Setting Expectations

I have zero medical education or training. I’m a software developer / technology guy by training and trade.

And while I’m an intellectually curious person that tries to understand the topics I engage with, medical subjects aren’t a big focus for me.

I’ve spent limited time perusing the papers and information on this topic.

I am not presenting myself as an expert, or even claiming to be well-versed on this or similar topics. At most, I’m offering some considerations as people weigh information.

Generally this is a topic I would shy away from (I have a big post about vision transformer models I need to finalize and get published), but seeing yet another grossly misleading (e.g. deceptive) video from a health influencer has spurred me to write a minimal piece on this. I’m going to touch on the classic misinformation I see repeated ad nausea whenever this comes up on discussion boards.

My Biases / Disclosure

I’m fully vaccinated¹. My kids are fully vaccinated. I trust science on the whole, while understanding that fields like medicine and nutrition² are full of contradictions and abundant with uncertainties and paradoxes. The biology of humans is insanely complex and only partly understood.

Our bodies are layers of reactive processes³ that “error correct” in such a way that cause and effect of a stimuli is often difficult to measure and can be highly counterintuitive. Where the consequences of an effect can sometimes take decades to manifest in a statistically significant way, as various systems adjust and offset to survive hostile conditions, and slow-developing disease can be a chain-reaction of increased probabilities.

I’m not a health nut, nor am I paralyzed by the fear of mortality. I don’t lament the shortness of human life. I’m far more concerned with healthspan, as Peter Attia often describes it, than lifespan. I want to ensure that I’m not a burden and can continue enjoying life with my family for as long as possible. I have zero ambition to “slow down”, and don’t romanticize that being idle is a desired destination. “Retirement” sounds like a nightmare⁴, at least if you aren’t doing the boastful “made lots of money” change of careers fake retirement.

I wake up feeling great. I’m an ideal weight. I try to close my fitness rings through a variety of exercises each day. A few times a week I start my day with some movement exercises. I eat lots of red meat, eggs, and drink 2% milk, but I also enjoy lots of whole grains, vegetables, lean meats and fish. I avoid simple carbs to a reasonable degree, but occasionally partake. Sucralose is the common sweetener in my hot drinks.

My goal is living, not merely existing.

I long had high LDL cholesterol, low HDL, coupled with high blood pressure, which diet and lifestyle adjustments⁵ had little effect in controlling. After consulting my doctor⁶ and spending some time digging into the medical research on these topics, I went along with his medication recommendations: I take telmisartan (a blood pressure medication), atorvastatin (a statin) and amlodipine (another type of blood pressure medication), the last two in the form of one pill called caduet. I’ve been on this regime for years now, and my LDL and blood pressure both dropped to the low side of average, and my HDL rose to average.

I’m pro-statin⁷ and for low LDL cholesterol, and think the science overwhelmingly supports this position. This is my bias, and the rest of this piece is in the service of countering some of the common misinformation I see used to dismiss statins.

The Grift

This is completely tangential to this entry, but what is it with the chiropractic industry?⁸ Why does that field generate so many scammers and grifters?

I imagine the industry has some well-meaning practitioners that offer legitimate, long-lasting benefits to their clients⁹. Yet it’s simply astonishing how often you come across some health “influencer” saying ignorant nonsense, and it turns out they’re a chiropractor.

The field originated when a guy (Daniel Palmer) claimed a ghost told him during a seance that he should give spinal adjustments a try as a magical cure-all. I guess it’s an in for a penny in for a pound sort of thing, and that field is rife with nonsensical pseudoscience in the vein of the original sin.

It’s actually incredible it hasn’t faced regulatory obliteration, and was quackery that got grandfathered in. If someone is spouting nonsensical claims, there’s a surprisingly high probability it will turn out they hold a doctor of chiropractic degree. Seeing a D.C. backing a position biases me against it, acting as a negative credibility indicator.

I didn’t slur that field just for fun, though. On the topics of statins and cholesterol, it is astonishing how often misinformation, disinformation and lies can be traced back to chiropractor wellness influencers. That field seems to exist purely to take a big steaming shit onto the consensus with the illusion of authority, and to sow nothing but fear, uncertainty and doubt about actual medical science. They are the patient zero of almost every stupid belief in health and nutrition.

Chronic Disease, Cumulative Effect and the Area-Under-The-Curve

Imagine that you took a million teenagers and split them into equal-sized groups. To one group you prescribe a pack of cigarettes a day, and to the other you prescribe fresh air.

At the five-year mark you test both groups, finding a negligible difference in lung cancer rates.

“Smoking has no effect on cancer rates!” you proclaim.

That would be extraordinary medical malpractice. The influence of smoking on lung cancer rates is enormous and extremely well proven¹⁰, yet often takes decades¹¹ to manifest into statistically relevant, and then statistically overwhelming, consequences.

Because smoking is chronic and cumulative on lung damage, increasing the risks, long term, with every pack smoked. Each is like planting a little bomb with a very long fuse.

This is called the “area under the curve”. It’s a cumulative effect that usually has consequences years later, and the larger the area — the more cigarettes smoked for longer — the more likely and severe the eventual consequences.

There are many chronic conditions and lifestyle exposures that have the same area under the curve effect. Alcohol, excess weight, high blood pressure, sedentary lifestyle, saturated fat consumption, elevated blood sugar, sun exposure, high noise levels, asbestos exposure, high LDL levels, and many others. You can endure and abuse all of these things within reason for years while being “healthy” … until it eventually catches up to you and you aren’t. Many people die prematurely¹² because seemingly benign activities have long term damage.

The Absolute vs Relative Risk Deception

Every naysayer of statins¹³ always references the claim that the relative risk reduction (RRR) of statins look good, but the absolute risk reduction (ARR) is marginal. It’s an absolute go to. These claims are always based upon this paper from JAMA 2022, and are always a sort of “statins proven ineffective” trump card. This meta-analysis has been referenced countless times, usually by don’t-sweat-cholesterol crowd.

That systemic review (basically a study of studies) — Evaluating the Association Between Low-Density Lipoprotein Cholesterol Reduction and Relative and Absolute Effects of Statin Treatment — shows that statins achieve some remarkable relative reductions during the study duration. Almost 30% fewer myocardial infarctions for the statin group. 15% fewer strokes. About 9% less mortality in general. But then it points out that the actual incidence of all of those events in the test groups were low, ergo the absolute risk reduction was marginal to irrelevant.

Statins, the paper concludes, have a “modest” benefit given this small absolute risk reductions. It proposes that the benefits are oversold.

Here’s the problem, and it loops back to the prior section on cumulative effect: The average duration of the study they considered was 4.4 years (from as short as 1.9 years to 6.1 years).

These studies took a cohort of subjects with often decades of high cholesterol exposure — a very large area under the curve — and to half they prescribed a statin and the other half a placebo. The West of Scotland Coronary Prevention Study, one of the trials considered, the average age of participants was 55, and ran for just 4.9 years.

Over just that period, and despite the area under the curve already presumably being enormous — many long-fuse bombs already being set, and the participants were selected for their high cholesterol levels — a large relative difference was already seen over the short study period. The mortality rate of men 55-60 is fairly low — about 5 per thousand — so that the absolute rate wasn’t large is not surprising.

There have been many other distortions of this study. Again, the mortality rate of the participants was already fairly low, and even still the relative risk was significantly improved. Yet because the absolute risk was small, the calculated lifespan addition by the study duration of statins was just three days (later to be corrected to 17 days). You can find this critique frequently in statin discussions. Again, it is similar to the teenager smoker study where after five years neither group died, therefore smoking does not increase mortality. It is grossly misleading and inaccurate.

Statins are a long-term preventative treatment for a chronic, long-developing condition, reducing the buildup of plaque in artery walls¹⁴. They are not generally viewed as an acute treatment, though there is some evidence that they can stabilize plaque for very advanced cases. The relative measured benefit over such a short period when mortality is still quite low is remarkably high, and it’s pretty amazing this is held against it.

But it gets even better. The study authors monitored the health records of participants for decades more. After the study concluded and neither placebo nor stain recipient were given any advice or treatment, and either set could pursue whatever treatment they wanted, the statin group still showed a significant if not even widening benefit over the placebo group.

Many in the placebo group pursued post-study statin treatment, and many of those who were in the statin group stopped the drug altogether, yet the residual benefit of that 5-year area under the curve reduction carried forward for decades. They had banked and benefitted from a smaller area under the curve (I will continually reference that concept as it is critically important to recurring exposure risks).

The Weight of Evidence

There is overwhelming evidence to the benefits of statins and lower “bad” cholesterol in general. Better still is getting your cholesterol down without statins being necessary through lifestyle, but leveraging medication where necessary. The earlier the better.

We’re in interesting times when the same people who push positions with little to no science on their side — the bizarre vilification of seed oils and heralding of tallow has to be the current pinnacle of this nonsense — are the ones who will clutch onto every iota of anti-statin meta-analysis, usually grossly misunderstanding or misrepresenting said findings.

Optimizing the Benefits

I started statins in my early 50s, after being measured as having high LDL-C and low HDL-C incidentally while investigating an issue with migraines. I can’t know for sure how my levels were prior to this, but in all probability it has been at these levels for years. To circle back to that overused phrase, I’ve already probably accumulated a lot of area under the curve.

I’d be better still if I got it under control much earlier, whether through diet, lifestyle or medication. But I still appreciate that it greatly reduces my chances of stroking out or having a debilitating infarction that turns me into a burden.

The Likely Retorts

”Cholesterol Is Important For Life”

Cholesterol is a critical sterol (a type of lipid) that serves as a fundamental building block for cells and hormones. We need cholesterol to live. It is used throughout our body, including in our brains.

No one is advocating cholesterol annihilation. Intervention is to get cholesterol back into the normal range. This is very similar to blood sugar control, where we need blood sugar to power our bodies, and if it gets too high or too low there are consequences.

”People With High Cholesterol Actually Die Less”

This is where reverse causation might rear its head. There are observational studies that demonstrate that high cholesterol at study inception is correlated with lower mortality (less likely to die), such as “Association of lipoprotein levels with mortality in subjects aged 50 + without previous diabetes or cardiovascular disease: A population-based register study” (DOI: 10.3109/02813432.2013.824157). This study notably excluded those with CVD or diabetes, and excluded those taking statins at the start.

This statistical aberration can occur because people with many other health conditions often have low cholesterol levels. Cancer, for instance, uses cholesterol as a building block, and can dramatically reduce blood cholesterol levels, sometimes for years in advance of cancer being detected and diagnosed. Any diseases where you waste away, including drug addiction, also naturally leads to collapsing cholesterol levels. Dying as a process sees cholesterol fall towards zero.

Proving this paradox, of the people followed during this observational study, those that then started taking statins during the study actually had even better mortality outcomes. High cholesterol was a luxury of being otherwise healthy and food rich, but getting it down was even better still.

Similar effects have been seen with BMI. People with chronic disease often lose significant amounts of weight, leading to mortality U-shaped curve where people at mid to low BMIs have higher mortality than people who are overweight, at least if you only count the BMI at the time of death.

”People Dying At Hospitals Usually Have Low Cholesterol, Not High”

Basically the same as the last point, but it’s a claim I’ve seen expressed frequently in debates.

Dying as a process often entails falling cholesterol. They aren’t dying because of low cholesterol.

”Low Cholesterol Leads to Dementia”

The preponderance of evidence is that high cholesterol actually leads to increased risks for dementia. Yet among those with dementia, low cholesterol levels are often observed. As with the prior two retorts, it’s reverse causation.

”People Having Heart Attacks Usually Have Normal Cholesterol”

This is a frequently cited study among high-cholesterol apologists. It’s a bit ironic as the intention of the study authors was that guidelines needed to be lowered even more to effectively reduce risk, and they weren’t diminishing the importance of cholesterol measures.

A heart attack is the destination, not the journey. The cholesterol levels of an elderly individual says incredibly little about their levels for the decades before. The area under the curve could be enormous.

”What about Lean Mass Hyper Responders?”

Dave Feldman et al. are doing some novel work in studying a group of people dubbed lean mass hyper responders (LMHR). This phenotype is lean and active, metabolically healthy people on very low-carbohydrate / ketogenic diets, and they generally exhibit very high levels of LDL cholesterol, but very low levels of triglycerides. The hypothesis is that in this unique situation, lipids are primarily energy carriers and not as dangerous.

He has had some interesting findings, and he is putting considerable money towards novel research.

His research has zero relevance to the overwhelming bulk of people suffering high cholesterol, however, most of whom also have high triglyceride levels courtesy of a carbohydrate rich diet. Seeing it cited by overweight, metabolically unhealthy individuals on high carb/ultraprocessed diets, in the service of minimizing the threat of LDL cholesterol, is extremely sad and counterproductive.

Once it was clear during COVID that the available vaccines had a limited effect on controlling spread with rapidly evolving strains, I came to believe that vaccine mandates were counterproductive. I got the vaccine and appreciated the personal benefits and reduced risks, but if someone had opposition it was absolute folly to induce them to take it.

Vaccine and COVID mandates had the unintended consequences of super-charging stupidity and grifters, and was a painfully predictable outcome that we are going to suffer the consequences of for years ↩
Remember when we purged fat from our diets, replacing them with simple carbs and sugars? A disastrous outcome caused by unintended consequences ↩
Seriously though, it is astonishing how robust the human body is against abuse and suboptimal conditions. This is one of the reasons there is often conflicting advice and findings that seem entirely at odds with each other

It is incredible how people can often abuse their bodies for decades before the bill is due. Many unhealthy behaviours don’t manifest negatively until future-you has to suffer the consequences ↩
Retirement traditionally was a gate where the average person hit their expiry date and needed a pretend “reward” to get them out of the way. Their body had been abused to the point where the area under the curve had cumulated across such a range of measures that it was more useful to toss them aside, while pretending it’s some great goal line we are all racing towards ↩
To be fully honest, I was only willing to adjust my lifestyle moderately. I likely could have solved my cholesterol issue by diet alone if I were fully committed, but there are a lot of saturated-fat rich foods that I really enjoy and don’t want to give up ↩
I had consulted my MD due to recurring migraine headaches. These completely disappeared with the medication. I still get the pre-migraine aura, but the migraine no longer follows and I haven’t suffered one in years ↩
With the caveat that some people have bad side effects of statins. Obviously if someone responds negatively, the algebra changes for a given patient.

And obviously the best scenario is that lifestyle and diet alone gets your cholesterol levels where you want them. Pharmaceutical intervention is a secondary option ↩
To be fair, the tech industry has slung an endless procession of garbage people with garbage takes on the world, but the chiropractic industry is more dangerous in that it is shrouded in the illusion of medical competency ↩
I mean…does it? It seems entirely pseudoscience based and of remarkably little demonstrated value to anyone ↩
Yet as with any extremely well proven and accepted fact, you can of course find contrarian clowns that will intentionally misrepresent stats and facts to try to make a name by going against the grain. There are currently wellness “influencers” making a name by claiming that fiber, fruits and vegetables are what really ails society. Whatever contrarian position gets them the attention they crave and can monetize ↩
Cigarette consumption and lung cancer curves both peak about 30 years apart. The lag between action and consequence, on average, is about three decades ↩
Or arguably worse they have a significantly abbreviated healthspan. Medical science might keep them going for decades more, but now they live a significantly worsened enjoyment of life ↩
In most cases these are advocates of diets that have a side effect of very high blood cholesterol levels (courtesy of high levels of saturated fats), for instance keto diets, so minimizing the downside of excess cholesterol and thus any cholesterol management regime is just a secondary battle they adopted through necessity, cherry-picking to support that argument ↩
There is some convincing research that aggressive LDL cholesterol lowering via statins can actually reverse plaque accumulations in artery walls, and the lower the blood LDL, the more plaque reduction occurs. In this case the treatment can actually be acute, and it might explain why there was the relative benefits over even the short term of something like the WOSCOPS trial. But generally statins are prescribed as a long-term preventative measure ↩