I have more than my fair share of complaints about Trump, but I did like the idea of charging $100,000 per year for every H1B visa. It would have ultimately helped American workers by giving them more negotiating power and higher salaries. So, naturally, Trump was talked out of doing it yearly and it looks like it's legally questionable whether it will stand-up at all. It appears things worked out in a way that benefits wealthy corporations... again.
No, companies were already having trouble getting prospective staff H1Bs. Making them more expensive just increases the incentive to move the job offshore.
Once the offshore team is large enough, companies stop hiring in the USA.
I'm not sure how that act would differentiate between hiring someone in India vs outsourcing to India.
Also, how would it differentiate between outsourcing and SAAS?
A _better_ solution would be to remove the H1-B cap and continue to skim the best graduates worldwide. Same with removing the green card quotas. Make sure if someone gets an H1-B, they can transition to a green card and then to citizenship.
That's always been the US's super power.
Keep the density of innovation in the USA by inviting people in.
A lot of these things Trump doesn't want to actually do, and knows are totally infeasible, so he just throws them out there as a way to score points without actually spending any political capital. We just saw it today with the promise of $2,000 stimulus checks at the same time he's going out of his way to make sure people can't get SNAP benefits, even with state assistance.
That isn't what happened at all. The SNAP funds have to be appropriated by Congress. Congress has not appropriated the funds. Some groups sued and some judge was asking the Executive Branch to break the law using some emergency fund or funds from WIC or other pots of money that aren't truly earmarked for SNAP. The Judiciary way overstepped there. Then, when a percentage of funds were made available via some mechanism, a few blue states jumped the line and took 100% of them, leaving most states high and dry sans funds. So that looks pretty bad--instead of an even allocation of a percentage, most people get nothing.
SNAP should be audited and there needs to be a way to limit the number of recipients because there's no way 42M Americans need it that bad. If they all do, then we're pretty far gone as a country.
As far as the $2k checks go, I have no idea. Sigh... Dumb dumb dumb! I just want the national debt paid down and the US Govt. to have a budget and live within its means without deficits. Is that so hard?
I do think Trump sends up trial balloons that exist solely to distract the media.
That isn't what happened at all. The SNAP funds have to be appropriated by Congress. Congress has not appropriated the funds. Some groups sued and some judge was asking the Executive Branch to break the law using some emergency fund or funds from WIC or other pots of money that aren't truly earmarked for SNAP.
The SNAP contingency funds probably are earmarked for SNAP. Whether they can properly be spent on benefits if there isn't a budget appears to be a harder question to answer. I see arguments being made in both directions.
> SNAP should be audited and there needs to be a way to limit the number of recipients because there's no way 42M Americans need it that bad. If they all do, then we're pretty far gone as a country.
I might have some bad news for you. Come let me drive you around Louisiana.
I believe statins reduce risk by about 30%, so there's a roughly 30% chance the statins have done good things for your dad.
(I think that's what the stats mean, right? I'm open to correction on this. I do believe the statin studies, I'm not a science denier. I think what I've said matches the science, as far as I understand.)
I am not a statin skeptic--or rather, I don't want to be a statin skeptic. I've done the research and it makes sense to me, but I still feel some social and psychological pressures to reject statins.
When I see that it is widely accepted that ApoB is better to measure than LDL-C, but the industry continues to measure LDL-C, but not ApoB, I wonder why. It makes me skeptical.
When I see that the purpose of statins is to reduce plaque buildup in the arteries, and that we have the ability to measure these plaque buildups with scans, but the scans are rarely done, I wonder why. Like, we will see a high LDL-C number (which, again, we should be looking at ApoB instead), and so we get worried about arterial plaque, and we have the ability to directly measure arterial plaque, but we don't, and instead just prescribe a statin. We're worried about X, and have the ability to measure X, but we don't measure X, and instead just prescribe a pill based on proxy indicator Y. It makes me skeptical.
In the end statins reduce the chance of heart attack by like 30% I think. Not bad, but if you have a heart attack without statins, you probably (70%) would have had a heart attack with statins too. That's what a 30% risk reduction means, right?
As you can see, I'm worried about cholesterol and statins.
If you fix it without statins through better lifestyle and diet, that is the preferrable route.
As to why medicine is like this, it's because it's conservative, usually about 17 years behind university research[0], and doctors are shackled to guidelines in most health systems or risk losing their licenses. It isn't a coincidence that the article author had his out-of-pocket concierge doctor tell him the more up-to-date stuff.
I have an objection to the "better lifestyle and diet" approach.
Sure, it is absolutely true that better lifestyle and diet has a huge effect. However it is absolutely certain that the vast majority of people who are told to improve their lifestyle and diet, won't.
The result is doctors giving advice that they know won't be followed. And thereby transferring potential fault from the doctor to the patient, with no improvement in actual outcomes. "I told the patient to lose weight and maintain that with a controlled diet." And yet, most people when told to diet, won't. Most people who start a diet won't complete it. And most people who lose weight on a diet, have the weight back within 5 years. Where each "most" actually is "the overwhelming majority". And the likelihood of the advice resulting in sustained weight loss probably being somewhere around a fraction of a percent.
What, then, is the value of the doctor giving this lecture?
(Disclaimer. I have lost 20 of the pounds I gained during COVID, and am making zero progress on the remaining 30. A few months ago I successfully started a good exercise routine. Given my history, I would expect to only follow it for a few years before falling off the wagon. I believe that this poor compliance puts me well above average. But do you know what I do reliably? Take my prescribed medicine!)
Your health is ultimately your own responsibility - it's your body. You have free will, and your appetite for risk is yours alone. You can choose to ignore expert advice and refuse to wear a seatbelt, skip your rehabilitation exercises, invest all-in on crypto, or smoke cigarettes. None of this responsibility should fall on the expert if they communicated the risks clearly.
What you're communicating here, perhaps unintentionally, is that what matters is not results, but blame. If the doctor said what to do but the patient didn't do it, all that matters is the patient is to blame.
You've communicated that by ignoring or dismissing the question of whether better outcomes are possible through other means than demanding that everyone follow doctors' orders and blaming them if they don't.
"Who cares if better outcomes are possible, so long as blame is in the right place"? Is that how we want to approach this?
Struggling to change is different from not wanting to change. People seem to have trouble with basic distinctions like this when they're heavy into moralizing failure to change.
Profound point. My mother struggled with alcoholism and ultimately succumbed to that disease. In philosophy of mind they use “akrasia” and “akratic thinking” for acting against ones better judgement. It helped me somewhat getting to understand what my mother was going through at that time.
She wanted to change, tried a many multiple of times and it failed. Fault, guilt, blame are useless concepts to use on the Other. And only in moderation should they be applied to the Self. There deep disconnects between what we think, know and do.
I find it helps to explicitly abandon the expectation that each person has a unitary and consistent will.
Bob the gambler wants to quit and wants to wager, sometimes sequentially and sometimes simultaneously.
The question isn't whether the whole Bob "means it", but which version of Bob we want to ally-with to war against the other, and what conditions or limitations we put on that assistance.
Reading this thread it seems like you're the only one moralizing and looking down on people. I don't see anyone here shaming people for their choices. But somehow you seem to have read the worst interpretation of every reply.
Drugs expand what helping yourself means to the point where people will actually do so.
Statins, GLP-1 antagonists, etc isn’t magic, but it changes people’s behavior and bodies in such as way as to diminish the importance of willpower. Thus, it’s not that people are lacking instead our medicine is simply to primitive to help with a wide range of issues.
Or, as we're becoming aware with GLP-1 drugs, an injection. (For now!). It's better to help people behave better with drugs than moral condemnation. Almost infinitely better, as it turns out, regarding a lot of problematic behavior regarded as "untreatable" previously.
It may not be the case for statins specifically, but my main concern is side effects. If there was a panacea, I would support giving it to everyone, but lifestyle changes are usually more available, if not easier.
Yeah this prickles my hackles too. It took a fairly high dosage of zepbound and many months for me to get to a normal set of eating habits after a couple of decades of bad, but a prediabetes scare surprise on my labs pushed me into the program, but I would not have done it by "white knuckling". I needed some medication to help me along. All these people just saying "calories in and calories out" "just start exercising dude" are making a complex issue into a "simple solution" that almost never works because change takes time; a lot of time that many people don't feel on a deep level that they have to apply to it. So, they just give up after a couple of weeks of "grit" and "will-power". Isn't it like maybe 1-3% succeed over time, while the rest fail when trying to lose significant weight or other health issues that could be resolved with habit only?
To me the terms mix and it helps to separate the things that are externally manageable from the things that are not. The physical is complex but straightforward - the body biochemistry operates on material in, biochemistry mix, expenditure out. The brain is physical - neurons, pathways, etc. The mind, OTOH, is a virtual little candle isolated in a prison of meat and bone trying to understand how to interact with the world around it. External forces can alter the body and brain, but only the mind can change the mind. And does, in ways that are very difficult to control because the sole operator is part of the mechanism. People who try to change on their own and can't aren't failing or weak, it's just really f-ing hard.
If my health is my responsibility, then shouldn't the treatment that I receive be to the standard that I request?
In 2015, https://pubmed.ncbi.nlm.nih.gov/26551272/ showed that medicating all of the way to normal works out better than medicating down to stage 1 hypertension, then insisting on diet and exercise. And yet my request in 2018 to be medicated down to normal blood pressure was refused, because the professional guidelines followed by the experts was to only medicate down to stage 1 hypertension, then get the patient to engage with diet and exercise. The expert standard of care was literally the opposite of what research had shown that they should do.
I agree that experts should not be accountable for my laziness. But can you agree that experts should be accountable for following standard of care guidelines that are in direct conflict with medical research? And (as in my case) refusing the patient's request to be treated in a way that is consistent with what medical research says is optimal?
Thanks for posting this. While I would generally advise a healthy dose of skepticism for any individual study, this one was very large and seems to be both well designed and executed. While there was a (statistically) significant increase in side effects with more intensive treatments, only about 1% more patients had adverse effects versus the standard treatment group, which seems like a very reasonable risk given the improved outcomes.
I've been trying to get my blood pressure under control recently and was thinking getting down to 12x/8x was good enough, but this has me rethinking that.
Maybe 80-90% of people should take doctors at face value, but it is easy and only getting easier to at least access the knowledge to better advocate for your own healthcare (thanks to LLMs), with better outcomes. Of course, this requires doctors that respect your ability to provide useful inputs, which in your case did not happen.
My advice would be to "shop around" for doctors, establish a relationship where you demonstrate openness to what they say, try not to step on their toes unnecessarily, but also provide your own data and arguments. Some of the most "life-changing" interventions in terms of my own healthcare have been due to my own initiative and stubbornness, but I have doctors who humor me and respect my inputs. Credentials/vibes help here I think: in my case "the PhD student from the brand name school across the street who shows up with plots and regressions" is probably a soft signal that indicates that I mean business.
Open to evidence either way. I haven't seen people improve it even with what seems to be terrible negative consequences associated with poor temporal discounting ability, but I'd love to read differing perspectives.
Research on heritability have found that the amount of temporal discounting we do is moderately heritable. With twin studies ranging from 30-60% of our natural variability explained by genes.
This strongly suggests that genetics definitely slips a thumb on the scale, but ultimately we are able to also impact our personal behavior.
More importantly, research such as https://pubmed.ncbi.nlm.nih.gov/31270766/ shows that there are techniques (such as mindfulness practices) that have been demonstrated to improve our abilities in practice. I have personally seen these have an impact.
Of course if you have a condition such as severe ADHD, you might not be able to reach the same level as is possible for someone with good genetics. But you still have the ability to move the needle. If you have a condition such as traumatic brain injury, even your ability to move the needle may be lacking.
But most of us should be able to make a positive change.
> This strongly suggests that genetics definitely slips a thumb on the scale, but ultimately we are able to also impact our personal behavior.
If it's 30-60% heritable, that leaves 70-40% to split between personal decisions and environment. It does not guarantee that personal decisions matter much at all...
> Sure, it is absolutely true that better lifestyle and diet has a huge effect.
not for me. My cholesterol was hovering in the high 200's, then finally hit 300 and I completely freaked out, radically changed my diet, and lost 22 pounds (from 180 to 158).
What did my high cholesterol do ? It did absolutely nothing. ticked down to like, 280.
So I'm on the statins. my total cholesterol went from high 200's to about 150 in a month and was impacting my liver function. so we reduced the statins to a very low dose (5mg three times a week, crazy low). My total cholesterol hovers around 200 now. My cardiologist tells me that the conventional wisdom of "diet and exercise" is almost entirely disproven to have any meaningful effect on lipids these days (though i havent researched deeply).
> My cardiologist tells me that the conventional wisdom of "diet and exercise" is almost entirely disproven to have any meaningful effect on lipids these days (though i havent researched deeply).
I would be immensely skeptical of this unless he was talking about something much more narrow, like how there's a fraction of people who have really unfortunate genetics and can only improve their blood lipids with medication.
We have mountains of data showing that diet can massively improve lipids, and the combination of diet and exercise are our largest levers for reducing the risk of heart disease for most people. (There are always some fraction of people who can do everything right but have outlier genetics that require medication anyway, just as some people have outlier genetics and can smoke a pack a day their whole lives and reach their 90s.)
I'd check out the Barbell Medicine podcast for anything related to the intersection of lifestyle and health. They're extremely evidence based with a preference for measurable improvements in outcomes over hypothetical mechanisms.
Relevant to this thread are their episodes on testing and screening, hypertension / high blood pressure, cholesterol, fiber, and the new PREVENT heart disease risk calculator.
I'd also check out the episodes on diabetes, Alzheimer's, fatty liver disease, and health priorities.
> I would be immensely skeptical of this unless he was talking about something much more narrow, like how there's a fraction of people who have really unfortunate genetics and can only improve their blood lipids with medication.
I am one of those unfortunate genetic people, sadly, and have had high cholesterol numbers since my early 20s. Most of my older grandparents passed from heart disease. Now in my 40s, have a decent diet, and my numbers are < 100 for LDL. Current (and previous) PCPs have indicated to me that diet will have little effect for me, and that I will likely be on statins for most of my life. Experiments with stopping the statins have shot my LDL numbers through the roof.
The good news is that it's a pretty low dose with decently high effect.
both of my parents have low cholesterol, my mom's cholesterol is naturally under 200, my dad is on statins but the highest he ever got was about 230. they are in their 80s. Nobody on any side of my family (for which I have about 25 first cousins) has ever had any heart disease of any kind, no bypass surgeries, no heart attacks, nothing.
I'm familiar with the genetically high cholesterol thing and when you look at that you see parents/grandparents having heart attacks in their 40's. nothing like any of that in my family.
anyway yes im on the statins and probably need to boost my dose a little more to be below 200.
Diet and exercise are hugely important to health in general, and can make a significant impact on lipids.
They are unlikely to get lipid levels down low enough to reach soft plaque regression levels. You need to get sustained levels below 50 to 70 depending on genetics, Lp(a), etc.
If you've lived a healthy life in general and don't have genetically bad Lp(a) this advice is probably enough for you staying that way. If you've spent a significant portion of it with bad lipids for whatever reason, you almost certainly need to go on a combo therapy to get to regression levels.
Your anecdotal report that diet and exercise did not have a huge effect on your cholesterol does not discount the mountain of evidence that we have showing that diet and exercise has a huge effect on health and lifespan.
These effects were first demonstrated in 1953. And has been confirmed over and over again since.
So don't discount the value of diet and exercise just because losing weight didn't fix your cholesterol.
yeah I read all that and it's why i did "diet" (already exercised) first.
still doesnt explain what my cardiologist was talking about, though. he's not the first dr. to tell me that "diet isn't really going to help you much". one dr. said, "if you went totally vegan, maybe it would have a slight effect". so no I didnt go totally vegan.
i think the idea is diet/exercise can make a 20 point dent in your total cholesterol but in practice, not much more than that, if you have total cholesterol over 250 kind of thing.
I think people use it as cudgel to blame people and as a crutch to avoid action. And we ignore the psychological and other factors that make improving lifestyle and eating better difficult.
No doctor wants their patient to have a stroke. But they also only get to meet patients where they are.
You're arguing against a strawman. The reality is that most doctors will tell the patient their options and let them pick. While statins have some significant side effects in many patients, there is no downside to a better diet and frequent hard exercise (assuming proper technique). So it usually makes sense to at least try lifestyle modification as the initial therapy. And if that doesn't work for whatever reason then prescribe the drugs.
> While statins have some significant side effects in many patients
Some statins have significant side effect in some patients.
We have many "new" statins that the overwhelming majority of people have no side effects on. Exceedingly small amounts of people have issues with things like rosuvastatin and pitavastatin, and for people that do, repatha and other pcsk9 inhibitors often work fine.
> no downside to a better diet and frequent hard exercise (assuming proper technique). So it usually makes sense to at least try lifestyle modification as the initial therapy.
There is a downside to delaying treatment, and particularly so when they are far out of range, or have spent an extended amount of time out of range.
Accepted medical guidelines not long ago said to bring blood pressure from the dangerous range, to elevated, then encourage patients to engage in diet and exercise. Research such as https://pubmed.ncbi.nlm.nih.gov/26551272/ demonstrated that it is better to medicate all of the way to the normal range.
I personally had specialist in blood pressure follow the old advice around 2018. I asked for further medication, and he refused to give it. In so doing, he was following accepted practice, per professional guidelines. This left me with elevated blood pressure for several years. This despite the fact that when I was personally physically fit (when my blood pressure problems were discovered, I still had my crossfit bod), that did not help my blood pressure.
Guidelines are continuing to evolve. Even today, guidelines about how far down to take blood pressure are somewhat vague in the USA. Many countries stick to the older, higher, targets in who even gets medicated in the first place.
It wasn't until about 2 years ago that I encountered a doctor who was willing to medicate me all of the way into the normal range. Given the 2015 research, I'm very happy about this. But it is far from a guarantee that a random person on HN with high blood pressure will encounter a doctor who is willing to do the same.
That's why I believe that this is not a strawman position. I'd be curious to hear your case explaining why you wrongly assumed that it was.
Yes, I'm sure you were arguing against a strawman. The majority of doctors will tell patients about the available options which are generally safe, and allow them to pick. And they don't usually blame patients. Your personal experience might have been different but it was atypical and just an anecdote.
First, if I'm basing it on things that actually happened, then by definition it cannot be a strawman argument. And your insisting otherwise is just plain rude.
Second, you are just giving your opinion about doctors. You are not providing evidence. In fact what you claim about doctors is just straight up wrong.
I already gave you a link to a 2015 study that demonstrates what the standard of care was at that point. Here is https://www.aafp.org/pubs/afp/issues/2018/0115/p72.html demonstrating that in 2018, the year I had my interaction, the standards were shifting. With not all major medical organizations endorsing bringing blood pressure down to what the 2015 study said they should.
In fact if you look at the actual AAFP guidance, see https://www.aafp.org/pubs/afp/issues/2018/0315/p413.pdf. Read to the last page and look for "Follow up". This matches my experience. I was brought to stage 1 hypertension, then "nonpharmological interventions" were recommended. Namely diet and exercise.
And now it is apparent that you were dead wrong. My doctor in 2018 was not some rogue jerk. My doctor was exactly following the recommended standard of care put forth in that year by a major medical association.
While the USA has evolved their standards further, that 2018 standard in the USA is still common in many other countries.
But look on the bright side. You just were given the opportunity to learn something.
> While statins have some significant side effects in many patients
It's more accurate to say that certain statins have significant side effects in certain patients. Atorvastatin made me dizzy. But I switched to Pravachol and that went away. I switched again to Rosuvastatin and it stayed away.
That is because dietary advice they give is actually bad. It mostly boils down to "limit calories while eating standard western diet" but that is impossible to follow long-term as SWD and similar (e.g. food pyramid) diets are nutrient-deficient.
How many doctors recommend things like paleo diet, intermittent fasting and so on? Not many, I think - most simply focus on calories, combined with the advice that is either extremely generalized ("avoid sugar") or outright counterproductive ("eat 5 - 6 meals a day"). And then they wonder why people can't follow their diet.
To expand, one of the coverage pillars of malpractice insurance (in the US) is the "standard of care". This is basically what most doctors and their associations consider acceptable, which by definition excludes new, better techniques.
This is both a bug and a feature. A move fast and break things philosophy would cause more harm than good, but it also prevents rapid adoption of incremental improvements.
You are conflating two different things. The standard of care in a malpractice lawsuit is not necessarily the same as clinical practice guidelines. In reality doctors are free to rapidly adopt incremental improvements, especially when they are evidence based.
17 years is far from rapid or move fast and break things. ApoB has been known about for quite a long time, since the 90s its effects have been obvious, and showed up in research in the 70s-80s!!! It's still not part of standard testing!!!
Guidelines also leads to standards of care being random and heavily driven by politics & financial reasons disguised as medical best practice. South Korea and India are "parallel testing" places, which saves time, while the USA & others are serial testing places mostly because of their funding models.
Talk to any American doctor and they will give you a bunch of emotionally wrapped cope about why it's bad because the cognitive dissonance sucks and there are liability reasons to avoid admitting your wrong. I would argue that in many cases, parallel testing is cheaper because $300 of tests is cheaper than 4 chained $500 doctor visits. But whatever.
No, actually, you should improve your lifestyle and diet and also take statins.
Ever cardiologist ever will tell you that statins work best when you make diet and lifestyle changes. They tell you that, to your face. It's not a secret. This actually goes for A LOT of medications. Usually, medication + diet and exercise is better than medication alone. They also test medications like this.
There is virtually zero chance that a doctor will lose their medical license for diverging from the from the usual clinical practice guidelines around statins. Check the state medical board disciplinary records.
But if they're employed by a health system and fail to follow company policy then yes, they could be fired.
Different countries are different, some are far more trigger happy about it like Canada. What you suggest as an alternative other than 'git gud' diet & exercise also changes it.
You can only do things to reduce your risk. And whatever intervention would be based on overall population statistics, since it's difficult to know your own personal risk. Heart disease kills marathon runners. You can't just "fix it". Someone who has naturally high cholesterol won't magically be okay by changing their lifestyle and diet.
Many commercial health plans will only cover an ApoB blood test for patients with certain conditions or risk factors. But if you want it you can pay out of pocket for like $70.
> When I see that it is widely accepted that ApoB is better to measure than LDL-C, but the industry continues to measure LDL-C, but not ApoB, I wonder why. It makes me skeptical.
ApoB is shaping up to be an incremental improvement in measurements, but health and fitness influencers have taken the marginal improvement and turned it into a hot topic to talk about.
This happens with everything in fitness: To remain topical and relevant, you always need to be taking about the newest, most cutting edge advances. If it’s contrarian or it makes you feel more informed than your doctor, it’s a perfect topic to adopt for podcasts and social media content.
ApoB is good, but it’s not necessarily the night and day difference or some radical medical advancement that obsoletes LDL-C. For practical purposes, measuring LDL-C is good enough for most people to get a general idea of the direction of their CVD risk. The influencers like to talk about edge cases where LDL-C is low but then ApoB comes along and reveals a hidden risk, but as even this article shows there isn’t even consensus about where the risk levels are for ApoB right now. A lot of the influencers are using alternative thresholds for ApoB that come from different sources.
> In the end statins reduce the chance of heart attack by like 30% I think. Not bad, but if you have a heart attack without statins, you probably (70%) would have had a heart attack with statins too. That's what a 30% risk reduction means, right?
30% reduction in a life threatening issue is huge. I don’t see why you would want to diminish that.
If you were given the choice of two different dangerous roads where one road had a 30% lower chance of getting into a life-threatening car crash, you would probably think that the choice was obvious, not that the two roads were basically the same.
numbers often quoted in favor of statins use relative instead of absolute risk. when seen in absolute terms there is little case for statins except in some possible particular cases. they also do little, if anything, when it comes to life extension — the expected lifespan of a statin user is often estimated to be four days longer than that of those who do not use them. not only is this essentially statistical noise, it discounts the lowered quality-of-life side effects experienced by many who have been put on statins.
This is all true. If you take a statin and it causes no issues, you're... maybe (30%, yay!) better off for it.
If a statin makes you feel miserable, I think any doctor would sympathize with a calculated decision to stop them. There are many types of statins to try though, so hopefully one would work without side effects.
Most with efficacy determined by the proxy variable of LDL-C levels, and with even more questionable results in actual lifetime improvement.
I too really wanted not to be that skeptical about medicinal research. But if I had high cholesterol and a doctor recommended newer statins to me, I don't think I would take them.
>If you were given the choice of two different dangerous roads where one road had a 30% lower chance of getting into a life-threatening car crash, you would probably think that the choice was obvious, not that the two roads were basically the same.
You could absolutely think that they were basically the same, depending on the base rate. The differece between a one-in-a-million and 0.7-in-a-million is 30%, but it wouldn't be humanly perceivable. We're all likely faced with situations like that regularly. Differing airlines probably have much greater variances in their crash statistics, but it just doesn't matter in 99.99999% of flights.
Meta-analysis conclusion: This literature-based meta-analysis did not find evidence for the benefit of statin therapy on all-cause mortality in a high-risk primary prevention set-up.
Have you read their methodology and understood how they did their selection? You could critique their actual methodology. Maybe their selection is backed by strong arguments, right? And if you think their methodology is weak, then please explain why.
Not just throw a two-line comment disparaging the work of experienced specialists in the field.
For the curious, here are the author affiliations for this study:
Department of Public Health and Primary Care, University of Cambridge, Cambridge, England (Drs Ray, Seshasai, and Erqou); Department of Cardiology, Addenbrooke's Hospital, Cambridge (Dr Ray); Department of Clinical Pharmacology and Therapeutics, Imperial College, and National Heart and Lung Institute, London, England (Dr Sever); Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands (Dr Jukema); and Department of Statistics (Dr Ford) and BHF Glasgow Cardiovascular Research Centre, Faculty of Medicine (Dr Sattar), University of Glasgow, Glasgow, Scotland.
This is totally unsourced now but I did a deep dive quite a while ago now and it seemed to me that studies largely found that statins after a heart attack helped all cause mortality (though not by a ton), but if they were prescribed to someone before a heart attack it wasn’t nearly as clear. Considering how they often make people feel it seems like people should be a bit skeptical.
If you actually read the article, you would find the selection criteria and the explanation for the criteria.
First, a preface.
The article was published in 2009. At the time, AstraZeneca, the maker of the controversial statin Rosuvastatin, had been engaged in a yearslong intensive campaign to promote the drug. The editor of The Lancet wrote "AstraZeneca's tactics in marketing its cholesterol-lowering drug, rosuvastatin, raise disturbing questions about how drugs enter clinical practice and what measures exist to protect patients from inadequately investigated medicines"; CEO Tom McKillop [1] angrily fired back. Consumer rights group Public Citizen tried to get the medicine withdrawn for safety reasons; the FDA denied the request [2.]
AstraZeneca prevailed, and Rosuvastatin proceeded to make billions of dollars a year in sales. Today, 42 million Americans take it and in 2015 it was the most prescribed branded drug in America.
Now, back to the article. Most new drugs focus on studying the most diseased patients first and then, if possible, attempt to expand to the (far larger and more lucrative) prevention markets later. Statins are no different. The overwhelming majority of research on statins has been industry-funded, done on patients with CVD. Pharma companies want to expand to a larger market, of course. So there are efforts on many fronts. One was to broaden the definition of CVD or other criteria for starting statins. For example, in 2017 the definition of high blood pressure was successfully changed from 140/90 to 130/80. That bumped up the proportion of US adults with CVD from 36% in 2011-2014 [3] to 48% in 2013-2016 [4], or in other words, added 30 million US adults to the market. Similarly, in 2013 the 2013 ACC/AHA guidelines encouraged starting statins for anyone with LDL-C ≥190 mg/dl "even in the absence of other risk factors" which increased statin use from 31 million to 92 million Americans from 2008-09 to 2018-19 [5.]
Where did these changes come from, what motivated them? Studies, of course. Studies like the AstraZeneca-funded JUPITER trial, which claimed an improvement in the health of participants with even _low_ levels of LDL-C. A lot of this stuff was considered fairly strange, and it didn't seem to replicate. Thus the meta-analysis. Are statins truly useful for prevention?
So, in short: Most studies investigating statins in real depth are funded or influenced by industry. They usually focus on the sickest patients, presumably to get a larger effect size, yet the industry is constantly trying to prescribe to a wider audience - the healthier patients - often on grounds that mainstream health authorities find weak. This meta-analysis was only able to include 11 studies because industry SOP is to study the sickest patients yet prescribe to a wider audience. And as you might then expect: "This literature-based meta-analysis did not find evidence for the benefit of statin therapy on all-cause mortality in a high-risk primary prevention set-up."
[1] If the name sounds familiar, it's because Tom McKillop was the CEO of RBS who "aggressively" pursued leveraged buyouts up until its collapse and bailout in 2008.
Lots of people. Statins are fairly cheap and a lot of people are on them. Cholesterol is also cheap to measure. As a result the two are commonly studied. Even if your goal isn't the above it is probably in the study data.
Guidance from the National Lipid Association, based on a review of the current understanding of the science across quite a few different meta-studies, analysis, etc. Many of the referenced studies are meta-studies significantly larger than the one here.
We have mountains of studies showing the negative impact of LDL-C (and inflammation! Which statins also reduce) on health. We have mountains of studies showing positive impact from statins. We have specific mechanistic understanding of how LDL-C and other atherogenic particles cause heart disease. We have mountains of studies show that statins directly lower the amount of atherogenic particles you have.
This has been studied enough and sliced enough ways that yeah, there is evidence on both sides. But one side is effectively a mountain range, and the other is a small hill. I know which way I'm going to land on it.
Concentration of ApoB-carrying lipoproteins in the bloodstream as the driver of heart disease is one of the most strongly proven facts in medicine. Statins are proven to lower LDL (a close-enough substitute for ApoB in most situations) by about 30%. I can't look at the study now, but most likely it's a situation where patients' cholesterol has not been lowered enough by medication to make a meaningful difference. If you have an LDL of 160, statins aren't going to be sufficient. The issue is doctors/patients not targeting a sufficiently low cholesterol level.
> When I see that it is widely accepted that ApoB is better to measure than LDL-C, but the industry continues to measure LDL-C, but not ApoB, I wonder why. It makes me skeptical
Because this is a recent understanding and healthcare tends to be a conservative industry that moves slowly. Sometimes too slowly.
And also because LDL remains an excellent measure. The risk with LDL isn’t false positives. If someone has high LDL they likely have an elevated risk of heart disease. The problem with LDL testing is that someone with low LDL may still have a high risk of heart disease which may be captured in APoB testing.
> When I see that it is widely accepted that ApoB is better to measure than LDL-C, but the industry continues to measure LDL-C, but not ApoB, I wonder why. It makes me skeptical.
Part of this is just that insurance coverage lags science. We've known that ApoB is more accurate than LDL since the 1990's or 2000's, but to be covered by insurance, several more steps have to happen.
First, the major professional societies (like the American College of Cardiology or National Lipid Associations) have to issue formal guidelines.
Then, the USPSTF (US Preventive Services Task Force) needs to review all of the evidence. They tend to do reviews only every 5 or 10 years. (Countries aside from the US have different organizations that perform a similar role.)
If the USPSTF issues an "A" or "B" rating, then insurance companies are legally obligated to cover ApoB testing. But that also introduces a year or two lag since medical policies are revised and apply to the next plan year.
The net effect is that the entire system is 17 years, on average, behind research.
ApoB blood tests are relatively cheap. You can pay out of pocket about $70 if you really want one and insurance won't cover it.
Most commercial health plans will cover an ApoB test for members with certain cardiac risk factors or medical conditions. But they generally won't cover it as a preventive screening for all members. I don't think we have enough evidence to justify broad screening yet, although that may be coming.
> When I see that the purpose of statins is to reduce plaque buildup in the arteries, and that we have the ability to measure these plaque buildups with scans, but the scans are rarely done, I wonder why.
I'd love to know where to get the right advice on this topic.
I have high LDL-C, had a heart CT in hospital last week, yet the hospital's cardiologist phoned me yesterday to cancel a scheduled appointment to discuss the results(!), because she said I have zero arterial plaques and there's simply no need for us to meet.
How old are you? I was told that they're not considered diagnostic until somewhat later in life (>50) because the plaque may not have calcified yet, which could cause a false negative.
I was found to have high cholesterol in my late 20s. At the time the doctors (my cardiologist, then a second one brought in for advice) determined that the source was hereditary, but the effects would be the same. So they put me on statins. It's been 40 years now. I changed the statins three times since, when the actual one, at a specific time was no longer able to keep the values within acceptable limits. Approximately 8-9 years ago (I think) I ended up on Rosuvastatin 20mg, which I'm still taking every day. I do not maintain any diet (it'd be very hard, as I'm a heavy meat eater) and cholesterol levels are still staying within acceptable limits. Of course YMMV
No heart attacks or strokes? I'm in the same boat (hereditary issue), and altering my diet has never had any substantial effect on my numbers. I'm not overweight and rarely eat red meat, but have had trouble keeping onto a primary care physician long term (the people I keep picking seem to move between clinics constantly) in order to retain consistent access to a statin prescription, but as I continue to age I've been getting increasingly anxious that my time is coming.
So far everything is good. I only had more of a logistic issue, once, when moving to France from the US, a few years back (retirement) and when my new doctor told me that the French do not recommend statins for people at my age and overall good shape (active, fit, etc. ), even if the numbers are high. I asked her to give me a referral to a cardiologist, to whom I mentioned my 35 years of statins in the US, and who was of the opinion that after such a long time and with no apparent side effects, he would recommend continuing on this type of médication. And that was it, so I'm now getting the prescription renewals almost "automatically", even as my cholesterol is staying within limits (under the assumption that it may increase, should I stop, especially considering the amazing cuisine and products to which I now have access :) )
I haven't had to touch statins to get my lipids profile much better. I used zepbound to lose about 50lbs and then weaned myself off that. I was a little afraid my “completely normal after 8 months of weight loss” blood panel status at the end of my zepbound journey would go back to the “bad” region, but I have maintained going on a year with a much better whole foods/lean meats based diet and moderate exercise (I do let myself have some red meat on Saturdays, otherwise I would explode from hamburger desires). So it was done through a combination of lifestyle changes and zepbound to help me bury the hunger monster long enough to learn new habits and get to a new normal. Him suggesting that “probably” most people should be on statins whether they need them or not seems like covering up the source of the problem. I do know that some people just naturally have lipid issues even when doing “all the healthy things” though. My mom is one of them.
I ALSO want to not be a statin-skeptic but, like you, these things look very weird to me. The most prescribed drugs in the country and we don't even try to check if they are addressing the actual problem?
We have checked to see if they are addressing the problem more than probably any drug in history. The idea that we haven't is the result of skeptics cherry picking results that back up their point while ignoring the huge quantities of evidence supporting the efficacy of statins and other LDL lowering medications like ezetimibe, pcks9 inhibitors, etc.
Statins are so good at what they do they even reduce the risk in people who are already at low risk for heart disease.
That's fair. I know a lot of generic drugs are imported too, so maybe there isn't much pressure within the USA there. Unless the big domestic pharmaceutical companies are still making a lot of money on it even if generic options exist? I don't know.
That prior discussion gives no good reasons. The linked medium posts are, to be frank, trash.
Statins are well-tolerated drugs with little to no noticeable side effects. You might have to try a few. You may need to combine ezetimibe to maintain a moderate statin dosage level, and that's it. (Like the author of this article)
Source: Leading cardiologists worldwide, and doctors of the rich and famous.
I pointed to this BMJ reference because in the article there is the following: "To help drive down our ApoB, we have statins which do miracles for lipid management. Some people believe that everyone should be on a statin so long as they don’t have adverse side effects."
Most statins prescribed today are not for secondary prevention.
A lot of doctors prescribe a statin immediately on seeing just one measure of "high" LDL without looking at any other parameter or context.
Yeah, for each level of cardiovascular risk (in America, probably calculated with PREVENT) there is a target LDL which should guide whether you should start or not a statin.
I recently went on a statin (atorvastatin) and found I have the WILDEST dreams of my life if I don't take them in the morning, and my doctor said my liver readings were elevated after use but not enough he wants to switch it yet. Which alternative statins should I be looking at, or do they have even harder side effects to deal with?
I have intense anxiety attacks on atorvastatin. Rosuvastatin at the low dose (5mg) doesn’t do much, but at 10mg and 20mg it caused the same effects. It took years and multiple cycles of going on and off the drugs to become confident this was the problem. I switched to Repatha which doesn’t have this problem (it does make me a bit hungry though) but it’s expensive and it took a while for my insurance to approve it.
> Statins are well-tolerated drugs with little to no noticeable side effects.
Sorry, that's nonsense. It is a dangerous drug with plenty of side effects. If it had no side effects it would be sold over the counter. The brain needs cholesterol to function. If you artificially remove cholesterol this is what happens: https://www.health.harvard.edu/cholesterol/new-findings-on-s...
No, your post is nonsense. You link a random article that doesn't even make the argument that you're making - that it's low cholesterol causing the memory loss - or that statins are causing the memory loss at all.
And considering serum cholesterol cannot pass the blood brain barrier and that it is all synthesized de novo in the brain makes it an even sillier claim. Your serum cholesterol level does not have impact on your brain's cholesterol levels.
Quite a few organs have the ability to synthesize cholesterol as needed and can do so just fine. Another area where we make use of cholesterol is for synthesizing hormones... but those organs can all synthesize it de novo just fine too.
The new pkcs9 inhibitors have gotten people down to extremely low levels of LDL (<30 and <10!) and found no impact to cognition, hormone production, etc. We have mendelian randomization studies looking at people that genetically do not produce pkcs9 and have basically nonexistent serum levels of LDL, no impact to cognition, hormone production, etc.
The human body creates cholesterol because it is essential for several vital biological functions. Cholesterol is a key structural component of cell membranes, providing rigidity and fluidity necessary for cellular function.
> Memory loss and confusion have been reported with statin use.
People reporting things doesn't mean much, because as your own original link mentions, people tend to overreport stuff when they are going to the doctor already for other things. What do actual studies that have controls show? We have human RCTs here that have looked at this very thing - and found no evidence of it.
A random article on webmd also says very little when it contradicts the data we have from human RCTs and provides no sources. The trials I linked specifically looked at the common concerns that people have raised as being possibly related to low cholesterol - and didn't find them.
No one is saying that cholesterol isn't essential - your brain literally won't work without it, among many other things. But there is a difference between serum cholesterol levels and its use in in your body. You do not need high serum LDL-C levels for your body to create cholesterol where it needs it.
Those studies I linked quite specifically check for these concerns on people with way lower LDL-C from PKCS9 inhibitors than even combo therapy of statins and ezetimibe will get most people.
You can do a "study" to prove anything you want. And study outcomes often do vary depending on who is paying for it. The FDA is a neutral party. I recommend prioritizing the FDA warnings over "studies".
The FDA errs on the side of placing more warnings rather than fewer. They'd rather have false positives than false negatives. The warning is also clear that there is not a definitive causal link.
If you want to trust individual anecdotes over RCTs while scare quoting the primary way we advance science in these fields, be my guest.
I'm a big statin sceptic so just putting that up front.
I think things haven't changed because most people underestimate how slow institutional scale change is. There is a reason why HR departments and consultants have Change Management experts. The inertia is huge. Young people don't appreciate this because they thrive on new ideas. Old folks don't and will subconsciously push back, like a form of institutional homeostasis.
Also, while I believe your heart attack stats are correct, I'm more interested in all cause mortality. I believe there statins are a net negative.
A single study showed a single statin reducing GLP-1 levels and ascribed it to gut microbiome changes that could be totally resolved with UDCA supplementation.
If this even ends up being reproduced it at most says there is an easy fix for people taking atorvostatin and that it might be a concern with other statins, but this should be treated with the same health skepticism of any other single study finding.
Not all statins raise blood sugar either - pitavastatin usually shows an improvement in insulin sensitivity.
How many doctors are cycling through all the statin classes to find the least-bad option for each patient?
(I'll rant about one guy I know.. was any of this related to statin over perscribing? who can know)
Now that we have your LDL under management isn't it easier to just add metformin and gabapentin into the mix? I mean what are the chances you're not also put on a calcium blocker too?
Now you've got brain fog and sleepiness? weird! we have some modafinil for that but now that you're developing early-stage dementia know that it's progressive.
If you have metabolic syndrome (heart disease, diabetes, obesity, hypertension, liver disease etc) then yes, you will take many different drugs. Because these are all complex conditions that must be managed, and that will lower your quality of life and raise your mortality.
It sometimes seems like if you get one, you get the others. That's because all these diseases feed into each other.
If you go and tell your doctor you're having trouble with a statin, they should have you try a new one, yeah. Some might need to get clued in on pitavastatin, as it only recently went generic and insurance companies really didn't want to approve it before this due to the cost and wide field of generic statins, but it tends to have one of the best profiles when it comes to side effects.
The PKCS9 inhibitor monoclonal antibodies are an option for most people if they show intolerance to multiple statins - insurance will usually relent at that point.
If your doctor isn't willing to work with you to find the medication that works best for you, then find a new doctor.
one better simple indicator than large panels, if you can't get access to them or don't have them is simply your triglycerides/hdl ratio. aim to be under 2 if using mg/dl and under 0.87 if using mmol/L. it's one of the strongest correlated indicators of cardiovascular disease. way better than any classic cholesterol ratios.
Statins can be effective for many patients (and there are multiple different statins with varying effects) but there are also alternative or additional drugs such as Leqvio (inclisiran) and Repatha (evolocumab). Patients should do their research and talk to their doctors. It might take some trial and error to figure out what works best.
The general advice is that the scans are only useful sometimes. That is, they can show a problem. But a clear scan doesn’t mean you’re fine. So don’t base anything on a clean scan, be proactive with all the rest of it. My two cents, by the way: Repatha is pretty amazing.
There is no reason take statins, ever. They will destroy your muscles, then cause diabetes and thus indirectly kill you. They will prevent a heart attack by... four days.
If biomarkers are elevated, the question must always be, "why is this elevated", and "is there a natural change in habit and diet that can reverse this elevation".
Artifically lowering the marker with a drug is like pasting duct tape on a leaking pipe - the leak is still there and it will likely quietly get worse over time and then eventually kill you anyways.
I find it unbelievable that our society swallows any drug without second thought. You body produces cholesterol on purpose. There must be reason why it produces it. "Ah well, who cares, let's just throw in a wrench and make it stop producing the cholesterol" and hope for the best...
Arguing against nonsense like this gets so exhausting.
Statins do not destroy your muscles. Newer statins make this already exceedingly rare side effect even rarer, but let's look at them as a general class:
Blinded RCT/Meta-analysis shows about 11 complaints per 1k patient years, with 90% of them not actually being due to the statin. But because people act like they're common, they mistakenly believe it was the statin, which just reinforces this idea. And that's for muscle pain.
For actual significant muscle injury? Even lower. 1 or less per 10,000 patient years.
Effectively, you might get one muscle ache per year per 100 people and at most a 1 in 10,000 chance of serious myotoxicity.
As for diabetes, rosuvstatin usually has a neutral to positive impact on insulin sensitivity, and pitvastatin almost always has a positive impact. Some statins do have negative impact, but it's not universal.
It's not like duct tape on a leaking pipe - it's like removing items in a pipe that damage the pipe walls. Yeah, ideally they're not in the pipe to begin with, but removing them is better than letting them stay, and diet and exercise only do so much to remove said items.
Your body can synthesize LDL de novo in the organs that use it, and one of the heaviest users, the brain, can't get cholesterol out of your diet/serum levels at all - LDL cannot pass the blood brain barrier.
There are people with genetic mutations that mean they don't produce LDL, or at least not at high levels - their increased longevity and incredibly rare incidents of ASCVD is what drove the creation of PKCS9 inhibitors.
Statins also lower LDL-C levels - they don't make your body stop producing cholesterol in general, or even LDL-C. Even if your body couldn't make it on-demand where needed, statins aren't going to drop your serum levels to 0.
I feel like statins are harder to accept than vaccines. With vaccines we can say it is just training our existing immune system to recognize and fight something. So how would you straightforwardly explain statins to a scientifically literate adult so they can make an informed decision. But part of that means honestly acknowledging whatever scientific unknowns and uncertainties there are in this area of human biology.
> When I see that it is widely accepted that ApoB is better to measure than LDL-C, but the industry continues to measure LDL-C, but not ApoB, I wonder why.
That's pretty simple to explain. No conspiracy.
LDL-C is much much cheaper to measure. ApoB costs 36x times as much, so Insurance Companies don't like to pay for it
My wife had high cholesterol numbers, so her doctor wanted to give her statins. She asked about a scan, he begrudgingly said well, I guess you could do that. Her scan showed 0 plaque.
It was almost certainly the former, and the former is is basically an indicator that the damage is already done.
Soft plaque takes a long time to calcify. But soft plaque is the stuff that ruptures, and will clog up your arteries just as much.
Statins are best used as a preventative measure - once the plaque is there it's difficult to regress it even while soft, and as far as we know effectively impossible once it is calcified.
I now have a cardiologist and just had an MRI to check on the state of my aorta, as a recent calcium scan brought up concerns.
I've now been on rosuvastatin and ezetimibe for several years with zero noticeable negative effects. I'm hoping that this with other behavior modification can help stave off further damage for a while.
I've been thinking the AI bubble wouldn't pop, because even the AI advances we've already seen can change the majority of industries if it is carefully integrated with existing technology. But if there's a mass movement to use older and/or smaller models, then yeah, all the money going into newer bigger models will pop.
Or, maybe the training datasets getting polluted with AI slop will mean that new models are worse than old models. That would pop the industry.
Or, maybe the GPT-4 era was the golden era for AI, and making them bigger and better is just overfitting (in the classical machine learning sense of the word) and is both worse and more expensive. This would pop the industry too.
I guess there's a few ways for the industry to pop, but this trend of using older models makes me especially skeptical of AI.
Since the day GPT-5 released, I've felt quite confident that the GPT-4 era was the golden era for AI.
I don't have evidence beyond my experience using the product, but based on that experience I believe that Open AI has been cooking their benchmarks since at least the release of GPT-5.
What if people just publicized their own social security number, and then whenever they had to deal with "identity theft", they just pointed out that their SSN is public information and so it was negligent for the company to believe it was them just because of a SSN.
Just for the record, I think it’s a crazy idea to make things like DNA or fingerprints public. But a social security number is different. It’s wild how in the US, if someone gets hold of your number, they can do so many things with it. I’m from Sweden, and here we have a similar number called a personal identification number. The last digits are not secret but still sensitive. You can actually Google and find out almost anyone’s number if you want to, and it’s used for similar purposes. But it wouldn’t be enough to cause serious harm just by knowing someone’s number. Identity theft happens here too, but for a company it’s not much different from someone just having your name. It’s still a pain, but it’s nothing like in the US where your life can basically fall apart if someone gets your social security number.
Most doctor's offices just use my name and birthday to assume authorization to transfer sensitive medical information. I kinda feel like privacy is massive "emperor has no clothes" aspect of society.
This behaviour is just because their IT system doesn’t allow regular users to search for names, just for birth dates. Then they pick you by name from a list of people with that birthday.
This is nowhere near the only use of the "birthday + name == all info" hack in the US medical industry. It's basically one big giant frat club with shakes and implicit trust all around. Except that it doesn't actually work; you can fake being a doctor to just about any US medical office and get nearly any American's private medical data.
Exactly. This is just snake oil. No idea why I'm getting downvoted for stating the truth: the employee doesn't care about privacy. They don't use the birthdate because they think it's more secure, the ask for it because they have to.
So what? The person on the counter doesn't care at all about your privacy. They just cannot type your name into a search box, they have to ask for your birth date first before they can select you from a list based on the name that you state afterwards. At least that's the case at many doctor's offices I've been to.
What do you mean so what? How does asking for a name help if it comes back with a list of multiple people with the same name? Adding the birthday makes it (much closer to) unique
Being AI-generated is not the problem. Being AI-generated and not understandable is the problem. If they find a way to make the AI-generated code understandable, mission accomplished.
How much of their time should open source maintainers sink into this didactic exercise? Maybe someone should vibe-code a bot to manage the process automatically.
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