do a particularly good job of assessing overall risk when making treatment decisions and recommendations. A major problem, here, is that we doctors can be stuck on the ‘all-important’ LDL-cholesterol levels.
As I’ve said before, I think we doctors have been subjected to a form of collective brainwashing on cholesterol and its role in heart disease. The fact remains that we will often prescribe statins to people who have very little chance of benefiting from them. These drugs are not without risk either – a critical point that I did not evade the authors of this recent survey.
The bottom line is that we doctors can often end up recommending statins for people for whom they are more likely to do harm than good.
References:
1. Johansen ME, et al. A National Survey of the Treatment of Hyperlipidemia in Primary Prevention. JAMA Intern Med. Published online 11 March 11 2013
I had my cholesterol measured at a pharmacy rather than via my GP, in order to avoid being diagnosed with a statin deficiency 🙂
My total cholesterol was 5.05 but the Total/HDL ratio which features on the risk charts was pleasingly low.
The trouble is too many doctors get their information about cholesterol from statin salesmen, rather than the plethora of new and recent independent research. I questioned a GP about why the tests he suggested didn’t include LDL particle size (or trigylcerides) and he just gave me a blank stare, looked at the form and replied “it’s not on the form”. He was only too happy to prescribe statins on incomplete evidence so I declined the tests. Scary.
Dr Briffa,
Interesting article.. I was wondering if there is any research on treatment for women? Im 38, diagnosed with high cholestoral, low vitamin D and my cholestoral could be familial. Are there any thoughts on treatment for this type of patient? The focus seems to always be on middle aged males.
From my experiece so far, doctors seem to be keen to immediately advise going onto statins as a matter of course with little or no consideration of overall weight/health/lifestyle factors. There seems to be a myriad of opinions with little concensus which results in huge confusion for people in my situation. I would be interested to know your thoughts on this. Many thanks.
Nice writeup. You might have also mentioned that not only are traditional cholesterol numbers of questionable importance, but also that the connection between dietary fats/cholesterol and blood lipid profiles are weak in the case of many people. Indeed, triglyceride levels are correlated with high GI carbs, as summarized here: http://www.proteinpower.com/drmike/cardiovascular-disease/elevated-triglycerides-are-driven-by-carbohydrate-consumption/
Thanks again for all your posts – all very useful.
#SD: my experience, as a female, is that statins are the first thing a GP reaches for in a female who has raised cholesterol. My query is: why? Pressure on GPs? Financial inducements to prescribe statins? Lack of time/interest to investigate a very complex issue? Successful and cynical manipulation of research by ‘big pharma’? Whatever it is, we are all potential ‘patients’ if ‘medically- advised’ cholesterol levels continue to be reduced. And that is something that leads one towards a rather paranoid response to the medical establishment that is totally undesirable for long-term health.
I don’t mean to be rude for the sake of it, and there are obvious exceptions (Dr Briffa, for example), but nearly all the GPs I have met in my life have been dullards: procedural, and sort of meta-lazy. I don’t think it’s unfair to say that a gentleman amateur who knows how to read randomised-controlled trials will, with a week of study, have greater perspicacity than the average GP.
Everyone I know has a story about a lazy GP misdiagnosis, some of which are amusing but plenty of which are frightening.
Saying this doesnt bring me any cheer: it’s frightening that this layer of listless bureaucratic mediocrity are now more than ever the inefficient bouncers and gate-keepers to the Health Service. I’d prefer to visit a good computer terminal and a well-trained statistician than a GP much of the time!
This seems to be along the same lines as overuse of antibiotics in the past and almost certainly to some extent still now. Understandable in the past when information was not so quickly available and before the dangers of creating resistant bacteria was known. I guess there is the issue of assessing information to see what is reliable.
Dr. Briffa you say “we Doctors”, do you prescribe Statins even though you don’t believe a patient will benefit? Is this why GPs do so, because they feel they should, just in case? I often feel that medication is handed out “just in case” rather than because it’s justified. Despite my GP saying I was a “woman of mystery” because he had no answers for my bout of sudden, very painful, muscular spasms, he nevertheless offered me anti-inflammatories (despite my still taking lansoprazole for a suspected ulcer) and more painkillers. I declined both.
To make matters worse, after examination, he told me I have a palpable liver, said absolutely not when I said “doesn’t everyone” and left it at that. Dr. Google (I know!) suggests that this serious. This is the same GP who persuaded my husband, Type ll, that he really should take his statins! I despair.
The benefits significantly outweigh the risks of statin use. If you have high cholesterol then you need to be medicated. Why do you think heart disease is so much lower now than it was 20 years ago? People are living longer because drugs like statins clean out their arteries. My doctor told me that as long as I take my statin (Simvastatin 20mg) everyday my arteries will stay clear. I also avoid dangerous foods such as eggs, butter, red meat and most dairy products. I eat plenty of whole grains and love sandwiches made with flavored soy and kelp. I also take a beta blocker and a calcium channel blocker (my BP was 131/64 my doctor said was way too high and that I was considered borderline hypertensive), now my BP is 109/50 which is right for me. I’m 36 and although I don’t exercise much I’m in very good health. I firmly believe that my medication regime is going to allow me to live many years heart disease free.
I am female, in my early 40s, and I have also been urged to get my ‘cholesterol under control’. My cholesterol – at my last testing – was 5.0, lower than my younger sister AND my younger husband (and neither of them were told their cholesterol needed to be go ‘under control’). When I questioned this (while scratching my head) I was told that it will creep up if I don’t do something about it NOW…and was duly handed the usual NHS diet sheets about the virtues of eating “foods such as pasta, bread, grains and rice” for at least “one-third of every meal”, plus snacking on starchy foods between meals and making sure I was filling up on starchy foods to ward off hunger.
I guess the next step is being offered statins.