Archive for the “Bad Medicine” Category

I’ll turn 59 in November. That means in just 15 months, I should start taking a statin. That’s the conclusion of a new study reported in the U.K. Independent online:

Almost every older person should be taking statins, a new study has found. Almost all men over 60 and women over 75 should be taking the drugs, the research found. And more than a third of people between 30 and 84 should be allowed to do so.

Sure, let’s put all older people on statins. Society would really benefit by having more older folks with memory problems and damaged muscles.

The sweeping findings could suggest that GPs will be asked to prescribe the drugs to the majority of their patients, leading to huge strain on doctors.

That was, of course, my first concern as well. Oh my goodness! If we start giving statins to all older people, won’t that be a strain on doctors?!

The research looked to investigate the effects of guidance that was set by the National Institute of Health and Care Excellence (Nice) in 2014. That controversial ruling allowed many more people to receive statin therapy on the NHS, since it suggested that anyone with cardiovascular disease should be given the drug, and anyone with a more than 10 per cent chance of developing it in the next 10 years should take it too.

The latest study, published in the British Journal of General Practice, examined the algorithm endorsed by Nice for the assessment of CVD risk and compared it to data from the 2011 Health Survey for England to estimate the number of people who are eligible for statin therapy under the guidance.

Let me explain how that algorithm works: if you’re a male older than 60 or a woman older than 75 and still have a pulse, statistics say there’s a decent chance you may have a heart attack at some point in the future, so the algorithm says you should be on statins. The actual health of your heart doesn’t figure into it much.

Last month, I admitted that I’m a member of the anti-statin cult that Dr. Steve Nissen (America’s Statinator-In-Chief) blames for scaring people away from these wunnerful, wunnerful, life-saving drugs. So you won’t be surprised that I’m under orders from the cult leaders to explain why guidelines that would put nearly all older people on statins are complete nonsense. (I’m also under orders to smack myself in the head with my t-post hammer if the post doesn’t draw at least a thousand views, but I’m negotiating on that one.)

Advertisements for statins throw out impressive-sounding claims, such as reduces the risk of heart attack by 33 percent! If you didn’t know any better, you’d think a third of the people taking statins are saving themselves from a heart attack.

But of course, that’s not the case. That figure is derived from results like this: in a statin trial lasting some number of years, two of every 100 patients with known heart disease who took the statins had a heart attack, while three of every 100 patients with known heart disease who took a placebo had a heart attack. Two is one-third less than three, so the relative reduction is 33 percent.

But in absolute terms, it means for every 100 patients who took the drug, one was saved from a heart attack. So the number needed to treat (NNT) is 100. That’s the figure that matters.

There’s a site called The NNT that provides exactly those kinds of figures. Here’s what it says on the home page:

We are a group of physicians that have developed a framework and rating system to evaluate therapies based on their patient-important benefits and harms as well as a system to evaluate diagnostics by patient sign, symptom, lab test or study.

We only use the highest quality, evidence-based studies (frequently, but not always Cochrane Reviews), and we accept no outside funding or advertisements.

The b.s. guidelines suggested by the new study say almost everyone over a certain age should be on statins, whether they actually have heart disease or not. Here’s what The NNT tells us about statin trials conducted on people who don’t already have heart disease:

Benefits:
None were helped (life saved)
1 in 104 were helped (preventing heart attack)

Compare the statin groups to the placebo groups, and the combined results say not a single death was prevented by the statins. The statins prevented an average of one non-fatal heart attack for every 104 people who took them for five years.

Wowzers. Doesn’t that make you want to run out and fill that statin prescription as soon as you turn 60?

But wait, let’s not forget to look at the other side of the equation:

Harms:
1 in 50 were harmed (develop diabetes)
1 in 10 were harmed (muscle damage)

And keep in mind, these figures are mostly from studies published by the makers of statin drugs. In other words, they’re the most positive studies. We don’t know how many studies conducted by Big Pharma were simply dumped because the results were less-than-positive. Here’s what the gang at The NNT says on the subject:

Virtually all of the major statin studies were paid for and conducted by their respective pharmaceutical company. A long history of misrepresentation of data and occasionally fraudulent reporting of data suggests that these results are often much more optimistic than subsequent data produced by researchers and parties that do not have a financial stake in the results.

The combined results of these mostly-positive studies say 10% of the people on statins suffered muscle damage. I’ll bet you dollars to donuts (and you can keep the donuts) the figure in the real world is much higher. When Big Pharma conducts these studies, they screen out patients who report side effects from other drugs. So the population that goes into the study is less likely to experience side effects than the population at large.

But what the heck, let’s suppose the figure is actually the 10% reported in the studies instead of the 25% or greater I suspect we’d find in the real world. And let’s suppose you’re a man 60 or older, or a woman 75 or older, with no previous heart attacks or known heart disease. Let’s put you in a group of 100 of your peers and give you all statins. Here’s what would happen, according to the most positive data Big Pharma can produce:

  • One of you will be prevented from having a non-fatal heart attack, but none of you will be prevented from actually dying. (And preventing the one non-fatal heart attack will likely only apply to the men.)
  • Two or more of you will develop diabetes you wouldn’t otherwise have had (which increases the odds of heart disease or stroke down the line).
  • Ten or more of you will end up with damaged muscles, thus seriously reducing your quality of life.

I think we should ignore this latest edition of the Statins For Everyone! guidelines.

At least that’s what the cult leaders told me to say.

 

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Hi Fatheads,

I told Tom I thought I felt another blog coming on, and he was happy to have the chance to spend the rest of the week putting the finishing touches on the final version of the Fat Head Kids DVD. So I get to stay in The Big Chair this week, too!

Think of it like this — your loss is his gain!

Feel better?

As always, I appreciated the comments people took time to write on my last couple of posts. Also, as always, I especially tend to appreciate the ones from people who don’t necessarily share my perspective. Everyone seems thoughtful and articulate. The international group we get showing up here still amazes me – this time while in The Big Chair, I got comments from Germany, Singapore, and New Zealand! The comment from our Kiwi friend, “S,” accidentally hit one of my triggers (hey, I’m a sensitive guy, ok?):

“…I’m not saying I support Obamacare… But perhaps the US should start thinking about *evidence based* health-care policies. There’s plenty of evidence out there if one is willing to look…”

Arrrrgh.

Yeah, Obamacare doesn’t rattle me much, but I tend to have a visceral reaction whenever I hear the phrase “evidence-based.”

First of all, it gets some contempt just because it’s soooo overused. It’s one of those phrases that everyone seems to feel sounded cool when they first heard it, then started sneaking in anywhere they can.

Like right after Newt Gingrich lead the Republicans to take control of the House. You couldn’t have a conversation with a lobbyist without them saying “I would submit that….(blah, blah, blah).”

Another was as IT was sweeping the economy in the late 90’s as everyone decided they needed to computerize and network all of their systems at once, and the Project Management field got flooded with sharp, young, eager, confident consultants who probably still had to have their parents drop them off at work. If you were in a meeting and asked a question the consultant deemed not relevant to the whole group (meaning they had no idea what the answer was), they’d say “let’s take that off-line.” I heard a corporate type use it three times in a one hour presentation. To cob one of Tom’s lines — Head. Bang. On. Desk.

But those kinds of affectations are just irritating. Then there are the kind of things you hear all the time that are designed to mislead, usually repeated incessantly by people who have no idea what they’re saying.

One example Fat Head types have probably heard often (usually by some 10% body fat “expert” in Spandex) is “you need carbs because they’re your body’s main source of fuel!”

I always considered this a trifecta — it’s a misstatement of an intentionally misleading fact that’s also false. Tom and others have covered this one over the years, but it still comes up. The misstatement is that the correct term is “primary,” which denotes order (primary, secondary, tertiary, etc) – not “main,” as in quality. The correct statement is designed to mislead the uninformed to interpret it as the misstated version. And it’s false – your body will burn alcohol preferentially over carbs, because too much blood alcohol will kill you faster than too much blood sugar.

“Evidence-based” is all the way in this category, and then some.

It sounds appealing. It sounds like science, only with maybe a bit more rigor built in, doesn’t it? Like hey, this isn’t just theory – we’ve also got evidence! It also is cursed with an origin in good intentions. “Evidence-based medicine” is the root, which proposed that physicians incorporate clinical results in their decisions instead of just going by their particular beliefs and experience.

We all know how the “clinical studies” thing worked out, now that Big Pharma owns the medical schools, clinical study industry, and most of the professional journals, right? “Hey, statins reduce heart attacks by a third! Don’t take our word for it – here’s a clinical study — it’s ‘evidence-based!’ 

That kind of success was duly noted by the rest of the groups that regularly line up at the trough. You can’t read a letter to the editor these days without whoever is begging for more of other people’s money citing “evidence-based” research. There’s evidence-based school funding, evidence-based juvenile justice reform, evidence-based climate science, evidence-based management, etc., etc.

Makes one wonder, for example, what they’ve been going by in Illinois for the last decade or so, where we keep pouring $35-40 billion dollars a year into the public schools. “Spitballing it-based” funding, perhaps?

There’s more, of course. I kind of think the icing on the cake is — wait for it…

“Evidence-Based Dietetics Practice” (!)

…brought to you by the Academy of Nutrition and Dietetics. Yeah, the same turds who’ve been pushing the Soda-, Grain-, Candy-, and Pharma-sponsored “arterycloggingsaturatedfat, hearthealthywholegrains, calories-in/calories-out” program for decades. That’s “evidence-based” now, too.

What all these advocates seem to have in common is that people are catching on to them. As I replied when another commenter (Brandon), while finding the plethora of “evidence-based education” initiatives laughable, thought perhaps it was a hopeful improvement:

“Evidence-based” is strictly a rhetorical (or perhaps more accurately — “marketing”) device. It’s used by people who’ve already been wrong so many times that even they realize people are onto them. It’s a term invented to give the impression there is something like science involved … when it’s the exact opposite of science. 

Collecting evidence (even done objectively, with no intention of isolating results that support a preferred outcome) and then developing recommendations based on interpretations of that data is not science. Its old (discredited) name was Observational Study.

Science is when you take that collected data, form a question, design a disprovable hypothesis, test the bejeesus out of it, then if you can’t disprove it, send it out to see if other people can replicate the results. No one using the term “evidence-based” has any interest in that kind of activity, although they desperately want whoever they’re lobbying to think of it as scientific.

Teachers’ unions use “evidence-based.”  Bureaucrats use “evidence-based.” Lobbyists use “evidence-based.”  Politicians use “evidence-based.”

Galileo didn’t use “evidence-based.” Newton didn’t use “evidence-based.” Einstein didn’t use “evidence-based.” They used “science.”

My suggestion is to adopt a mental habit of whenever you hear or see the phrase “evidence-based,” you automatically substitute “circumstantial evidence-based,” “cherry-picked evidence-based,” or “evidence- instead of science-based” before processing the rest of whatever statement a person has issued.

I believe you’ll find that the reconfigured statement will be much more understandable, both in integrity and intent.

Tell all your friends.

Cheers!

The Older Brother

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Greetings Fat Heads!

Well, still here. Hope you had a great Memorial Day weekend. Special thanks to all vets and their families. Tom and family are back from the 2017 Low Carb Cruise, happily exhausted. I’m looking forward to getting the full report. I told him if he wanted to wait until next week, I’d fill in Thursday with an “evidence-based” rant.

Anyway, when I left off at the last post, Jimmy Kimmel’s son was doing great and I was in a bad mood. Not about Mr. Kimmel’s son of course. That was the wonderful part. The level of care we have available in this time and in this country is beyond the imagination of what was available to the richest people and kings even a few decades ago.

I wasn’t even particularly stirred up over Mr. Kimmel’s making the availability of the miraculous procedure that saved his son somehow tied in with keeping Obamacare intact. Between being a dad just past a major health scare and living in La La Land among the economically illiterate (seldom right, but never in doubt) I’m okay with him calling it any way he wants. I put it in there with the “all brides and babies are beautiful” protocol. It accomplishes nothing to argue, and it’s just plain rude.

The rest of the Idiocracy, however, deserves no so respect. Instead of politely giving Jimmy’s emotional description props and then moving on, they treated his completely sincere and completely uninformed comments on insurance and Obamacare as the Magnum Opus of the health care debate.

At any rate, I stated toward the end “It’s not like we don’t have major issues with the health care system in the good old U.S. of A. But the issues are with the availability of dollars, not doctors, …”

There are issues with dollars. As I mentioned, I was aware of Kimmel’s son’s condition because The Oldest Grandson had the same thing – and the same miraculous treatment – when he was born just about ten years ago (yes—before Obamacare).

His mom, my daughter-in-law, pointed out that back then just his hospital tab was over $300,000, which would break anyone without insurance, not to mention that he’s facing at least two more surgeries. Under insurance as it mostly existed prior to the current debacle, there could be real issues with lifetime spending caps and him trying to get health insurance as an adult with that type of pre-existing condition.

To paraphrase an old politician, $300,000 here, $300,000 there – pretty soon you’re talking real money! Definitely a dollars issue.

So what’s a libertarian to do? Is there a solution other than “I’m sorry, Mr. Kimmel, there’s nothing we can do?” That’s what you would hear in most of those countries where it’s “free.” Don’t we want to save babies in this country? Wouldn’t it be nice to be able to do that and not go broke? How can we do that today, and still be able for that kid to afford reasonable health care later?

Fortuitously, Dr. William Davis’ new book – “Undoctored” came out just recently, and Tom did a book review.

[Confession time – I don’t read Tom’s book reviews any more. When I see he’s written one, I just save myself the time and buy the damned book.]

Now, if you want a great book on the disastrous macro-economics of our health care system, and policy proposals to address insurance and health system availability at a national level, don’t buy this book. That’s totally not what it’s about.

What it is about is you getting control of your health, which Dr. Davis reiterates throughout is not particularly connected to medical care. In fact, unless you get yourself informed and proactive, medical care can often be inversely related to your health. Although he doesn’t do a deep dive on the economic history of the health care system, he does do a great job illuminating how the money and incentives in the current system don’t line up with attaining real health as an individual. Then you’re off on a terrific primer in how to evaluate, improve, and monitor your health, in conjunction with health care professionals who will work with you and at your direction when needed.

Seriously, buy the book.

Okay, so how’s that tie in with the subject at hand? Well, the idea that the medical industry is more responsive to money than patient outcomes was nothing new to me – or probably any Fat Head, really. “Have a $tatin with that hearthealthywholegrain muffin” vs. “have the bacon and eggs and take a walk,” right? So, I was already on board with the concept.

Right in the introduction to “Undoctored,” Dr. Davis noted that we spend (endlessly pointed out with delight by the single-payer cheerleaders) over $3 trillion dollars a year – 17% of our GDP — on health care. Which I also already knew.  But this time when I read it I’d been thinking about Kimmel’s performance, and my daughter-in-law’s point, and then pretty close in to the beginning of the book Davis points out that:

“The system is ready and willing to commit you to a life of taking drugs and injectable insulin for diabetes, … providing “education” designed by people who put commercial interests first, while no one provides the handful of inexpensive health strategies that have been shown to reduce, even fully reverse, type 2 diabetes.”

Once again, nothing I didn’t already know, but it kind of all came together at that point and I thought, “well, just how the hell much do we spend on all of this crap?!?”

So I looked it up.

I tend to do that. I just stopped reading and went Googling for info on how much money we spend on the various medical substitutes for good habits. I’d like to think it’s due to my insatiable inquisitiveness when I’ve got an intellectual conundrum, but it’s probably just ADD.

I struck gold fairly quickly when I found a JAMA paper from 2016 titled “US Spending on Personal Health Care and Public Health, 1996-2013.” They collected seven years of data from 183 sources and sorted them into 155 conditions. The numbers, which, once again, we’ve probably all heard at different times, are stunning when you look at the whole picture.

The total spending for 2013 – the last year in the study – was $2.1 trillion. The estimate for 2014 was $2.9 trillion, so Dr. Davis’ $3 trillion seems to line up well with the reports info, and it would be safe to assume that the numbers I’ve got increased proportionately.  So, pretty much every number I’ve got has likely gone up by 50%. But here are some of the things we see:

Right off the bat, “diabetes had the highest health care spending in 2013, with an estimated $101.4 billion in spending, including 57.6% spent on pharmaceuticals…”

Keep in mind, that’s more like $150 billion today. One hundred and fifty billion dollars. A year. For a “disease” that’s easily 90% treatable by just stepping away from carbs.

Heart disease – the one that Dr. Davis put himself out of business from treating by getting people to change their lifestyles vs. post factum medical treatment — was $88.1 billion, so I’m calling it $130 billion.  I’m not saying no one would ever have a heart attack if we all stopped cooking with vegetable oil and started taking an evening walk, but it wouldn’t be an industry that by itself would rank in the top quarter of the rest of the world’s GDP’s.

Plus, that $130 billion does NOT include treatment for hyperlipidemia (i.e., statins) which earns itself $52 billion ($75B?) all by itself, or high blood pressure.

Here’s some other big ticket items, almost all of which the case studies of folks in “Undoctored” either completely reversed or substantially improved – often within weeks – of making the simple changes that Dr. Davis promotes:

Blood Pressure:  $84 Billion

Back & neck pain (think largely obesity and sedentary lifestyle related, so I’m counting it): $88 Billion

Depression (think mood disorders and gut biome dysbiosis. Not considered are other “mental” health issues – ADD, bipolar, etc): $70 Billion

Dental (tooth decay, inflammation): $66 Billion

Skin conditions: $55 Billion

Alzheimers and other dementias (i.e., Type III diabetes): $36.7 Billion

The 2013 numbers for all of those come up to about $469 Billion, which scales up to over $700 Billion in today’s spending. Mostly avoidable by straightforward, understandable lifestyle modification.

Like I said, some people will still have heart attacks, or pull a back muscle, or get depressed and need some help so you don’t have a 100% savings on the table; but the largest part of these diseases are self-inflicted and self-treatable.

I also left out other categories (Osteoarthritis – $47.9B; Asthma – $32.5B; Endocrine, metabolic, and immune disorders – $19.6B; and cancers, which were disaggregated into 29 separate conditions); so there’s some pickup available from the same lifestyle changes in areas I’m not counting. The point is that nearly one quarter of our health care spending is going to conditions that we have the capability of exerting a large degree of control over. Quickly.

Preterm birth complications, BTW, ranked 73rd at just under $5 Billion, so it seems like if we could get a handle on our grain and industrial foods habit, Jimmy Kimmel’s son and my grandson shouldn’t cause too much financial discomfort to the system.

After thinking about this, I had an epiphany.

I know Tom and many others, including myself, have compared the various and sundry mandatory coverages — dictated via Obamacare and other legislated and regulatory bodies — to requiring your auto insurance provider to include free oil changes, tire rotation, tune-ups, etc.  in your policy. The point being that these are known conditions that are a routine part of automobile ownership. Inclusion in a policy would only increase overhead and incentivize over-utilization, resulting in inevitable, recurring premium increases.

We completely misrepresented the argument. It’s correct as far as it goes, but it stops so short of reality that I count it as a huge error.

Our entire medical cost reimbursement system, as currently comprised, is like requiring that all auto insurance companies include DUI coverage in your policy.

It was stupid that my health insurance covered the two or three doctor office visits for the ear infections we knew The Sons were each going to get each year when they were toddlers. Same for the bottle of pick stuff we’d pick up at the pharmacy after each visit.

But it’s insane that insurance would pay for insulin for the 90% of people who could avoid the pharmacy if they’d stop blasting their system with sugar in all its forms. Same with all those other diseases of civilization driving a quarter of our spending. We’re making it convenient and cheaper for people to engage in behavior that’s harming them.

Add in the USDA budget with its massive grain subsidies and the SNAP (food stamp) program, and it’s like after adding the DUI coverage, we then pass out free booze to the people with the worst driving records.

So what about this — I say we should remove mandated coverage of all of those lifestyle diseases – Type II diabetes, blood pressure, non-emergency heart disease treatment, etc.

Companies would be free to make them available, but they’d be add-on items to a base policy and they’d also be rateable. I’m not interested in preventing someone from purchasing diabetes “treatment” coverage with their insurance, but I don’t want to be forced to “chip in.”

Rateable means they could adjust the premium, for example, based on a periodic A1C, fasting insulin, or some other marker to account for the risk and behavior of the policy owner. Behavior instantly gets coupled to economic consequences.

So people could pay higher premiums for diabetes treatment coverage, pay out of their own pocket for drugs and medical attention, or eat more veggies and fat and cut back on the sugar. I predict immediate, dramatic changes.

I don’t see why we couldn’t reduce medical spending by half a trillion dollars, plus another $100 billion a year by driving a stake through the USDA’s heart.  Putting money aside for just a moment, can you begin to imagine the quality of life improvements people would get?

Of course, I do see why we can’t. Politics. Money. Bureaucracy. Power. The usual suspects. But that doesn’t mean it’s not technically possible or the right thing to do.

It also doesn’t mean that you can’t get started, or step up your game so that you can limit your interaction with the medical system as much as possible. Just because you have to sacrifice them your money doesn’t mean you have to sacrifice your health, too!

Cheers,

The Older Brother

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Hey Fat Heads! Long time.

Tom’s still off on the Low Carb Cruise, so I get to staff the Big Chair for a bit. Folks on the cruise are going to get to see the almost final cut of the Fat Head Kids DVD. Tom, being Tom, in order to avoid disaster (long time Fat Heads may recall there was an audio issue on one of the first cruises), took a copy on his laptop, a DVD, a backup drive, an extra laptop, and an extra projector. Just in case. He’s also left copies at home, and at the in-laws, just in case the ship sinks and his house burns down at the same time. I asked him if the odds weren’t pretty astronomical on that kind of coincidence, and all he said was

“Three words: President. Donald. Trump.”

That pretty much took care of that argument.

I meant to post last week, but, in addition to a flooded basement (again) and a mouse-infested camper to deal with, I also officially passed into old age last Tuesday. The Big Six-Oh. Doesn’t actually feel any worse than the day before, to tell you the truth. Tom called to rub it in a bit under pretense of “Happy Birthday” wishes, and we agreed that hitting a calendar date really never had much psychological impact.

Over the years, I’ve only had a couple of those “OMG, I’m getting OLD” moments. The first was a couple of months past forty — which I’d pretty much shrugged off – when the friend who’d been cutting my hair for the previous ten years or so was finishing up and nonchalantly went for my face with the scissors, explaining “I’m just going to trim those eyebrows up.” I was thunderstruck – “holy crap, my eyebrows have forgotten which direction to grow!”

The next time was a few years later. The same friend had just finished my hair (okay, and eyebrows) and then — just as casual as can be — shifted to my side and said “let’s get those ear hairs taken care of.” Fortunately for my self esteem, she retired shortly thereafter, and I was able to find a new barber with bad eyesight.

Anyway, on account of the milestone, I thought I’d give myself a present and commandeer the Big Chair and talk a little about health care and piss everyone off.

You were warned.

The source of my most current irritation wasn’t at the health care system, per se, but at some really good news. The good news being the amazing story of Jimmy Kimmel’s son. The boy was born late last month (April), and Kimmel did an emotional monologue on returning to his show on how the baby was rushed into surgery immediately after birth with the deadliest version of a rare heart condition. During the monologue, as he described the procedure he said the surgeon “did some kind of magic I can’t even begin to explain…”

And then kind of turned the whole experience into a morality tale on why we need to keep Obamacare, only bigger.

I don’t have a problem with Kimmel projecting his personal experience onto a larger issue that I’m sure he’s not particularly well-informed on. I do have a problem with how the media instantly elevated Jimmy to the status of Economic Savant, and I find it sadly not surprising that politicians on both (wrong) sides of the issue felt compelled to rush for a camera and pontificate as if this was some new large issue that hadn’t been debated.

As it turns out, I’m actually familiar with the condition and can also explain the “magic” to Mr. Kimmel.  The condition is called a Tetralogy of Fallot with pulmonary atresia, where there’s a blocked valve with a hole in the baby’s heart. It requires immediate surgery, with a couple of more “upgrade” heart surgeries as the child grows, because the replacement valves don’t grow along with the child.

See, the Oldest Grandson — the one we lucked into when the Middle Son got married last year – was born with the exact same thing. He’s nine now, so it turns out that treatment was available before Obamacare. Within a couple of hours of being born, he was whisked via helicopter from Springfield — where we have pretty damned good neonatal hospital departments – to Saint Louis, MO, ninety miles away where they had specialized facilities and pediatric cardiologists.

The actual Magic — the reason Jimmy Kimmel’s son and my grandson are alive – is called “the Market.” You see, if Jimmy and his wife, despite the blessings of wealth his talent and hard work have brought him, had been in Canada (the current darling of the “free” health care advocates) I suspect it would’ve been a much darker monologue.

Not necessarily, of course. They might’ve been lucky enough to have their baby in a city with one of the seven pediatric cardiology units within Canada’s 3.8 million square miles of land mass. There are 122 in the continental U.S., despite having 20% less area (3.1M). Caring, forward-thinking Canada has 81 Pediatric Cardiologists. Here in health care’s evil empire, we’ve got 2087 on tap.

And I do mean in a city. Ninety miles away doesn’t get it in Canada, like it works here. If you don’t believe me, ask Liam Neeson. In case you don’t recall, his wife died because it took over three hours to transport her 77 miles by ambulance as helicopters weren’t available where she was injured. But hey, what are the odds of needing an airlift for emergency medical care at a ski resort, right?

[Another helicopter story – several years ago, my brother-in-law’s niece was critically injured in an early morning slippery roads/tree vs. car accident on her way to school. This was in very rural North Carolina. They got a helicopter shortly after the accident was discovered. She flat-lined three times in the air, but she pulled through.]

It’s not like we don’t have major issues with the health care system in the good old U.S. of A. But the issues are with the availability of dollars, not doctors, and Obamacare makes both worse, not better. And Jimmy Kimmel is a terrific entertainer and wonderful human being and I am truly overjoyed at his good fortune, but he’s not a very good economist. Better than Paul Krugman. But not very good.

I’m going to address those dollars next, and my thoughts on that happen to dovetail nicely with Dr. William Davis’ book that Tom just reviewed. If you haven’t got your own copy yet, you’re missing a really good read that can do more to improve your health than any elected official can possibly do for you.

Cheers,

The Older Brother

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As you’ve probably heard, there was quite a stir across the pond last month when two British medical journals got into a verbal war over statins.  Hostilities began when The Lancet published a study claiming that by gosh, statins are indeed wunnerful, wunnerful drugs  — which means that people who raise doubts about them are killing babies and should perhaps be silenced.

No wait, let me check my notes … okay, slight correction:  The Lancet suggested that statin skeptics are killing adults, not babies.  Sorry for the confusion, but when The Anointed trot out the “we must shut you up because your skeptical opinions could kill the planet—er, we mean people” line, I sometimes get brain-lock.

Anyway, The Lancet specifically warned that those who question the effectiveness and safety of statins might be killing adults with heart-disease risk factors (defined in such a way as to include almost every adult with a pulse) by scaring them away from statins.

Here are some quotes from a U.K. Guardian article that appeared after The Lancet published its pro-statin study:

Statins to lower cholesterol prevent 80,000 heart attacks and strokes every year in the UK, far outweighing the harm from rare side-effects, according to a review of the evidence which aims to put a heated controversy to rest and reassure the public that statins are safe.

The review is published by the Lancet medical journal, whose editor, Richard Horton, likened the harm done to public confidence by the critics of statins to that caused by the paper his journal published on the MMR (measles, mumps and rubella) vaccine in 1998.

“Controversy over the safety and efficacy of statins has harmed the health of potentially thousands of people in the UK,” he wrote in a comment published with the review. In six months after the publication of “disputed research and tendentious opinion” on the side-effects of statins in 2013, a study estimated that over 200,000 patients stopped taking a statin. It predicted there would be 2,000 extra heart attacks and strokes over the next decade as a result.

“Disputed research and tendentious opinion” means there are scientists and doctors out there who – egads! – dared to examine the research and conclude that The Anointed are wrong.  Worse yet, those researchers have managed to catch the ear of the public through books, blog posts, documentaries and even some articles in major media outlets.

The Anointed don’t take kindly to being questioned, which is why The Lancet’s editorial included this gem:

Some research papers are more high risk to public health than others. Those papers deserve extra vigilance. They should be subjected to rigorous and extensive challenge during peer review. The risk of publication should be explicitly discussed and evaluated. If publication is agreed, it should be managed with exquisite care.

Let me interpret that gobbledygook:  Research papers that suggest We The Anointed are wrong should be squashed – for the sake of public health, of course.  We can’t have the little people doubting us.

What we’re seeing here is a ramping up of the Save The Statins Campaign – which is very much like the Save The Grains campaign.  Both are a reaction to the fact that people are deciding those wunnerful, wunnerful products they’ve been told to consume might not be so wunnerful after all – a result of the Wisdom of Crowds effect, which actually is wunnerful.  The Anointed are fighting back with articles that say, in effect, “Damnit, people!  Those negative effects you think you’re experiencing are all in your tiny little heads!  Stop listening to people who disagree with us!  We’re The Anointed, and we know what’s best for you!”

The British Medical Journal has been critical of the statins-for-everyone position taken by The Lancet.  So after The Lancet slammed the critics of statins, the British Medical Journal chimed in to slam The Lancet. This is almost as much fun as a good football game.  (I’m talking about the kind of football where wide receivers make acrobatic catches, running backs collide with linebackers and touchdowns are scored, not the kind where men in shorts run around for two hours, during which perhaps one goal is scored.)

Let’s have the U.K. Daily Mail pick coverage of the game – er, the controversy from there:

Patients who take statins were plunged deeper into confusion last night after the country’s two leading medical journals went to war over the safety of the drug.

The row was triggered by a major review in The Lancet last week that concluded the pills are safe and their benefits far outweigh any harm.  It was the biggest ever review into their use, but now the rival journal The BMJ has cast doubt on the assertions by claiming ‘adverse’ side effects are far more common than the study implied.

Professor Rory Collins, lead author of the Lancet review undertaken by a team of Oxford researchers, concluded the pills were so beneficial that six million more adults should be taking them.

Collins and his cohorts, by the way, receive a ton of research money from the pharmaceutical industry.   I’m sure that doesn’t surprise you.

The Lancet’s editor, Richard Horton, also launched a strong attack on research published in The BMJ that had warned of the possible side effects of the pills.  He said two studies that had appeared in the journal in 2013 resulted in 200,000 patients stopping their statins, potentially harming their health.

Or potentially avoiding diabetes, joint pain, permanently damaged muscles, liver damage and memory loss.

But last night The BMJ defended this research and questioned The Lancet’s claims that the pills are safe and effective.

Writing for the journal, Dr Richard Lehman, a retired GP and Oxford University academic, said muscle pain and fatigue were ‘prevalent’ and ‘recurrent’ in many patients on statins. And Professor Harlan Krumholz, a cardiologist at Yale University in the US, said many scientists still had ‘persistent concerns’. Also writing for the journal, he added there was a ‘lack of good evidence’ for the pills’ benefits in elderly patients.

Health experts urged the two journals to resolve their differences so they could work together to uncover the truth about statins. Tam Fry, of the National Obesity Forum, said: ‘I find it unbelievable that the medical establishment should be at loggerheads over whether they are worthwhile or not.

Say what?  I find it entirely believable that there’s an ongoing battle over statins.  It’s believable for the same reason that the Save The Grains Campaign will fail and the Save The Statins Campaign will fail:  once people know something, it’s impossible to persuade them to not-know it – especially when it comes to their own well-being.

I’ve mentioned that I have a co-worker whose wife suffered from migraines for years.  She went from doctor to doctor looking for relief.  One prescription pill after another failed to provide that relief.  Back in the dark ages of, say, the 1990s, that’s where the story would have ended:  with her suffering from migraines and hoping for the magic pill to come along someday.  That’s because in the dark ages, access to information was limited and it generally flowed from the top down.

But we’re not in those dark ages anymore.  Thanks to the internet, the average person has access to almost endless information, and that information flows in every direction.  So here’s how the story ended:  at a dinner party one night, a friend-of-a-friend mentioned that some people have gotten relief from migraines by giving up grains.  He knew this because he’d done some online research on migraines.  So my co-worker’s wife stopped eating grains as an experiment and – voila! – the migraines went away.

She now knows that giving up grains put a stop to her migraines.  She’ll never not-know it – no matter how many pro-grain articles the Save The Grains Campaign manages to place in media outlets.  Likewise, I’ll never not-know that after giving up grains, I waved goodbye to psoriasis, arthritis in my shoulder, a mild case of asthma and frequent belly aches.

The promoters of the Save The Grains Campaign and the Save The Statins Campaign apparently haven’t figured out how the game works now.  They still think it’s the old game, where most people only know what the officially-sanctioned experts decide they should know.  That’s how we ended up with pretty much everyone believing low-fat diets prevent heart disease.  Several prominent researchers disagreed, but the arterycloggingsaturatedfat! crowd won the war and became the information gatekeepers.

That strategy doesn’t work anymore because the gates are gone.  Yes, there are still official proclamations handed down from on high, but those proclamations are easily undermined by the Wisdom of Crowds effect.  If you suffer from migraines and someone who’s done a bit of research online suggests that giving up grains might cure them, you’ll probably give it a try.  If the migraines go away, you’re not going to be persuaded to eat grains again because a researcher funded by the Save The Grains Campaign releases An Official Study saying grains don’t cause migraines.  You know your migraines went away when you dumped the grains, and you can’t not-know it.

That’s why the Save The Statins campaign will fail.  We may be outraged when journals like The Lancet insist side-effects are rare (I saw plenty of outrage on the internet), but seriously, it’s no big deal.  Let the industry-funded hacks at The Lancet and elsewhere publish all the b.s. studies they want.  It won’t make any difference.

My mom dutifully took her statin despite the muscle and joint pains for only one reason:  she didn’t know the statin was the cause of the pains.  But once she knew statins were the cause (because I told her), she couldn’t not-know it.  In fact, I didn’t have to convince her that statins were absolutely, positively the cause of her muscle pains.  I just had to convince her they were a likely culprit.  Going off the statin and experiencing the happy result was the final convincer.   Hundreds of thousands of people are being similarly convinced.

The Save The Statins Campaign is already a failure – although the hacks at The Lancet may choose to not-know it for some time.

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Bacterial pneumonia, once a leading killer of the old and the very young, is caused by (duh) bacteria.  If you kill the bacteria, the pneumonia goes away.  It doesn’t really matter how you kill the bacteria, either.  If a patient is allergic to one drug that kills the bacteria, a doctor can prescribe a different drug that kills the bacteria and – bingo! – the pneumonia goes away. Why?

BECAUSE THE PNEUMONIA IS CAUSED BY THE BACTERIA, FOR PETE’S SAKE!  

And how do we know that?

BECAUSE IF WE KILL THE BACTERIA, THE PNEUMONIA GOES AWAY, FOR PETE’S SAKE!

Okay, but let’s suppose we kill the bacteria we believe causes the pneumonia, but the pneumonia remains and the patient dies.  And let’s suppose this happens with multiple patients.  Then what would we conclude?

IF KILLING THE BACTERIA DOESN’T MAKE THE PNEUMONIA GO AWAY, THEN THE PNEUMONIA ISN’T CAUSED BY THE BACTERIA, FOR PETE’S SAKE!  WHAT ARE YOU, AN IDIOT?

No, I’m just pointing out some basic logic here.  If we kill the bacteria but the pneumonia remains, we have to conclude that while a bacterial infection may be associated with pneumonia, it isn’t the cause.  That’s what we’d expect any honest scientist to say.

But strangely, this basic logic seems to escape researchers when a cholesterol-lowering drug fails to prevent heart attacks. Here are some quotes from a New York Times article:

It is a drug that reduces levels of LDL cholesterol, the dangerous kind, as much as statins do. And it more than doubles levels of HDL cholesterol, the good kind, which is linked to protection from heart disease.

That’s the Lipid Hypothesis in a nutshell: LDL is dangerous.  It causes heart disease — just like that nasty bacteria causes bacterial pneumonia.  HDL, meanwhile, protects against heart disease.

As a result, heart experts had high hopes for it as an alternative for the many patients who cannot or will not take statins.

Everybody sing: “Oh, we’ve got hiiiigh hopes.  Yes, we’ve got hiiiigh hopes …”

But these specialists were stunned by the results of a study of 12,000 patients, announced on Sunday at the American College of Cardiology’s annual meeting: There was no benefit from taking the drug, evacetrapib.

No benefit?  But LDL causes heart disease!  Did the drug fail to lower the LDL that causes heart disease?

Participants taking the drug saw their LDL levels fall to an average of 55 milligrams per deciliter from 84. Their HDL levels rose to an average of 104 milligram per deciliter from 46.

Well now, that is an amazing improvement in lipids.  The American Heart Association would be delighted with those numbers … although strangely, I can’t find recommended LDL levels on the AHA site anymore.  Perhaps they hired the former KGB artists who used to make people disappear from official photos once they became an embarrassment to the Kremlin.  Anyway …

Yet 256 participants had heart attacks, compared with 255 patients in the group who were taking a placebo.

In other words, no difference.  A total fail.

“We had an agent that seemed to do all the right things,” said Dr. Stephen J. Nicholls, the study’s principal investigator and the deputy director of the South Australian Health and Medical Research Institute in Adelaide.

Yup.  If high cholesterol – and specifically high LDL – causes heart disease, then you did indeed have an agent that seemed to do all the right things.

“It’s the most mind-boggling question. How can a drug that lowers something that is associated with benefit not show any benefit?” he said, referring to the 37 percent drop in LDL levels with the drug.

Boy, that’s a real head-scratcher.  Let me think for a minute … uh … uh … perhaps the fact that two things are associated doesn’t mean one is causing the other?  I seem to recall a good scientist or two saying as much.

“All of us would have put money on it,” said Dr. Peter Libby, a Harvard cardiologist. The drug, he said, “was the great hope.”

And how are those Enron shares working for ya?

Researchers have hypotheses, but no one is certain what went wrong. “It may be that the LDL level is less important than how it gets changed,” said Dr. Paul Thompson, a cardiologist at Hartford Hospital.

Ah, yes, that must be it.  LDL causes heart disease, ya see, but lowering LDL only works if you do it exactly the right way.  And if you have bacterial pneumonia, it’s not wiping out the bacteria that cures you; it’s how you kill them.  Kill them the wrong way, and you’ll still have pneumonia … even though bacteria cause the pneumonia.

Here’s an alternate hypothesis about why the latest study was a big, fat fail:

LDL DOESN’T CAUSE HEART DISEASE, FOR PETE’S SAKE!

That would be the most logical conclusion:  we beat people’s LDL levels down, but they didn’t have fewer heart attacks.  So LDL doesn’t cause heart disease.  But beating cholesterol levels down is a $36 billion per year (and climbing) business.  So we’re getting the illogical conclusion instead:

Cardiologists still have high hopes for a new class of cholesterol drugs, known as PCSK-9 inhibitors, that cause LDL to plummet to levels never seen in drug treatments.

Try to wrap your head around that one:  in a multi-year study of 12,000 people, dramatically lowering LDL levels didn’t prevent heart disease.  But cardiologists have high hopes for a new class of drugs that lower LDL levels EVEN MORE!

Everybody sing: “Oh, we’ve got hiiiigh hopes.  Yes, we’ve got hiiiigh hopes …”

And here’s the reason for those high hopes:

The PCSK-9 inhibitors can cost more than $14,000 a year …

Fourteen grand per patient, per year, year in and year out.  Yeah, that would generate a lot of hope.

… while statins can cost just pennies a day, so determining what portion of patients are truly statin intolerant has become an important question.

Yeah, about that “statin intolerant” problem: funny how research funded by drug companies is starting to demonstrate a real problem with statins isn’t it?  In one of his many great posts, Dr. Malcolm Kendrick predicted this would happen:

For years the experts have informed us that this is utter rubbish, statins are wonder-drugs, and adverse effect free. All of a sudden, now that the pharmaceutical industry is about to launch new cholesterol lowering agents, we are suddenly going to find that, why, after all, statins do cause a whole range of nasty adverse effects.

I watch this stuff with a kind of morbid fascination. The marketing game is on, billions are about to be spent pushing PCSK9-inhibitors. The Key Opinion Leaders who tirelessly promoted the wonders of statins, and who told us that they were virtually side-effect free, are now singing a completely different tune.

Sure enough, a big ol’ study just concluded that lots and lots of people have real problems with statins.  The study was led by Dr. Steve Nissen, one of the long-time pimps for — er, promoters of statins.  Returning to the New York Times article:

A second study presented at the cardiology meeting on Sunday and published online in JAMA, the Journal of the American Medical Association revealed just how vexing the issue is.

The study, directed by Dr. Nissen and paid for by Amgen, a pharmaceutical company, included more than 500 people with extremely high levels of LDL cholesterol who had tried two or more statins and had reported aching or weak muscles so severe that they said they absolutely could not continue taking the drugs.

[The result] indicated that 57 percent of patients actually could tolerate statins. Researchers then randomly assigned the remaining 43 percent to take either Amgen’s PCSK-9 inhibitor, evolocumab, or another cholesterol-lowering drug, ezetimibe, which is often taken by statin intolerant patients but has never been shown to reduce heart disease risk when taken without an accompanying statin. The patients tolerated both drugs.

My, my, my … statins go off patent (thus reducing the cost to just pennies per day), and through sheer coincidence, we get a major new study showing that nearly half of all people can’t tolerate statins – but they can tolerate the new drug that costs $14,000 per year.

And of course, we know this new and very expensive drug will prevent heart attacks because it lowers LDL.  High LDL cholesterol causes heart disease, ya see.  We’ll just continue believing that even when a drug that dramatically lowers LDL fails to prevent heart attacks.

Perhaps someday, after yet another LDL-lowering drug fails to prevent heart attacks, researchers will respond by going before the cameras and announcing that it’s time to bury the Lipid Hypothesis once and for all.

But I don’t have high hopes.

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