A pigouvian tax* on added sugars and pigouvian subsidy* for fiber in foods and beverages would probably accomplish orders of magnitude more for public health. But people would be mad, and this administration would never do it.
* not in the sense of classical externalities, but in the sense of people's hyperbolic-discounting, marshmellow-test-failing monkey brains making decisions that impose costs on their future selves who effectively didn't get to participate in the decision.
Hey Brian - great questions, thanks for prodding! FWICT the clearest and most consistent evidence shows that statins primarily reduce cardiovascular events — and that’s where their biggest benefit lies (IMO we’ll get a much clearer picture of statins’ true preventive value beyond MACE when STAREE and PREVENTABLE deliver their final readouts. Both are designed to answer exactly this question with high-quality prospective data).
Mechanistically, it tracks: LDL-rich plaque → inflammation → rupture → clot → heart attack or stroke. Inhibit HMG-CoA reductase, drop LDL, and you interrupt that cascade. As I mentioned in the piece, the 2010 CTT meta-analysis of statins in prospective RCTs (~170,000 patients) found ~20% fewer major vascular events per 1 mmol/L LDL reduction.
If I'm thinking of the studies you're recollecting: claims that high LDL is protective usually come from retrospective datasets riddled with survivor bias - the same statistical trap that once made metformin look like an anti-aging miracle.
For a great breakdown of the cholesterol debate, I recommend checking out Thomas Dayspring’s podcast appearances. He’s a world-class lipidologist with a gift for cutting through noise (and adding a few laughs along the way, he's pretty funny).
ChatGPT tells me you would need to treat 250 moderate to high risk individuals for 5 years to prevent one all cause mortality. The annual cost for taking it otc would be about $50. So that's 250*5*$50 = $62500 per life saved. Let's round it off to $10k per QUALY. It's not malaria nets but in the US context it's orders of magnitude more efficient than most of our other healthcare spending.
ChatGPT verbatim:
"Primary Prevention (Individuals Without Established Cardiovascular Disease)
Low-Risk Individuals: For those with a 10-year cardiovascular risk below 10%, studies have shown no statistically significant mortality benefit from statin therapy. The Cholesterol Treatment Trialists' (CTT) meta-analysis, encompassing over 130,000 patients, found no significant reduction in all-cause mortality for these low-risk groups.
Moderate to High-Risk Individuals: In populations with higher baseline cardiovascular risk, statins have demonstrated a modest mortality benefit. For example, the U.S. Preventive Services Task Force (USPSTF) analysis reported a 0.4% absolute reduction in all-cause mortality over approximately 5 years, translating to an NNT of 250. "
A pigouvian tax* on added sugars and pigouvian subsidy* for fiber in foods and beverages would probably accomplish orders of magnitude more for public health. But people would be mad, and this administration would never do it.
* not in the sense of classical externalities, but in the sense of people's hyperbolic-discounting, marshmellow-test-failing monkey brains making decisions that impose costs on their future selves who effectively didn't get to participate in the decision.
Why don’t you do all cause mortality rather than cardiovascular events? Data I have seen seems to suggest high LDL has protective effects
Hey Brian - great questions, thanks for prodding! FWICT the clearest and most consistent evidence shows that statins primarily reduce cardiovascular events — and that’s where their biggest benefit lies (IMO we’ll get a much clearer picture of statins’ true preventive value beyond MACE when STAREE and PREVENTABLE deliver their final readouts. Both are designed to answer exactly this question with high-quality prospective data).
Mechanistically, it tracks: LDL-rich plaque → inflammation → rupture → clot → heart attack or stroke. Inhibit HMG-CoA reductase, drop LDL, and you interrupt that cascade. As I mentioned in the piece, the 2010 CTT meta-analysis of statins in prospective RCTs (~170,000 patients) found ~20% fewer major vascular events per 1 mmol/L LDL reduction.
If I'm thinking of the studies you're recollecting: claims that high LDL is protective usually come from retrospective datasets riddled with survivor bias - the same statistical trap that once made metformin look like an anti-aging miracle.
For a great breakdown of the cholesterol debate, I recommend checking out Thomas Dayspring’s podcast appearances. He’s a world-class lipidologist with a gift for cutting through noise (and adding a few laughs along the way, he's pretty funny).
ChatGPT tells me you would need to treat 250 moderate to high risk individuals for 5 years to prevent one all cause mortality. The annual cost for taking it otc would be about $50. So that's 250*5*$50 = $62500 per life saved. Let's round it off to $10k per QUALY. It's not malaria nets but in the US context it's orders of magnitude more efficient than most of our other healthcare spending.
ChatGPT verbatim:
"Primary Prevention (Individuals Without Established Cardiovascular Disease)
Low-Risk Individuals: For those with a 10-year cardiovascular risk below 10%, studies have shown no statistically significant mortality benefit from statin therapy. The Cholesterol Treatment Trialists' (CTT) meta-analysis, encompassing over 130,000 patients, found no significant reduction in all-cause mortality for these low-risk groups.
Moderate to High-Risk Individuals: In populations with higher baseline cardiovascular risk, statins have demonstrated a modest mortality benefit. For example, the U.S. Preventive Services Task Force (USPSTF) analysis reported a 0.4% absolute reduction in all-cause mortality over approximately 5 years, translating to an NNT of 250. "