Blog | Thursday, June 24, 2010

Cholesterol: validation of the self

This post by John H. Schumann, FACP, appeared at GlassHospital.

It's hard to think of a medical concept (let alone any concept!) from the last quarter century that has achieved as much penetration into our culture than CHOLESTEROL. Every patient I can think of, whether rich or poor, old or young, educated or not knows that "cholesterol is bad for you," and that you should strive to "keep your cholesterol under control," whatever that means.

importance of a nail by red twolips via FlickrWell, doctors are hammers, and we like to hit nails. Surgeons like to do operations. It turns out that the more they do, the better they get.

Primary care docs (such as internists, like me) run lab tests. When we see a value that falls outside of norms, we like to "do" something about it. Unfortunately, this has come to almost always mean writing a prescription.

The whole cholesterol hypothesis works very well with this paradigm, now that we have relatively safe and effective drugs with which to "treat" high cholesterol.

I put "treat" in quotes, since high cholesterol (except in rare cases where the cholesterol is sky high in genetic conditions) is not a disease, but a modifiable risk factor for vascular issues like heart attacks and strokes.

There is overwhelming evidence from the medical literature that people who control their cholesterol with statin drugs (simvastatin [Zocor], atorvastatin [Lipitor], rosuvasatin [Crestor], and others) have fewer vascular events (heart attacks, strokes).

This is because the drugs lower the liver's manufacture of cholesterol in the body and alter the ratio of "good" cholesterol to "bad." A lower level of circulating cholesterol helps reduce and stabilize the cholesterol-laden plaques that build up in our arteries, mostly due to our higher fat, highly processed American diets.

I still remember learning about this from a superb Grand Rounds lecture I attended more than a decade ago by Dr. Peter "I used to think I was incorruptible because I took money from EVERY drug company" Libby. His research demonstrates that statins not only reduce cholesterol in the blood and in arterial plaques, but even reduce the amount of overall inflammation in the blood vessel wall.

Some researchers have gone as far as suggesting we put statins in the water supply, since their benefits seem so clear and ubiquitous.

Yet as with all things that become a form of orthodoxy, there are contrarians. Start with those who've had side effects from the drugs: liver injury, muscle inflammation, and less specific aches and pains. Some question the long term effects of being on the medication; others question the incessant marketing of the drugs and the seemingly ever-expanding indications for prescribing them.

Should we prescribing statins for people without risk factors? Even when the cholesterol is not "high?"

It worries me that cholesterol has become the marker of virtue at the doctor's office. It's all due to oversimplification of the physiology and the major societal buy-in to these drugs.

For the more competitive patients, the lower the total cholesterol number, the higher the achievement. Never mind that what determines the number is largely genetics mixed with diet and exercise.

How big a role does diet play?

I admit, having prescribed statins for so long, I was skeptical that lifestyle alone could make a dramatic impact. I posted about what a dietary change did for me in the course of one month. I was quite surprised.

Of course, not everyone can make the lifestyle changes necessary to improve their health profiles. Behavioral change, like all change, is difficult to both initiate and sustain.

The statins give us an alternative to making this change. It's just that we're sliding quickly down the slippery slope to pushing them on everyone.

When you're a hammer, you like to see nails. Even if you have to go out and find more of them.

John Henning Schumann is a general internist in Chicago's south side, and an educator at the University of Chicago, where he trains residents and medical students in both internal medicine and medical ethics. He is also faculty co-chair of the university’s human rights program. His blog, GlassHospital, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people that inhabit them.