The Wednesday Wellness threads are meant to encourage users to ask for and provide advice and motivation to improve their lives. It isn't intended as a 'containment thread' and any content which could go here could instead be posted in its own thread. You could post:
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Requests for advice and / or encouragement. On basically any topic and for any scale of problem.
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Updates to let us know how you are doing. This provides valuable feedback on past advice / encouragement and will hopefully make people feel a little more motivated to follow through. If you want to be reminded to post your update, see the post titled 'update reminders', below.
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Advice. This can be in response to a request for advice or just something that you think could be generally useful for many people here.
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Encouragement. Probably best directed at specific users, but if you feel like just encouraging people in general I don't think anyone is going to object. I don't think I really need to say this, but just to be clear; encouragement should have a generally positive tone and not shame people (if people feel that shame might be an effective tool for motivating people, please discuss this so we can form a group consensus on how to use it rather than just trying it).
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The Number Needed To Treat for statins is about 138. I would suspect that given standard monetary values of QALY and DALY in the West, it would be a net positive given how damn cheap drugs are.
As for eggs, I have more or less given up on attempting to understand nutritional science, there's hardly a more cursed and confounded field on the planet. But from what I'm aware of, eggs have swung from being unfairly maligned to being good for you.
Finances willing, I'd put very many people on GLP-1 agonists, so if granny could do with losing weight and not just cholesterol, that's my recommendation.
Statins being cheap should not be a factor for recommending them or not. It should be side effects vs what it improves and whether you can afford it should only come into consideration afterwards.
I pointed out that the benefits weakly outweighed the drawbacks, in terms of effect on diseases and side effects. After that, the relevant question is whether it's cost-effective.
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Cost should always be part of the "cost/benefit analysis".
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I believe her LDL is around 135.
Assuming they actually prolong life. My understanding is that "statin clinical trials have shown marginally significant benefits on mortality" at best over 5 years, and there's no good evidence they reduce long-term morality. That's why I came here to ask the question, I'm curious if there's newer or better evidence to support their effectiveness. If they don't work, then we're just risking side-effects for no gain.
I get that nutrition is hard to study, but do you really have no opinions about this topic as a doctor? Shouldn't lifestyle changes be the first line of treatment for this sort of thing? If you had to recommend the optimal diet to a patient with high cholesterol, what would it be?
I ask this because my mother is something of a health nut and will follow credible diet and lifestyle advice religiously. When her doctor told her to cut out red meat, butter, and eggs, she completely eliminated these things from her diet. If a doctor told her eating nothing but unseasoned boiled potatoes was the key to lower cholesterol, she'd eat nothing but unseasoned boiled potatoes. On the other hand, her doctor has not told her to avoid things like processed sugars or margarine, so she still eats plenty of that stuff.
So I'm interested in trying to set her up with the best evidence-based diet and lifestyle interventions possible. Since she is going to religiously follow some sort of diet program regardless, it may as well be the best possible program.
She is not at all overweight, goes on long hikes/jogs daily, skis, bikes, and is otherwise very physically active for a 70 year old.
Number Needed To Treat means you prescribe statins to 138 people and 1 person among them is expected to have positive effects. I am not a doctor but 135 LDL is pretty normal, you need to take statins for years before they statistically show improvement (lower cardiovascular events, for example), and there is no evidence for or against statins for people over 75, so doctors don’t usually recommend statins for people over 75.
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I haven't seen any studies recently that have made me update significantly. I do agree that the benefits from statins are marginal, which is why I pointed out that they're so cheap that it's not too much of a fuss to take them. For primary prevention, it's minimal, it's somewhat better for secondary prevention where an adverse cardiovascular event has already occurred.
The risks, however, are also rather small. So we have a class of drugs that doesn't do very much good, doesn't do very much harm, but on the margin seem slightly positive and don't cost much. I wouldn't go out of my way to recommend them, but I have no issue with prescribing them either.
Please keep in mind that I'm a psychiatry trainee haha. While dietary advice isn't out of my core practice, especially with diseases like bulemia or when some drugs cause weight gain, I genuinely think that overly obsessing over dietary intake beyond basic, Common Sense™ knowledge is of minimal utility.
If someone did ask me for dietary advice (and everything is from a do as I say, not as I do stance, don't look at what I eat), then I'd suggest making sure they're eating leafy greens, and avoiding large quantities of deep fried or smoked meats. I'm not going to tell them how many eggs to eat, or what brand of milk to drink. Even for the advice against highly processed meat, the carcinogenic risk is also tiny in absolute terms, so I wouldn't belabor the point.
I do this not because I enjoy being ignorant, but because nutritional science makes no sense. As long as your diet avoids any obvious nutritional deficits and you're getting vitamins and minerals, while keeping to a healthy weight I'd be fine with it.
More specific advice would be tailored towards people with particular diseases like diabetes, and for those with cholesterol issues, I'd stress weight loss more than any particular category of food.
(Mild exception, I think the evidence for ice cream being good for you is interesting, and unless you eat a bucket a day having more won't hurt)
She's doing better than me! I'd tell her to keep on keeping on really. While GLP-1As have some surprising benefits, with interesting evidence emerging of all kinds of surprising yet positive impacts, including reduction in Alzheimer's risks, I would at least recommend looking into them, though of course you'd need a doctor willing to prescribe them. But if she's otherwise doing well and her existing diet isn't grossly unhealthy, I'd say to not fix what isn't broken.
Thanks, I really appreciate you taking the time to share your thoughts.
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Is there a better formula besides just looking at LDL? Certainly HDL, Trigylcerides, and blood pressure would be relevant. Are there any downsides to statins?
I tried one of those cardiac risk score things, and it said my 10 year risk of a cardiac event was about 1.5%, below the 5% threshold in which statins would be advised. That didn't feel super comforting. I know people like Peter Attila recommend statins to most of their patients. But he also recommends aggressive prostate screening which has not been shown to increase life span, so he may have a harmful "do something" bias.
I wish I was better informed about cholesterol, but statins do have minor risks and side effects, such as muscle pain and outright muscle breakdown in rhabdomyolysis. It's rare, but hardly unheard of.
There's always been debate about the benefits of statins, but at least in the UK they're usually prescribed to middle aged people with cardiovascular risk factors, or the elderly who have had heart attacks or strokes as secondary prevention. You're right that aggressive screening of prostate cancer is a net negative, especially in the elderly.
I actually know a physician who ended up with this:
https://en.wikipedia.org/wiki/Statin-associated_autoimmune_myopathy
Huh. Never heard of this before, poor bastard.
There's def reasons we don't give everyone Statins and Metformin, but everyone always forgets lol.
I assumed the reason we don't give everyone metformin is because of the very memorable bathroom visits that it causes.
Metformin is seemingly more benign than statins (which have a bigger argument) but has a few significant drug interactions and a bunch of
hypothetical(read: hotly debated) kidney and Lactic Acidosis issues.Most otherwise safe medications have COVID vaccine problems - you give em to the entire population and weird shit starts happen. One in a million side effects happen hundreds of times.
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