Against cholesterol hysteria


Ever since that class that I sat in

If  patients of mine start to fatten

Exercise

And diet I prize,

I don’t just reach for a statin.

At the Care Initiatives Hospice meeting this week we discussed a new patient.  Metastatic cancer, emphysema, and a massive stroke justified the patient’s terminal care.

“Well,” I said, “Let’s look at the med list…(Pause)…Is there any reason a person in their mid 90’s ought to be on a statin?”

The very next thing we sent a message to the attending physician asking, politely and respectfully, if it would be OK to stop the cholesterol lowering agent, seeing as how it would do nothing for comfort.

We haven’t heard back yet.

I don’t buy into the cholesterol hysteria.  (By way of background: cholesterol is a waxy substance, triglycerides are fats, just like olive oil or lard.)

After a lecture on the evils of high cholesterol in the early ‘80s a naysayer in the back of the room asked why changing the cholesterol doesn’t change all-cause mortality.  The lecturer, a nationally known figure, waited an embarrassed moment and then said that yes, for every one we save from heart attack and stroke we lose one from homicide, suicide, car accidents and respiratory infections, BUT…

The audience laughed, because the association sounded so improbable.  The same data came across the next year at the same education event and we laughed but not as hard, and the third year we didn’t even chuckle.  To this day we have dozens of studies that fail to show that cholesterol therapy lowers total death rate, but only a couple that show it does.

Before the statins (which are more properly called HMG co-A reductase inhibitors), my approach stayed pretty mainstream.  I’d check the thyroid, then I’d say, “Well, your cholesterol is high.  Eat less, exercise more, and come back in 3 to 6 months.”  Of course, half of them didn’t come back.  At the follow-up visit I would say either, “Look how well you’ve done, keep up the good work and come back in three to six months,” or “You really do need to eat less and exercise more, come back in three to six months.”  Once again, half wouldn’t come back.  Which meant that I didn’t have to treat a whole lot of high cholesterol.

After all, the guidelines say that lifestyle modification, mostly diet and exercise, remains the first line of treatment.

Cholesterol hysteria’s grain of truth lurks in diet and exercise.

Exercise can become its own reward, and you don’t have to wait for years to get the payoff.  Yes, it pays off in the long term, and it has to do with fewer fractures, less depression, sleeping better, delaying dementia, and a better sex life.

Obviously food tastes better when you’re a little hungry, and essentially any weight loss diet will leave you a little hungry.  Most people who overeat ignore rather than enjoy their food, and truly don’t realize how much they eating.

Few patients listen when I give them advice about weight loss, and the ones who do live longer, happier lives.

Nowadays I still check everyone’s thyroid and testosterone in men, but I also check vitamin D.  I still tell them about diet and exercise, but by now most of my patients know me pretty well and that advice hasn’t worked yet, and it’s not likely to in the future.  So I start people on fish oil and niacin.

I have many reasons to recommend fish oil, mostly to do with mental vigor and joint resilience, unless you’re going to surgery.

A well-known family practice lecturer asserts that any patient who takes a high enough dose of a statin for a long enough period of time will ache so badly they can’t exercise.  I agree.  Just recently I got an elderly patient out of the wheelchair and back walking by stopping that drug.

Still I live in the real world. Any physician who flies in the face of the standard of care risks law suits. So I prescribe statins when the other things fail, enthusiastically when the patient has known heart disease.  Unless the levels are very abnormal, I am ambivalent about treating the number, rather than the person.

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One Response to “Against cholesterol hysteria”

  1. Herbert Stern Says:

    With all due respect, your comments are at best inaccurate and at worst totally misleading. There is a direct correlation between cholesterol levels and risk of heart disease. There is better correlation with the type of cholesterol elevation explaining why some patients with only modest elevations in total cholesterol get heart disease.
    In my twenty plus years of practicing as a cardiologist, I have watched the evolutuion of heart disease as an acute event leading to death to one of a more manageable chronic disease. In my opinion and many other leaders in the field it is in part due to statins.
    You should not discourage your blog followers into not using statins when in my experience many patients are frightened of their well-known but generally benign side effects- they are a miracle class of drug that prolongs life.

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