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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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Not just a one-quack mind: ducks are capable of abstract thought

Newborn ducklings can differentiate between objects that are the same and objects that are different, causing scientists to rethink the place of abstract thinking.

There’s a particular loftiness to abstract thought. British philosopher and leading Enlightenment thinker John Locke asserted that “brutes abstract not” – by which he meant anything which doesn’t fall under the supreme-all-mighty-greater-than-everything category of Homo sapiens was most probably unequipped to deal with the headiness and complexities of abstract thinking.

Intelligence parameters tail-ended by “bird-brained” or “Einstein” tend to place the ability to think in abstract ways at the Einstein end of the spectrum. However, in light of some recent research coming out of the University of Oxford, it seems that the cognitive abilities of our feathery counterparts have been underestimated.

In a study published in Science, led by Alex Kacelnik – a professor of behavioural psychology – a group of ducklings demonstrated the ability to think abstractly within hours of being hatched, distinguishing the concepts of “same” and “different” with success.

Young ducklings generally become accustomed to their mother’s features via a process called imprinting – a learning mechanism that helps them identify the individual traits of their mothers. Kacelnik said: “Adult female ducks look very similar to each other, so recognising one’s mother is very difficult. Ducklings see their mothers from different angles, distances, light conditions, etc, so their brains use every possible source of information to avoid errors, and abstracting some properties helps in this job.”

It’s this hypothesised abstracting of some properties that led Kacelnik to believe that there must be more going on with the ducklings beyond their imprinting of sensory inputs such as shapes, colours or sounds.

The ability to differentiate the same from the different has previously been used as means to reveal the brain’s capacity to deal with abstract properties, and has been shown in other birds and mammals, such as parrots, pigeons, bees and monkeys. For the most part, these animals were trained, given guidance on how to determine sameness and differences between objects.

What makes Kacelnik’s ducklings special then, as the research showed, was that they were given no training at all in learning the relations between objects which are the same and object which are different.

“Other animals can be trained to respond to abstract relations such as same or different, but not after a single exposure and without reinforcement,” said Kacelnik.

Along with his fellow researcher Antone Martinho III, Kacelnik hatched and domesticated mallard ducklings and then threw them straight into an experiment. The ducklings were presented pairs of objects – either identical or different in shape or colour – to see whether they could find links and relations between the pairs.

The initial pairs they were presented served as the imprinting ones; it would be the characteristics of these pairs which the ducklings would first learn. The initial pairs involved red cones and red cylinders which the ducklings were left to observe and assimilate into their minds for 25 minutes. They were then exposed to a range of different pairs of objects: red pyramid and red pyramid, red cylinder and red cube.

What Kacelnik and his research partner found was that the ducklings weren’t imprinting the individual features of the objects but the relations between them; it’s why of the 76 ducklings that were experimented with, 68 per cent tended to move towards the new pairs which were identical to the very first pairs they were exposed to.

Put simply, if they initially imprinted an identical pair of objects, they were more likely to favour a second pair of identical objects, but if they initially imprinted a pair of objects that were different, they would favour a second pair of differing objects similar to the first.

The results from the experiment seem to highlight a misunderstanding of the advanced nature of this type of conceptual thought process. As science journalist Ed Yong suggests, there could be, “different levels of abstract concepts, from simple ones that young birds can quickly learn after limited experience, to complex ones that adult birds can cope with”.

Though the research doesn’t in any way assume or point towards intelligence in ducklings to rival that of humans, it seems that the growth in scientific literature on the topic continues to refute the notions that human being as somehow superior. Kacelnik told me: “The last few decades of comparative cognition research have destroyed many claims about human uniqueness and this trend is likely to continue.”