The Dangers of Visiting Your Doctor

These days when you visit your doctor it’s more than likely that he or she will, while you’re there, estimate your risk of heart disease. This can be done at the click of a button using a method called Q Risk. It’s simple and easy. All that’s needed is a few basic measurements, including your blood pressure and cholesterol level and these are usually on the computer already. In an instant you will know your risk of heart disease over the next 10 years. Here we have modern technological medicine at its best. What could possibly be wrong with that?

In fact, a lot could be wrong. If your doctor goes ahead and presses that tab what happens next is very unlikely to end up happily. Let me explain.

The first point is that Q Risk is inaccurate, in fact wildly inaccurate. A team from America compared the estimated risk with actual events. They found it overestimated the risk five or six-fold. What would you think if the HMRC estimated your tax bill at five times what is should be? It would be bad enough if was double, never mind five times too high.

The second point I’d like to make is  that raised cholesterol is not a cause of heart disease. Now I know what you’re thinking. We must have a right crackpot here. Everybody knows cholesterol causes heart disease. But hear me out.

Well for a start let’s look at who get’s heart attacks. A major study of the 1.7 million or so patients that had suffered heart attacks or strokes in the USA each year found that more and half have normal or low cholesterol level. And this study was no fluke. A previous study of 137,000 patients admitted with heart attacks in the USA found that, on average, their cholesterol was low (4.46) and their LDL (sometimes called bad cholesterol) was also lower than normal.

The average cholesterol level in Japan has risen from 3.9 to 5.2 over the last 50 years so you might well expect a bonanza of heart attacks. But no, heart attacks went down 60% and strokes were down by 700%. Switzerland at one time had the dubious record for the highest average cholesterol in the world (6.2). Surely they should be dropping like flies. But no, they had the second lowest rate of heart disease in Europe.

But you might say what about the famous Framingham study? Didn’t this show a link between raised cholesterol and heart disease? No, the initial study showed a correlation only in those less than 47 years of age. However cholesterol was not linked with heart disease in those over 50 and those with a falling cholesterol levels had higher rates of heart disease and shorter life expectancy. I could give you much more evidence but let’s move on.

One fact that shows up time and time again is that low cholesterol is dangerous. So why is every cardiologist in the world desperately trying to bring it down? I can’t answer that one. Perhaps they should read a study published in a major medical journal in 2007 of men between 60 and 85. This found those with a (raised) cholesterol of over 5.5 had a 24% reduction in mortality and those with a (low) cholesterol of less than 4.4 had a 60% increase in mortality. A huge Austrian study of 149,650 men and women found that low cholesterol over the age of 50 was significantly associated with reduced life expectancy.

And high cholesterol is great news for the elderly. Eighteen separate studies have noted a link between raised cholesterol and longevity in the elderly.

Okay, you might say, maybe cholesterol is not so bad after all but the real villain is surely LDL. Not so. A review of 17 studies in 2016 in the BMJ Open involving 68,000 people over 60 found that 80% of people living the longest had the highest levels of LDL. What’s more they were less likely to develop cancer, respiratory, gastro-intestinal disease and, believe it or not, heart disease. Wow, they were really doing well, surely we could all do with a bit more of this LDL, it seems to help with just about everything.

Now the way Q Risk works is the higher your cholesterol the higher it estimates your risk of heart disease and vice-versa. In other words it is based on a fallacy and a pretty big one at that. Now because age is also a big part of the Q Risk calculation, it will calculate that every man over 60 and every woman over 70 is at high risk of heart disease and hence a candidate for statins. Yes that’s a huge chunk of the population and yes they apparently all need statins, at least according to Q Risk.

But why would anyone give this group of people over sixty, who we already know will live longer if their cholesterol levels are higher, statins? Surely that’s plain crazy? You might well ask. But it gets a lot worse. The benefits of statins for prevention are not what they are cracked up to be and the side-effects are well, serious. This is where you might wish your doctor had kept his finger off the button.

When patients are given drugs and know very little about the benefits and dangers of those drugs I start to get worried. If they did know, I think most would say “No thank you, doctor”. I also suspect many doctors don’t know the real benefits and downsides of statins either.

So let’s look at the facts. Let’s look at the benefits of what is called primary prevention (that is a patient without heart disease who has come up on Q Risk as having high risk).

In medicine there is something called Numbers Needed to Treat (NNR) and it works out at 104 for statins. This means 104 people would need to be treated for 5 years for one person to benefit by not having a heart event (such as angina or a heart attack).

We could put it another way: 98% of patients given statins for primary prevention would get no benefit. The way the figures pan out is that 1 in 104 (0.9%) would avoid a heart attack and 1 in 154 (0.4%) would avoid a stroke How many lives would be saved? The answer may surprise you. It is zero. Dr Kendrick has pointed out that cancer patients are usually told how much longer a drug would, on average, prolong their life. He notes that statins will prolong life by 3.2 days if taken for 5 years.

My guess is that few patients would take the drugs based on these statistics and I don’t blame them. Not least, because lifestyle changes (diet, exercise, sunlight) will give far greater benefits with none of the risks (see leaflet on Food and the heart).

And there’s more. A review by the BMJ found no benefit from taking statins in those over 75 and a JAMA review of 2900 patients also found no benefit for those over 65 taking statins (and those over 75 were more likely to die if they were taking statins). The American Medical Director’s Association made the statement “we recommend not routinely prescribing statins to those aged 70 or over based on the lack of an association between high cholesterol and outcomes in older adults as well as the potential for an increased risk of adverse events”. And yet every person in the UK is automatically a candidate for statins based on Q Risk. To my way of thinking, that’s just plain bonkers.

But even the benefits I have mentioned should be taken with something of a pinch of salt. Pharmaceuticals companies are not known for telling the truth and nothing but the truth. In the last 10 years there are been five fines of over a billion dollars for major fraud related to medical trials (the largest went to GSK for $3 billlion). However even without fraud drug companies use many underhand tactics, such as not to publishing negative trials, spinning negative trials to produce a positive result, not mentioning mortality data if it doesn’t fit and omitting serious adverse effect. So regulations were tightened in 2005. Since that time it’s interesting that statin trials have failed to consistently show any mortality benefit.

But the scariest part is yet to come. Cholesterol is essential to life and if you block it you are asking for serious trouble. Two things will happen. You start running short of essential hormones (cholesterol is the building block for these) and you block substances essential for the energy production in your cells (the best known, but not the only one, is Co-enzyme Q10).

You become more liable to diabetes (there is a 50 to 363% increase in various studies) and you become more liable to cancer. A study by McDougall in 2013 found women who had used statins for 10 years or longer had an 83% higher risk of invasive ductal cancer of the breast and a 97% increased risk of invasive lobar carcinoma of the breast.

Now this study is really important because it was long-term study and showed a large increase in cancer. The reason it is so crucial is that drug safety studies only follow-up patients for a maximum of 5 years and they will miss this sort of long-term effect. Thyroid cancer, Merckel cell cancer and melanoma have all been found to be increased by statins. And we also know that the more you reduce the cholesterol the greater the cancer risk. A Japanese study of people taking simvastatin found three times the number of cancer deaths in those with the largest reductions of cholesterol as compared with those with smaller reductions. Low cholesterol really is bad news.

At least thirty separate studies have shown that people with low cholesterol have a greater risk of getting cancer. Three studies have demonstrated the link between low LDL and increased cancer incidence. These are important studies because I believe few people would trade the minimal heart benefit of statins for a greater risk of cancer if they were told about it.

But what frightens me most is what statins do to the brain.

Researchers at Boston University have studied the link between brain function and cholesterol in 789 men and 1105 women who performed tests on brain function every 6 years. They found that as cholesterol went up every aspect of brain function improved. They found subjects with “desirable levels” of cholesterol performing less well than those with high cholesterol whilst those with the lowest cholesterol performed the worst.

Statins damage the neurological system by reducing cholesterol in the brain where it is an essential nutrient. I have personally seen people thought to be developing dementia who recovered on stopping statins. I have also seen statins trigger a case of Parkinson’s disease and in this case he didn’t recover. A rare but particularly horrible outcome is motor neurone disease. An increase in the number of cases of this disease on people on statins has been flagged up by the World Health Organization. Basically statins are toxic to the nervous system.

A big problem is that many of the changes caused by statins are difficult to spot as they are often put down to getting old: muscle pains, forgetfulness, fatigue, dizziness, poor balance. I always worry when I see low cholesterol, especially in the elderly (cholesterol below 4) and I see it a lot; it is very often due to statins. I hate to think how many thousands of patients are spending the later part of their life in poor health due to a completely avoidable cause.

So that’s why I believe your doctor should never press the Q Risk button? Nothing good is likely to come from it.

My thanks, in writing this, go to Drs Malcolm Kendrick and Dr Uffe Ravnskov, who have taken the time and trouble to investigate cholesterol studies and statin trials and disentangle the half truths, misleading information and important omissions in these studies. This is no easy task and they have done an immense service to everyone. My only wish is that it was more widely known, not least by cardiologists.