More statin madness

statin-adherence-medscape-heading

I’ve had a number of people email me about a new study appearing in the Archives of Internal Medicine purportedly showing that statins really do provide benefit to those who take them regularly.  As you can see from the heading of an email piece I pasted above, even Medscape is all over this article and blasting it out to physicians all over the world.

I’m sad to say that this is the same kind of paper I would have been taken in by 20 years ago before I really understood how to read the scientific literature critically.  In fact, I would have used it myself to justify giving statins to all kinds of people, and I’m sure other physicians are doing so right now.  But I would have been in error to base my prescribing on this paper, and all the other docs out there giving statins like they were candy are in error as well.

If you don’t want to read a dissection of this study, let me just tell you up front that it doesn’t really mean a thing.  It certainly doesn’t prove that you should rush out and get started on statins.  If, however, you do want to learn about how perniciously deceptive these kinds of studies are and how to analyze them, read on.

Here’s the deal.  Researchers went back and combed through the records of a large HMO in Israel and pulled those of patients who had been prescribed statins from 1998-2006.  Since the HMO provided the statin prescriptions, there were records of how many of these people who were prescribed statins actually filled their prescriptions (and, one would assume, took the medications).  Then the researchers figured out how many of those people prescribed statins died.  The final step was to compare the list of those who died with the list of those who took their statin prescriptions (or, more accurately, those who filled their statin prescriptions).  After crunching all this data, it turns out that those patients who filled over 90 percent of their prescriptions were 45 percent less likely to die than those who filled under 10 percent of their prescriptions.  Which, to the uncritical reader (including, obviously the Medscape writers and the peers who reviewed this piece for the journal in which it was published), this appears to be pretty persuasive evidence that statins confer some kind of benefit in terms of preventing death.  After all, those that took them lived while those who didn’t died.

As I say, these kinds of studies are pretty beguiling.  But do they really mean anything?

Before we get to the specifics of this study, let’s contemplate this type of study in general to see why the data they generate is often misleading.

The gold standard for scientific studies is the randomized, double-blind, placebo-controlled trial.  In this type of study, researchers randomize the study population into two similar groups and give the members of one group the drug being studied and the other a placebo.  Double blinded means that neither the researchers nor the subjects know who got what.  At the end of the trial, the data are analyzed to determine if the study drug really showed any difference in efficacy as compared to the placebo.  If it did, then it can be said that the drug works to treat whatever condition was being studied.  Or that it decreases all-cause mortality, if that is the end point of the study.

It’s impossible to do these gold standard studies with diet and/or exercise because a) they involve lifestyle changes and b) they can’t be double blinded.  When it comes to diet and exercise, there are basically two ways studies can be done.  Researchers can allow subjects to self-select which arm of the study they want to be in.  Or researchers can put subjects into one arm or the other.  Neither of these choices is optimal, but they are all that are available.

If I decide that I’m going to compare a very-low-carb diet to a very-low-fat diet, I can recruit volunteers and ask them which diet they would prefer.  If readers of this blog were recruited into such a study, I would assume most would opt for the very-low-carb diet.  Those who are fans of Dean Ornish would opt for the other.  What you end up with is people in each arm of the study who are already believers in the diet they will be following, and they will be more likely to remain on the diet until the end of the study.  At the end, the data will be a little polluted because it really doesn’t prove that one diet is superior to the other – it only proves that people who self-select into that diet do better on that diet than people who self-select into the other.  The last it an important point, especially when applied to exercise.  More about which in a moment.

The other way to study diet is to gather a group of people together and randomize them into one diet group or the other.  That takes the self-selection bias out of the equation.  But it creates other problems.  If a person committed ideologically to a low-carb diet gets randomized into the low-fat group (or vice verse) there are problems with compliance.  Most nutritional studies randomized this way end up with large numbers of dropouts.  If you do an intention-to-treat analysis of the data (which includes the drop outs), you usually find little difference between the two diets.  If you look at only those subjects who hung in there for the duration on whichever diet they were randomized onto, it raises the issue of whether these subjects may have been the same ones who would have self-selected themselves into this same diet if given the chance, which then creates the same problems as self-selection.  These issues make diet studies difficult to do and difficult to interpret validly.  It’s even worse with exercise.

I get a ton of email and comments from people who can’t come to grips with the idea that there is no proof that exercise brings about weight loss.  I say this because it is difficult to come by this proof.  Even those who are adamant that exercise brings about weight loss agree that pretty intensive exercise is required to do so.  The typical prescription to just get out and move a little more virtually everyone realizes is worthless.  Most people believe that it’s intensive exercise that does the trick.  Maybe so, but how do you prove it?

If you randomize people into an intensive exercise group and another into a no exercise group to see which loses the most weight (assuming diet is held constant), how many of those sedentary people are going to stick with the intensive exercise for any length of time.  They will be the dropouts.  If you allow people to self select, all the people who enjoy exercise will put themselves into the exercise group while those who hate it will put themselves into the sedentary group.  Then if those in the exercise group do lose weight, how can you tell it’s the exercise and not due to some other component of a person who will commit to an intensive exercise program that brings about the weight loss?  The answer is that you can’t tell.  Which is why the notion that exercise brings about weight loss is similar to a particular religious belief: it is accepted as an article of faith, not as a product of scientific investigation.

You can send me a comment (as several people have done) telling me how you were stuck in your weight loss efforts at 220 pounds and then you decided to start high intensity interval training.  After a couple of months of this, you lost 25 more pounds.  Therefore that’s proof that exercise brings about weight loss.  Wrong!  That’s proof that in you exercise brought about weight loss.  There may be something different about you that allows you to commit to such a regimen that others might have difficulty following AND allows you to lose weight.  This sounds ridiculous, but it is true.  And it is the key to understanding why this statin study is bogus in terms of whether or not taking statins makes people live longer.

Almost thirty years ago a study was published in the New England Journal of Medicine looking at this very idea.  The study that inspired the article didn’t start out looking at this idea, but one of the investigators noted a key piece of the data and published on it.  The study was looking at clofibrate, a pre-statin cholesterol lowering drug and all cause mortality.  Subjects were randomized into two groups – those in one group got the drug, those in the other got the placebo.  After the subjects were on either the drug or the placebo for five years, researchers calculated the mortality from the number of deaths in each group.  Turned out that the five-year mortality of those on clofibrate was 20.0 percent whereas the five-year mortality of those on the placebo was 20.9 percent, or essentially the same.  Taking the drug was no different than taking the placebo, i.e., the drug was worthless. Had one of the researchers not looked a little closer, that would have been the end of the story.

When the data were looked at from the perspective of how many people actually took the drug as prescribed, the researcher discovered that those subjects who took at least 80 percent or more of their clofibrate had a five year mortality of only 15.0 percent, substantially less than the overall five-year mortality.  Those who took their clofibrate sporadically had a five-year mortality of 24.6 percent, significantly higher than those who took it as directed, a piece of data that would seem to confirm the efficacy of clofibrate.  Right?  Not necessarily.  Let’s look at compliance with the placebo.

Turns out that those subjects on the placebo who regularly took their placebo had a five-year mortality of 15.1 percent while those who took their placebo sporadically had a five-year mortality of 28.3 percent.  What this study really showed was that there is something intrinsic to people who religiously take their medicine that makes them live longer.  There was no difference between the drug and placebo in either those who took them regularly or those who took them sporadically, but there was a huge difference in mortality between those who took either drug or placebo on schedule and those who didn’t.

Lest you think this was a bizarre one-of-a-kind study, another study published a few years ago in The Lancet showed a virtually identical outcome.  Patients taking a medication for congestive heart failure were compared to those taking placebo.  Those taking the drug (Candesartan) showed no difference in mortality compared to those taking placebo.  But when compliance was evaluated, those taking either the drug or the placebo as directed had much lower mortality than those taking either one sporadically.  In fact, as you can see from the graph below, the mortality curves were almost identical.

From Lancet (2005); 366(9502):2005-2011

From Lancet (2005); 366(9502):2005-2011

So there is something about adherers to a drug regimen that promotes longevity as compared to non-adherers.

Getting back to our statin study, how do we know that the decreased risk of death in those who religiously stuck with their statin prescriptions as compared to those who didn’t came about because they were adherers and not because of the statins?  We don’t.  In fact, based on the two studies I detailed above, it’s much likelier that the decreased mortality in those who took all their statins came about not because of the statins, but because those who stuck with them are adherers and have what ever quality it is that adherers have that makes them live longer.  And, if this is the case in this study as in the others, the statins don’t really do anything at all.

Despite its not really proving that statins confer greater longevity, the study does provide some interesting admissions and entertaining confabulations.

First, the study authors admit that there is no gold standard, randomized controlled study data showing that statins are of benefit in preventing death except for one group of people (and they even get that wrong).

The beneficial effects on cardiovascular mortality of treatment with statins to decrease levels of low-density lipoprotein cholesterol (LDL-C) have been established in several long-term, placebo-controlled trials.

The value of primary prevention with statin therapy in the reduction of overall mortality has recently been questioned.

A pooled analysis of 8 randomized trials in primary prevention populations showed that statins did not reduce overall mortality, indicating that lipid-lowering therapy with statins should not be prescribed for true primary prevention in women of any age or in men older than 69 years.

What they’re saying here is that statins have been shown to reduce mortality from heart disease in those who have elevated LDL, which is true.  But this decrease in deaths from heart disease is compensated for by an increase in deaths from cancer and other causes, so there really isn’t a gain.  You’re still dead.  Just maybe not from heart disease, but what difference does it make.  Are you going to spend $200 per month for the rest of your life and stay on medications that may make you feel lousy and lose your memory just so you can die of something other than heart disease?

In the last paragraph in the quote above, the authors confess that the data from actual randomized control trials show that statins confer no all-cause mortality benefits to women of any age and to men over 69.  They are playing a little fast and loose with the truth here because as I have posted before, the gold standard trials have shown no benefit for women and no benefit to men over 65 or to men under 65 who have never had heart disease.  The only improvement in all-cause mortality has been in men under 65 who have been diagnosed with heart disease, and even that benefit is so small that many people question if the extra cost and side effects of the statins are worth it.

So the authors of this study acknowledge that there has never been a randomized control trial that has shown any benefit to taking statins, but that doesn’t stop them.  They forge ahead trying to figure a reason that all these clinical trials haven’t shown an advantage.

Because clinical trials do not usually include individuals with multiple comorbid conditions or those receiving an extensive list of medications, there are considerable concerns regarding the applicability of findings from randomized clinical trials to the general population of patients seen in routine clinical practice.

Aha! They are saying that because the randomized controlled trial didn’t show what they wanted them to show – that statins worked for everyone all the time (thus the “considerable concerns”) –  that they need to figure out a better way to study them, one that involves patients with a lot of problems so that they don’t have to randomize them and confront failure yet again.

In light of the controversy surrounding lipid-lowering treatment for reduction of mortality among primary prevention populations, we undertook the present study to evaluate the effect of statin therapy in a large and diverse cohort of patients treated for dyslipidemia in a single health maintenance organization.

Interesting take.  There is no controversy.  The randomized controlled studies clearly show very little benefit to statin therapy in terms of decreasing all-cause mortality, the one statistic that really counts.  The controversy arises because the statinators simply don’t want to believe what these carefully performed trials tell them.  They by God want statins to work.  And they’re going to keep looking and fiddling with the data until they get a study that tells them what they want to hear whether the data is valid or not.

It’s pitiful that they are so desperate.

Don’t fall for the false promise of this or any other version of an observational study.  These kinds of studies do not prove causality.  Nor do they prove that a drug regimen works.  The patients in this study who religiously took their statins had better all-cause mortality than those who didn’t.  But, as we saw above, adherers always have better all-cause mortality than non-adherers.  In this case, was it that the adherers lived longer or was it that statins conferred some sort of benefit.  We can’t tell.  But we do know that in the real studies, the randomized control trials, statins didn’t do squat, so my vote would be that what we’re seeing here is an adherer effect and not a statin effect.

My advice is to continue to regard statins with a jaundiced eye.  So far, we haven’t seen any evidence that justifies the expense and the side effects of these drugs.

Please note: I reserve the right to delete comments that are offensive or off-topic.

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88 thoughts on “More statin madness

  1. Given the fact that its not the statin that lowers the cholesterol but another variable in a compliant group or group of those who stuck with the drug regimen, why not do a study that implements a design in which those who dropped out before or werent as compliant are put in a controlled study and monitored again but this time assuming they stick to the regimen. Or it is still difficult to decipher which one variable would bring on the desired effect. Lets say I would to set up a study to see if having more sex reduces a chance of having a heart attack. I would then devide people in two groups or three. If I were to come up with the result that more sex group proved that more sex indeed prevents heart attack, one would still not know that its the sex or some other variable that is unique to that group broguht on the effect. So why not have the group that didnt have much sex do a seperate study and have them more sex this time? Would it be more scientificly accurate?

  2. Doctor Eades,

    Thanks for the information. I’m confused, however. You speak of statins being useful for men under 65 who have heart disease. I thought that you had previously said that it was useful for men under 55 who had had heart attacks. I probably misread something earlier, but could please clear my confusion. Also, are heart attacks and heart disease the same thing?

    Please keep the information coming. I’m down 18 pounds in three months.

    I don’t have the papers with me right now, but as I remember it, statins showed some minor benefit in men under the age of 65 who had been diagnosed with heart disease. That means diagnosed with heart disease, not just having high cholesterol levels.

  3. On a seperate note Dr Mike I have my own story to tell depicting how difficult it is to decipher causation. I have been on induction phase of low carb for the past 4 days. Incidently or not I started having worst palpitations ever that coincided wiht me starting the induction. It starts with a burning sensation in my stomack and than brings about a cascade of symptoms such as stomack spasms and erratic heart rate. I feel my whole stomack vibrating and churning and pulsation so strong that others notice it. it is also accompanied by hot flash in a face and lightheadness. I did go see my doctor. He dsaid I definitely have some sort of GERD or acidity related problems that might bring on the palpitations. But he also didnt exclude the posibility of palpitations brought by anxiety that cuases the stomach problems. Question: I know you are not a big fan of exercising during an induction phase ( I do walk and do light weight lifitng), but could a change in enzyme production necessarily to fascilitate low carb transition for a body cause palpitations due to some kind of adrenalin overproduction? Or is it more like some other issues. Have you ever had a patient having palpitations due to going on a low carb induction? Can induction cause stress and some sort of anxiety from your experience? I have had other symptoms before but not palpitations. I have been kind of sleep deprived with two jobs juggling night shift at Suny Downstate and doing adult echo scanning, but still… My cardiologist who I work for cant think to put his fingers on what causes my palpitations. He thinks its a vagal nerve response broguth on by my stomack. I think its far stretched. Because I have had them without stomach being a problem, its just its 100 times worse when stomach joins in on parade!

    I can’t possibly diagnose you from this history. But, I haven’t had any patients (that I know of) who have experienced what you’re reporting. I doubt that it’s GERD, however, since a low-carb diet almost always makes GERD go away, not get worse. Have you had your potassium level checked? Are you taking potassium? If not, that would be a good place to start.

  4. Thanks, Dr. Mike! I would never have tumbled to the fact that there is something about people who take their medication religiously (be it placebo or study drug) that makes them live longer. Do you have any idea what the “something” might be?

    I don’t have a clue. Maybe they’re just more health conscious all the way around. Maybe those kinds of people get better sleep. Who knows, though? There are a zillion variables that would have to be worked through.

  5. Thanks for the analysis. I saw a blurb on this that only raised questions in my mind and, as they say, the devil is in the details. I haven’t had time to check out the details, so I appreciate your doing so. Deep down, I knew it had to be bogus. Sadly, in our sound bite culture, people just pick up on the headlines, so the headlines can say whatever they want, the more sensational, the better.

    Just one more example of how figures lie & liars figure. :)

  6. Your blog should be required reading in every high school biology class (or maybe every high school science class). The number of people (my own personal physician included) who don’t or won’t understand the points you are making here boggles my mind.

  7. Great stuff.

    I think that in the US in particular that the “Puritan ethic” which founded this country is still with us, in some sense. Most people have the attitude that suffering is inherent to life, and the only path to something good is through pain or deprivation. Take your example of someone who thinks they lost weight via intensive exercise. It’s almost certain that increased exercise was not the only lifestyle change made by this person, but it probably was the most arduous, the one that they can be proud of and bitch about loudly. So they credit their weight loss (positive outcome) with to the thing that caused them the most suffering. And nobody wants to think that they suffered for nothing, so they hang on to this hypothesis like grim death.

    I avoided dieting my whole life, because voluntary prolonged suffering just ain’t the way I roll. After losing weight on a low carb diet without any suffering (barring that first week), I felt like an idiot for having bought into the Puritan mindset. Ditto my experiences with Slow Burn. It may seem strange, but I think this whole business is one of the biggest barriers in getting people to adopt a low carb diet. When I tell friends and family about my experience, they often look at me like I’m insane. You lost 100 pounds, didn’t have to starve and exercise until you puked? Too good to be true.

  8. “it raises the issue of whether these subjects may have been the same ones who would have self-selected themselves into this same diet if given the chance, which then creates the same problems as self-selection. These issues make diet studies difficult to do and difficult to interpret validly. ”

    This reminds me of an aspect of the
    low carb/ low fat debate that I have been thinking about a lot recently.

    Some people do quite well on a higher carb diet. They can lose weight on one. In many cases these are the people who would self select for that diet in the kinds of situation you outline in your post. As you have said, there is about 25% of the population who do NOT have some degree of insulin dysfunction.

    Those people “know” that they do not need to give up all or most of their carbs. And others have observed that these people do not need to give up their carbs. That alone is enough reason for many people not to buy into the low carb argument. Especially because, as we all know so well, nobody wants to give up their carbs.

    The problem as I see it is that low carb/high carb debate usually comes across as though there were one answer for everyone.

    I think more progress would be made if we worked hard to disabuse people of that concept. So when low carb dieting was discussed, an attempt should always be made to clarify that it applies only to a certain segment of the population. Along with some brief guidelines as to how to determine who was one was in that segment. It might also be helpful to also clariy that the low carb segment was a *continuum* in which some people only need to lower their carbs to moderate, while others need to virtually eliminate them.

    It is a lot of information to pack into some of the more brief discussions we all might have on the subject or to a media soundbite. But I think that if it were more widely understood, there would be greater willingness to accept the low carb concept.

  9. Speaking of madness:

    Low-carb? Low-fat? Study finds calories count more
    The study, which appears in Thursday’s New England Journal of Medicine, was led by Harvard School of Public Health and Pennington Biomedical Research Center in Louisiana.

    “Though the diets were twists on commercial plans, the study did not directly compare popular diets. The four diets contained healthy fats, were high in whole grains, fruits and vegetables and were low in cholesterol.”

    Comment: In other words, the so-called low carb diet in the study wasn’t really a low carb diet at all.

    http://www.google.com/hostednews/ap/article/ALeqM5g5nH6bV4fr0ofSKGT8ZjkSVjbM_AD96IS5Q81

    You’re correct. It was not a low-carb diet. And, can’t be claimed to be, although the authors are trying to.

  10. Nice post! These critical reads are always a favorite of mine.

    I’ve got another post idea that may go over well in this economic climate.

    How do you do a low-carb diet well on a budget?

    Eating meat is good, eating ethically raised meat is even better (for the eater and the eaten) but getting most of my calories from ethically raised meat on a grad student’s income is damn near impossible. I can see families having trouble making ends meet having the same problem.

    So priorities must be set and comprises must be made… In your opinion what is the budget-minded hierarchy of priorities and comprises for a low carber?

    Filling up on whey and local eggs (more or less what I do now) seems to be better than filling up on cheap carbs but it still feels lacking.

    This is more of an MD type of post since she does all the shopping. I’ll pass it along to her.

  11. Excellent posting! Thanks for taking the time to explain this. Now I have something to say to the people who sheepishly follow their doctor’s orders about everything.

  12. “You can send me a comment and tell me how you were stuck in your weight loss efforts at 220 pounds and then you decided to start high intensity interval training. After a couple of months of this, you lost 25 more pounds. Therefor that’s proof that exercise brings about weight loss. Wrong! That’s proof that in you exercise brought about weight loss. ”

    Or maybe the person was just on a plateau that would have resolved after a couple of months even without the exercise.

  13. New study out today in New England Journal of Medicine.

    http://content.nejm.org/cgi/content/full/360/9/859

    “In conclusion, diets that are successful in causing weight loss can emphasize a range of fat, protein, and carbohydrate compositions that have beneficial effects on risk factors for cardiovascular disease and diabetes.29,40 Such diets can also be tailored to individual patients on the basis of their personal and cultural preferences and may therefore have the best chance for long-term success.”

    The ‘low carb’ diet was 35% of calories and saturated fat was limited to 8%. 35% of calories from carbs is not low carb in my book.

    Nor mine. In fact, it’s not low-carb in any of my books. :-)

  14. Since getting a high calcium score from a heart scan, I have joined Dr. Davis’s “Track Your Plaque” program. He is not as anti-statin as you are. Since both my doctor and cardiologist have been pushing statins, I have agreed to a trial of a weaker one at low dosage to see if I get the same bad side effect that I did from Lipitor. What I get from this article is some comfort that it is safe to try this.

    The only minor change that I have made in the Protein Power diet that I have been following over the past year is to totally eliminate wheat. I lost 40 pounds over the year and am awaiting my latest blood tests.

  15. I love this article. And I think I love you too. 😀 Thank you for writing an article for the rest of us mere mortals so we can understand the scientific method a little bit better. Yay!

    I’m glad you enjoyed the post.

  16. My most recent doctor, reluctantly but cheerfully, went along with my adamant stand that I would not take statins. I even volunteered to “send” him a letter regarding my views. He declined, but did deliver a very short “lecture” about the benefits of statins, which no doubt he entered into the records. I have no problem with this. I asked if he would like occasional columns (like the one you just did), but said he read only abstracts. I know from a PhD Statistician/surgeon residency acquaintance that we should never rely on abstracts to make important medical decisions. Are there abstracts regarding why those of us who have not had heart problems/over 65 would not find statins useful? RobLL

    ps – the neuro/fatigue thing which hit me in May is largely resolved, but my recovery time from exercise is much poorer than before. Statins may be the culprit

    There is a post answering your questions about statins. Type ‘statin panic’ into the search function.

  17. So the important question is this; what is fundamentally different about adherers vs non-adherers? And can adherer traits be transferred to non-adherers via training or pharmacology?

    As William Styron said, “It is hopelessness, even more than pain, that crushes the soul.” Is it the hope that the compound will work that is the crucial element here? If so, what is the most effective technique to teach hope to the hopeless and those of little faith?

    Be well,
    Ben Fury

  18. Great post, great analysis. I may not be in the medical profession, but I do know a thing or two about statistical research, and the vast majority of these statin studies are just crap passed off as the truth. This is one of them, and it is very sad.

    On another subject–the situations in which statins appear to work (only because they have anti-inflammatory properties) I have read an opinion by someone whose name I won’t mention that says statins are some of the “best” anti-inflammatory meds around and that is why they show favorable results in men (and only men under 50) who have a previous history of CVD. But is there really a study that shows that statins are such great anti-inflammatory agents compared to others especially in light of the side effects that they engender? I am skeptical.

    The studies that show statins to be anti-inflammatory usually compare statins to arginine, an amino acid that does have anti-inflammatory properties. Statins do seem to exert their anti-inflammatory effects through the same pathways as does arginine. Which begs the question: Why don’t we just take arginine? It’s cheap, it’s safe, and it’s found in large amounts in wild game, so it was probably a Paleolithic anti-inflammatory.

  19. Nice. Another quality post, Mike. Cheers!

    In unrelated news, I can’t wait to hear your take on this latest “study” that’s been bombarding the internet, local news stations, and any other media outlet desperate for content enough to repeat it. I must have heard 10 different people talk about it since last night…

    Whats the tag line on this one? “Low-Fat, Low-Carb, Neither… just low calories!” {sigh}

    I’m almost finished with Taubes book too, so I just slap my forehead harder now when I hear things like this. :)

  20. Dr. Eades

    I agree about the statins.

    I also agree about the exercise. Exercise does not burn anywhere near the calories that most persons think it does, plus it can get you extremely hungry later in the day. Out eating exercise is incredibly easy to do, with hardly any effort.

    Diet, specifically low carb diet is what accounts for 80-90 % of fat loss. I was at my leanest when I exercised minimally to moderately tops and watched my diet very, very closely.

  21. Hi All–

    MD and I are traveling today. There are about a hundred comments stacked up that I will get to when we get to Seattle. My Mac battery ran down on my laptop, so I’m sitting in the floor of LAX right now so I can poach off of one of the wall outlets.

    Thanks–

    MRE

  22. I think that low budget carbing is a valid concern these days. I was very fineky when I was concerned about mad cow disease and had the $$$ for grass fed, organic, etc. Since that time I have backed off a lot on all that and don’t notice much difference. I try to practice no-carb so I am eating protein/fat three times a day.

    McDonalds is the best low-carb value out there, I believe all their cattle used to be grass fed in the Amazon which destroyed the rain forest but is a high quality beef non the less. So you can go there and get side order of sausage for 99 cents, coffee or tea is 1.25. Back for lunch is two double cheeseburgers @1.39 each (they were on that $1 menu but cheese is too expensive), toss the buns, add free glass of water or pay for tea again or bottled water. You can usually get 16 oz ground 85% lean chuck for 2.99-3.99 range for dinner. Often bags of chicken legs/thighs are .59 a pound in bulk. There is usually one pork product in the 1.99-2.99 range. Eggs are actually more expensive than they use to be and I don’t care for them much anymore but an 3-egg omelete is a great low carb meal. Try to find unsalted butter, it makes a great sauce sauce swirled in meat drippings and adds to your fat. I often find uncured, organic bacon on sale, ditto for organic turkey and parts after major holidays. I usually refrigerator age my steaks and lamb so if they are marked down because they are a day or two old, so much the better. Sirloin is often on sale but is too lean and needs added fat in my opinion.
    The health benefits one derives from a true low-carb diet are worth the time and the money. Also, Taubes says in GCBC that most cancers are caused from carbs in diet, not from any additives in the animal feeding process. Choose your poison, I pick our meat supply for mine!!

  23. What a great post, thank you. Your blog is so refreshing to read. It reassures me that I’m not the crazy one in this high-carb Lipator-fueled world.

  24. Pretty good post; it really elucidates upon the fact of how we need to see the limitations of science, and how we can mitigate them. I think a lot of the study limitations that you mention may be able to be somewhat be sorted out certainly with larger sample sizes (as well as other external validity changes), to the point of where drop outs and such aren’t really significant to the result of the overall study. Yet it seems that many to most studies do not tend to have a very high sample size. Moreover for people to take each study with a grain of salt and learn how to read critically is incredibly important.

    But I’m all for you continuing to pound into people’s heads that correlation does not equal causation. Great for determining some hypotheses, yes…though poor when it comes to what science is really all about.

    Rob

  25. Dr. Eades,

    Wow, another great analysis of flawed “scientific” research. I rank it near the “Baboon Business” post, which is one of your all-time best.

    One question:

    In this post, you mentioned both statins and fibrates, but I am not sure I’ve ever read you mention bile acid sequestrants (BAS) such as Questran or Welchol. These older forms of cholesterol lowering meds had more moderate success in lowering cholesterol (not as much as the supposedly superior statins), and have largely been dropped by the statin-pushers.

    My question is this: since BAS drugs operate via a non-absorbed, non-systemic action (they are anion-exchange resins), are they at all dangerous? That is, they basically bind bile acids and prevent the re-uptake via the entero-hepatic cycle, causing the liver to request more cholesterol from the blood so as to synthesize more bile when necessary. The polymer resin in the BSA is bound in an insoluble form in the gut and is evacuated in the stool, thus it doesn’t directly affect any metabolic pathways or systems, save for the increased pulling of cholesterol out of the blood. This is, of course, quite different from statins and their dangerous way of interfering with enzymatic reactions inside the liver.

    Do you have any thoughts on these drugs? From reading your books and this blog, I understand the overall argument about the false idea of trying to lower blood cholesterol as the main or only means of reducing threats to heart health. I see how keeping insulin in check, getting lots of good fats, etc. are the better way of avoiding not only heart problems, but lots more (syndrome x, t-2 diabetes, aging, etc.).

    Nevertheless, I am curious what you might have to say about the drugs as such. Since I know, as a matter of law, that you cannot answer direct medical questions or offer diagnoses, I will leave my question at the general level of: given the mechanism of their action and their nature, do you have any opinion about the safety or potential hazards of this class of drug? (Just to tip you off, there is a very useful off-label use that is widely known among GI specialists, which is the source of my curiosity.)

    Thanks so much, and keep up the great blogging and writing. I’ve benefitted greatly from reading your work.

    E

    I don’t know a lot about these drugs (the BAS) because they were never shown to be effective. I’ve never given one, and I’ve never really read much about them. And, I don’t know about the off-label use for them.

  26. Hello Dr. Eades.
    I was wondering if you had read this article from the NYT about parents “giving” their kids eating disorders through their own food obsessions.
    http://www.nytimes.com/2009/02/26/health/nutrition/26food.html?_r=1&scp=1&sq=eating%20disorder&st=cse

    As a parent trying to raise a kid without packing her full of granola bars and Cheerios, I wonder about your response to this article.

    I wouldn’t put a whole lot of stock in the story. Sounds like way too many low-fatters are worrying about too much. I suspect that if you keep your kids on a sort of low-carb diet, they won’t develop food phobias. Seems like most people who have those phobias are phobic against fat, which isn’t a worry on a low-carb diet.

    BTW, Dr. James Greenblatt, pictured in the article, looks like he should spend a little more time worrying about his own diet rather than telling others not to worry about theirs.

  27. Hello Dr.Eades How is all? I had a quick question and by the way i do appreciate your time. Me And my husband are going to start following a zero carb diet, lots of red meat eggs and dairy! We want to prevent scurvy so we had a question. We had a small concern regarding vitamin c. In your book you mention that vitamin c increases non-heme iron absorbtion but would it increase heme iron absorbtion? Also do you think a 500mg dose is safe for us? Thank you doctor eades.

    It shouldn’t increase heme iron absorption. I think 500 mg is a safe dose.

  28. Welcome back to Seattle!
    Hope you didn’t hit the snow/traffic on Thursday.

    Thanks. The snow was mostly gone by the time we arrived. Two snowstorms in two trips would have been a little much.

  29. Dr M hola……If the body doesnt ‘know’ where its food comes from i.e. its stores or food then why does it seem so difficult to move fat the second or thrid time on a low carb diet.

    The whole set-point thingy of weight is nonsense according to GT and yourself (whom i take at their word based on understanding) so wonder why if there’s no set point the bod just doesnt hook into its reserves easily esp as we seemingly didn’t evolve to store oodles of fat ?

    Is it another nonsense question ?

    I think there is a mind-body connection. When you lose weight easily the first time, then regain it, and then try to lose again, the mind part of the equation steps in and says, hey, we’ve been down this road before. Let’s tighten up, hold on to our fat, and this too shall pass. Then we’ll be back to our old way of eating that’s keeping us fat and happy. It’s been my experience that the second, third, etc. time through is a little more difficult than the first. I’ve also noticed that people going through a low-carb diet the first time tend to really stick to it religiously whereas people going through it again often aren’t so diligent.

  30. So, Dr. Eades are you more of an advocate of intermittent sprinting (and weights Fred Hahn style) than walking real long for fat loss ? Of course diet is number one.

    Take Care

    Razwell

    Yep, I am more of an advocate of intermittent high intensity training, especially resistance training.

  31. Dave,

    I think you make a great point about the “Puritan ethic” playing a part here. I remember when the Adkins diet first gained popularity a few years ago, and all of these obese people I knew were losing weight. I didn’t think it was fair, it was like they were cheating…they didn’t deserve it.

    I think we see the same sort of dynamic at work in regards to many issues that dominate the health care industry. If one is diagnosed with cancer, AIDS, heart disease, diabetes, etc., they must suffer for their sins before they can be “forgiven”. But all too often as we know one does not survive their trial by fire.

  32. Vadim,

    I had a similar experience to the one you expressed in your second post above. I had just started the diet about a week ago, had been exercising a lot and went on something of an intermittent fast. After breaking the fast with some bratwurst, hamburger, and sausage I began to feel flush and lethargic. Every 10-15 minutes a sharp pain developed around where one would normally get heartburn, and that night I got a heart “cramp” worse than I had ever received before, although this may have been unrelated.

    The symptoms did not subside until later the next day, and then flared up again after a piece of bacon. Bingo! I googled nitrates and heartburn, and apparently nitrates and nitrites form nitrosamines in the body (http://www.deliciousorganics.com/controversies/nitrates.htm) which cause some problems. The remedy according to this site is vitamin c or vitamin e, so I popped a tab of vitamin e and the symptoms went away in about 30 minutes.

    Hope this helps

  33. I always wondered about that all-cause mortality bit… it seems to be implying that statins are somehow correlated with increased mortality, ie, maybe somehow causing increased mortality, ie, killing people. But that seems like a stretch, doesn’t it?

    Well, they’re really not prolonging life, so…

  34. Many years ago, working my first real job as a writer for a health magazine, I learned just how little the average journalist understands about interpreting research. The Chicago Tribune ran an article about smoking and traffic fatalities, explaining that while smokers and non-smokers are involved in roughly the same number of traffic accidents, the smokers are more likely to die.

    I began to wonder … are they weaker? Heart more likely to give out in the ambulance? Less likely to survive emergency surgery? I couldn’t figure it out from the article.

    I called one of the researchers, who was still fuming (no pun intended). He said the reporter was an idiot who missed the most relevant piece of data –the smokers were less likely to wear their seat belts.

    The smokers are non-adherers. They don’t wear the belt, they don’t give up the smokes, they don’t exercise or watch what they eat. I think the best description of non-adherers is “people who don’t give a @#$%.” Of course they’re more likely to die younger.

    Dave, good call on the Puritan mentality. I have two friends, near-vegetarians, who run almost every day, skip breakfast, sometimes skip lunch — and then the first meal of the day includes rice or whole-wheat pasta. They just barely keep the weight down. I think they believe it’s supposed to be difficult … leanness as a reward for sacrifice and virtue.

    They are also convinced I will eventually come down with colon cancer or heart disease because I eat so much red meat.

    Dr. Mike, you’ve probably seen this, but here’s yet another study claiming fat causes heart disease, this time via inflammation. I tried to find the full text to give it a look, but can only dig up an abstract.

    http://www.medicalnewstoday.com/articles/139648.php

    Full text just became available yesterday, and though I’ve pulled it, I haven’t had a chance to read it critically yet.

  35. Thank you Dr Mike! I have checked my potassium levels before and I do take potassim pills plus I eat plenty of avocado which is loaded with it. I changed Magnesium oxide to a magnesium malate. I have no idea if its better but people claim it absorbs more efficient. I also started taking multi-vitamin. Happy to report that my palpitations subsided a lot. I have been sleep deprived so I need to start learning how to relax more. My GERD has also gone away today. I have never had a problem with food regurgitation before. So it might be that recent carb binge has caused some sort of imbalance or it could have been viral infection or any sort of inflammation, who knows.

    Today is my fifth day back on low carb! I am puzzled at how simple and convenient it is to be on it, yet I cant stop to wonder how and why in the name of Great Creator do I ever fall off. I did throw away the scale, what a liberation! I will only weigh once a month just to keep on top of it, but will gage my progress by the way my cloth fits. I do eat liberally and I do eat a lot. Saying that I also walk a ton. i have recently found a great joy in walking around golf park. I get to watch golf and there is a dog park next to it, so I get to see tons of dogs play!

    When I first came in USA I was mezmorized by a lot of things, but more than anything by dog parks! Only in America dogs have parks to play in with so much room to run and paly fetch! Or may be its NY deal.

    Hope you have good day in Seattle and I still havent seen Dr Feinman come by to exercise. I dont want to bother him about it. He did buy a membership card and havent even picked it up! We do charge Downstate employees $100 a year. I know that he doesnt need to lose weight any more, but we do have other nice amenities suchas swimming pool, coffeehouse with live music and movie nights with popcorn. Ok, I will make sure we have low carb cheesecake and chicken wings for him will he decide to check out our monthly coffeehouse series. He did pay for his yearly memebership, might as well enjoy it. And we have a singer coming in this month who will sing Piaf and other songs in 20 different languages. If you talk to him pass it along. I am sure he can dance too!

  36. ME: “Yep, I am more of an advocate of intermittent high intensity training, especially resistance training.”

    A recent study has shown the value of as little as 15-20 minutes a week of high intensity exercise done on a stationary bike in improving insulin sensitivity. The program involves a succession of 30 second sprints followed by 4 minute low intensity ‘rest’ periods. According to the study, 5 or 6 cycles of this activity one day per week can have a dramatic effect on insulin sensitivity.

    As one who was literally born on a bicycle I have long believed that cycling is far more effective than any amount of walking or even running for improving BG metabolism. Discussions on the merits of cycling vs resistance training typically evoke images of one pedaling along on flat terrain at a leisurely pace. But the high intensity cycling I am referring to is nothing like that. Few people even have the endurance or muscle capacity to engage in a series of all out 30 to 40 second hill sprints. These place a huge workload the biggest muscles in the body. In my opinion high intensity cycling is at least equal in its effect on insulin sensitivity to resistance training.

  37. Excellent post, Dr. Eades. As an obese, female, low-carbing, hypothyroid diabetic with an LDL of 105 I have been prescribed a statin, which I declined to take. (By some reasoning, that might make me a non-adherer doomed to a relatively earlier demise.) I guess there has been some recent hoopla over diabetics getting statins. Have you addressed that issue specifically? If so, I am not finding it. If not, might you?

    Thanks for this analysis and all of your other blog entries. Best to you and yours!

    I haven’t addressed the diabetic-statin study in a post, but it’s the same kind of study I dissected in this post: a retrospective observational study. As such, it’s not worth a fig in terms of proving causality or even proving that statins help those with diabetes.

  38. David MacPhail: In my opinion high intensity cycling is at least equal in its effect on insulin sensitivity to resistance training.

    you may be right, but you should try doing 500 + pound leg presses on a Medex machine very slowly for 60 odd seconds… I think it’s more intense and it’s def. more time efficient, although you do miss the fun of flying down the hill you just climbed.

  39. Loren Cordain seems to be a very strong supporter of statin use–to get LDL down to hunter- gatherer levels. Have you read his papers on this subject?

    I’m not so sure he’s a supporter of statin use to get LDL down; my impression (based on many conversations with him) is that he is a supporter of using the Paleolithic diet to get LDL down. The conflict arises over what the Paleolithic diet encompasses as far as fat goes.

  40. Whenever I am faced with the statement that a calorie is a calorie is a calorie, that calories in = calories out, and that calories are all that count in weight loss, I think about a co-worker of mine. She is probably not even 5′ tall on a good day, and weighs less than 100 pounds. She’s lean and muscular, not skinny. Then here am I, a good 7 inches taller than her, and probably 90 pounds heavier than her. She eats from sun up to sun down (mostly junk food carbs), and at least 3 to 4 times the amount of food I eat. Did I mention that she’s 23 and I’m 53. I keep telling her that she she hits 40, watch out!

    If everything “they” say about calories is true, SHE should be close to 200 pounds (or more!), and I should be down around 100 pounds.

  41. In my latest cholesterol test, my HDL was fabulously high, my triglycerides were fabulously low, but my LDL was rather elevated. I’m not too worried, particularly since (due to my diet) that LDL is likely to be the unproblematic large-and-fluffy kind. Plus, I’m a healthy woman in my mid-30s with a perfectly clean heart scan last year. Still, if a re-test yields the same results, I suspect that my doctor is going to recommend that I go on statins. I will refuse — and see if I can get a particle-size test.

    However, here’s what’s so much worse: I recently got a letter from my insurance company telling me that I really ought to talk to my doctor about my high LDL — and that I really should consider cholesterol-lowering drugs. They were definitely pushing the drugs. That seemed so intrusive. And if I didn’t know all that I know about them from you, I might be inclined to go on them.

    *#&*@^&^&#^&@!&#%@

    BTW, I have a new post on the worthless new study touting weight loss via “any diet that is low in calories and saturated fats and high in whole grains, fruits and vegetables.”

    http://www.dianahsieh.com/blog/2009/02/worthless-study-worthless-reporting.shtml

    The letter from your insurance company is troubling. It’s obvious that the folks responsible for it haven’t bothered to actually read the medical literature, but are instead falling prey to all the myths and misconceptions that abound. Too bad. And frightening. And this is (presumably) from a private insurance company. Just wait until the government gets involved in health care. Fasten your seat belts in preparation for a very rough ride.

  42. “In my latest cholesterol test, my HDL was fabulously high, my triglycerides were fabulously low, but my LDL was rather elevated.”

    I think this is what my mother is experiencing. (background: she’s T2 diabetic, extremely overweight with wild b.s. swings on the insulin roller-coaster; was finally convinced to try low-carb, supplied with Dr. Bernstein books, and lowered her dosage of insulin, lost some weight, and lowered her triglycerides/overall cholesterol; Dr. was thrilled). NOW, my mother went back and her total cholesterol had gone to 240; Dr. is now NOT happy and wants to put her back on the Lipitor, even tho’ Mom had terrible repercussions on it and had stopped taking it on her own. My mother is a “pleaser” and I’m fearful that she will succumb to the pressure and stop doing carb-restriction just to make her doctor happy. Last night she was saying, “Maybe it’s the cheese…”

  43. Tom Naughton Said:

    “I think the best description of non-adherers is “people who don’t give a @#$%.””

    …or maybe it’s that the non-adherers are people who don’t even realize there is a @#$% to give about. They just don’t comprehend the consequences for what ever reason. Poor brain development, never thought much in life? I don’t know but I’ve noticed this difference in some people. In fact, a lot of people won’t make the effort to learn about nutrition and deem weight loss impossible; strength training – and struggle at the gym for over 5 hours a week with minimal results; philosophy – and make all kinds of epistemological errors.

  44. Dr mike what is your take on MCT oil ? jimmy Moore recently interviewed a neurologist Dr Mccleary who claims that pure MCT oil increases ketones bodies and provides energy for body to use and is not absorbed by fat cells. in other words it is used by brain as an immediate energy and gives you a boost. I read few reviews and people are raving about it all over the net. Bodybilders claim it works right away. what you think?

    The neurologist is actually a neurosurgeon, and he’s our partner. Yes, I think MCT oil is good stuff. If you want to read more about Dr. McCleary, put ‘Brain Trust’ in the search function of this blog.

  45. The letter from your insurance company is troubling… Just wait until the government gets involved in health care. Fasten your seat belts in preparation for a very rough ride.

    that reminds me, I decided to try to find a low carb friendly doc in the NYC area, but all the ones I find on the internet don’t take insurance, you gotta pay in cash and hope your insurance reimburses you. I’m wondering if such an animal -doc who supports low carb and works with my insurance- even exists around these parts.

    Don’t know. You can try Keith Berkowitz, MD. I know he does low-carb, but I don’t know the insurance situation.

  46. at this point,readers of this blog are aware of the vast over prescribing of statins. A better question, perhaps might be when and under what circumstances should a statin be prescribed,and you should consider taking it? Sounds like your view is if you have demonstrated heart disease (evidenced by coronary event, or heart scan), and maybe out of control small LDL particles not responsive to carb restriction then it might be ok to try. Correct?

    I wouldn’t take it myself for out of control small LDL particles. If I were under 65, which I am, and had been diagnosed with heart disease, which I haven’t, I would consider taking a statin. But even then, I’m not sure I just wouldn’t throw back a few grams of L-arginine a day and be done with it.

  47. Anatomy of a statin ad
    January 09th, 2009
    Best seller list April 1-Sep 30, 2008
    November 21st, 2008
    Crucial Conversations
    June 26th, 2008
    Best seller list Jan 1-Mar 31, 2008
    June 05th, 2008
    Next Page »

    Those are the results of the search. Which one is it? I’ve never had any luck with the search on this page.

    I don’t know what you’re searching for. You can keep going by clicking on Next Page >>.

  48. This adherer vs non-adherer thing: isn’t there a conventional explanation for the difference? Isn’t this the placebo effect?

    The adherers get the benefit of the placebo effect, and the non-adherers don’t, for both control group and experiment group. This seems pretty clear, so what am I missing here?

    It’s not really the placebo effect. The placebo effect is when a person is given a placebo but thinks it may be the real drug and so has side effects or changes that he/she attributes to the drug. But it isn’t the drug; it’s a placebo.

    In this case, the adherers know their adhering while the non-adherers know they’re not.

  49. It’s not just the insurance companies doing the big push on the statins. Three years ago I was prescribed 1 med for Type 2, one for BP and Zetia for cholesterol – which was the dr’s last ditch effort due to side effects from all others. I have since stopped taking all of these meds due to even worse side effects (and am doing fine without them even though the dr was not happy with me). However, even though it’s been many months since I refilled any of the meds, the big chain drug store I switched to is still dutifully sending me a form letter every few months reminding me to refill the (very expensive) BP med and, naturally, the Zetia. Apparently they don’t care if I die of diabetes, though, since they have never reminded me to refill that one…….

  50. Squire hiya… What about ‘these folks’ who suggest a big carb meal once per week to get insulin up..canny recall the term.
    Is it gibberish ?

    Thanks

    It probably doesn’t cause any harm in young, healthy non-insulin-resistant people. But I wouldn’t do it if I were trying to lose weigth or rehab my metabolism.

  51. Sir and again here is the link.
    Maybe am doing the bloke a disservice here but this sounds pure gibberish ( a four hour workweek.Lordy i hope folks don’t believe such twoddle.
    Like the Brit bloke who wrote a book and has or used to have a mag called ‘The Idler’.I’ll wager my left nad that 4 hour bloke spends more than 4 hours on his work week..of course one can be deceitful by definition and Tom the Idler is anything but idle..an idler wouldnt write such a book ?
    Its more than a pound of muscle per day gained ?

    Is it tripe please ?

    http://www.fourhourworkweek.com/blog/2007/04/29/from-geek-to-freak-how-i-gained-34-lbs-of-muscle-in-4-weeks/

    I know Tim and think he’s an honest, straightforward guy, so I don’t think he’s BSing here. But, he is young (30 years old), which makes an enormous difference. I doubt that someone 50 years old could do the same even on the same regimen.

  52. Sorry here in the blokes own words

    Rule #4: Take one day off per week

    I recommend Saturdays as your “Dieters Gone Wild” day. I am allowed to eat whatever I want on Saturdays, and I go out of my way to eat ice cream, Snickers, Take 5, and all of my other vices in excess. I make myself a little sick and don’t want to look at any of it for the rest of the week. Paradoxically, dramatically spiking caloric intake in this way once per week increases fat loss by ensuring that your metabolic rate (thyroid function, etc.) doesn’t downregulate from extended caloric restriction. That’s right: eating pure crap can help you lose fat. Welcome to Utopia.

  53. Hi Dr Mike! I just recieved the results of my blood test. My doctor wanted to speak to me about it. My total cholesterol was 177 , with HDL= 67 and LDL= 105. Actually I never had my HDL that high. My triglecerides were 36. Here is where my doctor had some concerns about me being on low carb even though I didnt do it consistenly. My Blood Urine Nitrogen level was high at around 29. My creatine was 0.9n so the ration was a bit high which never happened before. He is now concerned that low carb is causing my kidneys to function less than optimal. Should I be concerned? BTW my potassium was a bit hight too, 5.7. I did take potassium pills though.

    You know that I can’t diagnose you over the internet. But I can say that I doubt that your kidneys are being affected by the protein in your diet. The lab results you got were probably as a result of being a little dehydrated. Especially if you fasted overnight for them.

  54. Dr Hi de hi……Lower cal slows metabolism is this right please ?

    Typically. I’m not sure it applies to low-carb diets in the same way as lower-fat, lower-protein diets, however.

  55. Once again you dig into the things that the Peers who did the Reviews ought to have noticed prior to publication.

    Just one thing

    After crunching all this data, it turns out that those patients who filled over 90 percent of their prescriptions were 45 percent less likely to die than those who filled under 10 percent of their prescriptions.

    NO!!! They are all 100% likely to die. Just not yet

    Good point.

  56. Yes, I think MCT oil is good stuff.

    Is MCT oil good enough that it’s worth the additional expense over consuming coconut oil (which I gather is mostly MCT oil?) [Please correct me if I’m wrong.]

    Coconut oil is about half MCT, so you get plenty if you’re a fair amount of consuming coconut oil. But some people don’t like the taste of coconut oil and plain ol’ MCT oil is kind of tasteless, so they use it instead.

  57. ME: ” And this is (presumably) from a private insurance company. Just wait until the government gets involved in health care. Fasten your seat belts in preparation for a very rough ride”.

    What seems to be happening is that government health agencies are being sold the spin by big pharma that ‘preventative treatment’ with drugs like statins reduces risk and with it overall costs to the system. In this paradigm those who refuse to take meds such as statins are being labeled ‘high risk’ and therefor a liability to the system who are unnecessarily driving up the costs. With health care costs spiraling out of control it doesn’t take crystal ball to see where this is headed. The statinator enforcers are coming to take away those who resist………. and soon.

    Frightening.

  58. “In this case, the adherers know their adhering while the non-adherers know they’re not.”

    I don’t understand the distinction you are making. In one arm, you have people assigned to a control, a known non-effective pill. Some of those people take the pill (the adherers), some don’t (the non-adherers). By the nature of the placebo effect, only the adherers would benefit, as the non-adherers know they aren’t taking the pill.

    In the other arm, you have a potentially active pill. Again, there are adherers and non-adherers. Again there will be a placebo effect (that’s one of the reasons the control arm is there, to get a base-line for this effect, so it can be accounted for). Again, only the adherers will benefit from the placebo effect, as the non-adherers know they aren’t taking anything.

    So, what we have here (where the drug is known from better trials not to work) is that the adherers in both arms see the benefit of the placebo effect.

    Sure, the adherers know they are adhering, but *not what to*. What is controversial about this? It’s how one expects the placebo effect to work, surely?

    I see your point, but I’m still not sure the improvements in longevity can be chalked up to the placebo effect. My take is that there is something intrinsically different about people who adhere as opposed to those who don’t. As another commenter said, non-adherers probably just don’t give a flip about a lot of things. They may smoke more, use seat belts less frequently, and follow other risky behaviors, all of which could contribute to their decreased longevity.

  59. If I read the article correctly there is an interesting unanswered question: why did the “adherers” survive at a higher rate? Here are some thoughts:

    First it probably doesn’t have anything to do with the medical effect of statins if, as the article implies, the same effect is seen regularly for other medications.

    The next thought is that perhaps the cost of the drugs is the real health indicator. Those who can afford it, either because they are wealthy or have good health insurance, may, on average, be leading less stressful lives as indicated by wealth and/or the consistent employment. that ongoing health insurance generally implies.

    Another possibility is that the adherers were the ones who had good doctors who they visited regularly and who kept them generally healthier. (This would surprise me.)

    It may be as simple as discipline. Those who had it (are at least cultivated it) were more likely to survive.

    This last point suggests another: Perhaps the adherers were the patients who were sufficiently scared by their recent bad health that they became determined enough to change their lifestyles, while th others were not.

    Just as the recently published studies of the nature of the placebo effect unveiled important knew ideas about the interaction of the deep brain with active medications. it seems to me that a rigorous study of the “adherer effect” might also lead to truly useful medical knowledge.

    I agree.

  60. You can try Keith Berkowitz, MD. I know he does low-carb, but I don’t know the insurance situation.

    nah, they only accept Medicare. If you dont mind me asking, did you guys accept ins. when you had a practice? I am beginning to think that if a doc. accepts insurance, then he has to toe the party line when it comes to giving out advice on diet, cholesterol issues, ie. prescribe statins and recommend low fat. If this is true, its a sad state of affairs.

    We accepted some insurance for some things, but not all. It’s a huge, huge hassle to deal with. We’re I in practice today, I wouldn’t accept it. Especially not medicare. Talk about a giant hassle.

    Another low-carb doc you might try is Fred Pescatore.

  61. Exercise by walking rapidly an hour every day (i.e., about 4% of the day) and avoid high-glycemic and animal fats. You won’t be able to put on fat, no matter how much you eat.

    Not quite sure I buy into this as a general rule, but if it works for you, go for it.

  62. Here in the UK doctors are actually bribed to prescribe statins. In order to afford the statins the PCTs are stopping test strips for Type 2 diabetics and only using TChol instead of full lipid panels. The tail is wagging the dog.

    A sorry state of affairs.

  63. I work as a medical transcriptionist. The service I work for has two main hospital accounts, one of them being a major teaching hospital in Southern California. If the message is getting out (regarding the worthlessness of statins and the idiocy of the anti-fat, anti-cholesterol hysteria, and the falsity of the cholesterol hypothesis of heart disease), it sure as heck isn’t trickling down to the interns, residents, and full-fledged doctors dictating at either of these hospitals.

    Just about every patient in there has hypercholesterolemia as one of his diagnoses. Just about every report I type up other than an operative reprot (that is, H&P, consultation, discharge summary) shows the patient either being on statins or being prescribed statins (or other anti-cholesterol med) upon discharge. Nearly all the discharge summaries for cardiac patients show them being advised to follow a “heart-healthy, low-fat” diet.

    I’m “just” a transcriptionist, but I understand a lot of what I’m typing up; and this stuff (plus the famous arrogance of too many doctors) is something that puts me off regular visits to a doctor, never mind the expense!

    It seems to me that the standard, orthodox medical treatments for the major degenerative diseases (especially heart disease and cancer) are worse than the diseases themselves.

    At the very best, the standard orthodox treatment for heart disease doesn’t do much of anything positive and can have negative consequences. That’s at the very best. Too bad the new docs coming up can’t think for themselves.

  64. To the person who is worried about doing low-carb on a budget: Here are a few things which have helped me greatly in keeping down the grocery bills (I shop for two of us, plus three cats).

    1. Buy a used freezer if you can. In about 2001, I got a used, 12-cubic-foot, upright freezer for about $50 plus the cost of hauling it. This has saved me a lot of money over the years. The regular refrigerator I have is also fairly good-sized (with a fairly large top freezer), and was also bought used.

    2. Regularly peruse the grocery ads for your area. See what’s on sale. Visit the grocery stores and see which ones you like. I follow the grocery ads fairly closely, especially for meat and produce. I don’t buy much canned food, except for tuna. At some point in the next couple of years, I might be able to get more of my meat at Sam’s Club or Costco.

    3. I’m in Southern California. We often have California-grown whole chickens on sale for about 77 cents per pound (used to be down as low as 59 cents a while back). Learn to cut them up yourself. Sometimes leg/thigh quarters are on sale for as low as 59 cents per pound. We do eat mostly chicken at the current time, but I make sure that we have some other stuff around for variety.

    4. Ground hamburger is another option… however, right now it’s up around $3.00 per pound or more. A cheaper way is to buy such cuts as round steak, London Broil, etc. and grind your own. We regularly get London Broil on sale for under $2.00 per pound.

    5. Pork is often on sale, in various cuts, with and without the bones, for under $2.00 per pound, sometimes a lot less.

    6. I have seen tri-tip cuts of beef on sale for $2.49 per pound or less.

    7. Turkeys are often on sale after the holidays. Some stores have them at give-away prices just after Thanksgiving and others wait until after the New Year. I’ve still got about four of them in my freezer, just waiting to be made delicious.

    8. Eggs… cheap at Wal-Mart, but they are the supermarket variety. Trader Joe’s also has acceptable eggs (better than Wal-Mart, but not as good as free-range, pastured eggs) for about $1.48 per dozen (also some more expensive types of eggs). Sometimes feed stores also have locally-produced eggs on sale (free-range?) in the $2.00 to $3.00 per dozen range. If you save your egg cartons and recycle them, sometimes you can get a bit of a discount. Also check Craigslist for your area.

    9. For good-tasting water, if that is a problem for you: Get a water filtration unit. I have the large Pur unit which sits in the refrigerator, plus a Pur pitcher (both on sale or at discount stores). I have found that Wal-Mart sells the two-stage filters (newer kind) for cheaper than other stores around here. And you can use those filters for a bit longer than the instructions state.

    10. It may or may not pay you to become a member of a warehouse club such as Sam’s ($40 per year) or Costco ($50 per year). You can buy, for instance, big blocks of cheese, which you can then divide up and freeze.

    11. We have the 99 Cents Only Stores (now $1.00 for most items) here. When in stock, they are a good source for Danish Creamery butter… $1.00 for 1/2 pound, which works out to $2.00 per pound, which is a lot less than the regular retail for this brand. You can freeze butter for several months at a time.

    12. See if there are any outlet stores in your area. We had a Grocery Outlet here for a long while, which was a source for some bargains.

    13. I guess my basic advice would be to become aware of what things generally cost, and also become aware of when something is on sale at a good price, which is when it’s time to stock up.

    Thanks for the definitive list. I’m sure many people can profit from your suggestions. Thanks for taking the time to write them.

  65. Okay, Dr. Mike, since you and MD are not in practice right now, do you know of any low-carb-friendly doctors in the Southern California area? I am technically in Lancaster, which is about an hour’s drive north of Los Angeles itself. I’d be willing to travel a bit to find a doctor whose orientation was compatible with what I’ve read in your books. Thanks in advance.

    Right now I’ve been going to a county clinic, because that’s what I can afford right now; but in the future I would like to upgrade my medical care, as it were.

    Unfortunately, I don’t know anyone in the Lancaster or Southern Cal area that practices low-carb nutrition. I’m sure there are a few practitioners, I just don’t know them.

  66. Thanks for responding, Dr. Eades. The closest thing to a low-carb practitioner I’ve found locally in Lancaster, on the advice of a conventional diabetes nurse/nutritionist/educator, is someone who allegedly follows the “Sugar Buster” approach. At some point I might show up in his office.

    I read the blog comment by one lady which stated that after going to about 10 different doctors, she had found herself a “gem.”

    Crikey, even if I had the money for 10 office visits (at how many dollars a pop?), I’m not sure I’d be eager to spend that amount of time in various doctors’ offices only to be disappointed.

    Apparently doctors who are simpatico at all to low-carbing are just really hard to find.

    A while back I was hanging out on the forums at Dr. Richard K. Bernstein’s website, and one of the frequently asked questions was for any kind of doctor recommendations. Sounded to me like most of the diabetics there were taking care of their condition themselves and just relying on the doctors for lab tests; it also sounded to me as if most of the “professional help” they received from their doctors, nutritionists, and other diabetic educators was the same-old ADA stuff which they basically ignored.

    I like eating low-carb. I absolutely adore eating meat, and I also like vegetables. My significant other, fortunately, is willing to eat just about anything I cook, although he also is something of a carb addict… he drinks a lot of RC Cola and eats a lot of stuff that’s a no-no for me (sometimes it’s hard to keep away from the bread and taquito snacks).

    I’ve tried to tell him that giving up the carbs would help with his blood pressure control (he’s not fat like me yet… he’s still densely muscular from the time when he used to be buff). He does have a problem with reflux, and he uses both famotidine and antacids on a regular basis.

    I really enjoy reading your blog. I hope that someday I will find a doctor who is more simpatico with your approach.

    I checked with Jonny Bowden, a nutritionist friend of mine who deals with many physicians in the greater LA area. He tells me that two very good ones are Prudence Hall and Howard Leibowitz, who practice at The Hall Center (www.thehallcenter.com) in Santa Monica. Hope this helps.

  67. Thank you very much, Dr. Eades. I will check out those referrals.

    I’m not against doctors per se (although I might sound like it sometimes)… It’s just that I am not willing to submit to the “tender mercies” of a statin pusher, nor to a low-fatter, etc.

    Were I to suffer a broken leg, of course I would get myself to the nearest urgent care or ER ASAP, as the treatment would most likely be straightforward–cast the leg, etc.

    But I don’t yet have the money, time, or inclination to have to fight with multiple doctors over every pat of butter, fish oil capsule, or egg… and I will not count calories.

    Well, thanks again for your recommendations.

  68. I am confused. I am a practicing cardiologist and often agree with your views on diet. However, there have been several randomized controlled trials with statins in patients with heart disease that have shown mortality benefits as well as cardiovascular benefits. Please relook at 4S study with simvastatin and Lipid trial with pravastatin. These trials included placebo groups and presumably there were adherent patients in both arms. The 4s trial specifically showed a mortality benefit in women and those over the age of 60.

    I would agree that it has been difficult to prove mortality benefit in primary prevention. However, that is true for almost all preventative interventions including diet, exercise, vitamins, cancer screening, etc.

    Here is 4S abstract:

    Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S)

    Lancet 1994 Nov 19;344(8934):1383-9.

    Drug therapy for hypercholesterolaemia has remained controversial mainly because of insufficient clinical trial evidence for improved survival. The present trial was designed to evaluate the effect of cholesterol lowering with simvastatin on mortality and morbidity in patients with coronary heart disease (CHD). 4444 patients with angina pectoris or previous myocardial infarction and serum cholesterol 5.5-8.0 mmol/L on a lipid-lowering diet were randomised to double-blind treatment with simvastatin or placebo. Over the 5.4 years median follow-up period, simvastatin produced mean changes in total cholesterol, low-density-lipoprotein cholesterol, and high-density-lipoprotein cholesterol of -25%, -35%, and +8%, respectively, with few adverse effects. 256 patients (12%) in the placebo group died, compared with 182 (8%) in the simvastatin group. The relative risk of death in the simvastatin group was 0.70 (95% CI 0.58-0.85, p = 0.0003). The 6-year probabilities of survival in the placebo and simvastatin groups were 87.6% and 91.3%, respectively. There were 189 coronary deaths in the placebo group and 111 in the simvastatin group (relative risk 0.58, 95% CI 0.46-0.73), while noncardiovascular causes accounted for 49 and 46 deaths, respectively. 622 patients (28%) in the placebo group and 431 (19%) in the simvastatin group had one or more major coronary events. The relative risk was 0.66 (95% CI 0.59-0.75, p < 0.00001), and the respective probabilities of escaping such events were 70.5% and 79.6%. This risk was also significantly reduced in subgroups consisting of women and patients of both sexes aged 60 or more. Other benefits of treatment included a 37% reduction (p < 0.00001) in the risk of undergoing myocardial revascularisation procedures. This study shows that long-term treatment with simvastatin is safe and improves survival in CHD patients.

  69. Look for more about how wonderful statins are now that this article about a polypill in India has hit the megaphone.

  70. Dr Mike, Apologies if I have missed a subsequent post that already deals with this matter, but JI’s comment on the 4S study (4 comments up) looks to be a serious one that does raise some substantive questions. It would be great if you could revisit this question sometime soon when you get the chance.

    BTW, I’m 47 and have never smoked, and had a heart attack last year. (I’m only one person, but I remember you saying in another post that everyone you knew who had had a heart attack was a smoker, so I thought I should mention this.) Since then, I’ve been on an ACE inhibitor, a beta blocker, a statin, and aspirin. The possible side effects of the drugs concern me, but it requires some courage to reject the confident advice of one’s primary physician and cardiologist, and I figure that the positive effect, even if slight, on people under 65 with pre-existing heart disease, might well be worth it for me.

  71. An Appeal for Support and Conformation of Adverse Effects

    My daughter has lived with ALS like symptoms for almost 3 years. The worst of the symptoms began when her simvastatin was increased to 80mg in 2008.
    Her MRI’s show LESIONS in the brain stem, specifically in the PONS area of her brain.
    Of course, her 4 physicians refuse to believe that statin is involved. They are all satisfied with the diagnosis of “Ataxia”.

    My Appeal is to all those who have similar brain lesions as shown and documented in MRIs. Please reply.

  72. Just stumbled upon this old post.

    These guys that are managing the medical journals really ought to get their act together. The term “peer reviewed” is really starting to lose its significance.

    I’m glad my country (Iceland) isn’t as drug-infested as the U.S., the teachers at my med school keep telling us about how the drug industry has an influence on the medical industry and that drugs aren’t always the answer.

    Here it’s also illegal to advertise drugs in the common media so people are never exposed to any pharmaceutical commercials.

  73. Of course compliers live longer – 1) the non-compliers forget to take pills mostly because they have a touch of dementia or a very disorganized life;. 2) the compliers have faith in their doctors, and if they find something wrong, they make an appointment to have it seen to; 3) the non-compliers may have depression and figure it isn’t worth it to take pills that probably won’t do any good anyway. 4) the compliers may have strong motivation for staying alive.