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.
Well, 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.
Labels: cholesterol, diet, exercise, pharmaceuticals, statins
posted by John Schumann, M.D. at
1:00 PM
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Blog log
Members of the American College of Physicians contribute posts from their own sites to ACP Internist and ACP Hospitalist. Contributors include:
Albert Fuchs, MD
Albert Fuchs, MD, FACP,
graduated from the University of California, Los Angeles School of
Medicine, where he also did his internal medicine training.
Certified by the American Board of Internal Medicine, Dr. Fuchs
spent three years as a full-time faculty member at UCLA School of
Medicine before opening his private practice in Beverly Hills in
2000.
David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned
authority on nutrition, weight management, and the prevention of
chronic disease, and an internationally recognized leader in
integrative medicine and patient-centered care.
DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about
health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more
than a decade and is an Associate Professor of Medicine at an
academic medical center on the East Coast. His time is split
between teaching medical students and residents, and caring for
patients.
Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science,
medicine, health and healing in the 21st century.
FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the
Internal Medicine Residency and Assistant Dean of Scholarship &
Discovery at the Pritzker School of Medicine for the University of
Chicago. Her education and research focus is on resident duty
hours, patient handoffs, medical professionalism, and quality of
hospital care. She is also an academic hospitalist.
Glass
Hospital
John H. Schumann, MD, FACP, 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 who inhabit them.
Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the
University of North Carolina School of Medicine, and the Program
Director for the GI & Hepatology Fellowship Program. He
specializes in diseases of the esophagus, with a strong interest in
the diagnosis and treatment of patients who have
difficult-to-manage esophageal problems such as refractory GERD,
heartburn, and chest pain.
I'm dok
ACP Member Mike Aref, MD, PhD, ACP Member, is an academic
hospitalist with an interest in basic and clinical science and
education, with interests in noninvasive monitoring and diagnostic
testing using novel bedside imaging modalities, diagnostic
reasoning, medical informatics, new medical education modalities,
pre-code/code management, palliative care, patient-physician
communication, quality improvement, and quantitative biomedical
imaging.
Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites
for influential health commentary.
MD
Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of
medical practice, including controversies in the doctor-patient
relationship, medical ethics and measuring medical quality. When
he's not writing, he's performing colonoscopies.
Medical
Lessons
Elaine Schattner, MD, ACP Member, shares her ideas on education,
ethics in medicine, health care news and culture. Her views on
medicine are informed by her past experiences in caring for
patients, as a researcher in cancer immunology, and as a patient
who's had breast cancer.
Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a
small community hospital in Connecticut. His blog is a series of
musings on medicine, medical care, the health care system and
medical ethics, in no particular order.
Reflections
of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being
a doctor in a community hospital in Atlanta.
Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in
education, social media and networking, practice management and
evidence-based medicine tools, personal information and knowledge
management.
White Coat Underground
Peter A. Lipson, MD, ACP Member, is a practicing internist and
teaching physician in Southeast Michigan. The blog, which has been
around in various forms since 2007, offers musings on the
intersection of science, medicine, and culture.
ACP Internist and ACP Hospitalist also contribute to and draw upon content from Get Better Health, a network created by Val Jones, MD, to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the clinician's point of view on health care reform, science, research and patient care.
Other blogs of note:
American
Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine
publishes original clinical articles of interest to physicians in
internal medicine and its subspecialities, both in academia and
community-based practice.
Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP
Member, associate program director at New York University Medical
Center's internal medicine residency program. Faculty, residents
and students contribute case studies, mystery quizzes, news,
commentary and more.
db's Medical
Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating
medicine and the health care system.
Interact
MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so
he can create an independent, clinician-reviewed space on the
Internet for physicians to report and comment on the medical news
of the day.
PLoS
Blog
The Public Library of Science's open access materials include a
blog.
White Coat Rants
One of the most popular anonymous blogs written by an emergency
room physician.
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