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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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Forget fake news on Facebook – the real filter bubble is you

If people want to receive all their news from a single feed that reinforces their beliefs, there is little that can be done.

It’s Google that vaunts the absurdly optimistic motto “Don’t be evil”, but there are others of Silicon Valley’s techno-nabobs who have equally high-flown moral agendas. Step forward, Mark Zuckerberg of Facebook, who responded this week to the brouhaha surrounding his social media platform’s influence on the US presidential election thus: “We are all blessed to have the ability to make the world better, and we have the responsibility to do it. Let’s go work even harder.”

To which the only possible response – if you’re me – is: “No we aren’t, no we don’t, and I’m going back to my flowery bed to cultivate my garden of inanition.” I mean, where does this guy get off? It’s estimated that a single message from Facebook caused about 340,000 extra voters to pitch up at the polls for the 2010 US congressional elections – while the tech giant actually performed an “experiment”: showing either positive or negative news stories to hundreds of thousands of their members, and so rendering them happier or sadder.

In the past, Facebook employees curating the site’s “trending news” section were apparently told to squash stories that right-wingers might “like”, but in the run-up to the US election the brakes came off and all sorts of fraudulent clickbait was fed to the denizens of the virtual underworld, much – but not all of it – generated by spurious alt-right “news sites”.

Why? Because Facebook doesn’t view itself as a conventional news provider and has no rubric for fact-checking its news content: it can take up to 13 hours for stories about Hillary Clinton eating babies barbecued for her by Barack Obama to be taken down – and in that time Christ knows how many people will have not only given them credence, but also liked or shared them, so passing on the contagion. The result has been something digital analysts describe as a “filter bubble”, a sort of virtual helmet that drops down over your head and ensures that you receive only the sort of news you’re already fit to be imprinted with. Back in the days when everyone read the print edition of the New York Times this sort of manipulation was, it is argued, quite impossible; after all, the US media historically made a fetish of fact-checking, an editorial process that is pretty much unknown in our own press. Why, I’ve published short stories in American magazines and newspapers and had fact-checkers call me up to confirm the veracity of my flights of fancy. No, really.

In psychology, the process by which any given individual colludes in the creation of a personalised “filter bubble” is known as confirmation bias: we’re more inclined to believe the sort of things that validate what we want to believe – and by extension, surely, these are likely to be the sorts of beliefs we want to share with others. It seems to me that the big social media sites, while perhaps blowing up more and bigger filter bubbles, can scarcely be blamed for the confirmation bias. Nor – as yet – have they wreaked the sort of destruction on the world that has burst from the filter bubble known as “Western civilisation” – one that was blown into being by the New York Times, the BBC and all sorts of highly respected media outlets over many decades.

Societies that are both dominant and in the ascendant always imagine their belief systems and the values they enshrine are the best ones. You have only to switch on the radio and hear our politicians blithering on about how they’re going to get both bloodthirsty sides in the Syrian Civil War to behave like pacifist vegetarians in order to see the confirmation bias hard at work.

The Western belief – which has its roots in imperialism, but has bodied forth in the form of liberal humanism – that all is for the best in the world best described by the New York Times’s fact-checkers, is also a sort of filter bubble, haloing almost all of us in its shiny and translucent truth.

Religion? Obviously a good-news feed that many billions of the credulous rely on entirely. Science? Possibly the biggest filter bubble there is in the universe, and one that – if you believe Stephen Hawking – has been inflating since shortly before the Big Bang. After all, any scientific theory is just that: a series of observable (and potentially repeatable) regularities, a bubble of consistency we wander around in, perfectly at ease despite its obvious vulnerability to those little pricks, the unforeseen and the contingent. Let’s face it, what lies behind most people’s beliefs is not facts, but prejudices, and all this carping about algorithms is really the howling of a liberal elite whose own filter bubble has indeed been popped.

A television producer I know once joked that she was considering pitching a reality show to the networks to be called Daily Mail Hate Island. The conceit was that a group of ordinary Britons would be marooned on a desert island where the only news they’d have of the outside world would come in the form of the Daily Mail; viewers would find themselves riveted by watching these benighted folk descend into the barbarism of bigotry as they absorbed ever more factitious twaddle. But as I pointed out to this media innovator, we’re already marooned on Daily Mail Hate Island: it’s called Britain.

If people want to receive all their news from a single feed that constantly and consistently reinforces their beliefs, what are you going to do about it? The current argument is that Facebook’s algorithms reinforce political polarisation, but does anyone really believe better editing on the site will return our troubled present to some prelap­sarian past, let alone carry us forward into a brave new factual future? No, we’re all condemned to collude in the inflation of our own filter bubbles unless we actively seek to challenge every piece of received information, theory, or opinion. And what an exhausting business that would be . . . without the internet.

Will Self is an author and journalist. His books include Umbrella, Shark, The Book of Dave and The Butt. He writes the Madness of Crowds and Real Meals columns for the New Statesman.

This article first appeared in the 24 November 2016 issue of the New Statesman, Blair: out of exile