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Why the stats about statins don't tell the whole story

For those without the relevant risk factors, statins aren't the wonder-pill they've been sold as by the media.

Maggie came hot-foot from a “health check” where she’d had her cholesterol measured. “Six point two!” she told me. “The nurse said that’s high.” She sounded rather spooked. “I’d like you to give me a statin.”

I’ve known Maggie for years. She’s a sensible academic in her early fifties. She’d done enough googling to learn that a “high” cholesterol means you are “at risk” of cardiovascular disease (CVD) – heart attacks and strokes – and that statins lower cholesterol and reduce CVD risk by 25 per cent. Her request for treatment made perfect sense to her . . . except she had fallen for the same myth that leads to several million people in the UK swallowing a statin every day for no good reason at all.

Focus for a moment on that 25 per cent risk reduction. If you’re at high risk of something nasty, then lopping off a quarter of that risk makes sense. The people at greatest risk of heart attacks and strokes are those who have previously suffered one. Giving statins to these patients (secondary prevention) does convey modest benefits. If you take 100 heart attack survivors and get them to take a statin for five years, you’ll save one life, prevent two or three non-fatal heart attacks, and avert one stroke. That is worthwhile, even if the statins will fail to prevent at least 15 other heart attacks/strokes, and will cause two patients to develop diabetes, and provoke muscle weakness in ten others. Notice, though: 95 per cent of these highest-risk patients will derive absolutely no benefit from their five years of statin consumption.

Come back to Maggie. Using a statin on someone without existing CVD is termed primary prevention. Maggie has no other risk factors (high blood pressure, smoking, diabetes, and so on) and so her chance of developing heart disease is very low. In Maggie’s case, because her risk is so small to start with, a 25 per cent reduction is minuscule and meaningless. You’d have to treat hundreds of Maggies for years on end to hope to make a jot of positive difference to one of them, and the side effects from statins (we’re still discovering what these are) will far outweigh any putative benefit.

There are large numbers of people just like Maggie who are taking statins and who should come off the tablets. But what about individuals at greater risk – people with high blood pressure or obesity, or smokers? Is there a level of risk at which primary prevention is worthwhile? For some time the UK’s National Institute for Health and Clinical Excellence (NICE) has suggested a threshold of 20 per cent risk over ten years.

At first glance, the trial data does suggest a marginal impact at this sort of level: roughly two heart attacks/strokes are averted among 100 people treated for five years. But, crucially, death rates are not altered; no lives are saved by using statins. This probably reflects the harm also caused by statins, and how any small reduction in CVD is negated by disability and death from other causes.

Taking up regular exercise, or adopting a Mediterranean diet, reduces CVD risk by degrees comparable with statins – in the case of diet, substantially more so. If someone smokes, quitting is similarly helpful. What’s more, once one has adopted these lifestyle changes, statins become virtually redundant. Lifestyle modification is also cheap; there are very few harms besides. And, unlike with statins, these measures protect against other causes of death and disability, such as cancer and the frailties of advancing age. Oh, and they’re good for mental health, too.

This February, NICE initiated a consultation on halving its primary prevention threshold to 10 per cent risk. If achieved, this would add hugely to the six million people in the UK who take statins on prescription. Rather than exacerbate our statin fetish, NICE could design simple decision aids that would help doctors understand the more effective improvements that lifestyle changes can bring to health and well-being – and which would illustrate these benefits to patients.

Once we’d talked things through, Maggie resolved to start attending the university gym a few times a week. She decided to forget the statin prescription, too. As a nation, we’d do well to try the same. 

This article first appeared in the 26 February 2014 issue of the New Statesman, Scotland: a special issue

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Fark.com’s censorship story is a striking insight into Google’s unchecked power

The founder of the community-driven website claims its advertising revenue was cut off for five weeks.

When Microsoft launched its new search engine Bing in 2009, it wasted no time in trying to get the word out. By striking a deal with the producers of the American teen drama Gossip Girl, it made a range of beautiful characters utter the words “Bing it!” in a way that fell clumsily on the audience’s ears. By the early Noughties, “search it” had already been universally replaced by the words “Google it”, a phrase that had become so ubiquitous that anything else sounded odd.

A screenshot from Gossip Girl, via ildarabbit.wordpress.com

Like Hoover and Tupperware before it, Google’s brand name has now become a generic term.

Yet only recently have concerns about Google’s pervasiveness received mainstream attention. Last month, The Observer ran a story about Google’s auto-fill pulling up the suggested question of “Are Jews evil?” and giving hate speech prominence in the first page of search results. Within a day, Google had altered the autocomplete results.

Though the company’s response may seem promising, it is important to remember that Google isn’t just a search engine (Google’s parent company, Alphabet, has too many subdivisions to mention). Google AdSense is an online advertising service that allows many websites to profit from hosting advertisements on its pages, including the New Statesman itself. Yesterday, Drew Curtis, the founder of the internet news aggregator Fark.com, shared a story about his experiences with the service.

Under the headline “Google farked us over”, Curtis wrote:

“This past October we suffered a huge financial hit because Google mistakenly identified an image that was posted in our comments section over half a decade ago as an underage adult image – which is a felony by the way. Our ads were turned off for almost five weeks – completely and totally their mistake – and they refuse to make it right.”

The image was of a fully-clothed actress who was an adult at the time, yet Curtis claims Google flagged it because of “a small pedo bear logo” – a meme used to mock paedophiles online. More troubling than Google’s decision, however, is the difficulty that Curtis had contacting the company and resolving the issue, a process which he claims took five weeks. He wrote:

“During this five week period where our ads were shut off, every single interaction with Google Policy took between one to five days. One example: Google Policy told us they shut our ads off due to an image. Without telling us where it was. When I immediately responded and asked them where it was, the response took three more days.”

Curtis claims that other sites have had these issues but are too afraid of Google to speak out publicly. A Google spokesperson says: "We constantly review publishers for compliance with our AdSense policies and take action in the event of violations. If publishers want to appeal or learn more about actions taken with respect to their account, they can find information at the help centre here.”

Fark.com has lost revenue because of Google’s decision, according to Curtis, who sent out a plea for new subscribers to help it “get back on track”. It is easy to see how a smaller website could have been ruined in a similar scenario.


The offending image, via Fark

Google’s decision was not sinister, and it is obviously important that it tackles things that violate its policies. The lack of transparency around such decisions, and the difficulty getting in touch with Google, are troubling, however, as much of the media relies on the AdSense service to exist.

Even if Google doesn’t actively abuse this power, it is disturbing that it has the means by which to strangle any online publication, and worrying that smaller organisations can have problems getting in contact with it to solve any issues. In light of the recent news about Google's search results, the picture painted becomes more even troubling.

Update, 13/01/17:

Another Google spokesperson got in touch to provide the following statement: “We have an existing set of publisher policies that govern where Google ads may be placed in order to protect users from harmful, misleading or inappropriate content.  We enforce these policies vigorously, and taking action may include suspending ads on their site. Publishers can appeal these actions.”

Amelia Tait is a technology and digital culture writer at the New Statesman.