I just want to eat pizza again is that too much to ask

LibrarianMeg said:

The gap between trial results and real-world results is consistent and it is not fraud.

This is where I part company with the consensus forming above. I would add the less popular caveat: these trial populations under-represented several groups, older adults and the highest BMI categories among them. The results probably generalise, and "probably" should be stated as an assumption rather than dropped.

Ask again with the specifics and you will get a better answer than this one.

TomFromTexas said:

My own curve sits about four points below the published mean and I spent two months assuming that meant something was wrong with me or with my…

TomFromTexas said:

...regarding the trial evidence...

I think this is an underappreciated point. To expand on it with some data:

A recent meta-analysis of 15 RCTs (n=12,300) found that the trial evidence was associated with a clinically meaningful effect size across diverse patient populations[1].

The NNT was 12, which is comparable to antihypertensives for stroke reduction. That's a strong clinical argument for this approach.

MikeFit_NJ said:

I would add the less popular caveat: these trial populations under-represented several groups, older adults and the highest BMI categories among them.

Forest plot interpretation for the the trial evidence meta-analysis: when reading the pooled estimate, pay attention to:

1. Point estimate (HR/RR/OR) — center of the diamond
2. Confidence interval width — precision of the estimate
3. I² statistic — heterogeneity across studies
4. Individual study weights — are results driven by one large trial?
5. Prediction interval — range of plausible true effects in future settings

The the trial evidence meta-analysis shows a pooled RR of 0.76 (95% CI 0.67-0.86), I²=34%. This is a robust and consistent effect.

One thing that is still open after wanda_boise’s answer:

Did your prescriber agree with that reading, and if not what was their objection?

Closing the loop on my own question.

Update — my curve sits below the published mean and the explanation is that the trial arm had support I do not have. That was reassuring rather than otherwise.