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Epidemiology:
doi: 10.1097/EDE.0b013e318296e646
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Lifestyle Profile Among Statin Users

Thomsen, Reimar Wernich; Nielsen, Rikke Beck; Nørgaard, Mette; Horsdal, Henriette Thisted; Stürmer, Til; Larsen, Finn Breinholt; Sørensen, Henrik Toft

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Department of Clinical EpidemiologyInstitute of Clinical MedicineAarhus University HospitalAarhus, Denmarkrwt@dce.au.dk

Department of Clinical EpidemiologyInstitute of Clinical MedicineAarhus University HospitalAarhus, DenmarkDepartment of EpidemiologyUniversity of North CarolinaChapel Hill, NC

Public Health and Quality ImprovementCentral Denmark RegionAarhus, Denmark

Department of Clinical EpidemiologyInstitute of Clinical MedicineAarhus University HospitalAarhus, Denmark

Department of Clinical Epidemiology is a member of the Danish Centre for Strategic Research in Type 2 Diabetes (the Danish Research Council, grant no. 09-075724 and 10-079102).

The authors have no conflicts of interest to disclose.

To the Editor:

Use of statins has been associated in observational studies with a wide range of positive health outcomes beyond those related to cardiovascular health.1 There is ongoing debate over whether these findings are causal or due at least in part to uncontrolled healthy-user or healthy-adherer bias.2–4 We investigated whether statin users have a more healthy lifestyle.

In 2006, a random sample of 31,500 people aged 25–79 years living in central Denmark (1.25 million inhabitants) was invited to participate in a questionnaire-based survey on lifestyle factors (available in Danish: http://www.cfk.rm.dk/udgivelser/befolkningsundersøgelser); 21,708 (69% of those invited) completed the questionnaire.

We linked all participants aged 45+ years (n = 13,996) with the population-based prescription and hospital databases5 to identify all use of statins and hospital diagnoses at the date of the survey (±100 days). We further subdivided statin ever users into: 1) current new users (statin prescription filled between 100 days before and 100 days after the survey, with first-ever statin prescription filled within 1 year before the survey),2) current long-term users (current use, with first-ever statin prescription filled more than a year before the survey), and3) former users (no current use and previous statin prescription filled more than 100 days before the survey). We calculated prevalence ratios (PRs) for lifestyle factors comparing statin current (new and long-term), former, and never users, directly age and sex standardized to the cohort of all participants.

Thirteen percent of respondents (N = 1,850) had ever used statins (Table). Statin users were older, predominantly male, and had more comorbid diseases (not shown). Thirty-five percent of statin users had ischemic heart disease versus 4% of never users, and 55% had a Charlson index score ≥1 versus 19% of never users. Current statin users had a higher prevalence of obesity (21% vs.13%, standardized PR = 1.80 [95% confidence interval = 1.60–2.02]), were less likely to exercise regularly (36% vs. 42%, PR = 0.87 [0.81–0.94]), but reported a healthier diet than never users (28% vs. 22%, PR = 1.43 [1.30–1.56]) (Table). Fewer statin users were current smokers (20% vs. 24%, PR = 0.91 [0.81–1.02]) and more were former smokers (52% vs. 38%, PR = 1.26 [1.19–1.34]). Current statin users had a similar prevalence of high alcohol intake (19% vs. 20%, PR = 0.98 [0.87–1.11]).

TABLE. Prevalence an...
TABLE. Prevalence an...
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New (n = 401) and long-term (n= 1,240) statin users were remarkably similar with respect to lifestyle factors, with no indication of a healthy-adherer effect (Table). The 209 former statin users were less comorbid, less obese, and more physically active than current statin users.

We found no evidence of a healthy lifestyle associated with statin use in Denmark, which corroborates observations from England and Wales.6 Instead, statin users appeared less healthy than other persons, with less healthy personal habits. Denmark’s publicly funded national healthcare system covers most drug expenses for all citizens, allowing for complete registration of statin use.5 Selective drug prescribing or registration related to socioeconomic factors is less likely than in the United States. Denmark has lagged behind other countries in prescribing statins for primary prevention, which could partly explain why Danish statin users appear less healthy than American users. Our data may be useful in quantifying the amount of uncontrolled confounding by lifestyle factors in studies of statin effects in Denmark.

Reimar Wernich Thomsen

Rikke Beck Nielsen

Mette Nørgaard

Henriette Thisted Horsdal

Department of Clinical Epidemiology

Institute of Clinical Medicine

Aarhus University Hospital

Aarhus, Denmark

rwt@dce.au.dk

Til Stürmer

Department of Clinical Epidemiology

Institute of Clinical Medicine

Aarhus University Hospital

Aarhus, Denmark

Department of Epidemiology

University of North Carolina

Chapel Hill, NC

Finn Breinholt Larsen

Public Health and Quality Improvement

Central Denmark Region

Aarhus, Denmark

Henrik Toft Sørensen

Department of Clinical Epidemiology

Institute of Clinical Medicine

Aarhus University Hospital

Aarhus, Denmark

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REFERENCES

1. Nielsen AG, Nielsen RB, Riis AH, Johnsen SP, Sørensen HT, Thomsen RW. The impact of statin use on pneumonia risk and outcome: a combined population-based case-control and cohort study. Crit Care. 2012;16:R122

2. Glynn RJ, Knight EL, Levin R, Avorn J. Paradoxical relations of drug treatment with mortality in older persons. Epidemiology. 2001;12:682–689

3. Danaei G, Tavakkoli M, Hernán MA. Bias in observational studies of prevalent users: lessons for comparative effectiveness research from a meta-analysis of statins. Am J Epidemiol. 2012;175:250–262

4. Danaei G, Rodríguez LA, Cantero OF, Logan R, Hernán MA. Observational data for comparative effectiveness research: an emulation of randomised trials of statins and primary prevention of coronary heart disease. Stat Methods Med Res. 2013;22:70–96

5. Ehrenstein V, Antonsen S, Pedersen L. Existing data sources for clinical epidemiology: Aarhus University Prescription Database. Clin Epidemiol. 2010;2:273–279

6. Hippisley-Cox J, Coupland C. Unintended effects of statins in men and women in England and Wales: population based cohort study using the QResearch database. BMJ. 2010;340:c2197

© 2013 by Lippincott Williams & Wilkins, Inc

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