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“High Cholesterol,” Statins & Diabetes

My mom went to the doc yesterday. As a Type 2 diabetic who controls it pretty well, she nonetheless still does regular visits. She's very low-carb Paleo-ish, and while she was able to be off insulin for a time completely, still finds she needs very small doses now and then.

To the endocrinologist's credit (a new doc), she did acknowledge being impressed with my mom's diet and supplement regime. But there was one little problem: mom's total cholesterol is 217. The doc asked her if she wanted cholesterol lowering meds. But my mom reads this blog and was thus prepared, indicating that for women, higher cholesterol is associated with increased longevity (lowest all-cause mortality and not just an overly reductionist tunnel vision, zeroed in on cardiovascular mortality).

But the doc retorted with something I can't recall reading or hearing about, specifically. She asked my mom if the studies and information she's relying on concerned women with diabetes and not just a general cross-section, as diabetes is associated with twice the heart disease and stroke as for non-diabetics (according to the doc).

Hmm.... So I did some initial digging around. I ended up writing this in a reply email.

The problem is: what level of diabetes? You control yours pretty well, so there is no comparison between you and someone who doesn't.

There is ZERO benefit to lowering cholesterol, especially in women (indeed, the greater chance is it's harmful). Cholesterol doesn't cause heart disease; inflammation does and this is how statins, when they work, work. But keeping grains, legumes, sugar, and vegetable/seed oils out of your diet has an even more anti-inflammatory influence I suspect. Actually, it simply allows your body to go back to its natural, non-inflammatory state.

I added links to an article by Dr. Duane Graveline at Spacedoc, as well as Chris Kresser's 2-part video series on statins at The Healthy Skeptic. The problem is, neither of those seemed to address the issue specifically, and moreover, there's this quote from the first link.

The fact that there is no statistically proven cardiovascular benefit from the use of statins for cholesterol reduction in women was first publicly disclosed by Uffe Ravnskov in his book, Cholesterol Myths and has been corroborated repeatedly by numerous longitudinal clinical studies.

The ASCOT study, the largest randomized clinical study of statin effectiveness in women, found that the women who took Lipitor, developed more heart attacks than women in the group given placebo.

While not statistically significant this finding hardly supports cardiovascular benefit. In this ASCOT study, 2,000 women were included among 10,000 patients having elevated blood pressure and at least three other cardiovascular risk factors.

Again and again, clinical studies have failed to show that the use of statins lowers cardiovascular risk in women who do not already have coronary heart disease or diabetes.

So just when you think it's all settled, there's that D word, right at the end. This is off the top of my head but as I recall, statins have only been shown statistically beneficial to men who have had a previous coronary event (statins reduce the rate of subsequent events). But is there another category of benefit out there I don't know about?

So I did more digging and came up with this:

Is diabetes a coronary risk equivalent? Systematic review and meta-analysis

Abstract

Aims To determine whether patients with diabetes without prior myocardial infarction (MI) have the same risk of total coronary heart disease (CHD) events as non-diabetic patients with previous myocardial infarction.

Methods Using MEDLINE, EMBASE, Cochrane and MeSH in this systematic review and meta-analysis, extensive searching was carried out by cross-referencing from original articles and reviews. The study consisted of cohort or observational studies with hard clinical endpoints, including total CHD events (fatal or non-fatal myocardial infarction), stratified for patients with diabetes but no previous myocardial infarction, and patients without diabetes but with previous myocardial infarction. Studies with less than 100 subjects, follow-up of less than 4 years and/or without provisions for calculating CHD event rates were excluded. The review of articles and data extraction was performed by two independent authors, with any disagreements resolved by consensus.

Results Thirteen studies were included involving 45 108 patients. The duration of follow-up was 5–25 years (mean 13.4 years) and the age range was 25–84 years. Patients with diabetes without prior myocardial infarction have a 43% lower risk of developing total CHD events compared with patients without diabetes with previous myocardial infarction (summary odds ratio 0.56, 95% confidence interval 0.53–0.60).

Conclusion This meta-analysis did not support the hypothesis that diabetes is a ‘coronary heart disease equivalent’. Public health decisions to initiate cardio-protective drugs in patients with diabetes for primary CHD prevention should therefore be based on appropriate patients’ CHD risk estimates rather than a ‘blanket’ approach of treatment.

So on the one hand, statins are of no benefit to women, even those who have had a previous coronary event (unlike for men), and on the other, even men & women with diabetes who have never had a coronary event are far less likely to have one than non-diabetics who've had one.

While that's not a direct study of the question (do statins lower coronary events in women with diabetes?), putting 2 and 2 together seems to imply to me that given the rate of serious side-effects experienced by those on stains, combined with what seems like a very dubious benefit to a woman with well controlled diabetes, equals not much reason to take them and lots of reasons not to.

Anyone have anything contrary, or better. Either way.

Comments

  1. Richard,

    A few things:

    - Diabetes and CVD share a common etiology: inflammation. So yes, diabetes raises the risk of CVD because people with diabetes have inflammation, and inflammation is the primary cause of CVD.

    - I believe (and I imagine you would agree) that total mortality is a much more important endpoint than CVD risk. While some studies do show a minor CVD benefit with statins for women with pre-existing CVD (many other studies do not), statins have never been shown to reduce mortality in women of any age or disease status. Most people wouldn’t be satisfied with a reduction in CVD events if it came with an increase in risk of dying from cancer or other diseases.

    - Considering the strong association with low cholesterol and increased mortality in people over 65, as well as cognitive problems and depression, statins for women over 65 are double-trouble.

    - As you surely know, total cholesterol is nearly meaningless as a marker. What’s more, just a few years ago a TC of 217 was considered normal. The drug companies keep pushing these numbers down to turn healthy people into patients.

    The most important risk factors are particle-size and oxidized LDL (which itself can be predicted loosely based on particle size). A good way to estimate particle size is by dividing triglycerides by HDL. If the number is below 3, it suggests a preponderance of large, buoyant LDL. If above 3, it suggests small, dense LDL.

    - New studies show that side effects like muscle damage are far more common than previously believed. And some of them are irreversible. Not pretty.

    I think you know my vote.

  2. David Csonka says:

    I think we should dispense with the pleasantries and just refer to hospitals as “Insurance Benefit Providers” and doctors as “Pharmaceutical Dispensary Representatives”. It would go a long way to clear up their roles and what they actually do. ;D

  3. Twinklestarlet says:

    Your mom reads this blog…”F” words and all? Cool. Anyway, I appreciate this post very much. Diabetes runs in my family and I have “high” cholesterol and have for over 20 years. My doctors have always tried to get me on statins but I’ve always refused, knowing the facts. What troubles me is that my docs don’t seem to know the facts, nor do they seem to care. I just keep wondering when the mainstream medical profession is going to catch up with the truth and statins. Or are they too far in the pockets of Big Pharma?

  4. “Your mom reads this blog…”F” words and all?”

    Where do you think I learned it? :)

    No, seriously, she doesn’t often use such language, if ever, but she’s no prude.

    As for the rest of it, about a year ago I got a sliver of glass lodged in my foot that I couldn’t get out. I had to go to my primary doc so he could do a referral to a podiatrist if needed. When I saw him, he said:

    “I can’t do anything. I’m just a pill doctor.”

  5. Jonathan says:

    I think you are spot on with your advice. Diabetes doesn’t cause CVD, uncontrolled diabetes does. Diabetes is a condition of the body where the body is simply trying to protect itself from the crappy diet. It’s not the diabetes causing problems, its the crappy diet (not saying you can’t have genetic things causing it, it’s just more often coming from betacell burn out or resistance from years of abuse).
    Ever rubbed sugar on the tongue? It gets sore. I know blood glucose is different from candy but I don’t think it too far a stretch to say that excess glucose in the blood is abrasive or at the least inflammatory.
    Sounds like she fixed the crappy diet so nothing to worry about.

    when are doctors going to stop fighting the cholesterol our body needs to live and start fighting the inflammation none of us need.
    White blood cells are at infection sites so we will have a pill soon to reduce the amount of white blood cells we have to stop infections.

  6. Richard, in the end of this article I have a series of relevant papers about cholesterol and women:
    http://www.canibaisereis.com/2010/06/05/mulheres-e-colesterol-coisas-muito-complicadas/

  7. Lute Nikoley says:

    This is a good post, no comments from me, just want to receive comments by others. Although I totally agree with the Statins, been off mine for about a year and a half now. I feel better, have more strength, my triglycerides are at 80 with HDL at 65. That’s a 1.27% ration. I guess I lied above about no comment.

  8. Very cool that you have such a huge and positive influence on your Mom, Richard; I’ve been trying to get my father-in-law off of statins for over a year now. His regular GP put him on because of ONLY his TC—-which became “elevated” *note sarcasm* after I got him on fish oil. No hx of CVD or MI, very very healthy dude. I sat down, explain the shift of VLDL to large particle LDL with fish oil, explained the TG/HDL ratio, and sent him Chris’s video series (which are absolutely solid).

    His answer? “I’ll stay on the pills. My doctor says I should”. For me, that’s a tough pill to swallow.

    • I don’t know what to say, Mike, other than just keep trying. By example is probably best.

      • It’s a tough situation; my wife and I have talked about it extensively. Might be a bit of a stereotypical generalization, but folks from that generation (65+) tend to take the word of their physician as concrete truth.

        Pushing too hard might push them away.

    • Jonathan says:

      maybe get him a good book by a doctor. Dr. Uffe Ravnskov “Fat and Cholesterol are Good for You” is what I’m reading now. Great book. Shows how even LDL is good for you and there is no reason to want your cholesterol to come down unless you want cancer or memory loss or muscle pain or a host of other things.

  9. D. Kosovac says:

    http://www.diabetes-symposium.org/index.php?menu=view&source=lectures&sourceid=148&id=666

    Worth a read. Research argues that diabetes diagnosis is the equivalent of heart disease diagnosis and patient should be treated fpr both from the onset.

  10. Just came across this:
    “Statins and risk of incident diabetes: a collaborative meta-analysis of randomised statin trials”
    http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2961965-6/fulltext

    Statin therapy is associated with a slightly increased risk of development of diabetes (% actually)

    So why would you give statins to a diabetic?

  11. I don’t think lack of information is the problem with Mike’s father. The issue is a different perception of the authority of doctors in older generations. They come from a time when it wasn’t normal (or easy) to question doctors or do one’s own research. I’ve seen this over and over again in my practice. Sometimes it works to my advantage, since these patients are likely to be more compliant. However, it also means that they’re bound to listen to whatever their doctor tells them without investigating it further. Giving them information that conflicts with what their doctor says has little effect, or if anything, just makes them feel uneasy. Unfortunately, there’s little that can be done in this situation other than offering the information and being there to answer questions if they arise.

    • That’s exactly it, Chris. Well said.

    • Twinklestarlet says:

      Same experience I have in my family. We can thank the older generation for having respect for authority and we can also tell them that sometimes that unearned trust is not in their best interest. In spite of what doctors might believe, they are not GOD.

  12. There is a direct causal link between membrane cholesterol depletion and the failure of insulin secretion. Data from some statin trials connect cholesterol reduction with increased risk of type 2 diabetes. Statin use has been shown to be associated with a rise of fasting plasma glucose in patients with and without diabete. The underlying mechanisms of the potential adverse effects of statins on carbohydrate homeostasis are complex [10] and might be related to the lipophilicity of the statin. Source: http://www.lizscript.co.uk/Glyn/AMS01.pdf

  13. The benefit of statins for diabetics is questionable. The medical establishment points to the CARDS study which resulted in a CVD risk reduction of 9.1% to 5.6%, which isn’t that great to begin with, but the relative risk sounds impressive. The study was ended early as they decided that all study participants should take lipitor. However, there are criticisms of this study that the paritipants had multiple risk factors to begin with.

    Other long term studies show less CVD risk reduction, along the order of 11% to 9%. Then there was the ASPIRE study where the difference wasn’t statistically significant. I’m sure if I dug deeper, I’d find other studies showing no benefit to diabetics from statins. Even if there is a tangible CVD benefit to diabetics of taking statins, it’s minimal at best and not worth messing with.

    I’m a well controlled type 2 myself and have refused to take statins. I prefer to control inflammation by other means. You mom is one smart woman.

  14. Can I have your mom? My mom is overweight and has fibromyalgia, RA, and migraines, and still refuses to admit that changing her diet would help (even after I seriously reduced my frequency of migraines just by changing my diet). AND she complains that I “don’t eat anything” because half the time when I get to her house, she has processed lunch meats, frozen pizza, and grocery store baked goods to offer.

  15. Simple cardioprotective food choices for those at risk of cardiovascular disease.
    Increase consumption of:
    Garlic
    Porridge Oats
    Oily fish – mackerel, salmon, herring
    Unsalted nuts, seeds
    Olive Oil
    Onions
    Tea, especially green tea
    Blueberries, prunes, strawberries
    Fruit and vegetables
    Beans and pulses
    Wholegrains

    Reduce/Avoid consumption of:
    Coffee
    Fried foods
    White bread, pasta
    Nicotine
    Biscuits, soft drinks
    Excess alcohol/spirits
    Excess saturated/hydrogenated fats
    High sodium foods – e.g. bacon, tinned soup, pickles
    Table sugar – FOS (Fructo-oligosaccharrides) powder is an ideal substitute sweetener and valuable fibre source

    • Oats, beans, and wholegrains? Avoid coffee and alcohol? Grouping saturated fat in with trans fats?

      The complete lack of common sense leads me to believe you work for the government.

  16. We had a family get together on the weekend, I discovered my brother in law(50′s) had been put on statins.
    I asked if he’d noticed side effects like libido, strength loss etc.
    Yes – libido gone, memory and thinking impaired, pullups gone from 13 to 4 or 5, tiring easily in his work, gout flaring badly, dry skin, thinning hair.

    Her thought he must be getting some bad disease all these things were going wrong with him, I told him they were all side effects of statins – he was both stunned – had no idea that this was the cause, and relieved, he found out why his body and brain had deteriorated badly.

    Needless to say he’s stopping statins and altering his diet instead.
    Nasty drugs, should be banned.