Andrew Buelt and Joe Weatherly (Family Medicine and Preventive Health Center, Baltimore, USA) offer the following advice on fasting lipid screening, preventive statin therapy for low-risk patients, and the potential health risks of lipid-lowering therapy. 1. Do I need to fast for lipid testing? In an article published in Circulation, Doran et al. state that there is evidence that fasting lipid testing has little significant value and no significant benefit in predicting mortality. However, this type of study and analysis has been repeated many times in the past (Sidhu et al. and Langsted et al. have both published similar articles). And the final results of these studies all led researchers to the same conclusion – no fasting! It’s not medicine to make patients fast for lipid testing without a clear scientific benefit. And it’s not fair to the patients to do so without a clear health benefit either. So am I saying let them go out and eat 3 burgers and a dozen donuts and come back for a lipid test? Of course not! But just so you know, even a fasting lipid test has about a 15% margin of error! And eating only affects the test results by about 10-20%. Now we have patients fasting for the accuracy of the test, yet doing so may not even bring about more than the margin of error of the test itself. Some patients don’t get their lipids tested until lunchtime, risking stomach pain and hypoglycemia without any significant gains. The most important issue is to make sure patients get their lipid test results, not to make them fast. There is no point in continuing to do this. 2. How often should I get a lipid screening? And, for some patients, a one-time lipid screening may not be appropriate. Once a year or twice a year screenings are a thing of the past. When deciding on the frequency of lipid screening, we should give due consideration to the cost of the test, the pain during the blood draw and the lack of clinical benefit. For patients under 50 years of age, once a year lipid screening (for primary prevention) is sufficient because they don’t meet the criteria for statin therapy anyhow. I only mentioned statin because there is certainly no other more necessary lipid-lowering treatment now. 3. Are non-statin lipid-lowering drugs necessary? On the one hand, many patients are still taking health care drugs, and on the other hand, many doctors are still adding various cholesterol-lowering drugs to their patients, which really don’t help (fish oil, niacin and beta drugs, for example). These drugs also have little to no health value. It’s just a waste of time, money and effort to mess with them. So why do doctors continue to prescribe these drugs? I think these habits are ingrained in physician training. You know we are always good for numbers. However, it appears that the use of non-statin drugs to control cholesterol levels has little impact on patient prognosis, and, instead, these supplements and drugs can have some significant side effects. In my opinion, there is now ample evidence to abandon the use of non-statin lipid-lowering drugs. Although these drugs may make the lab results look a little better. However, if the end result is the same, then patients don’t need to get hung up on the alternative endpoint. 4. Statin use? The use of statins is one of the most studied, reviewed, and debated medical topics. The topic of their primary prevention alone could be discussed for hours. But right now, I think everyone at least agrees that statins do work. It is clear that the benefits of taking statins are much greater than the benefits of taking various vitamin, non-statin lipid-lowering medications. Although this benefit may be small, at least the side effects are also small for the majority of patients taking statins. 5. Focus on lifestyle interventions However, if the data from the observational study recently published by Lee et al. (suggesting that taking statins leads to reduced physical activity) are true, then the benefit from statin therapy is even smaller than previously thought. The topic that really needs attention is often overlooked for the issue of primary prevention in low-risk patients. We need to focus on lifestyle interventions, the development of healthy habits, and nutrition education. As physicians, we should not worry about whether or not the patient is eating before the next blood draw, whether or not to artificially raise HDL levels with niacin, or whether or not to lower triglyceride levels with fish oil, but rather we should focus on the patient’s daily diet. For most patients, true primary prevention should not be medication, but rather physical activity, nutritional quality, and healthy lifestyle and habits such as getting a pedometer to monitor how much walking is done each day, or adding more fruits and vegetables to the diet. That’s what doctors should be talking to their patients about. Never forget, exercise more, smoke less, and your health will always be with you.