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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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“WhatsApp isn't for parents”: how we contact all the different people in our lives

I wanted to find out how our digital hierarchies operate, so I asked people how they communicate with their family, friends, and colleagues. 

Recently, my family made an important decision. Too many conversations had petered out and decisions had been deferred because text messages had been going astray. Someone would end up calling someone else to talk for half an hour about how frustrating it was that they hadn’t replied to a question from three days ago, when all that was really required was a simple “Yes, see you there on Saturday”.

So, we became a WhatsApp-only family. It makes sense – we live on two different continents and travel quite a bit, and using the internet rather than cell service for sending text and pictures has already proved a lot more reliable. Still, though, when I need to tell my mum something and go to open the app, I can’t shake the feeling that it isn’t right. As far as I’m concerned, WhatsApp isn’t for parents; it’s for flatmates and groups of friends roughly the same age as me. It isn’t for your grandfather to pass on news of his latest Scrabble triumph.

This got me thinking – what is it about different methods of communication that make them feel appropriate to some people in our lives and not others? Why do I feel like text messages are inherently more “mum”, whereas Twitter DMs are really only for colleagues and creepy strangers? And does everyone have the same sense as I do? I’m a woman living in London in her late twenties and I work in the media: how does the hierarchy of digital communication methods look from other perspectives?

I designed a survey to try and find out. I asked respondents to select the means they use to communicate with people who occupy different roles in their lives, as well as for some basic personal information like where they live and how old they are.

I had hundreds of responses, from people of all ages and from all over the world (feedback came from places as far flung as Auckland, Puerto Rico and Kolkata). I think inevitably since I was promoting the survey via my own networks the respondents skewed to my own age group – 43 per cent were in the 22-30 bracket, but the second largest was 31-40 and the third was 51-60.

Nearly half of all respondents said that they would communicate with their mum and/or dad via phone call, while 47 per cent picked text message for siblings. The older the respondent, the more likely they were to pick phone call as the means of parental communication. Interestingly, for mums text messages came in a strong second (32 per cent), while with dads email and text tied on 24.7 per cent. The same goes for extended family – 44 per cent said they would call – but email came second on 35 per cent.

Facebook is the preferred means of communication for schoolfriends, at 52 per cent – something that was consistent across all age groups – whereas what I called “friends you’ve made as an adult” are mostly contacted via text message (56 per cent) or email (41 per cent). But there were some important distinctions made in the notes. One person commented: “When I have selected Facebook, I mean Facebook Messenger as a separate app on my phone and tablet rather than writing on their walls,” suggesting that there’s even greater nuance to how people are using the social network to stay in touch.

I’m unusual in using Twitter as a means of talking to colleagues, apparently: email came in at a whopping 70 per cent, followed distantly by text and phone call. Flat/housemates was a less conclusive spread, with 24 per cent using text messages, and 14 per cent apiece using WhatsApp and Facebook. Other messaging apps and systems that got frequently flagged for communicating with friends include: Telegram, Viber, Line, Instagram, Google Hangouts, iMessage and Skype chat. Interestingly, one person noted that “I haven't had a text from a person for months, now just a marketing channel for me”.

The majority of people still regard email as the most “official” means of digital communication, with twice as many people saying they would use it for their landlord as opposed to picking up the phone. And for the category I called “official, eg job application or complaint”, 92 per cent of respondents said they would use email.

Of course, there were lots of interactions that the survey couldn’t pick up – there were lots of comments of the kind that “I live with my mum and my partner, so it's mainly face to face”. What emerged as I was going through the data was that I am by no means alone in feeling that some methods of communication are more “appropriate” to people occupying particular roles in my life, but that we don’t agree on who goes with what.

There are myriad factors involved: when we first started using various apps and technologies; the age and tech literacy of both the person sending the message and the person receiving it; how we feel about privacy and security online; and much more besides. As technology has advanced, our means of communication have fragmented, and we’ve all gone in different directions. Somehow, it works.

That is, until my grandfather learns to use Snapchat – then all bets are off.

Caroline Crampton is web editor of the New Statesman.