Statins. Photo: Getty
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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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Why are online jokes funnier without punctuation and capital letters?

Academics and social media users weigh in on Twitter’s most unexplained phenomenon. 

The first person to notice it did so in 2010. “Sometimes I think a twitter joke is funnier if you omit punctuation,” tweeted @zacharylittle on 2 April. He was a pioneer. It took two years for anyone else to express the same thought, but they did so in droves. “I like not using punctuation like commas on twitter because its somehow funnier lol,” said @chxrliesheen, sans apostrophe. “I never use punctuation on twitter and tumblr I just think its funnier ok,” exclaimed @julieamarch. From then until now, people have been constantly questioning the phenomenon, but there are still no answers.

Why exactly are Twitter jokes funnier when they have grammatical errors, discard punctuation, lack capital letters, or are misspelled?

“There is a frisson, or sense of pleasure, from playfulness in language,” Dr Deborah Tannen, a professor of linguistics at Georgetown University, tells me over email – in which she demonstrates some of this playfulness herself. “writing wihtout caps, proper punctation, and leaving misspellings uncorrected also feels like private communication, like whispered kjokes, and therefore has the same potential thrill.”

Dr Hugh Rabagliati, a Chancellor's Fellow at the School of Philosophy, Psychology, and Language Sciences at the University of Edinburgh, warns me that most of his knowledge on the subject comes from “spending too much time on Twitter, rather than any obvious academic work”. It is true that research into the area is lacking – books about “internet language” get outdated quickly, and seem to focus on email and chatrooms, rather than more modern social media. “The misspellings [on Twitter] are often beautifully calibrated, like a very subtle malapropism, and the grammar errors are designed to make familiar material feel out of kilter,” he says.

Sometimes humour is found when grandiose sentiments are contrasted with train-wreck grammar, he argues, whereas other times the language can be exclusionary and people share it to prove they “get” the joke.

Perhaps the most famous Twitter user who has mastered the technique of the misspelled tweet is Jonathan Sun. Sun has gained 168,000 followers posing as an “aliebn confuesed abot humamn lamgauge”, and is part of what is known as “weird Twitter”, a subset of the site where humour is surreal and often bolstered by misspellings, a lack of punctuation, and grammatical errors. But while “weird Twitter” takes it to the extreme, many other arguably “normal” Twitter users will uncap the start of their Tweets or the word “I”.

“i’m not really sure why but i’ve been going out of my way to un-cap for ages,” one anonymous Twitter user told me via a direct message on the site. “i recognise that it is a stupid waste of time, ive had partners mock me for it.” Possibly, they theorise, they do this because they used to edit copy as part of their job. “it could be a reaction to that, to be completely armchair psychology about it.”

Naomi Baron, a professor of linguistics at American University and author of Words Onscreen: The Fate of Reading in a Digital World reinforces this point. She argues that language users are always looking for ways to distinguish their voices and express emotion. “A bevy of authors – from the poet e.e. cummings to social media scholar danah boyd – have further personalised their identity by eschewing the normal capitalisations in their names,” she says. “When it comes to social networking sites such as Twitter, lack of capital letters lends a tone of informality that makes the messages feel more speech-like.”

It’s hard to admit that you’re deliberately making mistakes in order to look offhand, as you are essentially revealing you try-very-hard-to-look-like-you’re-not-trying-at-all. But Rebecca Reid, a 25-year-old journalist, admits this is why she used to uncap her tweets. “Honestly I literally thought it made me look cooler,” she says. “I saw my sister doing it, and she's a couple of years younger and very trendy, so I thought it was just what we were doing. So I copied her. This is so tragic from me. And after a while I realised that it wasn't making me seem edgy, it was making it seem like the shift button on my key board was broken.”

It is true that informality is important in written messages, as a 2015 study revealed that ending text messages with a full stop was perceived to be insincere, most likely because it is seen as a sign of aggression. Twitter jokes that are written similarly formally – with full stops and capital letters – might also seem insincere, or be less inviting or inclusive than those with deliberate mistakes, run-on sentences, or five-too-many exclamation marks.

“There's also a phenomenon that linguists have only started discussing in the last decade, called ‘Eggcorns’,” says Rabagliati. “Here the speaker has learned a misanalysed locution. The phenomenon is named from the case of a woman who had, all her life, misheard the word acorn as ‘eggcorn’. ‘To all intensive purposes’ is a similar error. These mistakes play on our fear that our knowledge of language might not be as robust as we want to believe – think about all those words that you've read, but never heard aloud. Plus, the errors are fun because they demand some backwards reasoning to reconstruct.” 

More academic research is needed for a final answer on the phenomenon, but one thing is certain. If uncapitalising things on Twitter is cool, writing an 800-word article about it certainly isn't. 

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