What is the dirty little secret of drugs for lifestyle diseases? If patients knew the truth of how little these drugs actually worked, almost no one would agree to take them.
Are Doctors Misleading Patients About Statin Risks and Benefits?
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Below is an approximation of this video’s audio content. To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video.
Drug companies go out of their way, for example in direct-to-consumer ads, to “present… drugs as [the] preferred solution to cholesterol management while downplaying lifestyle change.” You see this echoed in the medical literature. “Despite decades of exhortation for improvement,” this editorial in the Journal of the American Medical Association read, “the high prevalence of poor lifestyle behaviors . . . persists, with [heart attacks] and stroke[s] remaining the leading causes of death in the United States.” Clearly, we need to put more people on drugs. A reply was published in the British Medical Journal. “Once again, doctors are implored to ‘get real’—stop hoping that efforts to help their patients and communities adopt healthy lifestyle habits will succeed, and start prescribing more statins.” Don’t you see how “this is a self-fulfilling prophecy.” I should “note that the author of [the pro-statin editorial] disclosed funding from 11 different drug companies,” which make billions of dollars of cholesterol-lowering drugs.
Every time the cholesterol guidelines expand the number of people eligible for statins, they’re decried as a “big kiss to big pharma,” understandably since the majority of guideline panel members may have financial conflicts of interest. But these days all the major statins are off-patent, so there are inexpensive generic versions. For example, the safest, most effective statin is generic Lipitor, sold as atorvastatin for as little as a few bucks a month, so these days the cholesterol guidelines are not necessarily part of some industry plot.
It’s the American way of life that’s the problem, not the guidelines. The reason so many people are candidates for cholesterol and blood pressure-lowering medications is because people are taking such terrible care of themselves. The bottom line is that “individuals must take more responsibility for their own health behaviors.” But if you are unwilling or unable to improve your diet and make lifestyle changes to bring down that risk, if your 10-year risk of having a heart attack is 7.5 percent or more and gonna stay that way, then the benefits of taking a statin drug likely outweigh the risk. But that’s really for you to decide. It’s your body, your choice.
“Whether or not the overall [balance of benefit and harm] justifies the use of a medication for an individual patient cannot be determined by a guidelines committee, a health care system, or even [your] physician. Instead, it is the individual patient who has a fundamental right to decide whether or not taking a drug is worthwhile.” This was recognized by some of medicine’s luminaries, but only recently “has the medical profession [shifted] from a paternalistic ‘doctor knows best’ stance towards one explicitly endorsing patient-centered, evidence-based, shared decision-making.”
One of the problems with communicating statin evidence to support this shared decision-making is that most doctors have a poor understanding of concepts of risk, probability, and statistics. But that understanding is critical for preventive medicine. When doctors offer a cholesterol-lowering drug, they’re doing something quite different from treating a patient who is sick. They’re almost like “life insurance salespeople, peddling deferred benefits in exchange for a[n] . . .ongoing cost. In this new kind of medicine, not understanding risk is the equivalent of not knowing about [basic anatomy].” So, let’s dive in and see exactly what’s at stake.
When drug companies say a statin reduces the risk of a heart attack by 36 percent, that’s what’s called the relative risk. If you follow this asterisk here, you can see how they came up with that. In a large clinical study, 3 percent of patients not taking the statin drug had a heart attack within a certain amount of time, compared to 2 percent taking the drug. So, the drug dropped heart attack risk from about 3 percent to 2 percent; that’s about a one-third drop, hence the 36 percent reduced relative risk statistic. But another way to look at 3 percent to 2 percent is that the absolute risk only dropped 1 percent. So, in effect, “your chance of avoiding a… heart attack [over] the next [few] years is about 97 percent without treatment, but you can increase it to about 98 percent by taking [a statin] every day.” Another way to say that is that you’d have to treat 100 people with the drug to prevent a single heart attack. That statistic may shock a lot of people.
If you ask patients what they were led to believe, they don’t think the chance of avoiding a heart attack within a few years on statins is 1 in a 100, but 1 in 2. “On average it was believed that most patients… would [be able to avert] a heart attack”, not just 1 percent of patients. And “this disparity between [the] actual [benefits] and expected [benefits] could be viewed as a [doctor’s] dilemma. On the one hand, it is not ethically acceptable for care givers to deliberately” mislead people into thinking a drug works better than it really does. But on the other hand, how else are we gonna get people to take their pills?
If you ask people, they want an absolute risk reduction of at least about 30 percent to take a cholesterol-lowering drug every day, whereas the actual absolute risk reduction is really only about 1 percent. So, the dirty little secret is if patients knew the truth—how little these drugs actually worked—almost no one would agree to take them. So, either doctors are just not educating their patients, or they are actively misinforming them. Given that the majority of patients expect a much larger benefit than they’d actually be getting, “there is a tension between the patient’s right to know… and the likely reduction in [willingness to take the drugs] if they [discovered the truth].” This sounds terribly paternalistic, but hundreds of thousands of lives may be at stake.
If patients were fully informed, people would die. About 20 million Americans are on statins. Even if they saved 1 in 100, that could mean hundreds of thousands of lives lost if everyone stopped taking their statins. “It’s ironic that informing patients about statins would increase the very outcomes they were designed to prevent.”
Please consider volunteering to help out on the site.
- Byrne S, Niederdeppe J, Avery RJ, Cantor J. "When diet and exercise are not enough": an examination of lifestyle change inefficacy claims in direct-to-consumer advertising. Health Commun. 2013;28(8):800-13.
- Robinson JG. Accumulating evidence for statins in primary prevention. JAMA. 2013;310(22):2405-6.
- Abramson JD, Rosenberg HG, Jewell N, Wright JM. Authors' reply to Huffman and colleagues. BMJ. 2014;348:g1523.
- Lenzer J. Half of panelists on controversial new cholesterol guideline have current or recent ties to drug manufacturers. BMJ. 2013;347:f6989.
- Rosenbaum L. Conflicts of interest: part 1: Reconnecting the dots—reinterpreting industry-physician relations. N Engl J Med. 2015;372(19):1860-4.
- Yebyo HG, Aschmann HE, Kaufmann M, Puhan MA. Comparative effectiveness and safety of statins as a class and of specific statins for primary prevention of cardiovascular disease: A systematic review, meta-analysis, and network meta-analysis of randomized trials with 94,283 participants. Am Heart J. 2019;210:18-28.
- Greenland P. Cardiovascular Guideline Skepticism vs Lifestyle Realism? JAMA. 2018;319(2):117-8.
- Newman CB, Preiss D, Tobert JA, et al. Statin Safety and Associated Adverse Events: A Scientific Statement From the American Heart Association. Arterioscler Thromb Vasc Biol. 2019;39(2):e38-81.
- Barrett B, Ricco J, Wallace M, Kiefer D, Rakel D. Communicating statin evidence to support shared decision-making. BMC Fam Pract. 2016;17:41.
- Martyn C. Risky business: doctors' understanding of statistics. BMJ. 2014;349:g5619.
- Lipitor.
- Lipitor.
- Diamond DM, Ravnskov U. How statistical deception created the appearance that statins are safe and effective in primary and secondary prevention of cardiovascular disease. Expert Rev Clin Pharmacol. 2015;8(2):201-10.
- Lytsy P, Westerling R. Patient expectations on lipid-lowering drugs. Patient Educ Couns. 2007;67(1-2):143-50.
- Trewby PN, Reddy AV, Trewby CS, Ashton VJ, Brennan G, Inglis J. Are preventive drugs preventive enough? A study of patients' expectation of benefit from preventive drugs. Clin Med (Lond). 2002;2(6):527-33.
- Diprose W, Verster F. The Preventive-Pill Paradox: How Shared Decision Making Could Increase Cardiovascular Morbidity and Mortality. Circulation. 2016;134(21):1599-600.
Video production by Glass Entertainment
Motion graphics by Avo Media
Below is an approximation of this video’s audio content. To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video.
Drug companies go out of their way, for example in direct-to-consumer ads, to “present… drugs as [the] preferred solution to cholesterol management while downplaying lifestyle change.” You see this echoed in the medical literature. “Despite decades of exhortation for improvement,” this editorial in the Journal of the American Medical Association read, “the high prevalence of poor lifestyle behaviors . . . persists, with [heart attacks] and stroke[s] remaining the leading causes of death in the United States.” Clearly, we need to put more people on drugs. A reply was published in the British Medical Journal. “Once again, doctors are implored to ‘get real’—stop hoping that efforts to help their patients and communities adopt healthy lifestyle habits will succeed, and start prescribing more statins.” Don’t you see how “this is a self-fulfilling prophecy.” I should “note that the author of [the pro-statin editorial] disclosed funding from 11 different drug companies,” which make billions of dollars of cholesterol-lowering drugs.
Every time the cholesterol guidelines expand the number of people eligible for statins, they’re decried as a “big kiss to big pharma,” understandably since the majority of guideline panel members may have financial conflicts of interest. But these days all the major statins are off-patent, so there are inexpensive generic versions. For example, the safest, most effective statin is generic Lipitor, sold as atorvastatin for as little as a few bucks a month, so these days the cholesterol guidelines are not necessarily part of some industry plot.
It’s the American way of life that’s the problem, not the guidelines. The reason so many people are candidates for cholesterol and blood pressure-lowering medications is because people are taking such terrible care of themselves. The bottom line is that “individuals must take more responsibility for their own health behaviors.” But if you are unwilling or unable to improve your diet and make lifestyle changes to bring down that risk, if your 10-year risk of having a heart attack is 7.5 percent or more and gonna stay that way, then the benefits of taking a statin drug likely outweigh the risk. But that’s really for you to decide. It’s your body, your choice.
“Whether or not the overall [balance of benefit and harm] justifies the use of a medication for an individual patient cannot be determined by a guidelines committee, a health care system, or even [your] physician. Instead, it is the individual patient who has a fundamental right to decide whether or not taking a drug is worthwhile.” This was recognized by some of medicine’s luminaries, but only recently “has the medical profession [shifted] from a paternalistic ‘doctor knows best’ stance towards one explicitly endorsing patient-centered, evidence-based, shared decision-making.”
One of the problems with communicating statin evidence to support this shared decision-making is that most doctors have a poor understanding of concepts of risk, probability, and statistics. But that understanding is critical for preventive medicine. When doctors offer a cholesterol-lowering drug, they’re doing something quite different from treating a patient who is sick. They’re almost like “life insurance salespeople, peddling deferred benefits in exchange for a[n] . . .ongoing cost. In this new kind of medicine, not understanding risk is the equivalent of not knowing about [basic anatomy].” So, let’s dive in and see exactly what’s at stake.
When drug companies say a statin reduces the risk of a heart attack by 36 percent, that’s what’s called the relative risk. If you follow this asterisk here, you can see how they came up with that. In a large clinical study, 3 percent of patients not taking the statin drug had a heart attack within a certain amount of time, compared to 2 percent taking the drug. So, the drug dropped heart attack risk from about 3 percent to 2 percent; that’s about a one-third drop, hence the 36 percent reduced relative risk statistic. But another way to look at 3 percent to 2 percent is that the absolute risk only dropped 1 percent. So, in effect, “your chance of avoiding a… heart attack [over] the next [few] years is about 97 percent without treatment, but you can increase it to about 98 percent by taking [a statin] every day.” Another way to say that is that you’d have to treat 100 people with the drug to prevent a single heart attack. That statistic may shock a lot of people.
If you ask patients what they were led to believe, they don’t think the chance of avoiding a heart attack within a few years on statins is 1 in a 100, but 1 in 2. “On average it was believed that most patients… would [be able to avert] a heart attack”, not just 1 percent of patients. And “this disparity between [the] actual [benefits] and expected [benefits] could be viewed as a [doctor’s] dilemma. On the one hand, it is not ethically acceptable for care givers to deliberately” mislead people into thinking a drug works better than it really does. But on the other hand, how else are we gonna get people to take their pills?
If you ask people, they want an absolute risk reduction of at least about 30 percent to take a cholesterol-lowering drug every day, whereas the actual absolute risk reduction is really only about 1 percent. So, the dirty little secret is if patients knew the truth—how little these drugs actually worked—almost no one would agree to take them. So, either doctors are just not educating their patients, or they are actively misinforming them. Given that the majority of patients expect a much larger benefit than they’d actually be getting, “there is a tension between the patient’s right to know… and the likely reduction in [willingness to take the drugs] if they [discovered the truth].” This sounds terribly paternalistic, but hundreds of thousands of lives may be at stake.
If patients were fully informed, people would die. About 20 million Americans are on statins. Even if they saved 1 in 100, that could mean hundreds of thousands of lives lost if everyone stopped taking their statins. “It’s ironic that informing patients about statins would increase the very outcomes they were designed to prevent.”
Please consider volunteering to help out on the site.
- Byrne S, Niederdeppe J, Avery RJ, Cantor J. "When diet and exercise are not enough": an examination of lifestyle change inefficacy claims in direct-to-consumer advertising. Health Commun. 2013;28(8):800-13.
- Robinson JG. Accumulating evidence for statins in primary prevention. JAMA. 2013;310(22):2405-6.
- Abramson JD, Rosenberg HG, Jewell N, Wright JM. Authors' reply to Huffman and colleagues. BMJ. 2014;348:g1523.
- Lenzer J. Half of panelists on controversial new cholesterol guideline have current or recent ties to drug manufacturers. BMJ. 2013;347:f6989.
- Rosenbaum L. Conflicts of interest: part 1: Reconnecting the dots—reinterpreting industry-physician relations. N Engl J Med. 2015;372(19):1860-4.
- Yebyo HG, Aschmann HE, Kaufmann M, Puhan MA. Comparative effectiveness and safety of statins as a class and of specific statins for primary prevention of cardiovascular disease: A systematic review, meta-analysis, and network meta-analysis of randomized trials with 94,283 participants. Am Heart J. 2019;210:18-28.
- Greenland P. Cardiovascular Guideline Skepticism vs Lifestyle Realism? JAMA. 2018;319(2):117-8.
- Newman CB, Preiss D, Tobert JA, et al. Statin Safety and Associated Adverse Events: A Scientific Statement From the American Heart Association. Arterioscler Thromb Vasc Biol. 2019;39(2):e38-81.
- Barrett B, Ricco J, Wallace M, Kiefer D, Rakel D. Communicating statin evidence to support shared decision-making. BMC Fam Pract. 2016;17:41.
- Martyn C. Risky business: doctors' understanding of statistics. BMJ. 2014;349:g5619.
- Lipitor.
- Lipitor.
- Diamond DM, Ravnskov U. How statistical deception created the appearance that statins are safe and effective in primary and secondary prevention of cardiovascular disease. Expert Rev Clin Pharmacol. 2015;8(2):201-10.
- Lytsy P, Westerling R. Patient expectations on lipid-lowering drugs. Patient Educ Couns. 2007;67(1-2):143-50.
- Trewby PN, Reddy AV, Trewby CS, Ashton VJ, Brennan G, Inglis J. Are preventive drugs preventive enough? A study of patients' expectation of benefit from preventive drugs. Clin Med (Lond). 2002;2(6):527-33.
- Diprose W, Verster F. The Preventive-Pill Paradox: How Shared Decision Making Could Increase Cardiovascular Morbidity and Mortality. Circulation. 2016;134(21):1599-600.
Video production by Glass Entertainment
Motion graphics by Avo Media
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Are Doctors Misleading Patients About Statin Risks and Benefits?
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This is the second video in a four-part series on statins. If you missed the first one, see Who Should Take Statins?.
The True Benefits vs. Side Effects of Statins and How Much Longer Do You Live on Statins? are coming up.
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