Malcolm Kendrick - A Statin Nation: Damaging Millions in a Brave New Post-health World

A lmost ten years ago, I wrote a book called The Great Cholesterol Con. I tried to outline, as clearly as I could, why the central ideas about cardiovascular disease (CVD, i.e. basically heart attacks and strokes) were absolutely, completely and totally wrong. I knew that the impact would be instant and earth shattering.

There would be an immediate realisation that saturated fat and cholesterol have nothing whatsoever to do with CVD. Medical experts and opinion leaders would reverse their thinking, and the public would fling their statins into the nearest dustbin. Guidelines would be hastily rewritten around the world. My Nobel Prize would be polished furiously in Sweden. My acceptance speech was already written and it was a cracker humble, witty, incisive.

History reveals that it hasnt quite worked out that way. It is true that, over the last ten years, the guidelines have been rewritten, but they now advise that hundreds of millions more people need to be put on statins, at ever-lower levels of blood cholesterol. Furthermore, people have never been more terrified of having a high cholesterol level than today. Supermarket shelves groan under the weight of low-fat foods, designed to lower cholesterol. Benecol sales seem to be going through the roof, rather than down the drain. I think it would be true to say that the Cholesterol hypothesis has never been more potent than now.

Oh well. Perhaps I should rewrite the ending of the story about the emperors new clothes So perfectly had everyone allowed themselves to be fooled, that even when the little boy shouted but he isnt wearing any clothes the crowd just turned on him, and told him to shut up and stop being so stupid. The End.

Undeterred, I am having another go, despite the fact that insanity has been defined as doing the same thing again and again while expecting a different result. (And before you say thats an Einstein quote, check it out on Wikipedia.) Perhaps I just need to shout a bit louder and carry a baseball bat to be used at good strategic moments.

In truth, over the last ten years many things have changed. Some for the better, some for the worse. Of course, whether you think things are better or worse rather depends on which side of the argument you are on.

Prescribing statins has continued to rise inexorably, with the latest recommendations in the UK being that every single man should be taking a statin by the age of sixty, regardless of whether they have any other risk factors for CVD. The official ceremony when you reach the age of lifelong statination is significantly younger in the US, as you might expect.

Looking at this latest development from a different angle, it is now possible to have perfect cholesterol levels, perfect blood pressure and perfect every other single risk factor, yet when you reach a certain age the danger of suffering a cardiovascular (CV) event is so frighteningly high that you will have to take a drug, every day, for the rest of your life. (An event is a heart attack, stroke or hospital admission with angina, or suchlike.) Of course, hardly anyone has perfect risk factors, which means that the average age when a man is required to take a statin is about fifty, and about ten years later for women.

And lo, it came to pass that all of the peoples in the world, past middle age, hast been defined as having a new medical condition that shalt be called statin deficiency syndrome (SDS). By order of the management. In other words, your cholesterol level can be low, medium or high, but the actual figure does not matter a jot, you still need a statin to lower it further. This remains true, even if your cholesterol level is lower than that found in any population in the world, even it if is lower than 99.99 per cent of anyone currently alive.

We now live in the upside down, a world where there is no cholesterol level that cannot benefit from being lower. A world where cholesterol can cause CVD, even when it is abnormally low. Try and pick the logic out of that, my friend. And if you do, please let me know how you did it.

If things continue their inexorable direction, the next argument which is already being made is that CVD gradually develops with ageing. Ergo, you should really start taking statins when you are a child. My prediction is that it will soon be recommended that everyone starts statination in their early twenties, and must continue forever. You read it here first. Then we truly will have a statin nation instead of the rather pathetic 14 million statin takers we now have. Or at least are supposed to have. In truth, a lot of people dont take them, even when they tell the doctor that they do.

And in addition to the statination of the entire adult population, we now have ever lower limits for treating blood pressure. About thirty years ago, hypertension was diagnosed if you had blood pressure of over 160/110mmHg. As with cholesterol levels, this target has fallen and fallen. At the time of writing we have reached 130/80mmHg, which means just about everybody has it.

Simultaneously, the concept of pre-hypertension has gained traction. Pre-hypertension means that you dont have blood pressure quite high enough to be diagnosed as hypertension, but you are nearly there and, as is the way of things, you will inevitably become hypertensive. Ergo, you might as well start taking drugs to lower your blood pressure now.

What else? We have a new medical condition known as pre-diabetes. A state of having a highish blood sugar level, but not actually high enough to be diagnosed as diabetes, at least not until they lower the diagnostic threshold once more. However, my friend, bad luck, you will inevitably develop diabetes over time so you might as well start the medications now.

Osteoporosis (thinning of bones), is something that women tend to get more than men, and if you have it you must start taking drugs for the rest of your life. These drugs (such as alendronic acid or risedronate) are usually called bisphosphonates and, as an added bonus, you will also take a calcium supplement and vitamin D at the same time.

But thats far from the end. In the same way that we now have pre-hypertension, pre-diabetes and the inexorable lowering of cholesterol levels, there has been pressure to further widen the market for osteoporosis drugs. This has led to the creation of a new condition called osteopenia, which means thinnish bones, not quite osteoporosis, but getting there. Pre-osteoporosis, if you like. So, guess what, time to start the medications to thicken up the old bones. To be taken forever, for the rest of your life. And you may have noticed a certain trend here

Now, heart disease. Whilst youre religiously taking statins, you might as well take an aspirin to add further protection. But aspirin can damage the lining of your stomach, so you should also take an anti-acid drug, such as omeprazole, to prevent this, which gives you two more drugs to take for the rest of your life. Then, if you are unlucky enough to have had an episode of chest pain, which might or might not have been related to your heart, there are a whole load of other drugs that you will be put on for the rest of your life. An ACE-inhibitor, a beta blocker, clopidogrel, etc. It doesnt much matter if the pain seemed cardiac, you cant be too careful you know.

So today, without really trying and without having any disease diagnosed, you can be on at least eleven drugs. Two to lower blood sugar, two blood pressure lowering drugs, aspirin, omeprazole, alendronic acid, the calcium/vitamin D combination, clopidogrel and a statin. In fact, in one of the places where I work Ive toyed with the idea of getting a large stamp with a list of these drugs imprinted on it. This will save me the time of writing them out for every single bloody patient who comes to my surgery. Just a quick whack on the prescription all drugs present and correct, sir.