Rafe Issues Challenge to Statin Industry

I have been trying to get the straight scoop on whether statins actually decrease mortality and morbidity in a significant way and I haven’t been able to find any real evidence that they do.

If you ask a cardiologist it’s clear that they believe unequivocally that statins work, mostly because they see what statins to do blood cholesterol levels.  But remember, cholesterol numbers in and of themselves do not matter.  They are a proxy variable for cardiovascular health.  Plaque buildup matters.  At one time blood cholesterol numbers were the only non-invasive indicator we had of plaque buildup, but that’s not true anymore.  However, drug companies are highly incentivized to prove that statins improve health.  So they fund lots of studies.

Notwithstanding the systemic bias when there are profit motives and publication motives, we can turn to these studies and see if statins actually work.  The best way to remove bias is to look at large-scale meta-analyses, like this one.  If you simply read the conclusion you see “statin use was associated with significantly improved survival and large reductions in the risk of major cardiovascular events.”  However, if you decode the numbers you see that “significant” means that, for example, at age 65 you improve your changes of dying within the next four years from 8% down to 7% [hat tip to Kevin for helping me decode the numbers].  Now, is that really significant?

If my cardiologist told me I needed to take statins and I said “prove it” and he produced that study above, I would absolutely not take them.  For one, there are known deleterious side effects (which could possibly account for the small overall mortality risk decrease).  For another, the average length of followup was only 4 years, whereas I am told that I am to take these drugs indefinitely.  How do I know that the long-term side-effects won’t overrun the long-term benefits sometime after the four year mark and thus increase my overall mortality risk?

On the other hand, some small scale studies done by well-respected physicians indicates that you can reverse even advanced heart disease, as measured by the number of cardiac events (i.e. what really matters) through diet and exercise alone.

You can object all you want to the statistical significance of small scale studies.  The real issue is, given the evidence, what would YOU do if you were diagnosed with heart disease or were at high risk of heart disease as measured by your cholesterol numbers?

Since I’m not such a candidate, I made a friendly wager with a good friend of mine about a year ago who is.  He has been under a physician’s care for years because he has abnormally bad cholesterol numbers, and it runs in his family.  His doctors told him that he couldn’t control it with diet and that statins are the only way to go.  Problem is, he has a hard time tolerating statins (i.e. deleterious side effects).  Despite being on various statins, his numbers had barely budged.  The wager was designed to test the hypothesis that through dietary changes and exercise he could improve his numbers, a proposition that he claimed was impossible because he’d changed his diet in the past but it didn’t work.  My claim was that he was misinformed about what he was supposed to be eating and what he was not.  He got some advice from another friend who knows the literature.  Here is the result:

Been on about an 80%ish vegan diet, taking 2 meds (that I’ve taken before to little effect) that are pretty mild as far as lipid management,my cholesterol on a recent test came back lower than it’s ever been:

total chol = 165, hdl = 40, ldl = 110, triglyc = 80

my LDL level was 270 less than a year ago, and my total chol was 350.

Still kind of stunned, and I expect the results are at least somewhat anomalous, but even if they prove to be outliers to my normalized levels it will represent a bigger improvement than I could have ever had taking super-dosage statins.

Here’s my challenge to the medical establishment: produce a meta-analysis of statins that shows absolute age-adjusted mortality rate decrease of greater than 10% over 20 years.*

In the mean time, I’ll be eating healthy, exercising regularly, and making money from people who want to take the same bet as my friend.

* Statins were commercially available in the U.S. starting in 1987, so the underlying data should exist.  And remember, going from 8% to 7% is a 12.5% relative decrease but only a 1% absolute decrease.  Since we care about human lives, not publishable results, isn’t it time that we start demanding absolute improvement from the medical community?

  • alexgolubev

    But there is no money to be (directly) made from the public’s increased diet and exercise. :) And noone’s gonna get remotely close to the statin “statistics”, because it’s going to be “doctor recommended”. Should the government require people to exercise and eat healthy? What if they work 2 jobs and can only afford big macs?

    It’s not that I’m arguing against your point. I think that we can definitely determine a handful of things that are statistically significant (like exercise and healthy diet), but ultimately the breakdown is in the incentive/capitalism/infrastructure land. Education is always there, but there’s money to be made behind some ideas and hopelessly $0 behind others.

    I guess doctors have ethical pledges to disemminate the correct information (without as much in direct monetary incentives). So they are one target to pursue. Seems like we need a medical snopes/wiki site to provide transperancy and intelligent unbiased interpretation for medical urban myths.

    • TheQuickBrownFox

      “Seems like we need a medical snopes/wiki site to provide transperancy and intelligent unbiased interpretation for medical urban myths.”

      I agree with that! Also, I think it should be standard for the data to be published separately to the interpretation in a study. One group of researchers could collect data and publish it and their own take on the results. Other people could then provide their own interpretations. All these documents could be linked to the data with equal weight, leaving it to the observer to decide which has the best reasoning. Why let the data-gatherers monopolise the interpretation? (Because they would be lowered down from their intellectual high-horses, of course.)

      The medical literature seems to be full of weak and vague statistical links followed by comments by the authors basically stating what they believed before doing the study succinctly enough to be quoted in the media.

    • Rafe Furst

      On snopes/wiki, and also separating interpretation from data: both good ideas. But there is a missing link which is the financial incentive for the truth to bubble to the surface and be taken seriously.

      In my opinion, one of the best ways we could do this is foster betting markets where the truth value of any sort of scientific claim is tied to its price, and people who believe the truth can make a profit off of people who do not. This is the concept behind prediction markets, and in particular, the Truth Markets proposal.

      • alexgolubev

        I really like the idea of Truth Markets, if at the least for the reason it makes us think about truthiness and trustiness. Just like there are multiple types of gambling games:
        1. roullete – odds and payoffs are fixed
        2. horses – odds are dynamic, payoffs are fixed
        3. stocks – odds and payoffs are dynamic
        there are different attributes of “Currents” (and “Futures”). I don’t think we can cram all staments into the same betting box. The truthiness of a lot of statments is not determinable for a variety of reasons. There is a lot of ambiguity out there some of which is even intentional (pretty much anything “politicians” say). The “TRUSTiness” of statements is what we may end up measuring, just to clarify it. I agree that the value of fiat currency is based on trust, but the truth value of medicine isn’t based on trust or the majority’s opinion. if anything that majority opinion will be biased based on big $ marketing.

        So the only way out seems to be to have a “library” of studies with interpretations and critiques by “experts” (opinion of study and topic of study). Split into pro’s and con’s and a vote by the experts. Currently this isn’t centralized and studies are randomly highlighted by headline seeking reporters and bloggers with little expertise, like myself. Consolidation => power. How would one attract experts to such a place? and how does one determine who is expert enough? Is it enough to simply tag studies by topic and show the unbiased conclusions? Maybe that is a starting point. If you build it, they will come.

        • alexgolubev

          looks like medpedia already exists

        • Rafe Furst

          Not sure that if I build it they will come. Adoption is a tricky thing, as evidenced by the fact that nobody knows about MedPedia and after browsing through it I’d still rather go to Wikipedia. I would bet a decent amount of money that MedPedia will never knock Wikipedia off the pedestal (as imperfect as Wikipedia is and always will be).

          Daniel, can you post some links to the systems that best approximate what TM is trying to do, including the Wikipedia coloring thing?

          • danielhorowitz

            One new startup in this market space is called motivist.(www.motivist.com) They are just getting started, and not using a market based system, but they have the right idea.

            The concept is originally derived from Robin Hanson’s seminal work known as “idea futures.”

            Some examples of why we need truth markets are:

            a) “Friedman unit.”

            b) Apple and Steve Jobs. (Gizmodo, more)

            Wikipedia is also moving to implement a color coded trust system that was developed at UC-SC.

  • Larry

    “Medical establishment” is an overly broad term, meaningless in this context. But whomever it includes, they’ll never hear of your self-aggrandizing challenge.

    • Rafe Furst

      The “challenge” was a gimmick to get people to read the post who might otherwise not. Looks like it worked :-)

      But I’m willing to put my money where my mouth is and bet that nobody comes up with such a study because I believe that the evidence is clear that statins do not significantly decrease your chances of dying.

      If I’m wrong, I will pay up gladly. Since I have many loved-ones (and perhaps myself) who are currently or will at some point in the future be faced with the decision to take statins, and I want us all to have the truth when we make those decisions.

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  • Torsten

    Forgot how much I enjoy reading the many thought-provoking posts here.
    Re/statins, even my primary care doc is skeptical about statins. He prescribed statins, then read a study in (I think), the NEJM and told me not to bother. Also, compare alcohol consumption as a way to reduce heart disease risk. See, for example http://www.webmd.com/heart-disease/news/20091118/alcohol-may-reduce-mens-heart-risk. Stunning and yet apparently repeated elsewhere.

  • Rafe Furst

    When I posted this originally, I didn’t realize how safe a bet it was. A year later The Huffington Post came out with this:


  • Buckley

    Hi Rafe, I realize that this is an old post … but check out my friend Beatrice Golomb’s work here: https://www.statineffects.com/info/.