Statins for healthy people? Hang on a minute…

Statins for healthy people? Hang on a minute…

I’ve had a few emails today alerting me to reports of a study concerning the use of statins in healthy individuals. The study in question is a meta-analysis (grouping together of similar studies) of statin trials [1]. Part of this meta-analysis involved assessing the impact of statin therapy in individuals deemed to be at relatively low risk of cardiovascular events such as heart attacks and strokes. One of the stand-out findings of this study is that statins led to a statistically significant reduction in risk of ‘major vascular events’. This was even true for individuals at less than 10 per cent risk of vascular events over a 5-year period. This has led to the suggestion that statins used might be widened to even people at low risk of cardiovascular problems.

Before we swallow this idea, though, it is perhaps a good idea to see just how effective statins were found to be in this meta-analsysis. First of all, what is meant by ‘major vascular events’? Actually, this is a term that includes many different potential outcomes including fatal and non-fatal heart attacks and strokes and ‘revascularisation’ procedures (such as placing tubes called stents in the coronary arteries). When a lot of different outcomes are grouped together, it makes it much more likely that a ‘statistically significant’ results will emerge.

When the outcomes are narrowed a little, the results are less impressive. For example, when we look at risk of death from any vascular event (a heart attack or stroke), we find that statins did not reduce risk in individuals deemed to be at low risk (<10 per cent over 5 years). This, by the way, was even true for those who had known vascular disease.

The ‘positive’ findings from this study have, as is often the case, been expressed as reductions in relative risk. The risk of vascular events overall was 21 per cent lower for each 1 mmol/l (39 mg/ml) reduction in levels of low density lipoprotein cholesterol (LDL-C). However, when overall risk is low, then a relative risk reduction might not amount to much in real terms.

We’re told by the authors this meta-analysis that treating with statins prevented 11 major vascular events for every 1000 people treated for a period of 5 years. Put another way, 91 people would need to be treated for 5 years to prevent one major vascular event. Or in other words, only about 1 per cent of people treated with statins for 5 years will benefit (and about 99 per cent won’t).

Overall, lowering LDL-C by 1 mmol/l was found to reduce the risk of death by 9 per cent over a 5-year period. Again, this might sound like a positive finding to some, but the actual reduction in risk of death was 0.2 per cent per year. What this means is that at this level of cholesterol reduction, 500 individuals would need to be treated with statins for a year for one person to have his/her life saved.
The authors of this meta-analysis give us some soothing reassurances about the fact that the benefits of statins vastly outweighing the risks of adverse events such as myopapthy (muscle pain and weakness). They quote of the excess incidence of myopathy as 0.5 cases per 1000 people over 5 years. However, the source they quote is based on diagnosing myopathy once the marker for muscle damage (creatine kinase) is at least TEN TIMES the upper limit of normal. Many individuals will have significant pain and weakness with much lower levels of creatine kinase. Statins are also linked with adverse effects on the liver and kidneys, and increase risk of diabetes too.

Despite the very positive interpretation of the data by the study authors and the media, this meta-analysis shows us again what previous evidence has revealed: statins are highly ineffective in terms of improving health and saving lives. And their risks are generally downplayed.

Collectively, the authors of the meta-analysis are referred to as the Cholesterol Treatment Trialists’ (CTT) Collaborators, including researchers from Clinical Trial Service Unit and Epidemiological Studies Unit at Oxford University. The conflicts of interest statement which accompanies this paper informs us that: “Some members of the writing committee have received reimbursement of costs to participate in scientific meetings from the pharmaceutical industry.” I suppose this may account, at least in part, for a data interpretation that appears so heavily biased towards statins.

References:
Cholesterol Treatment Trialists’ (CTT) Collaborators. The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta
-analysis of individual data from 27 randomised trials. The Lancet epub 17th May 2012
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Read the full atricle here.http://www.drbriffa.com/2012/05/18/statins-for-healthy-people-hang-on-a-minute/

Wheat: opiate of the masses?

Wheat: opiate of the masses?

Last week I was aboard a cruise liner in the Caribbean. I had a lot of fun but was primarily there to participate in a kinda conference organised by low-carb advocate Jimmy Moore. I was privileged to share the stage with some very lovely and inspiration speakers, among them the US cardiologist Dr William (Bill) Davis. I was looking forward to meeting Bill because I’d had a skype conversation with him some months ago, and was impressed by his warmth, humour and humanity. In person, Bill did not disappoint, and he also gave what I thought was a fascinating presentation about the perils of one of the modern-day diet’s most ubiquitous components – wheat.

Bill is the author of the highly acclaimed and readable book Wheat Belly, which systemically makes a strong case for the elimination of this grain from our diets. His lecture on the low-carb cruise’ focused on this aspect of his work, and focused on what I took to be three key areas:

1. wheat’s content of the readily-digested starch amylopectin A, which is highly disruptive to blood sugar levels.

2. The lectin (toxin) in wheat known as ‘wheat germ agglutinin’ which can cause inflammation in the gut and elsewhere.

3. Gliadin – a component of gluten in wheat which has, among other things, drug-like effects.

It’s this last issue I’m going to focus on in this blog post.

In his lecture, Bill drew our attention to the fact that gliadin may not be fully digested in the gut, and give rise to small protein molecules known as ‘polypeptides’. These can sometimes penetrate the gut to gain access to the bloodstream, after which they also have capacity to make their way across the ‘blood-brain-barrier’. Once there, gliadin polypeptides can bind to opiate receptors in the brain. Opiates include chemicals like morphine, heroin and opium.

The body can generate chemicals which bind to opiate receptors which are termed ‘endorphins’. However, when a substance comes from outside the body, it is termed an ‘exorphin’. Gluten-derived exorphins can induce a feeling of mild euphoria. This might explain why tucking into bread, or a bowl of pasta, or some biscuits can seemingly be so intensely pleasurable for some. It might also explain why some struggle with leaving wheat alone.

One of the main reasons Bill highlighted the opiate effects of gluten is because it appears, to all intents and purposes, to be an appetite stimulate. Of course you’d expect anything that is somewhat addictive to drive us to consume more of it. And as Bill pointed out, there does seem to be some scientific evidence for this.

To understand the nature of this research, we need to understand the effects of the drug naloxone. This drug binds to opiate receptors, knocking off anything else that may be bound there. As a result, naloxone reverses the effects of opiate drugs like heroin and morphine, and quickly too.
So, what happens when normal wheat-consuming people are treated with naloxone? In one study, individuals were given access to a free food and their intakes measured over two meals approximately 5 hours apart [1]. On another occasion the experiment was repeated after naloxone had been administered to the study subjects. On this occasion, they consumed about 400 calories less.

In another study, ‘binge-eaters’ were given access to a free buffet with and without nalaoxone [2]. With naloxone on board, individuals ate 28 per cent less in the way of wheat-based foods such as crackers, pretzels and bread sticks.

My experience in practice tells me that the ability of wheat (and other gluten-containing foods such as barley and rye) to have addictive qualities varies quite a lot between individuals. It does seem to be a real phenomenon, though, and there’s no doubt in my mind that eliminating or dramatically reducing wheat consumption usually leads to a significant improvement in wellbeing, energy levels, mental function (and usually weight loss) in the majority of people.

Starchy foods, especially ‘healthy wholegrains’ are often vigorously promoted to those looking to eat a nutritious diet. Wheat has a reputation as the staff of life. In reality, though, it’s often the stuff of nightmares.

References:
1. Cohen MR, et al. Naloxone reduces food intake in humans. Psychosom Med. 1985;47(2):132-8.
2. Drewnowski A, et al. Naloxone, an opiate blocker, reduces the consumption of sweet high-fat foods in obese and lean female binge eaters. Am J Clin Nutr. 1995;61(6):1206-12.
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Read the full article here.

The straight dope on cholesterol Part IV - Attia

The straight dope on cholesterol Part IV

Posted by Peter Attia on May 17, 2012

Previously, in Part I, Part II and Part III of this series, we addressed these 5 concepts:

#1 — What is cholesterol?

#2 — What is the relationship between the cholesterol we eat and the cholesterol in our body?

#3 — Is cholesterol bad?

#4 – How does cholesterol move around our body?

#5 – How do we measure cholesterol?

In this post we’ll continue to build out the story with the next concept:

#6 – How does cholesterol actually cause problems?

Asked another way, how does someone end up with a coronary artery that looks like the one in the picture above?

Quick refresher on take-away points from previous posts, should you need it:

1. Cholesterol is “just” another fancy organic molecule in our body but with an interesting distinction: we eat it, we make it, we store it, and we excrete it – all in different amounts.
2. The pool of cholesterol in our body is essential for life. No cholesterol = no life.
3. Cholesterol exists in 2 forms – unesterified or “free” (UC) and esterified (CE) – and the form determines if we can absorb it or not, or store it or not (among other things).
4. Much of the cholesterol we eat is in the form of CE. It is not absorbed and is excreted by our gut (i.e., leaves our body in stool). The reason this occurs is that CE not only has to be de-esterified, but it competes for absorption with the vastly larger amounts of UC supplied by the biliary route.
5. Re-absorption of the cholesterol we synthesize in our body (i.e., endogenous produced cholesterol) is the dominant source of the cholesterol in our body. That is, most of the cholesterol in our body was made by our body.
6. The process of regulating cholesterol is very complex and multifaceted with multiple layers of control. I’ve only touched on the absorption side, but the synthesis side is also complex and highly regulated. You will discover that synthesis and absorption are very interrelated.
7. Eating cholesterol has very little impact on the cholesterol levels in your body. This is a fact, not my opinion. Anyone who tells you different is, at best, ignorant of this topic. At worst, they are a deliberate charlatan. Years ago the Canadian Guidelines removed the limitation of dietary cholesterol. The rest of the world, especially the United States, needs to catch up. To see an important reference on this topic, please look here.
8. Cholesterol and triglycerides are not soluble in plasma (i.e., they can’t dissolve in water) and are therefore said to be hydrophobic.
9. To be carried anywhere in our body, say from your liver to your coronary artery, they need to be carried by a special protein-wrapped transport vessel called a lipoprotein.
10. As these “ships” called lipoproteins leave the liver they undergo a process of maturation where they shed much of their triglyceride “cargo” in the form of free fatty acid, and doing so makes them smaller and richer in cholesterol.
11. Special proteins, apoproteins, play an important role in moving lipoproteins around the body and facilitating their interactions with other cells. The most important of these are the apoB class, residing on VLDL, IDL, and LDL particles, and the apoA-I class, residing for the most part on the HDL particles.
12. Cholesterol transport in plasma occurs in both directions, from the liver and small intestine towards the periphery and back to the liver and small intestine (the “gut”).
13. The major function of the apoB-containing particles is to traffic energy (triglycerides) to muscles and phospholipids to all cells. Their cholesterol is trafficked back to the liver. The apoA-I containing particles traffic cholesterol to steroidogenic tissues, adipocytes (a storage organ for cholesterol ester) and ultimately back to the liver, gut, or steroidogenic tissue.
14. All lipoproteins are part of the human lipid transportation system and work harmoniously together to efficiently traffic lipids. As you are probably starting to appreciate, the trafficking pattern is highly complex and the lipoproteins constantly exchange their core and surface lipids.
15. The measurement of cholesterol has undergone a dramatic evolution over the past 70 years with technology at the heart of the advance.
16. Currently, most people in the United States (and the world for that matter) undergo a “standard” lipid panel which only directly measures TC, TG, and HDL-C. LDL-C is measured or most often estimated.
17. More advanced cholesterol measuring tests do exist to directly measure LDL-C (though none are standardized), along with the cholesterol content of other lipoproteins (e.g., VLDL, IDL) or lipoprotein subparticles.
18. The most frequently used and guideline-recommended test that can count the number of LDL particles is either apolipoprotein B or LDL-P NMR which is part of the NMR LipoProfile. NMR can also measure the size of LDL and other lipoprotein particles, which is valuable for predicting insulin resistance in drug naïve patients (i.e., those patients not on cholesterol-lowering drugs), before changes are noted in glucose or insulin levels.

Concept #6 – How does cholesterol actually cause problems?

If you remember only one factoid from the previous three posts on this topic, remember this: If you were only “allowed” to know one metric to understand your risk of heart disease it would be the number of apoB particles (90-95% of which are LDLs) in your plasma. In practicality, there are two ways to do this:

1. Directly measure (i.e., not estimate) the concentration of apoB in your plasma (several technologies and companies offer such an assay). Recall, there is one apoB molecule per particle;
2. Directly measure the number of LDL particles in your plasma using NMR technology.

If this number is high, you are at risk of atherosclerosis. Everything else is secondary.
Does having lots of HDL particles help? Probably, especially if they are “functional” at carrying out reverse cholesterol transport, but it’s not clear if it matters when LDL particle count is low. In fact, while many drugs are known to increase the cholesterol content of HDL particles (i.e., HDL-C), not one to date has ever shown a benefit from doing so. Does having normal serum triglyceride levels matter? Probably, with “normal” being defined as < 70-100 mg/dL, though it’s not entirely clear this is an independent predictor of low risk. Does having a low level of LDL-C matter? Not if LDL-P (or apoB) are high, or better said, not when the two markers are discordant.

But why?
As with the previous topics in this series, this question is sufficiently complex to justify several textbooks – and it’s still not completely understood. My challenge, of course, is to convey the most important points in a fraction of that space and complexity.

Let’s focus, specifically, on the unfortunately-ubiquitous clinical condition of atherosclerosis – the accumulation of sterols and inflammatory cells within an artery wall which may (or may not) narrow the lumen of the artery.

Bonus concept: It’s important to keep in mind that this disease process is actually within the artery wall and it may or may not affect the arterial lumen, which is why angiograms can be normal in persons with advanced atherosclerosis. As plaque progresses it can encroach into the lumen leading to ischemia (i.e., lack of oxygen delivery to tissues) as the narrowing approaches 70-75%, or the plaque can rupture leading to a thrombosis: partial leading to ischemia or total leading to infarction (i.e., tissue death).

To be clear, statistically speaking, this condition (atherosclerotic induced ischemia or infarction) is the most common one that will result in the loss of your life. For most of us, atherosclerosis (most commonly within coronary arteries, but also carotid or cerebral arteries) is the leading cause of death, even ahead of all forms of cancer combined. Hence, it’s worth really understanding this problem.

In this week’s post I am going to focus exclusively on what I like to call the “jugular issue” – that is, I’m going to discuss the actual mechanism of atherosclerosis. I’m not going to discuss treatment (yet). We can’t get into treatment until we really understand the cause.

“It is in vain to speak of cures, or think of remedies, until such time as we have considered of the causes . . . cures must be imperfect, lame, and to no purpose, wherein the causes have not first been searched.”
–Robert Burton, The Anatomy of Melancholy, 1893

The sine qua non of atherosclerosis is the presence of sterols in arterial wall macrophages. Sterols are delivered to the arterial wall by the penetration of the endothelium by an apoB-containing lipoprotein, which transport the sterols. In other words, unless an apoB-containing lipoprotein particle violates the border created by an endothelium cell and the layer it protects, the media layer, there is no way atherogenesis occurs.

For now, let’s focus only on the most ubiquitous apoB-containing lipoprotein, the LDL particle. Yes, other lipoproteins also contain apoB (e.g., chylomicrons, remnant lipoproteins such as VLDL remnants, IDL and Lp(a)), but they are few in number relative to LDL particles. I will address them later.
The endothelium is the one-cell-thick-layer which lines the lumen (i.e., the “tube”) of a vessel, in this case, the artery. Since blood is in direct contact with this cell all the time, all lipoproteins – including LDL particles – come in constant contact with such cells.

So what drives an LDL particle to do something as sinister as to leave the waterway (i.e., the bloodstream) and “illegally” try to park at a dock (i.e., behind an endothelial cell)? Well, it is a gradient driven process which is why particle number is the key driving parameter.

As it turns out, this is probably a slightly less important question than the next one: what causes the LDL particle to stay there? In the parlance of our metaphor, not only do we want to know why the ship leaves the waterway to illegally park in the dock, but why does it stay parked there? This phenomenon is called “retention.”

Finally, if there was some way an LDL particle could violate the endothelium, AND be retained in the space behind the cell (away from the lumen on the side aptly called the sub-endothelial side) BUT not elicit an inflammatory (i.e., immune) response, would it matter?

I don’t know. But it seems that not long after an LDL particle gets into the sub-endothelial space and takes up “illegal” residence (i.e., binds to arterial wall proteoglycans), it is subject to oxidative forces and as one would expect an inflammatory response is initiated. The result is full blown mayhem. Immunologic gang warfare breaks out and cells called monocytes and macrophages and mast cells show up to investigate. When they arrive, and find the LDL particle, they do all they can to remove it. In some cases, when there are few LDL particles, the normal immune response is successful. But, it’s a numbers game. When LDL particle invasion becomes incessant, even if the immune cells can remove some of them, it becomes a losing proposition and the actual immune response to the initial problem becomes chronic and maladaptive and expands into the space between the endothelium and the media.

The multiple-sterol-laden macrophages or foam cells coalesce, recruit smooth muscle cells, induce microvascularization, and before you know it complex, inflamed plaque occurs. Microhemorrhages and microthrombus formations occur within the plaque. Ultimately the growing plaque invades the arterial lumen or ruptures into the lumen inducing luminal thrombosis. Direct luminal encroachment by plaque expansion or thrombus formation causes the lumen of the artery to narrow, which may or may not cause ischemia.

Before we go any further, take a look at the figure below from an excellent review article on this topic from the journal Circulation – Subendothelial Lipoprotein Retention as the Initiative Process in Atherosclerosis. This figure also discuss treatment strategies, but for now just focus on the pathogenesis (i.e., the cause of the problem).
In this figure you can see the progression:

1. LDL particles (and a few other particles containing apoB) enter the sub-endothelium
2. Some of these particles are retained, especially in areas where there is already a bit of extra space for them (called pre-lesion susceptible areas)
3. “Early” immune cells initiate an inflammatory response which includes the direct interaction between the LDL particle and proteins called proteoglycans.
4. The proteoglycans further shift the balance of LDL particle movement towards retention. Think of them as “cement” keeping the LDL particles and their cholesterol content in the sub-endothelial space.
5. More and more apoB containing particles (i.e., LDL particles and the few other particles containing apoB) enter the sub-endothelial space and continue to be retained, due to the existing “room” being created by the immune response.
6. As this process continues, an even more advanced form of immune response – mediated by cells called T-cells – leads to further retention and destruction of the artery wall.
7. Eventually, not only does the lumen of the artery narrow, but a fibrous cap develops and plaques take form.
8. It is most often these plaques that lead to myocardial infarction, or heart attacks, as they eventually dislodge and acutely obstruct blood flow to the portion of muscle supplied by the artery.

Another way to see this progression is shown in the figure below, which shows the histologic progression of atherosclerosis in the right coronary artery from human autopsy specimens. This figure is actually a bit confusing until you understand what you’re looking at. Each set of 3 pictures shows the same sample, but with a different kind of histological stain. Each row represents a different specimen.

• The column on the left uses a stain to highlight the distinction between the intimal and media layer of the artery call. The intima, recall, is the layer just below the endothelium and should not be as thick as shown here.
• The middle column uses a special stain to highlight the presence of lipids within the intimal layer.
• The right column uses yet a different stain to highlight the presence of macrophages in the intima and the media. Recall, macrophages are immune cells that play an important role of the inflammatory cascade leading to atherosclerosis.

What is particularly compelling about this sequence of figures is that you can see the trigger of events from what is called diffuse intimal thickening (“DIT”), which exacerbates the retention of lipoproteins and their lipid cargo, only then to be followed by the arrival of immune cells, which ultimately lead the inflammatory changes responsible for atherosclerosis.

Why LDL-P matters most

You may be asking the chicken and egg question:
Which is the cause – the apoB containing LDL particle OR the immune cells that “overreact” to them and their lipid cargo?

You certainly wouldn’t be alone in asking this question, as many folks have debated this exact question for years. The reason, of course, it is so important to ask this question is captured by the Robert Burton quote, above. If you don’t know the cause, how can you treat the disease?

Empirically, we know that the most successful pharmacologic interventions demonstrated to reduce coronary artery disease are those that reduce LDL-P and thus delivery of sterols to the artery. (Of course, they do other things also, like lower LDL-C, and maybe even reduce inflammation.)

Perhaps more compelling is the “natural experiment” of people with genetic alterations leading to elevated or reduced LDL-P. Let’s consider an example of each:

1. Cohen, et al. reported in the New England Journal of Medicine in 2006 on the cases of patients with mutations in an enzyme called proprotein convertase subtilisin type 9 or PCSK9 (try saying that 10 times fast). Normally, this proteolytic enzyme degrades LDL receptors on the liver. Patients with mutations (“nonsense mutations” to be technically correct, meaning the enzyme is somewhat less active) have less destruction of hepatic LDL receptors. Hence, they have more sustained expression of hepatic LDL receptors, improved LDL clearance from plasma and therefore fewer LDL particles. These patients have very low LDL-P and LDL-C concentrations (5-40 mg/dL) and very low incidence of heart disease. Note that a reduction in PCSK9 activity plays no role in reducing inflammation.
2. Conversely, patients with familial hypercholesterolemia (known as FH) have the opposite problem. While there are several variants and causes of this disease, the common theme is having decreased clearance of apoB-containing particles, often but not always due to defective or absent LDL receptors, leading to the opposite problem from above. Namely, these patients have a higher number of circulating LDL particles, and as a result a much higher incidence of atherosclerosis.

So why does having an LDL-P of 2,000 nmol/L (95^th percentile) increase the risk of atherosclerosis relative to, say, 1,000 nmol/L (20^th percentile)? In the end, it’s a probabilistic game. The more particles – NOT cholesterol molecules within the particles and not the size of the LDL particles – you have, the more likely the chance a LDL-P is going to ding an endothelial cell, squeeze into the sub-endothelial space and begin the process of atherosclerosis.

What about the other apoB containing lipoproteins?

Beyond the LDL particle, other apoB-containing lipoproteins also play a role in the development of atherosclerosis, especially in an increasingly insulin resistant population like ours. In fact, there is some evidence that particle-for-particle Lp(a) is actually even more atherogenic than LDL (though we have far fewer of them). You’ll recall that Lp(a) is simply an LDL particle to which another protein called apoprotein(a) is attached, which is both a prothrombotic protein as well as a carrier of oxidized lipids – neither of which you want in a plaque. The apo(a) also retards clearance of Lp(a) thus enhancing LDL-P levels. It may foster greater penetration of the endothelium and/or greater retention within the sub-endothelial space and/or elicit an even greater immune response.

In summary

1. The progression from a completely normal artery to an atherosclerotic one which may or may not be “clogged” follows a very clear path: an apoB containing particle gets past the endothelial layer into the sub-endothelial space, the particle and its cholesterol content is retained and oxidized, immune cells arrive, an initially-beneficial inflammatory response occurs that ultimately becomes maladaptive leading to complex plaque.
2. While inflammation plays a key role in this process, it’s the penetration of the apoB particle, with its sterol passengers, of the endothelium and retention within the sub-endothelial space that drive the process.
3. The most numerous apoB containing lipoprotein in this process is certainly the LDL particle, however Lp(a) (if present) and other apoB containing lipoproteins may play a role.
4. If you want to stop atherosclerosis, you must lower the LDL particle number. Period.

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Read the full article here.

How do we measure cholesterol?

How do we measure cholesterol?

Posted by Peter Attia on May 10, 2012

Concept #5 – How do we measure cholesterol?

All this talk about cholesterol probably has some of you wondering how one actually measures the stuff. Much of the raw content I’m going to present here is actually material I’ve had to learn recently. One of the best resources I’ve found on this topic is the text book Contemporary Cardiology: Therapeutic Lipidology, in particular, chapter 14 by Tom Dayspring and chapter 15 by Bill Cromwell and Jim Otvos. Anyone aspiring to be a lipid savant like these three pioneers probably ought to get a copy. The other book that tells this story well is The Cholesterol Wars: The Skeptics versus the Preponderance of Evidence. For most folks, however, I’m hoping this series is sufficient and I’ll do my best to get the important points across.

As far back as the 1940’s scientists understood that cholesterol and lipids could not simply travel freely within the bloodstream without something to carry them and obscure their hydrophobicity, but it certainly wasn’t clear what these carriers looked like.

The initial breakthrough came during the Second World War when two researchers, E.J. Cohn and J.L. Oncley at Harvard developed a complex and elaborate technique to fractionate (i.e., separate) human serum (serum is blood, less the cells and clotting factors) into two “classes” of lipoproteins: those with alpha mobility and those with beta mobility. [“Alpha” versus “beta” mobility describes a pattern of movement seen by different particles, relative to fluid, under a uniform electric field, which is the essence of electrophoresis.]

You’ll recall that LDL particles are also called “beta” particles and HDL particles are also called “alpha” particles. Now you see why.

This work set the stage for subsequent work, by a physicist named John Gofman, using the techniques of preparative and analytic ultracentrifugation to fully classify the major classes of human lipoproteins. The table below summarizes what was gleaned by these experiments.


Cool, huh? Well, sort of. While this was an enormous breakthrough scientifically, it didn’t really have an inexpensive and quick test that could be used clinically the way, say, one could measure glucose levels or hemoglobin levels in patients routinely. What became crucial with Gofman’s discovery is that lipoproteins were now a recognized entity and they got their names according to their buoyancy: very low density, intermediate density, low density and high density.

There is more interesting history to this tale, but let’s fast-forward to where we are today. When you go to your doctor to have your cholesterol levels checked, what do they actually do?

Let’s start at the finish line. What do they report? The figure below is a representative result. It reports serum cholesterol (in total), serum triglycerides, HDL cholesterol (i.e., HDL-C), LDL cholesterol (i.e., LDL-C) and sometimes non-HDL-C (i.e., LDL-C + VLDL-C). But where do these numbers come from?

Blood is drawn into a tube called a serum separator tube (SST) and immediately spun in centrifuge to separate the blood from “whole blood” into serum (normally clear yellow, top) and blood cells (dark red, bottom). A gel film, from the SST, separates the serum and blood cells, as shown below. The tube is kept cool and sent from the phlebotomy lab to the processing lab.

As early as the 1950’s scientists figured out clever chemical tricks to directly measure the content of total cholesterol in the serum. The chemical details probably are not interesting to non-chemists, but I was able to find a great paper from 1961 that details the methodology. The point is this: initially it was only possible to measure the total content of cholesterol (TC), or concentration to be technically correct, in plasma. By that I mean it is the total mass (weight of all the cholesterol molecules) of cholesterol trafficked within all of the lipoprotein species that exist in a specified unit of volume: in the United States, we measure this in milligram of cholesterol per deciliter of plasma abbreviated as mg/dL, or in the rest of the world as mmol/Liter or mmol/L. Why? Think back to our analogy from last week:
Cholesterol is a passenger on a ship — the “ship,” of course, being a lipoprotein particle. The early methods of measuring cholesterol had to break apart the hull of the ship to quantify the cargo. The assays to do so, like the one described above, were pretty harsh. If you had a bunch of LDL ships, HDL ships, VLDL ships, and IDL ships, these assays ripped them all apart and told you the sum total of the cargo. Obviously this was a great breakthrough in the day, but it was limited. From this assay, one could conclude, for example, that a person had 200 mg/dL of cholesterol hiding out in all their lipoprotein particles.

Good to know, but what next? It turns out there were two other important factors that could be measured directly in blood: triglycerides and the cholesterol content within the HDL particle, HDL-C. Early on laboratories could easily separate apoA-I-containing particles (i.e., HDL) from the apoB-containing particles (i.e., VLDLs, IDLs and LDLs), but they could not easily and economically separate the various apoB-containing particles from one another. A full description of these methods is not necessary to appreciate this discussion, but for those interested, methodologies can be found here (TG) and here (HDL-C).

Important digression for context

What becomes critical to understand for our subsequent discussions is that the apoB particles have the potential to deliver cholesterol into an artery wall (the problem we’re trying to avoid), and 90-95% of the apoB particles are LDL particles. Hence, it is LDL particle number (LDL-P or apoB) that drives the particles into the artery wall. Thus, physicians need to be able to quantify the number of LDL particles present in a given individual. For decades there was no way of doing that. Then LDL-C (read on) became available and it served as a way (not entirely accurate, but nonetheless a way) of quantitating LDL particles.

Back to the story
How can one figure out the concentration of cholesterol in the LDL particle? As you may recall from last week, LDL is the “ship” that carries the most cholesterol cargo. More importantly, as I mentioned above, it is also the key ship that traffics cholesterol directly into the artery wall. Thus, there has always been an enormous interest in knowing how much cholesterol is trafficked within LDL particles.

For a long time it was not possible to directly measure LDL-C, the cholesterol content of an LDL particle. However, we did know the following had to be true:

TC = LDL-C + HDL-C + VLDL-C + IDL-C + chylomicron-C + remnant-C + Lp(a)-C
where X-C denotes the cholesterol content of a respective cholesterol-carrying particle. There are 2 particles in the equation above that I didn’t specifically mention last week, the remnant particle and the Lp(a) particle (pronounced “EL – pee – little – a,” which sounds less silly than, “Lip-a”). Lp(a) is an LDL-like particle but with a special apoprotein attached to it, aptly called apoprotein(a), which is actually “attached” to the apoB molecule of a standard LDL particle. Think of Lp(a) as a “special” kind of LDL particle. As we’ll learn later in this series, Lp(a) particles are bad dudes when it comes to atherosclerosis.

“Remnants” are nearly-empty-of-triglyceride particles of chylomicrons and VLDL. In essence they are larger TG-rich particles that have lost a lot of their TG core content as well as surface phospholipids and are thus smaller than, or remnants of, their “parent particles.” Hence,they are cholesterol-rich particles. Under fasting conditions, in a not-too-terribly-insulin-resistant person, IDL-C, chylomicron-C, and remnant-C are negligible. Furthermore, in most people Lp(a)-C does not exist or is not very high.

So we’re left with this simplification:
TC ~ LDL-C + HDL-C + VLDL-C
which is clearly an improvement in convenience over the first equation. But what to do about that pesky VLDL-C?

There are a number of variations, but essentially a breakthrough (mid 1970s) formula, called the Friedewald Formula, estimates VLDL-C as one-fifth the concentration of serum triglycerides (some variants use 0.16 instead of one-fifth, or 0.20). This assumes all TG are trafficked in one’s VLDL particles and that a normally composed VLDL contains five times more TG than cholesterol.
Rearranging the above simplified formula we have:
LDL-C ~ TC – HDL-C – TG/5
Let’s plug in the numbers from the above figure, as an example. TC = 234 mg/dL; HDL-C = 48 mg/dL, and TG = 117 mg/dL. Hence, LDL-C is approximately 234 – 48 – 117/5 = 163 mg/dL.
Kind of a long run for a short slide, huh? Perhaps, but it is important to understand that when you go to your doctor and get a “cholesterol test,” odds are this is exactly what you’re getting.
Therefore LDL-C can be estimated knowing just TC, HDL-C, and TG, assuming LDL-C matters (hint: it doesn’t matter much in many folks).

Furthermore, what if the LDL particle is cholesterol-depleted instead of its normal state of being cholesterol-enriched? Unfortunately, especially in an insulin resistant population (i.e., the United States), both TG content within lipoproteins and the exchange of TG for cholesterol esters between particles is very common, and using this formula can significantly underestimate LDL-C. Worse yet, LDL-C becomes less meaningful in predicting risk, as I will address next week.

What about direct measurement of LDL-C?

To chronicle the entire history of direct LDL-C measurement is beyond the scope of this post. Many companies have developed proprietary techniques to measure LDL-C directly, along with apoB, and ultimately LDL-P. I’ll address two “major players” here: Atherotech and LipoScience.

Atherotech developed an assay, called a VAP panel (VAP stands for Vertical Auto Profile) to do everything described above, but also to directly measure the amount of cholesterol contained within the LDL particle. Furthermore, they have developed assays to directly measure the cholesterol in IDL particles, VLDL particles, and even Lp(a) particles. Below is a snapshot of how VAP reporting looks.

A couple of things are worth mentioning:

1. Subparticle cholesterol content information is also generated, including 2 different classes of HDL particles (HDL-2, HDL-3) and 4 different classes of LDL particles (LDL-1, LDL-2, LDL-3, LDL-4).
2. LDL particles, based on the subparticle information, are classified as “pattern A,” “pattern B,” or “pattern A/B.” Pattern A implies more large, buoyant LDL particles, while pattern B implies more small, dense LDL particles.

Remember, though, while cholesterol mass concentration numbers may correlate with the number of particles, they often do not. They only convey the mass concentration of cholesterol molecules within all of the particle subtypes per unit of volume. VAP tests do not report the number of LDL or HDL particles, but they do attempt to estimate atherogenic particle number (apoB) using a proprietary formula based on subparticle cholesterol concentration and particle sizes. I should point out that the formula, to my knowledge, has not been validated in any study and not published in a peer reviewed journal.

A high estimate of apoB100 (i.e., what the VAP reports) is said to correlate with the actual measurement of apoB. Since apoB is found on each LDL particle, this serves as a proxy of LDL-P. The American Diabetic Associate and the American College of Cardiology Consensus Statement on Lipoproteins and the new National Lipid Association biomarker paper stipulates that apoB must be done using a protein immunoassay, not an estimate, such as that of VAP.

But how can one actually count the number of LDL particles and HDL particles?

There are several methods of doing this, but only one company, LipoScience, has the FDA approved technology to do so using nuclear magnetic resonance spectroscopy, or NMR for short. The other available methodologies are ion mobility transfer and ultracentrifugation (by Quest) and separation of LDL particles with particle staining (by Spectracell). Virtually all guidelines (e.g., ADA, ACC, AACC and NLA) only advise LDL-P via NMR at this time.

NMR, which is the basis for not only how to count lipoprotein particles, but also diagnostic tests such as MRI scans, is really one of my favorite technical topics. In residency I wrote a surgical handbook and on page145-146, if you’re interested, you can read a brief description of how MRI technology works, which will explain how NMR technology can actually count lipoprotein particles.

As an aside, and just to give you an idea of what a great sport my wife is, I wrote this surgical handbook over the course of a year while in residency. To do so, I had to read approximately 8,000 pages of surgical textbooks and try to distill them down to just this 160 page summary. Doing so required reading about 22 pages every day while working about 110 hours per week, typical of a surgical residency “back in the day.” Besides exercising, I spent every single moment of my “free” time reading for and writing this handbook. Finally, a few months into it, my wife asked, “Why the hell are you doing this? You never watch TV, you never go out, you never do anything else!” I responded that it was the best way I could learn this material, but also, that I wanted to have a legacy when I left residency. Half joking, I asked her, “What’s your legacy?” Blank stare. A few months later, for Valentine’s Day, she gave me this t-shirt. I think it’s safe to say not a single person has read this handbook. So much for my legacy…

A brief explanation of how NMR works to count (and measure) particles can also be found here.
Below is a snapshot of how NMR reporting looks. This particular report is from Health Diagnostics Laboratory (HDL), Inc. LipoScience performs the actual NMR test, but HDL, Inc. runs a number of complimentary biomarkers I will discuss in subsequent posts. I now use the HDL, Inc. test exclusively for reasons I will explain later.

In addition to counting the actual total number of LDL particles (LDL-P) and HDL particles (HDL-P) per liter, HDL, Inc. (not LipoScience) directly measures apoB and apoA-I. Furthermore, the size of each particle is measured using NMR in nanometers (to give you a sense of how small these things are, and why we need to use nanometers to measure them, about 1.3 million LDL particles stacked side-by-side would measure only one inch).

The final point I’ll make about the value of NMR reported subparticle sizes and diameters is particularly telling when it comes to insulin resistance. In the panel below, you can see that this person has small VLDL particles, small HDL particles, and LDL particles. Why is this interesting? The presence of increased large VLDL-P, large VLDL size, increased small LDL- P, small LDL size, reduced large HDL-P, small HDL size are early markers for insulin resistance, and such findings may actually precede more conventional signs of insulin resistance (insulin levels, glycemic abnormalities) by several years. In other words, the number and size of the lipoprotein particles is perhaps the earliest warning sign for insulin resistance.

In summary

1. The measurement of cholesterol has undergone a dramatic evolution over the past 70 years with technology at the heart of the advance.
2. Currently, most people in the United States (and the world for that matter) undergo a “standard” lipid panel which only directly measures TC, TG, and HDL-C. LDL-C can be measured directly, but is most often estimated.
3. More advanced cholesterol measuring tests do exist to directly measure LDL-C (though none are standardized), along with the cholesterol content of other lipoproteins (e.g., VLDL, IDL) or lipoprotein subparticles.
4. The most frequently used and guideline recommended test that can count the number of particles is the NMR LipoProfile. In addition to counting the number of particles – the most important predictor of risk – NMR can also measure the size of each lipoprotein particle, which is valuable for predicting insulin resistance in drug naïve patients, before changes are noted in glucose or insulin levels.
   

I know some of you are getting antsy. I thank you for your patience, and I hope you appreciate that it was a necessary step to get through this somewhat technical material and nomenclature. Next week we’ll get to the “fun” stuff – what does all of this cholesterol have to do with heart disease?

In addition, we’ll get further into the importance of using LDL-P as the best predictor of risk. If anyone wants to read up on another very important topic, especially for understanding why LDL-P is more important to know than LDL-C, get familiar with the concepts of discordant and concordant variables. You’ll be hearing a lot about these.
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Read the complete article here.

Be sure to read his complete series on cholesterol.

Previously, in Part I and Part II of this series, we addressed 4 concepts:
#1 — What is cholesterol?
#2 — What is the relationship between the cholesterol we eat and the cholesterol in our body?
#3 — Is cholesterol bad?
#4 – How does cholesterol move around our body?

Why Asians Should Ignore the Cholesterol Sham, and Why Healthy People Should Not Take Statins- Colpo

Why Asians Should Ignore the Cholesterol Sham, and Why Healthy People Should Not Take Statins

Anthony Colpo  Saturday, April 28th, 2012

Folks, before I get rolling, I would just like to dedicate this first instalment of many more cholesterol updates to come to my good buddies Pee Pee and Don Matesz and all those other dopey buggers who make a pastime of accusing me of being a cherry-picker. Today, I’m going to share with you studies you’ve probably never heard of, because they just happen to flatly contradict the mainstream assertion that low cholesterol is healthy and hence are quietly shoved aside by purveyors of this belief due to their embarrassing nature. As we know, one of the favourite strategies humans have for dealing with evidence that contradicts their cherished dogmas is to simply ignore it.

In the twisted worldview of Don, Pee Pee and their ilk, by presenting the studies that you likely never would have heard of due to their embarrassing nature, it is people like me – not them – that are cherry-picking.

Yeah, no worries.

Come and Get ‘Em!
Folks, who wants some cherries? I’ve got a basket full here, and you’re all welcome to grab a handful. They might not be highly-hyped, front page, AHA- or Big Pharma-press-release cherries, but they are definitely sweet, tasty, and certified peer-reviewed delicacies. Enjoy!

Low Cholesterol is Accompanied by Increased Mortality from Stroke, Heart Disease, and Cancer: The Jichi Study
The Asians we are told, are shining examples of the cholesterol theory. They eat a low-fat diet, which gives them wonderfully low cholesterol levels, which in turn not only protects them from heart disease but endows them with the longest average life expectancy on Earth.
Sounds great, doesn’t it?

Too bad it’s complete nonsense.

Being the cherry-picker I am, I discussed the evidence, so often ignored by others, in The Great Cholesterol Con that low cholesterol is strongly associated with increased mortality in Japan.
Yeah, shame on me for pointing out to our Japanese brethren that this whole cholesterol-lowering thing is just another overhyped Western wank, one with the potential to harm instead of hurt their health.

Funnily enough, I don’t feel any shame at all. Au contraire, I believe reporting the facts is a noble thing to do, even if it upsets every last dogmatic sod who can’t get his head around the fact he has fallen hook, line and sinker for a load of unscientific rot.

Which is why, dear readers, I bring you the results from The Jichi Medical School Cohort Study, which involved 12,334 healthy Japanese adults aged 40 to 69 years who underwent a mass screening examination (1992-2005), including total cholesterol measurement. Information regarding cause of death was obtained from death certificates, and the average follow-up period was 11.9 years. In total, 635 men and 423 women died during the study period.

The subjects were divided into 4 groups according to total cholesterol level (<4.14mmol/L; 4.14mmol/L to <5.17 mmol/L; 5.17 mmol/L to <6.20 mmol/L, and; >6.21 mmol/L).
Before I report the results, it should be pointed out that the lowest quartile of cholesterol (<4.14mmol/L) , in both male and female participants, was marked by a higher number of current cigarette smokers.

So did multivariate analyses, which many misguided Western researchers seem to think grants epidemiology the same accuracy as RCT data, and which in this instance included adjustment for smoking, age, systolic blood pressure, HDL, drinking, and body mass index confirm the wonderful life-saving benefits of having low cholesterol?

Nope.

The safest cholesterol range in the study was 4.14–6.20 mmol/L in men, and 4.14mmol/L – >6.21 mmol/L in women. As the researchers stated:

“We noted a clear relationship between low cholesterol and increased mortality. Okamura et al reported that occult liver diseases are associated with mortality; however, in the present study, the relationship between low cholesterol and increased mortality was unchanged in analyses that excluded deaths due to liver disease. Our results suggest that hemorrhagic stroke and heart failure excluding myocardial infarction,contribute to the relationship between low cholesterol and high mortality.”

You can check out the full text of the study here:

Nago N, et al. Low Cholesterol is Associated With Mortality From Stroke, Heart Disease, and Cancer: The Jichi Medical School Cohort Study. Journal of Epidemiology, 2011; 21 (1): 67-74.
Yeah, I know, shame on me for allowing you to view the paper yourself…I need to do what folks like Don and Pee Pee do and make sweeping claims and libelous accusations, then refuse to back them up with even a single paper!

Must be the cherry-picker in me…

Low Cholesterol is Associated with Increased Mortality from CVD in Korean adults.
Maybe the Koreans can save the cholesterol cartel’s Asian thesis, no?
No.

A total of 12,740 Korean adults aged 40 to 69 who underwent a mass screening examination were followed up from 1993 to 2008. Groups with the lowest cholesterol (< 160 mg/dL) as well as the highest (>= 240 mg/dL) were associated with higher CVD mortality in analysis adjusting for age, sex, smoking and drinking status, body mass index, level of blood pressure, triglyceride and HDL.

The researchers noted:

“Based on the results of this study, caution should be taken in prescribing statins for primary prevention among people at low cardiovascular risk in Korean adults.”

Aw c’mon guys, the nice folks from Big Pharma won’t like that, will they? Don’t you know that the Asian market, especially China, represents a huge and largely untapped reservoir of profit, but by showing the kind of independent and critical thinking sadly lacking in most of your Western colleagues you’re ruining the party?

Tsk tsk.

Again, dear readers, if you’d like to read the paper yourself, feel free to do so here:

Bae JM, et al. Low cholesterol is associated with mortality from cardiovascular diseases: a dynamic cohort study in Korean adults. J Korean Med Sci. 2012 Jan; 27 (1): 58-63.

Statins are Largely a Waste of Time
As for statins, they’re not just a wank for Asians, they’re a load of cobblers for Westerners too.
The Journal of the American Medical Association recently published a “for” and “against” installment posing the following hypothetical question:

“Should a 55-year-old man who is otherwise well, with systolic blood pressure of 110 mm Hg, total cholesterol of 250 mg/dL, and no family history of premature CHD be treated with a statin?”

To answer this question, JAMA enlisted Blaha, Nasir and Blumenthal from The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease for the “yes” case, and Redberg and Katz from the Division of Cardiology, Department of Medicine, University of California, San Francisco (Dr Redberg) and Department of Health Services, County of Los Angeles (Dr Katz) for the “no” case (Drs Redberg and Katz are also Editor and Deputy Editor, respectively, over at the Archives of Internal Medicine).

To support their “yes” case, the Hopkins crew begin by citing a bunch of cholesterol guidelines that were formulated by panel members sponsored by manufacturers of statins. Yep, I’m sure we can rely on those for accurate, unbiased guidance when tooling around with someone’s health!

They then cite the WOSCOPS and AFCAPS/TexCAPS trials and report the former lowered heart attack and CHD mortality by 31%, while the latter reduced heart attacks by 40%.
Um, fellas … isn’t there something you’re forgetting to tell us about those studies?

Like the fact that the 27% reduction in CHD mortality in AFCAPS/TexCAPS did not reach statistical significance? And that there was no reduction whatsoever in overall mortality?

And the fact that the 27% reduction in CHD mortality in WOSCOPS also did not reach statistical significance?

Instead of reporting these facts about actual death rates, the researchers only reported (read: cherry-picked) outcomes that managed to reach statistical significance and ignored those that didn’t.
Recommending a toxic drug to healthy individuals free of CHD using such dubious interpretation of these largely unsuccessful studies is, to my way of thinking, BoLLOCKS.

The Hopkins team then trot out the absolute farce that was JUPITER, this time including a total mortality reduction of 20% reported in that trial. For me to outline all the discrepancies in this trial – that was conveniently cut short as the mortality trajectories of the treatment and control groups began to menacingly converge – would be a whole other article. Luckily, someone else has already saved me the time and posted a pearler of a critique right here:

http://junkfoodscience.blogspot.com.au/2008/11/when-news-sounds-too-good-statins-new.html

After reading that, I’m sure most everyone apart from Pee Pee, Matesz and the JUPITER researchers themselves will agree that citing JUPITER in support of anything other than the all-too-frequent shadiness of Big Pharma-sponsored research is POPPYCoCK and HogWASH.

The Hopkins team then go onto cite some more theoretical figures, then argue that statins are safe, claiming only 5% of patients experience muscle pains.

Incorrect. The reality is that such complaints are dramatically underreported, thanks to doctors’ refusal to believe the ‘wonder drug’ statin they prescribed could ever do anything negative to their patient. And in those who do acknowledge the cause of the muscle pain, filing an official complaint is a time-consuming affair for which they receive no compensation and may even be subject to interrogation about the circumstances that led to the filing of the report.

But what happens when, instead of brushing people off and telling them their symptoms are just due to “getting old”, researchers carefully inspect patient data and make further enquiries? A study published in the October-November-December 2009 issue of Primary Care Cardiovascular Journal, indicates that statin-induced myopathy is far more common than previously claimed by drug companies and health officials. Researchers analyzed the patient records of one 8,000 patient practice and found only one recorded case of muscle symptoms in a patient taking statins. But after questioning 96 randomly selected statin-using patients from the practice, they identified 19 cases of potential muscle damage:

Sciberras D, et al. Is general practice the optimal setting for the recognition of statin-induced myotoxicity? Primary Care cardiovascular Journal, Oct-Nov-Dec, 2009; 2: 195-200.

As for the question of whether statins should be prescribed to women, Blaha et al cite a review by Kostis et al that claims statins also work in women – but ignore two other reviews that concluded statins do not:

1. Walsh JM, Pignone M. Drug Treatment of Hyperlipidemia in Women. JAMA. 2004; 291 (18): 2243-2252.
2. Petretta M, et al. Impact of gender in primary prevention of coronary heart disease with statin therapy: A meta-analysis. International Journal of Cardiology, 2010; 138 (1): 25-31.

So what do Redberg and Katz, who argue the “No” case, have to say in response to the selectively cited arguments of Blaha and co?

Instead of citing a small handful of incompletely reported trials, they report that:

“Data from a meta-analysis of 11 trials including 65 229 persons with 244 000 person years of follow-up in healthy but high-risk men and women showed no reduction in mortality associated with treatment with statins. A 2011 Cochrane review of treatment with statins among persons without documented coronary disease came to similar conclusions. The Cochrane review also observed that all but one of the clinical trials providing evidence on this issue were sponsored by the pharmaceutical industry. It is well established that industry-sponsored trials are more likely than non–industry-sponsored trials to report favorable results for drug treatment because of biased reporting, biased interpretation, or both of trial results.”

As for the commonly claimed low rate of side effects in statin users, they note:

“This underestimation of adverse events occurs because the trials excluded up to 30% of patients with many common comorbidities, such as those with a history of muscular pains, as well as renal or hepatic insufficiency. Many randomized trials also excluded patients who had adverse effects of treatment during an open label run-in period. For example, in the Treat to New Targets trial, after initial exclusions based on comorbidities, an additional 35% of eligible patients, or 16% of patients, were excluded during an 8-week, open-label, run-in phase because of adverse events, ischemic events, or participants’ lipid levels while taking the drug not meeting entry criteria. Additionally, the results of randomized trials of statin treatment likely underestimate common symptoms such as myalgia, fatigue, and other minor muscle complaints because these studies often only collect data on more quantifiable adverse effects such as rhabdomyolysis.

Numerous anecdotal reports as well as a small trial have suggested that statin therapy causes cognitive impairment, but this adverse outcome would not have been captured in randomized trials. The true extent of cognitive impairment associated with statins remains understudied. It is disappointing that more data are not available on important adverse events associated with statin treatment, despite millions of prescriptions and many years of use. This information could be easily collected in observational studies and from registries. One population-based cohort study in Great Britain of more than 2 million statin users found that statin use was associated with increased risks of moderate or serious liver dysfunction, acute renal failure, moderate or serious myopathy, and cataract. The risk of diabetes with statin use has been seen in randomized clinical trials such as JUPITER, which found a 3% risk of developing diabetes in the rosuvastatin group, significantly higher than in the placebo group. In observational data from the Women’s Health Initiative, there was an unadjusted 71% increased risk and 48% adjusted increased risk of diabetes in healthy women taking statins.”

Their conclusion?

“Based on all current evidence, a healthy man with elevated cholesterol will not live any longer if he takes statins. For every 100 patients with elevated cholesterol levels who take statins for 5 years, a myocardial infarction will be prevented in 1 or 2 patients. Preventing a heart attack is a meaningful outcome. However, by taking statins, 1 or more patients will develop diabetes and 20% or more will experience disabling symptoms, including muscle weakness, fatigue, and memory loss.”

Statins. They still suck.
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Read the complete article here.