Gluttony in the Time of Statins
ACCEL | There are two key components to treating hyperlipidemia: dietary modification and statin therapy. While caloric intake has increased overall in US adults from the 1970s through the 1990s, a plateau was reached starting in 1999 to 2000. Sounds promising, right? Overall, you are right, but the exception to the rule is a big one: Investigators have evaluated the time trends in food intake to see how they relate to statin use. In short, Martin Shapiro, MD, and colleagues conducted an analysis to, essentially, look at gluttony in the time of statins.1
They used a nationally representative sample of 27,886 US adults from NHANES from 1999 through 2010. In the 1999 to 2000 period, caloric intake was significantly less for statin users compared with nonusers (2000 vs 2179 kcal/d; p = 0.007). It was encouraging and appeared that patients on statins, aware of their lipid problems, may have moderated their eating.
WELL, THAT DIDN'T LAST
This modest difference between groups diminished over time so that by 2005 to 2006, there was no statistical difference between statin users and those not taking statins. Just leveling out, however, was not in the cards: caloric intake continued to increase so that among statin users, caloric intake in the 2009 to 2010 period was 9.6% higher (95% CI: 1.8-18.1; p = 0.02) than that in the 1999 to 2000 period. In contrast, no significant change was observed among nonusers during the same study period.
Changes in fat intake account for some of this increase in daily calories. Again, things started off promising, with statin users consuming significantly less fat in the 1999 to 2000 period compared to non-statin users (71.7 vs 81.2 g/d; p = 0.003). Over time, fat intake increased 14.4% among statin users (95% CI, 3.8-26.1; p = .0007) while not changing significantly among nonusers. Also, BMI increased more among statin users (+1.3) than among nonusers (+0.4; p = 0.02), with both assessed using data from the 2009 to 2010 period.
The presence or absence of hyperlipidemia diagnoses in nonusers, or higher prevalence of diabetes among statin users did not explain this difference in the time trends for caloric and fat intake between statin users and nonusers. For example, individuals not taking statins had similar time trends of caloric intake (upward in the earlier survey cycles and downward in the later survey cycles), whereas the trend among statin users was consistently upward.
Among the possible explanations: Some patients may have agreed to initiate statin therapy because they did not want to restrict their diet, whereas others who did not want to take medication may have declined the proposed pharmacotherapy in favor of following dietary recommendations. Maybe successful lipid control gave patients a rationale to indulge, driving up their caloric intake.
It's also possible that, with a widely available, highly effective lipid-lowering agent, emphasis has been more on prescriptive therapy and less on discussions relating to dietary composition. As Shapiro and colleagues put it, "We may need to reemphasize the importance of dietary modification for statin users."
- Sugiyama T, Tsugawa Y, Tseng CH, et al. JAMA Intern Med. 2014;174:1038-45.
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