Statins in the Drinking Water?

David L. Katz

On May 5, The New York Times "Well" blog explored the controversies of statin use for lipid lowering in women. The author, Roni Caryn Rabin, did a very thorough job, so I certainly recommend the column to you.

The issue, in essence, is that while statins lower lipids in women as they do in men, the evidence is less clear that they prevent heart attacks, strokes and premature deaths. Some experts think this represents truly distinct effects in men and women; others think it is merely a problem of statistical power. Too few women have been studied to date to determine if there is, for instance, a statin-related survival advantage. Thus, the argument is made that our problem is absence of needed evidence, not evidence of absence of needed effects.

All of this matters a great deal because statins have side effects. They cause muscle pain fairly commonly, although in my patients I have found that supplemental coenzyme Q10, which statin use depletes, may alleviate this. They cause liver inflammation less commonly, but often enough to warrant tracking of liver function blood tests.

But most importantly, statin use is associated with an increased incidence of diabetes in women in particular. This is of obvious concern, given that the reason to use statins is to prevent cardiovascular disease, and the onset of diabetes raises cardiovascular risk dramatically.

[See: Best Diabetes Diets .]

This important debate about statin use by women plays out against the backdrop of larger debate among cardiologists regarding optimal approaches to lipid lowering for public health benefit. Not long ago, a new set of guidelines for the use of lipid-lowering drugs to prevent heart disease was issued with considerable fanfare, and then set off a firestorm of controversy. The old approach relied heavily on levels of LDL cholesterol, while the new approach relies on a calculation of overall cardiac risk that leaves LDL out of the mix altogether. At stake are statin prescriptions for millions of us.

As a physician specializing in Preventive Medicine, and with a long-standing interest in cardiac risk modification specifically, I look at both debates -- how best to reduce cardiac risk overall, when to use statins in women -- with great interest. My impression thus far is that if the answer were truly clear in either case, there would be no controversy in the first place. With regard to lipid lowering, there appear to be strengths and weaknesses to both sets of criteria, the old and the new. Either way, it's clear that statins -- which in fact are rather good drugs -- can and do save lives when prescribed judiciously. The debate is all about what "judiciously" really means, and what is most judicious.

[See: Best Heart-Healthy Diets .]

Regarding statin use in women, there are clear indications of potential harms and strong suggestions of likely benefit -- including a reduction in all-cause mortality. But while studies indicative of such benefit include women, it is unclear as of yet if they have focused adequately on women specifically -- and thus the ongoing debate.

For those who embrace the general finding that statin benefits greatly outweigh harms for the population at large, enthusiasm prevails for their widespread use. Some lipidologists have suggested, perhaps seriously and perhaps not, that the prevalence of hyperlipidemia and heart disease in our culture warrants putting statins in the drinking water.

Whether or not that answer is serious, it invites a question that certainly is: How can a society look on passively at a situation that invites tens of millions of its citizens (no matter what criteria are used) to take a drug to fix what feet and forks could fix better, at lower cost, more universally, and absent the risk of side effects?

[Read: The Facts on Heart Disease .]

Statins really are good drugs, and under the conditions that now prevail, they do indeed save lives -- of both men and women, even if more reliably in the former. And under now prevailing conditions, tens of millions of us are candidates for them. But such conditions need not prevail, and should not prevail. Why do we let them prevail?

As far as I'm concerned, the entire debate about statins is part of our societal static. It's a background noise of cultural misdirection that favors the conflated interests of Big Food and Big Pharma, while ignoring the compelling, consistent signal of what lifestyle as medicine could do for us all.

We could prevent all those heart attacks, and more, without putting statins in the drinking water. We could add years to life, and life to years, and save rather than spend money doing it -- if lifestyle were our preferred medicine. The signal has been there for literal decades that minimally 80 percent of all heart disease could be eliminated by lifestyle means readily at our disposal. There is a strong case that, but for rare anomalies, heart disease as we know it could be virtually eradicated by those same lifestyle means. And the same lifestyle medicine that could do this job would slash our risk for every other bad outcome as well, while enhancing energy, cultivating vitality, and contributing to overall quality of life. And unlike our statin prescriptions, we could share these benefits with those we love.

But for the most part, we as individuals, and collectively as a culture, seem selectively deaf to this signal. We watch our peers and parents succumb to heart disease and wring our hands. We fret over the same fate overtaking us. We get prescriptions for drugs we wish we didn't have to take, worry about serious side effects, suffer through minor ones, grumble about co-pays and implicate ourselves in the unmanageable burden of "health" care costs. And so our debate about statins, seemingly so important, plays out in the static of the status quo.

Our culture makes a lot of noise about therapeutic drug use in general, statin use in particular. Caught up in the cacophony is the usual mix of conspiracy theory nonsense, and genuine sense both about the perils of side effects and the decisive benefits of using statins judiciously.

[Read: 8 Health Technologies to Watch For .]

But maybe what matters most is neither the sense nor nonsense in the noise, but the signal that is being sublimated altogether. Our cultural neglect of lifestyle as medicine propagates both the worried preoccupations attached to statin use and the need to consider their use in the first place. They neither take, nor need, many statins in the Blue Zones where lifestyle is the prevailing medicine.

If we made better use of lifestyle as our medicine -- if, for instance, when thirsty we actually turned far more routinely to drinking water and far less often to sugary soda -- there might be no basis in the first place to debate the need for statins in that water.

David L. Katz, MD, MPH, FACPM, FACP, is a specialist in internal medicine and preventive medicine, with particular expertise in nutrition, weight management and chronic-disease prevention. He is the founding director of Yale University's Prevention Research Center and principal inventor of the NuVal nutrition guidance system. Katz was named editor-in-chief of Childhood Obesity in 2011, and is president-elect of the American College of Lifestyle Medicine. He is the author of "Disease Proof: The Remarkable Truth About What Makes Us Well."