Statins: His & Hers?

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The Hidden Complexities of Statins and Cardiovascular Disease (CVD)

This is Dr. Barbara Roberts. She’s a cardiologist and the Director of the Women’s Cardiac Center at one of the Brown University Medical School teaching hospitals. She’s an Associate Clinical Professor of Medicine and takes care of patients, teaches medical students, and does clinical research. She specializes in gender-specific aspects of heart disease, and in heart disease prevention.

We previously reviewed Dr. Barbara Roberts’ excellent book “The Truth About Statins: Risks and Alternatives to Cholesterol-Lowering Drugs”. It prompted some requests to do a main feature about Statins, so we’re doing it today. It’s under the auspices of “Expert Insights” as we’ll be drawing almost entirely from Dr. Roberts’ work.

So, what are the risks of statins?

According to Dr. Roberts, one of the biggest risks is not just drug side-effects or anything like that, but rather, what they simply won’t treat. This is because statins will lower LDL (bad) cholesterol levels, without necessarily treating the underlying cause.

Imagine you got Covid, and it’s one of the earlier strains that’s more likely deadly than “merely” debilitating.

You’re coughing and your throat feels like you gargled glass.

Your doctor gives you a miracle cough medicine that stops your coughing and makes your throat feel much better.

(Then a few weeks later, you die, because this did absolutely nothing for the underlying problem)

You see the problem?

Are there problematic side-effects too, though?

There can be. But of course, all drugs can have side effects! So that’s not necessarily news, but what’s relevant here is the kind of track these side-effects can lead one down.

For example, Dr. Roberts cites a case in which a woman’s LDL levels were high and she was prescribed simvastatin (Zocor), 20mg/day. Here’s what happened, in sequence:

  1. She started getting panic attacks. So, her doctor prescribed her sertraline (Zoloft) (a very common SSRI antidepressant) and when that didn’t fix it, paroxetine (Paxil). This didn’t work either… because the problem was not actually her mental health. The panic attacks got worse…
  2. Then, while exercising, she started noticing progressive arm and leg weakness. Her doctor finally took her off the simvastatin, and temporarily switched to ezetimibe (Zetia), a less powerful nonstatin drug that blocks cholesterol absorption, which change eased her arm and leg problem.
  3. As the Zetia was a stopgap measure, the doctor put her on atorvastatin (Lipitor). Now she got episodes of severe chest pressure, and a skyrocketing heart rate. She also got tremors and lost her body temperature regulation.
  4. So the doctor stopped the atorvastatin and tried rosovastatin (Crestor), on which she now suffered exhaustion (we’re not surprised, by this point) and muscle pains in her arms and chest.
  5. So the doctor stopped the rosovastatin and tried lovastatin (Mevacor), and now she had the same symptoms as before, plus light-headedness.
  6. So the doctor stopped the lovastatin and tried fluvastatin (Lescol). Same thing happened.
  7. So he stopped the fluvastatin and tried pravastatin (Pravachol), without improvement.
  8. So finally he took her off all these statins because the high LDL was less deleterious to her life than all these things.
  9. She did her own research, and went back to the doctor to ask for cholestyramine (Questran), which is a bile acid sequestrent and nothing to do with statins. She also asked for a long-acting niacin. In high doses, niacin (one of the B-vitamins) raises HDL (good) cholesterol, lowers LDL, and lowers tryglycerides.
  10. Her own non-statin self-prescription (with her doctor’s signature) worked, and she went back to her life, her work, and took up running.

Quite a treatment journey! Want to know more about the option that actually worked?

Read: Bile Acid Resins or Sequestrants

What are the gender differences you/she mentioned?

Actually mostly sex differences, since this appears to be hormonal (which means that if your hormones change, so will your risk). A lot of this is still pending more research—basically it’s a similar problem in heart disease to one we’ve previously talked about with regard to diabetes. Diabetes disproportionately affects black people, while diabetes research disproportionately focuses on white people.

In this case, most heart disease research has focused on men, with women often not merely going unresearched, but also often undiagnosed and untreated until it’s too late. And the treatments, if prescribed? Assumed to be the same as for men.

Dr. Roberts tells of how medicine is taught:

❝When I was in medical school, my professors took the “bikini approach” to women’s health: women’s health meant breasts and reproductive organs. Otherwise the prototypical patient was presented as a man.❞

There has been some research done with statins and women, though! Just, still not a lot. But we do know for example that some statins can be especially useful for treating women’s atherosclerosis—with a 50% success rate, rather than 31% for men.

For lowering LDL itself, however, it can work but is generally not so hot in women.

Fun fact:

In men:

  • High total cholesterol
  • High non-HDL cholesterol
  • High LDL cholesterol
  • Low HDL cholesterol

…are all significantly associated with an increased risk of death from CVD.

In women:

…levels of LDL cholesterol even more than 190 were associated with only a small, statistically insignificant increased risk of dying from CVD.

So…

The fact that women derive less benefit from a medicine that mainly lowers LDL cholesterol, may be because elevated LDL cholesterol is less harmful to women than it is to men.

And also: Treatment and Response to Statins: Gender-related Differences

And for that matter: Women Versus Men: Is There Equal Benefit and Safety from Statins?*

Definitely a case where Betteridge’s Law of Headlines applies!

What should women do to avoid dying of CVD, then?

First, quick reminder of our general disclaimer: we can’t give medical advice and nothing here comprises such. However… One particularly relevant thing we found illuminating in Dr. Roberts’ work was this observation:

The metabolic syndrome is diagnosed if you have three (or more) out of five of the following:

  1. Abdominal obesity (waist >35″ if a woman or >40″ if a man)
  2. Fasting blood sugars of 100mg/dl or more
  3. Fasting triglycerides of 150mg/dl or more
  4. Blood pressure of 130/85 or higher
  5. HDL <50 if a woman or <40 if a man

And yet… because these things can be addressed with exercise and a healthy diet, which neither pharmaceutical companies nor insurance companies have a particular stake in, there’s a lot of focus instead on LDL levels (since there are a flock of statins that can be sold be lower them)… Which, Dr. Roberts says, is not nearly as critical for women.

So women end up getting prescribed statins that cause panic attacks and all those things we mentioned earlier… To lower our LDL, which isn’t nearly as big a factor as the other things.

In summary:

Statins do have their place, especially for men. They can, however, mask underlying problems that need treatment—which becomes counterproductive.

When it comes to women, statins are—in broad terms—statistically not as good. They are a little more likely to be helpful specifically in cases of atherosclerosis, whereby they have a 50/50 chance of helping.

For women in particular, it may be worthwhile looking into alternative non-statin drugs, and, for everyone: diet and exercise.

Further reading: How Can I Safely Come Off Statins?

Don’t Forget…

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  • 4 Practices To Build Self-Worth That Lasts

    10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

    Self-worth is internal, based on who you are, not what you do or external validation. It differs from self-esteem, which is more performance-based. High self-worth doesn’t necessarily mean arrogance, but can lead to more confidence and success. Most importantly, it’ll help you to thrive in what’s actually most important to you, rather than being swept along by what other people want.

    A stable foundation

    A strong sense of self-worth shapes how you handle boundaries, what you believe you deserve, and what you pursue in life. This matters, because life is unpredictable, so having a resilient internal foundation (like a secure “house”) helps you to weather challenges.

    1. Self-acceptance and compassion:
      • Accept both your positive and negative traits with compassion.
      • Don’t judge yourself harshly; allow yourself to accept imperfections without guilt or shame.
    2. Self-trust:
      • Trust yourself to make choices that benefit you and create habits that support long-term well-being—especially if those benefits are cumulative!
      • Balance self-care with flexibility to enjoy life without being overly rigid.
    3. Get uncomfortable:
      • Growth happens outside your comfort zone. Step into new, challenging experiences to build self-trust.
      • However! Small uncomfortable actions lead to greater confidence and a stronger sense of self. Large uncomfortable actions often doing lead anywhere good.
    4. Separation of tasks:
      • Oftentimes we end up overly preoccupying ourselves with things that are not actually our responsibility. Focus instead on tasks that genuinely belong to you, and let go of trying to control others’ perceptions or tasks.
      • Seek internal validation, not external praise. Avoid people-pleasing behavior.

    Finally, three things to keep in mind:

    • Boundaries: respecting your own boundaries strengthens self-worth, avoiding burnout from people-pleasing.
    • Validation: self-worth is independent of how others perceive you; focus on your integrity and personal growth.
    • Accountability: take responsibility for your actions but recognize that others’ reactions are beyond your control.

    For more on all of these things, enjoy:

    Click Here If The Embedded Video Doesn’t Load Automatically!

    Want to learn more?

    You might also like to read:

    Practise Self-Compassion In Your Relationship (But Watch Out!)

    Take care!

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  • Native Americans Have Shorter Life Spans. Better Health Care Isn’t the Only Answer.

    10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

    HISLE, S.D. — Katherine Goodlow is only 20, but she has experienced enough to know that people around her are dying too young.

    Goodlow, a member of the Lower Brule Sioux Tribe, said she’s lost six friends and acquaintances to suicide, two to car crashes, and one to appendicitis. Four of her relatives died in their 30s or 40s, from causes such as liver failure and covid-19, she said. And she recently lost a 1-year-old nephew.

    “Most Native American kids and young people lose their friends at a young age,” said Goodlow, who is considering becoming a mental health therapist to help her community. “So, I’d say we’re basically used to it, but it hurts worse every time we lose someone.”

    Native Americans tend to die much earlier than white Americans. Their median age at death was 14 years younger, according to an analysis of 2018-21 data from the Centers for Disease Control and Prevention

    The disparity is even greater in Goodlow’s home state. Indigenous South Dakotans who died between 2017 and 2021 had a median age of 58 — 22 years younger than white South Dakotans, according to state data.

    Donald Warne, a physician who is co-director of the Johns Hopkins Center for Indigenous Health and a member of the Oglala Sioux Tribe, can rattle off the most common medical conditions and accidents killing Native Americans.

    But what’s ultimately behind this low life expectancy, agree Warne and many other experts on Indigenous health, are social and economic forces. They argue that in addition to bolstering medical care and fully funding the Indian Health Service — which provides health care to Native Americans — there needs to be a greater investment in case management, parenting classes, and home visits.

    “It’s almost blasphemy for a physician to say,” but “the answer to addressing these things is not hiring more doctors and nurses,” Warne said. “The answer is having more community-based preventions.”

    The Indian Health Service funds several kinds of these programs, including community health worker initiatives, and efforts to increase access to fresh produce and traditional foods.

    Private insurers and state Medicaid programs, including South Dakota’s, are increasingly covering such services. But insurers don’t pay for all the services and aren’t reaching everyone who qualifies, according to Warne and the National Academy for State Health Policy.

    Warne pointed to Family Spirit, a program developed by the Johns Hopkins center to improve health outcomes for Indigenous mothers and children.

    Chelsea Randall, the director of maternal and child health at the Great Plains Tribal Leaders’ Health Board, said community health workers educate Native pregnant women and connect them with resources during home visits.

    “We can be with them throughout their pregnancy and be supportive and be the advocate for them,” said Randall, whose organization runs Family Spirit programs across seven reservations in the Dakotas, and in Rapid City, South Dakota.

    The community health workers help families until children turn 3, teaching parenting skills, family planning, drug abuse prevention, and stress management. They can also integrate the tribe’s culture by, for example, using their language or birthing traditions.

    The health board funds Family Spirit through a grant from the federal Health Resources and Services Administration, Randall said. Community health workers, she said, use some of that money to provide child car seats and to teach parents how to properly install them to counter high rates of fatal crashes.

    Other causes of early Native American deaths include homicide, drug overdoses, and chronic diseases, such as diabetes, Warne said. Native Americans also suffer a disproportionate number of infant and maternal deaths.

    The crisis is evident in the obituaries from the Sioux Funeral Home, which mostly serves Lakota people from the Pine Ridge Reservation and surrounding area. The funeral home’s Facebook page posts obituaries for older adults, but also for many infants, toddlers, teenagers, young adults, and middle-aged residents.

    Misty Merrival, who works at the funeral home, blames poor living conditions. Some community members struggle to find healthy food or afford heat in the winter, she said. They may live in homes with broken windows or that are crowded with extended family members. Some neighborhoods are strewn with trash, including intravenous needles and broken bottles.

    Seeing all these premature deaths has inspired Merrival to keep herself and her teenage daughter healthy by abstaining from drugs and driving safely. They also talk every day about how they’re feeling, as a suicide-prevention strategy.

    “We’ve made a promise to each other that we wouldn’t leave each other like that,” Merrival said.

    Many Native Americans live in small towns or on poor, rural reservations. But rurality alone doesn’t explain the gap in life expectancy. For example, white people in rural Montana live 17 years longer, on average, than Native Americans in the state, according to state data reported by Lee Enterprises newspapers.

    Many Indigenous people also face racism or personal trauma from child or sexual abuse and exposure to drugs or violence, Warne said. Some also deal with generational trauma from government programs and policies that broke up families and tried to suppress Native American culture.

    Even when programs are available, they’re not always accessible.

    Families without strong internet connections can’t easily make video appointments. Some lack cars or gas money to travel to clinics, and public transportation options are limited.

    Randall, the health board official, is pregnant and facing her own transportation struggles.

    It’s a three-hour round trip between her home in the town of Pine Ridge and her prenatal appointments in Rapid City. Randall has had to cancel several appointments when family members couldn’t lend their cars.

    Goodlow, the 20-year-old who has lost several loved ones, lives with seven other people in her mother’s two-bedroom house along a gravel road. Their tiny community on the Pine Ridge Reservation has homes and ranches but no stores.

    Goodlow attended several suicide-prevention presentations in high school. But the programs haven’t stopped the deaths. One friend recently killed herself after enduring the losses of her son, mother, best friend, and a niece and nephew.

    A month later, another friend died from a burst appendix at age 17, Goodlow said. The next day, Goodlow woke up to find one of her grandmother’s parakeets had died. That afternoon, she watched one of her dogs die after having seizures.

    “I thought it was like some sign,” Goodlow said. “I started crying and then I started thinking, ‘Why is this happening to me?’”

    Warne said the overall conditions on some reservations can create despair. But those same reservations, including Pine Ridge, also contain flourishing art scenes and language and cultural revitalization programs. And not all Native American communities are poor.

    Warne said federal, state, and tribal governments need to work together to improve life expectancy. He encourages tribes to negotiate contracts allowing them to manage their own health care facilities with federal dollars because that can open funding streams not available to the Indian Health Service.

    Katrina Fuller is the health director at Siċaŋġu Co, a nonprofit group on the Rosebud Reservation in South Dakota. Fuller, a member of the Rosebud Sioux Tribe, said the organization works toward “wicozani,” or the good way of life, which encompasses the physical, emotional, cultural, and financial health of the community.

    Siċaŋġu Co programs include bison restoration, youth development, a Lakota language immersion school, financial education, and food sovereignty initiatives.

    “Some people out here that are struggling, they have dreams, too. They just need the resources, the training, even the moral support,” Fuller said. “I had one person in our health coaching class tell me they just really needed someone to believe in them, that they could do it.”

    KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

    Subscribe to KFF Health News’ free Morning Briefing.

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  • Gut Health 2.0

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    Gene Expression & Gut Health

    Dr. Tim Spector, a renowned expert in Gut Health 2.0, offers valuable insights and expertise on the latest advancements in improving gut health and overall well-being. With years of research and

    This is Dr. Tim Spector. After training in medicine and becoming a consultant rheumatologist, he’s turned his attention to medical research, and is these days a specialist in twin studies, genetics, epigenetics, microbiome, and diet.

    What does he want us to know?

    For one thing: epigenetics are for more than just getting your grandparents’ trauma.

    More usefully: there are things we can do to improve epigenetic factors in our body

    DNA is often seen as the script by which our body does whatever it’s going to do, but it’s only part of the story. Thinking of DNA as some kind of “magical immutable law of reality” overlooks (to labor the metaphor) script revisions, notes made in the margins, directorial choices, and ad-lib improvizations, as well as the quality of the audience’s hearing and comprehension.

    Hence the premise of one of Dr. Spector’s older books, “Identically Different: Why We Can Change Our Genes

    (*in fact, it was his first, from all the way back in 2013, when he’d only been a doctor for 34 years)

    Gene expression will trump genes every time, and gene expression is something that can often be changed without getting in there with CRISPR / a big pair of scissors and some craft glue.

    How this happens on the micro level is beyond the scope of today’s article; part of it has to do with enzymes that get involved in the DNA transcription process, and those enzymes in turn are despatched or not depending on hormonal messaging—in the broadest sense of “hormonal”; all the body’s hormonal chemical messengers, not just the ones people think of as hormones.

    However, hormonal messaging (of many kinds) is strongly influenced by something we can control relatively easily with a little good (science-based) knowledge: the gut.

    The gut, the SAD, and the easy

    In broad strokes: we know what is good for the gut. We’ve written about it before at 10almonds:

    Making Friends With Your Gut (You Can Thank Us Later)

    This is very much in contrast with what in scientific literature is often abbreviated “SAD”, the Standard American Diet, which is very bad for the gut.

    However, Dr. Spector (while fully encouraging everyone to enjoy an evidence-based gut-healthy diet) wanted to do one better than just a sweeping one-size-fits-all advice, so he set up a big study with 15,000 identical twins; you can read about it here: TwinsUK

    The information that came out of that was about a lot more than just gene expression and gut health, but it did provide the foundation for Dr. Spector’s next project, ZOE.

    ZOE crowdsources huge amounts of data including individual metabolic responses to standardized meals in order to predict personalized food responses based on individual biology and unique microbiome profile.

    In other words, it takes the guesswork out of a) knowing what your genes mean for your food responses b) tailoring your food choices with your genetic expression in mind, and c) ultimately creating a positive feedback loop to much better health on all levels.

    Now, this is not an ad for ZOE, but if you so wish, you can…

    Want to know more?

    Dr. Spector has a bunch of books out, including some that we’ve reviewed previously:

    You can also check out our own previous main feature, which wasn’t about Dr. Spector’s work but was very adjacent:

    The Brain-Gut Highway: A Two-Way Street

    Enjoy!

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    Q: Where do I get cucumber extract?

    A: You can buy it from BulkSupplements.com (who, despite their name, start at 100g packs)

    Alternatively: you want it as a topical ointment (for skin health) rather than as a dietary supplement (for bone and joint health), you can extract it yourself! No, it’s not “just juice cucumbers”, but it’s also not too tricky.

    Click Here For A Quick How-To Guide!

    Q: Tips for reading more and managing time for it?

    A: We talked about this a little bit in yesterday’s edition, so you may have seen that, but aside from that:

    • If you don’t already have one, consider getting a Kindle or similar e-reader. They’re very convenient, and also very light and ergonomicno more wrist strain as can occur with physical books. No more eye-strain, either!
    • Consider making reading a specific part of your daily routine. A chapter before bed can be a nice wind-down, for instance! What’s important is it’s a part of your day that’ll always, or at least almost always, allow you to do a little reading.
    • If you drive, walk, run, or similar each day, a lot of people find that’s a great time to listen to an audiobook. Please be safe, though!
    • If your lifestyle permits such, a “reading retreat” can be a wonderful vacation! Even if you only “retreat” to your bedroom, the point is that it’s a weekend (or more!) that you block off from all other commitments, and curl up with the book(s) of your choice.

    Q: Any study tips as we approach exam season? A lot of the productivity stuff is based on working life, but I can’t be the only student!

    A: We’ve got you covered:

    • Be passionate about your subject! We know of no greater study tip than that.
    • Find a willing person and lecture them on your subject. When one teaches, two learn!
    • Your mileage may vary depending on your subject, but, find a way of studying that’s fun to you!
    • If you can get past papers, get as many as you can, and use those as your “last minute” studying in the week before your exam(s). This will prime you for answering exam-style questions (and leverage state-dependent memory). As a bonus, it’ll also help ease any anxiety, because by the time of your exam it’ll be “same old, same old”!

    Q: Energy drinks for biohacking, yea or nay?

    A: This is definitely one of those “the dose makes the poison” things!

    But… The generally agreed safe dose of taurine is around 3g/day for most people; a standard Red Bull contains 1g.

    That math would be simple, but… if you eat meat (including poultry or fish), that can also contain 10–950mg per 100g. For example, tuna is at the high end of that scale, with a standard 12oz (340g) tin already containing up to 3.23g of taurine!

    And sweetened carbonated beverages in general have so many health issues that it’d take us a full article to cover them.

    Short version? Enjoy in moderation if you must, but there are definitely better ways of getting the benefits they may offer.

    Q: Best morning routine?

    A: The best morning routine is whatever makes you feel most ready to take on your day!

    This one’s going to vary a lot—one person’s morning run could be another person’s morning coffee and newspaper, for example.

    In a nutshell, though, ask yourself these questions:

    • How long does it take me to fully wake up in the morning, and what helps or hinders that?
    • When I get out of bed, what do I really need before I can take on my day?
    • If I could have the perfect morning, what would it look like?
    • What can evening me do, to look after morning me’s best interests? (Semi-prepare breakfast ready? Lay out clothes ready? Running shoes? To-Do list?)

    Q: I’m curious how much of these things you actually use yourselves, and are there any disagreements in the team? In a lot of places things can get pretty heated when it’s paleo vs vegan / health benefits of tea/coffee vs caffeine-abstainers / you need this much sleep vs rise and grinders, etc?

    A: We are indeed genuinely enthusiastic about health and productivity, and that definitely includes our own! We may or may not all do everything, but between us, we probably have it all covered. As for disagreements, we’ve not done a survey, but if you take an evidence-based approach, any conflict will tend to be minimized. Plus, sometimes you can have the best of both!

    • You could have a vegan paleo diet (you’d better love coconut if you do, though!
    • There is decaffeinated coffee and tea (your taste may vary)
    • You can get plenty of sleep and rise early (so long as an “early to bed, early to rise” schedule suits you!)

    Interesting note: humans are social creatures on an evolutionary level. Evolution has resulted in half of us being “night owls” and the other half “morning larks”, the better to keep each other safe while sleeping. Alas, modern life doesn’t always allow us to have the sleep schedule that’d suit each of us best individually!

    Have a question you’d like answered? Reply to this email, or use the feedback widget at the bottom! We always love to hear from you

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  • Why rating your pain out of 10 is tricky

    10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

    “It’s really sore,” my (Josh’s) five-year-old daughter said, cradling her broken arm in the emergency department.

    “But on a scale of zero to ten, how do you rate your pain?” asked the nurse.

    My daughter’s tear-streaked face creased with confusion.

    “What does ten mean?”

    “Ten is the worst pain you can imagine.” She looked even more puzzled.

    As both a parent and a pain scientist, I witnessed firsthand how our seemingly simple, well-intentioned pain rating systems can fall flat.

    altanaka/Shutterstock

    What are pain scales for?

    The most common scale has been around for 50 years. It asks people to rate their pain from zero (no pain) to ten (typically “the worst pain imaginable”).

    This focuses on just one aspect of pain – its intensity – to try and rapidly understand the patient’s whole experience.

    How much does it hurt? Is it getting worse? Is treatment making it better?

    Rating scales can be useful for tracking pain intensity over time. If pain goes from eight to four, that probably means you’re feeling better – even if someone else’s four is different to yours.

    Research suggests a two-point (or 30%) reduction in chronic pain severity usually reflects a change that makes a difference in day-to-day life.

    But that common upper anchor in rating scales – “worst pain imaginable” – is a problem.

    Doctor holds hands of an elderly woman in a hospital bed.
    People usually refer to their previous experiences when rating pain. sasirin pamai/Shutterstock

    A narrow tool for a complex experience

    Consider my daughter’s dilemma. How can anyone imagine the worst possible pain? Does everyone imagine the same thing? Research suggests they don’t. Even kids think very individually about that word “pain”.

    People typically – and understandably – anchor their pain ratings to their own life experiences.

    This creates dramatic variation. For example, a patient who has never had a serious injury may be more willing to give high ratings than one who has previously had severe burns.

    “No pain” can also be problematic. A patient whose pain has receded but who remains uncomfortable may feel stuck: there’s no number on the zero-to-ten scale that can capture their physical experience.

    Increasingly, pain scientists recognise a simple number cannot capture the complex, highly individual and multifaceted experience that is pain.

    Who we are affects our pain

    In reality, pain ratings are influenced by how much pain interferes with a person’s daily activities, how upsetting they find it, their mood, fatigue and how it compares to their usual pain.

    Other factors also play a role, including a patient’s age, sex, cultural and language background, literacy and numeracy skills and neurodivergence.

    For example, if a clinician and patient speak different languages, there may be extra challenges communicating about pain and care.

    Some neurodivergent people may interpret language more literally or process sensory information differently to others. Interpreting what people communicate about pain requires a more individualised approach.

    Impossible ratings

    Still, we work with the tools available. There is evidence people do use the zero-to-ten pain scale to try and communicate much more than only pain’s “intensity”.

    So when a patient says “it’s eleven out of ten”, this “impossible” rating is likely communicating more than severity.

    They may be wondering, “Does she believe me? What number will get me help?” A lot of information is crammed into that single number. This patient is most likely saying, “This is serious – please help me.”

    In everyday life, we use a range of other communication strategies. We might grimace, groan, move less or differently, use richly descriptive words or metaphors.

    Collecting and evaluating this kind of complex and subjective information about pain may not always be feasible, as it is hard to standardise.

    As a result, many pain scientists continue to rely heavily on rating scales because they are simple, efficient and have been shown to be reliable and valid in relatively controlled situations.

    But clinicians can also use this other, more subjective information to build a fuller picture of the person’s pain.

    How can we communicate better about pain?

    There are strategies to address language or cultural differences in how people express pain.

    Visual scales are one tool. For example, the “Faces Pain Scale-Revised” asks patients to choose a facial expression to communicate their pain. This can be particularly useful for children or people who aren’t comfortable with numeracy and literacy, either at all, or in the language used in the health-care setting.

    A vertical “visual analogue scale” asks the person to mark their pain on a vertical line, a bit like imagining “filling up” with pain.

    A horizontal bar ranging from green at one end to red at the other, with different smiley faces underneath.
    Modified visual scales are sometimes used to try to overcome communication challenges. Nenadmil/Shutterstock

    What can we do?

    Health professionals

    Take time to explain the pain scale consistently, remembering that the way you phrase the anchors matters.

    Listen for the story behind the number, because the same number means different things to different people.

    Use the rating as a launchpad for a more personalised conversation. Consider cultural and individual differences. Ask for descriptive words. Confirm your interpretation with the patient, to make sure you’re both on the same page.

    Patients

    To better describe pain, use the number scale, but add context.

    Try describing the quality of your pain (burning? throbbing? stabbing?) and compare it to previous experiences.

    Explain the impact the pain is having on you – both emotionally and how it affects your daily activities.

    Parents

    Ask the clinician to use a child-suitable pain scale. There are special tools developed for different ages such as the “Faces Pain Scale-Revised”.

    Paediatric health professionals are trained to use age-appropriate vocabulary, because children develop their understanding of numbers and pain differently as they grow.

    A starting point

    In reality, scales will never be perfect measures of pain. Let’s see them as conversation starters to help people communicate about a deeply personal experience.

    That’s what my daughter did — she found her own way to describe her pain: “It feels like when I fell off the monkey bars, but in my arm instead of my knee, and it doesn’t get better when I stay still.”

    From there, we moved towards effective pain treatment. Sometimes words work better than numbers.

    Joshua Pate, Senior Lecturer in Physiotherapy, University of Technology Sydney; Dale J. Langford, Associate Professor of Pain Management Research in Anesthesiology, Weill Cornell Medical College, Cornell University, and Tory Madden, Associate Professor and Pain Researcher, University of Cape Town

    This article is republished from The Conversation under a Creative Commons license. Read the original article.

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  • Unprocessed 10th Anniversary Edition – by Abbie Jay

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