[mac-mc]

If you fix it without statins through better lifestyle and diet, that is the preferrable route.

As to why medicine is like this, it's because it's conservative, usually about 17 years behind university research[0], and doctors are shackled to guidelines in most health systems or risk losing their licenses. It isn't a coincidence that the article author had his out-of-pocket concierge doctor tell him the more up-to-date stuff.

[0] https://pmc.ncbi.nlm.nih.gov/articles/PMC3241518/

[btilly]

I have an objection to the "better lifestyle and diet" approach.

Sure, it is absolutely true that better lifestyle and diet has a huge effect. However it is absolutely certain that the vast majority of people who are told to improve their lifestyle and diet, won't.

The result is doctors giving advice that they know won't be followed. And thereby transferring potential fault from the doctor to the patient, with no improvement in actual outcomes. "I told the patient to lose weight and maintain that with a controlled diet." And yet, most people when told to diet, won't. Most people who start a diet won't complete it. And most people who lose weight on a diet, have the weight back within 5 years. Where each "most" actually is "the overwhelming majority". And the likelihood of the advice resulting in sustained weight loss probably being somewhere around a fraction of a percent.

What, then, is the value of the doctor giving this lecture?

(Disclaimer. I have lost 20 of the pounds I gained during COVID, and am making zero progress on the remaining 30. A few months ago I successfully started a good exercise routine. Given my history, I would expect to only follow it for a few years before falling off the wagon. I believe that this poor compliance puts me well above average. But do you know what I do reliably? Take my prescribed medicine!)

[a1studmuffin]

Your health is ultimately your own responsibility - it's your body. You have free will, and your appetite for risk is yours alone. You can choose to ignore expert advice and refuse to wear a seatbelt, skip your rehabilitation exercises, invest all-in on crypto, or smoke cigarettes. None of this responsibility should fall on the expert if they communicated the risks clearly.

[zzzeek]

> Sure, it is absolutely true that better lifestyle and diet has a huge effect.

not for me. My cholesterol was hovering in the high 200's, then finally hit 300 and I completely freaked out, radically changed my diet, and lost 22 pounds (from 180 to 158).

What did my high cholesterol do ? It did absolutely nothing. ticked down to like, 280.

So I'm on the statins. my total cholesterol went from high 200's to about 150 in a month and was impacting my liver function. so we reduced the statins to a very low dose (5mg three times a week, crazy low). My total cholesterol hovers around 200 now. My cardiologist tells me that the conventional wisdom of "diet and exercise" is almost entirely disproven to have any meaningful effect on lipids these days (though i havent researched deeply).

[Spooky23]

I think people use it as cudgel to blame people and as a crutch to avoid action. And we ignore the psychological and other factors that make improving lifestyle and eating better difficult.

No doctor wants their patient to have a stroke. But they also only get to meet patients where they are.

[nradov]

You're arguing against a strawman. The reality is that most doctors will tell the patient their options and let them pick. While statins have some significant side effects in many patients, there is no downside to a better diet and frequent hard exercise (assuming proper technique). So it usually makes sense to at least try lifestyle modification as the initial therapy. And if that doesn't work for whatever reason then prescribe the drugs.

[aldarion]

That is because dietary advice they give is actually bad. It mostly boils down to "limit calories while eating standard western diet" but that is impossible to follow long-term as SWD and similar (e.g. food pyramid) diets are nutrient-deficient.

How many doctors recommend things like paleo diet, intermittent fasting and so on? Not many, I think - most simply focus on calories, combined with the advice that is either extremely generalized ("avoid sugar") or outright counterproductive ("eat 5 - 6 meals a day"). And then they wonder why people can't follow their diet.

Here I described my own experiences: https://ketoview.wordpress.com/2025/11/09/low-fodmap-keto-di...

[gropo]

Sure it's absolutely true (I stopped reading there.)

[kryogen1c]

>doctors are shackled to guidelines

To expand, one of the coverage pillars of malpractice insurance (in the US) is the "standard of care". This is basically what most doctors and their associations consider acceptable, which by definition excludes new, better techniques.

This is both a bug and a feature. A move fast and break things philosophy would cause more harm than good, but it also prevents rapid adoption of incremental improvements.

[nradov]

You are conflating two different things. The standard of care in a malpractice lawsuit is not necessarily the same as clinical practice guidelines. In reality doctors are free to rapidly adopt incremental improvements, especially when they are evidence based.

[mac-mc]

17 years is far from rapid or move fast and break things. ApoB has been known about for quite a long time, since the 90s its effects have been obvious, and showed up in research in the 70s-80s!!! It's still not part of standard testing!!!

Guidelines also leads to standards of care being random and heavily driven by politics & financial reasons disguised as medical best practice. South Korea and India are "parallel testing" places, which saves time, while the USA & others are serial testing places mostly because of their funding models.

Talk to any American doctor and they will give you a bunch of emotionally wrapped cope about why it's bad because the cognitive dissonance sucks and there are liability reasons to avoid admitting your wrong. I would argue that in many cases, parallel testing is cheaper because $300 of tests is cheaper than 4 chained $500 doctor visits. But whatever.

[nradov]

There is virtually zero chance that a doctor will lose their medical license for diverging from the from the usual clinical practice guidelines around statins. Check the state medical board disciplinary records.

But if they're employed by a health system and fail to follow company policy then yes, they could be fired.

[mac-mc]

Different countries are different, some are far more trigger happy about it like Canada. What you suggest as an alternative other than 'git gud' diet & exercise also changes it.

[array_key_first]

No, actually, you should improve your lifestyle and diet and also take statins.

Ever cardiologist ever will tell you that statins work best when you make diet and lifestyle changes. They tell you that, to your face. It's not a secret. This actually goes for A LOT of medications. Usually, medication + diet and exercise is better than medication alone. They also test medications like this.

[31carmichael]

You can only do things to reduce your risk. And whatever intervention would be based on overall population statistics, since it's difficult to know your own personal risk. Heart disease kills marathon runners. You can't just "fix it". Someone who has naturally high cholesterol won't magically be okay by changing their lifestyle and diet.

[hshdhdhj4444]

Licensing but also insurance.

I think only recently have insurance companies started covering APoB testing in your annual exams (or that may just be my insurance…).

[nradov]

Many commercial health plans will only cover an ApoB blood test for patients with certain conditions or risk factors. But if you want it you can pay out of pocket for like $70.