In this episode, hosts Erin Welsh and Erin Allmann Updyke focus on what to do about high cholesterol, with an emphasis on cholesterol-lowering drugs, adherence, and the evidence behind current guidance. Updyke recounts the development of statins, including Akira Endo’s work screening thousands of microbes for compounds that inhibit HMG-CoA reductase, and describes how early clinical trials helped cement the cholesterol–heart disease link in mainstream medicine. The hosts discuss how statins became widely used and review evidence they say shows meaningful reductions in cardiovascular events and mortality.
A central theme is why patients decline or discontinue statins. Updyke cites practical barriers, concerns about identity and long-term medication use, and mistrust linked to conflicts of interest in medicine and pharmaceutical research. She also argues that misinformation—spread via social media, some wellness marketing, and potentially generative AI—contributes to negative attitudes and poor adherence.
Welsh explains how statins lower LDL by reducing liver cholesterol synthesis and increasing LDL receptor activity, and she outlines other options, including ezetimibe and PCSK9-targeting therapies, while noting cost and evidence gaps for newer drugs. The hosts discuss side-effects, particularly muscle symptoms, including the possibility of nocebo effects and the difficulty of individual risk–benefit decisions. They caution against ‘natural’ alternatives such as red yeast rice, which they characterise as an unregulated statin-like product. The episode closes with global cardiovascular burden figures and the argument that long-term LDL exposure in early adulthood shapes later risk.
Erin Allmann Updyke says around 40% of primary-prevention statin users and 25% of secondary-prevention users stop within two years. She argues refusals and drop-offs are driven by factors such as practical barriers, fear of side-effects, mistrust in medicine and misinformation on social media.
Read this moment →Erin Welsh describes a “recent meta analysis” of randomised controlled trials involving “over 150,000 people” that, she says, estimated fewer than 10% of reported muscle symptoms were directly attributable to statins. She frames this as part of the broader challenge of distinguishing true drug side-effects from other causes, including the nocebo effect.
Read this moment →Erin Welsh argues that red yeast rice products marketed as ‘natural’ cholesterol-lowering options work by the same pathway as statins, but without consistent dosing. The hosts say batch-to-batch variation and lack of supplement regulation can make the products unpredictable and potentially risky compared with prescribed medicines.
Read this moment →Erin Welsh cites figures she attributes to the 2023 Global Burden of Disease study, saying atherosclerotic cardiovascular disease kills about 19 million people a year and that around 600 million are living with cardiovascular disease globally. She uses the numbers to argue that LDL-lowering therapies, alongside other risk-factor changes, have major potential population impact.
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