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Does Every Diabetic Really Need A Cholesterol Pill?

In 2009, HMSA (Hawaii’s largest health insurance company) will start fining doctors who don’t put every last one of their diabetics over the age of 40 on a cholesterol lowering pill. No matter what your cholesterol, if you are a diabetic, your doctor will probably write you a prescription. Even if you don’t have heart disease. How can they justify this?

I asked HMSA’s medical director, an internal medicine MD. He says the practice is well supported by extensive research. But it appears he didn’t do the research himself, nor did anyone in HMSA. HMSA hired a company to outsource this decision making process. When I look at their package of supporting information, I see some very fishy writing.

Two of the articles are based on the opinions of nine doctors, eight of whom are paid drug company consultants.


Fatburn Fix Saves Life of Type 2 Diabetic

I would like to thank you for literally saving my life. Back in February, I had to be hospitalized while on vacation in Phoenix with an A1C of 11% and had to start taking 2 types of insulin and 2 other meds. I read the Fatburn Fix in April, and followed the program to a tee, and I’m down by 15 pounds, 6.8 A1C, and only one once weekly diabetes medicine. Prior to reading the book, it was almost impossible for me to lose weight as a diabetic. 

Leontyne Tompkins

I feel free

For the last month, I have really been reading all labels on everything. I have completely remove those 8 oils you talk about. I must tell you, I feel great! I have more energy and I am now 197 lbs (have always been around 205 to 210lbs). I eat potatoes with real butter, grass fed steak, pasta with the right toppings. I eat everything! I seem to crave less sugar. I love it! 

Robert Kirkendall

I feel so much better

I had terrible aches and pains everywhere in my body, my hands, shoulders and knees. I feel so much better and the way I feel is motivating me every day! Thank you

Mike Deb Wootan Burcin

Better than ever

I am an anesthesiologist in Orlando and a huge fan of both of your books! I have been incorporating your principles for the last 10 months and feel that my health is better than ever.

Marnie Robinson, MD

My allergies disappeared

The biggest difference for me (and a surprising one) is that my allergies have almost completely disappeared! This is a big deal for me, because I’ve had allergies most of my life and they have often affected what I do which is a teaching music in [a public school district].  In general, I feel much better and have more consistent energy throughout the day.

Erica Turrell

Heart Palpitations have Stopped

I’ve lost 20+ pounds (also fasting 16-24 hours daily) and haven’t had palpitations except for one occasion — I had a mini bag of Fritos for the first time in July. And, I feel better now on a daily basis than I ever did all through college.

Mike Wright
Deep Nutrition and Fatburn Fix reader
Mitzi Wilkinson Champion

I’ve lost over 50 pounds

I’ve lost over 50 pounds. I’m 56 years old. Cutting processed food and unhealthy fats from my diet was one of the first things I did on my health recovery journey...I went cold turkey off the bad oils. Emptied my pantry into the trash and just started eating real food

Mitzi Wilkinson Champion

Knowledge I didn’t know I needed

Your Fatburn Fix book is amazing, my friend. Thank you! I’m an Functional Nutritional Therapy Practitioner and I know my stuff. This is the extra layer of knowledge I didn’t know I needed. Well done!

Jennifer Dillman
Fatburn Fix reader

Lost a solid 20 lbs and my bloodwork is great

I have lost a solid 20 lbs and my bloodwork (after 3 months of eating your way) was even better! I was metabolically healthy (per your book) before I read your book, but barely. Lowering my weight, sealed the deal! I have been talking about you and your book to anyone who will listen...Thank you for all you’ve done and what you continue to do! You are changing lives for the better!

Missy Cramer
FatBurn Fix reader

Lost 20 lbs I could never shed

I love your Fatburn Fix!  Has helped me so so much!  I have had the dreaded weight all my life - 20 or so pounds I could never shed.  I have lost that now. I only eat 2 meals a day lunch and dinner with a glass of milk or cappuccino around 4 to hold me over. No snacking and not bad oils.  It has been the key to unlocking my fatburn.  I work out in the am and believe I am burning fat for energy not from food!

Lauren Smith

I feel great

My waist is four inches smaller. I feel great and many of the minor aches and pains that I had (knees and lower back) are gone. Also, my muscle tone is amazing, even though I have not increased my workout routine.

Richard Janelle
Completed Dr Cate's online course
Kent Matthes

The go-to for strength and conditioning coaches

Whenever I advise my clients about eating to perform I go straight to what I have learned from Dr. Cate. Her book Deep Nutrition has become the go-to for strength and conditioning coaches across the country.

Kent Matthes
Major League Baseball Agent with WME Sports
Ken D Berry

Dismantles the lie

Dr. Cate dismantles the lie that seed oils are healthy, which may the biggest lie about nutrition and health because it’s so insidious.  

Ken D Berry, MD
Author of Lies My Doctor Told Me
Dr. Drew Pinsky

She knows the chemistry

Dr. Cate alerts us to the harms of seed oils and she’s convincing because she knows the chemistry better than anyone.

Dr. Drew Pinskey, MD
Globally recognized internal medicine and addiction medicine specialist, media personality, LoveLine Host, and New York Times bestselling author
Kelly Starrett

No one is better at communicating nutritional truth

Dr. Cate has had the single greatest impact on how we talk to people about fueling for both performance or durability. While we all are a little unique, the foundational principles of human nutrition are immutable. If you are looking to create a more durable, resilient body, no one is better at communicating nutritional truth than Dr. Cate.

Dr. Kelly Starrett
Physiotherapist coach and New York Times and Wall Street Journal bestselling author
Brian Lenkzes

Highly recommend The Fatburn Fix

Dr. Shanahan has had a significant impact on my practice of medicine. I am known as a Low Carb Doctor, but I never really appreciated the negative effects of processed seed oils on the health of my patients. I highly recommend The Fatburn Fix to my patients and have a loaner copy in my waiting room. It is amazing how quickly blood sugars and overall health improves with cutting seed oils. It is not just about the carbs!

Dr. Brian Lenkzes, MD
CEO of LowCarbMD San Diego, co-host of Low Carb MD Podcast and host of Life's Best Medicine Podcast
Chris Kaman

Respected in the sports world

Dr. Cate reordered my diet when I was with the L.A. Lakers, and the benefits, for me personally, were felt immediately and have served me to this day. I’ve come to take real food so seriously I started a small family farm. I know of no M.D./nutritionist more respected in the sports world than Dr. Cate Shanahan.

Chris Kaman
NBA Player
Mark Sisson

Brought seed oil issue front and center

Cate brought the seed oil issue front and center. Healthy fats matter. So much so that I created an entire product line to swap out bad fats with good.

Mark Sisson
Founding Father of the Primal/Paleo Movement
Dallas Hartwig

Optimal health starts with food

If you want to understand how optimal health starts with food, start with Dr. Cate. Her book Deep Nutrition leaves you with an appreciation of the profound relationship between our genes and the planet, inspiring us to be good shepherds of both.

Dallas Hartwig
Attribution author of The Whole 30
Dwight Howard

Helped me with endurance

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Dwight Howard
NBA Player
Paul Grewal

Silver bullet for me

Dr Cate’s teachings helped me lose 60 pounds like it was nothing. It was like a silver bullet for me.

Paul Grewal, MD 
Dr Grewal Internal Medicine, MD, author of Genius Foods
Joesph Mercola

Radically improve your health…

Dr. Shanahan has provided a solid reference that deserves a place in the library of anyone who is seriously interested in nutrition. Her perspective on the vital role that healthy fat has in our diet is novel and, if implemented, can radically improve your health.

Dr. Joseph Mercola
Author of Fat for Fuel and Founder of Mercola.com
Dave Aspery

Pull up a chair…

I have based my work on the idea that getting the right kinds of healthy fats into your body and avoiding the worst fats is essential to optimal health. I've interviewed dozens of the world's top experts about this, and I know of no one who speaks more eloquently on this topic than Dr Cate. If she’s talking fats, pull up a chair. Take notes.

Dave Asprey
Author of the Bulletproof Diet

The key to unlocking my fatburn

I love your Fatburn Fix!  Has helped me so so much!  I have had the dreaded weight all my life - 20 or so pounds I could never shed.  I have lost that now. I only eat 2 meals a day lunch and dinner with a glass of milk or cappuccino around 4 to hold me over. No snacking and not bad oils.  It has been the key to unlocking my fatburn.  

Lauren Smith

Saved my life

I would like to thank you for literally saving my life. Back in February, I had to be hospitalized while on vacation in Phoenix with an A1C of 11% and had to start taking 2 types of insulin and 2 other meds. I read the Fatburn Fix in April, and followed the program to a tee, and I’m down by 15 pounds, 6.8 A1C, and only one once weekly diabetes medicine. 

Leontyne Tompkins

Tears of joy

 I'm crying tears of joy and appreciation for all you've done for me and my health! Without Deep Nutrition and Fatburn Fix, I would literally still be in the vicious cycle I'd been fighting all my life! In a nutshell - I am no longer a compulsive overeating addict suffering under the crushing 'thumb' of all food and alcohol.     

Penni Wicks

One citation is a CDC web site that has disappeared.

The only article of any merit is about a study done on about 2,000 people with diabetes, half of whom took a sugar pill and half of whom took a cholesterol pill. Almost two hundred people had to stop the cholesterol pill due to side effects. This effectively weeds out the more sickly people and so it is not surprising that in the group taking the pill there were fewer heart attacks – at least to start with. The study was stopped early, for reasons they don’t explain. What has me worried is that, when I look at the graph comparing death rates in the two groups, the first few years look pretty good for the group on the drug. But by the end of year three, people start dropping dead fast – so fast the line looks like its starting to go straight up. What is the real reason they stopped the study prematurely? Could it be that they saw where the line was heading, and decided to quit while they were ahead?

Remember, this line is the group of healthier people (b/c they could handle the side effects of the drug) and even they started to die after taking it for almost four years. HMSA wants diabetics to stay on it for life.

The research does show that some people who have had heart attacks do benefit from statins. But the research does not support what HMSA plans to pay your doctor to do now. If I don’t go along with this, I will lose money. This is not fair to me as a conscientious physician, and its not fair to HMSA’s customers who may pay a price with their lives in four years time.

If the drug helped the lines would diverge, like this (From 4S trial)
If the drug helped the lines would diverge, like this (From 4S trial, which studied the effects of statins primarily in male smokers who already had a heart attack)
from Lancet, 2004. 364(9435): p.685-96
from Lancet, 2004. 364(9435): p.685-96

Safe For Four Years? In this highly selected group of people, problems seem to increase just before the study was ended prematurely by the organizers.

A quick glance, and the graphs make the drug look pretty good. The two lines represent cumulative “endpoints” over time of (top to bottom) major heart attack, death, or other heart-related emergency room visit. And the top line represents people on placebo, the bottom represent people on the pill. The higher the line, the more people have been diagnosed with one of the endpoints, either major heart attack, death, or other heart-related emergency. But all is not as it seems, so to understand, you have to take a better look.

The middle graph is the most important because it answers the one question we really care about – does taking this pill prevent anyone from dying? So let’s look at the middle one. (Why is that the most important question? See below)

Right above the graph it says there’s a risk difference of 27%. That sounds pretty good. It sounds like more than a quarter. And if it were true that cholesterol pills could prevent one heart attack for every four people taking it, I’d be all for it. But that’s not what relative risk means. Relative risk is a handy way to exaggerate a minimal benefit of a drug. Most busy doctors fall for the trick.

If your doctor took the time to look real close, she’d see that at year one the number of people who were not taking the drug who died was 1418, versus only 1395 deaths in the group taking the drug. A minimal effect – less than one percent. Though the drug may have saved 22 lives that year, and the difference is real, certainly, to those 23 people, but it means that if you give the drug to 100 people, not even one will benefit. (So what if you take drugs that don’t help? Side effects, that’s so what- including memory problems, cancer, accidental death, and more. See my posts here and here.)

But the scary thing about the graphs, that most doctors don’t catch, is the total numbers of people who stay in the study till the end. Of the over 1400 who start, 5 years later the number dwindles to 350. Why? Did they die?

For the answer, stay tuned. There’s much more to “evidence based medicine” than meets the eye!

Dr. Cate

With over two decades of clinical experience and expertise in genetic and biochemical research, Dr. Cate can help you to reverse metabolic disease and reshape your body.

This Post Has 4 Comments

  1. Hi Josephine

    The group I belong to is affected by HMSA’s program that withholds pay from doctors who fail to prescribe statins to men or women who carry a diagnosis of coronary artery disease. I don’t like it one bit. But fortunately I only have one patient affected by the plan. This current arrangement is not as much of a threat to patient health or physician sanity as the plan they wanted to implement as of the summer of ’08, which would have required all patients who carry a diagnosis of diabetes to be on statins, or their physicians face penalties.

    Thank you for your thoughtful comments!

  2. It is now March 2009 and a very reliable source has recently informed me that HMSA is paying doctors bonuses if they prescribe statins to any of their patients both non-diabetic and diabetic. In addition, when doctors don’t sign up for this “bonus rewards program” and don’t prescribe statins to patients who have high cholesterol but don’t want to take drugs, HMSA still pressures them by sending them a list of patients who have high cholesterol and telling the doctors that they should be following the standard protocol. So, does following the standard protocol include coercion? or forcing doctors to force patients to take a drug with deadly side effects?

  3. Hi Dr. Cate,
    Yup, I learned from Owen of the Vitamin C Foundation that when they stop the study early it means that the results were not going in their favor. Similar to the Women’s Health Initiative where they were studying the effects of HRT and had to be stop early because either too many women were dying or coming down with cancer or heart disease. Although I am still confused about those charts, I really appreciate you pointing out that , “relative risk is a handy way to exaggerate the minimal benefit of a drug” and that “most doctors fall for the trick.” It makes me wonder how many other studies are out there for other drugs that use the “relative risk” trick in order to exaggerate their findings. I like that you also point out that if the drug were given to 100 people not one person will benefit but perhaps all will suffer from the side effects. I wonder if this is the reason why statins are mass marketed widely because the “benefit” only shows up if thousands of people are on the drug. But your last paragraph is the saddest part of all, because in the end we don’t know what happened to all those people who started out on the study and to think that HMSA is using these faulty studies to encourage wider use of a bad drug is criminal in my opinion. Shame on them. Thanks Dr. Cate for bringing awareness to this very important issue.

  4. Mahalo for detailing how special interest funding dictates what research look at and what research ignore to obtain needed justification for actions to increase profit margins possibly at the risk to patient life. It is a stretch to claim such flawed studies “scientific research”.

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