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Jhankaria B. Masala. Natl Med J India 2021;34:127-128
Statin Intolerance and Misinformation
Almost up to 50% of people who would benefit from statins are not prescribed statins or if they are, do not start statins or if they do, stop them, because of ‘statin intolerance’, which is often a subjective feeling of ill-health and weakness. Three recent articles have addressed this issue.
The nocebo effect-I
To study the importance of the nocebo effect with statins, Frances Wood et al. (Wood et al. N Engl J Med 2020;383: 2182–4) conducted an N-of-1 trial, where the patient was their own control and found a significant nocebo effect as explained in [Figure - 1].
|Figure 1: Symptoms when on placebo, imply a nocebo effect|
The nocebo effect-II
On the heels of the N-of-1 study, was published another one by Jungyeon Moon et al. (Moon et al. Circ Cardiovasc Qual Outcomes 2021;14:e007480), which looked at the data from the Food and Drugs Administration (FDA) adverse events database [Figure - 2].
|Figure 2: Retrospective study. FDA adverse event reporting system from January 2010 to December 2019|
They found a higher incidence of reported subjective ‘statin myopathy’ events compared to objective adverse events (AEs), by a factor of 4.89 times more in women than in men (58:42). It was assumed that a large number of the ‘subjective’ AEs were likely due to the nocebo effect.
To round off the statin intolerance issue is an article by Nelson et al. (Curr Atheroscler Rep 2020;22:37) that examined the reasons for ‘statin hesitancy’, which included a combination of issues and misinformation on social media, websites and among doctors and physicians.
Where are our doctors
We are significantly overestimating the healthcare workforce in India. An article by Anup Karan from the Indian Institute of Public Health (Hum Resour Health 2021;19:39), looked at the number of doctors culled from two sources, the National Health Workforce Account (NHWA) and the National Sample Survey Office (NSSO) and found that just 50% of the doctors that are registered with the Indian Medical Council are actually in active practice––a woefully inadequate number that is unlikely to improve in the future [Figure - 3].
|Figure 3: Doctors in India 2020–2030 (copyright: Dr Bhavin Jhankaria, Creative Commons CC-BY)|
Using non-doctors to improve health
The COBRA-BPS study (Control of Blood Pressure and Risk Attenuation––Bangladesh, Pakistan, Sri Lanka) by Tazeen Jafar et al. (I don’t know why India was excluded) showed that using community health workers in rural settings to diagnose hypertension and to educate the community in consultation with physicians resulted in significant improvement of hypertension control compared to usual care (Jafar et al. N Engl J Med 2020;382:717). A companion article by Eric Finkelstein et al. in the Lancet Global Health (19 Mar 2021, ahead of print) showed that this was also a cost-effective strategy. Clearly when we do not have enough doctors, empowering a non-doctor workforce for prevention and education is what we should be aiming for.
Two articles recently published showed how eating well improves cardiovascular health and mortality and eating badly leads to increased disease and mortality.
Fruit and vegetable intake
The study by Dong Wang et al. (Wang et al. Circulation 1 Mar 2021, ahead of print) showed that eating up to five portions of fruits and vegetables a day significantly reduced all-cause mortality as well as cardiovascular disease, cancer and respiratory disease mortality, as seen in this graph, with no additional benefit beyond five portions [Figure - 4].
|Figure 4: Fruit and vegetable portions|
Three weeks later came an article by Filippa Juul et al. (J Am Coll Cardiol 2021;77:1520) that showed that eating ultra-processed foods (UPFs) was associated with an increased incidence of cardiovascular events and mortality, but not all-cause mortality [Figure - 5].
|Figure 5: Rate of hard cardiovascular disease per 1000 person years|
It makes sense therefore to add fruits and vegetables to our daily food habits and to reduce UPFs such as packaged chips, etc.