Tell Me What You Want

I am asking readers to tell me what you want.  Not in general, but at a health or wellness talk.  A few weeks ago I was asked to speak at a wellness seminar given at a company for its employees about heart health.  The talk was well received, and we had a good discussion after my presentation.

What struck me was how willing people were, in a room full of co-workers, to ask questions about their personal health.  In the office, we have safeguards to protect privacy at check-in, in the waiting room and at check out.  Yet in this conference room, with people they know listening, I was told about cholesterol results and other tests, treatments they were given, etc.  Granted, we were talking about heart disease, which may not seem as socially or professionally awkward as some other topics, but it still surprised me.

It also made me wonder – what did they want?  My professional interpretation and opinion of their situation, or validation that the choices they had made in their own care were “good choices”?

I did my best based on the information people gave me to address their concerns, while encouraging them to speak to their doctors.  Some had questions understanding what they were treating or how to interpret their results.  Others had decided to try a different therapy (often homeopathic) than what their doctor recommended and wanted my approval – so the answer to my initial question is “both”.

I found it to be a little uncomfortable being asked to approve someone’s decisions with limited information, especially if I didn’t “approve.”  However, the talk and Q&A are for the attendees, not me, so I did my best to give a recommendation and encourage discussion between the person and their doctor.

This is a copy of the talk I gave – I want to thank TheVisualMD for the image support in the talk.

My question to you – if you went to a talk like this what would you prefer?  A general Q&A or time at the end to make a mini-appointment to discuss your questions one on one with the speaker?  Tell me what you want!

The path to wellness begins with a proper diagnosis

Steaks and Statins – weight gain and cholesterol management

Recently there have been several news stories with contradictory  health information; obesity has reached a peak, obesity is still rising.  Running leads to a longer life, but marathon runners don’t live longer.  Supplements don’t work, except when they do.

One of the latest stories is that people who take statins are gaining weight faster than those who don’t.    Have statins become a crutch or do statins cause weight gain?  Are we healthier now that we can have our steaks with a side of statins?

What did the study look at?

To assess the question of statins and weight gain the authors used a large database called the National Health and Nutrition Examination Survey (NHANES) which was a large study conducted from 1999-2010 that collected data on tens of thousands of Americans, looking at illnesses, medication use, diet, supplement use and other  items.

For this study, 28,000 people were evaluated:

  • those with high cholesterol and taking statins
  • those with high cholesterol and not on statins
  • those without high cholesterol and not on statins

They compared calorie and fat intake between statin users and nonusers in 1999-2000 and 2009-2010.  In 2010, statin users were eating almost 250 calories more a day than they did in 2000.  They were eating more fat, as well as having gained more weight than non-statin users.  However, statin users did have lower cholesterol.

What the study did not assess was if the rate of heart attacks changed in the groups – the study wasn’t designed to answer that question.  But is that the only question that matters?

The reason why it matters is that diabetes rates, linked to weight gain and obesity are still on the rise.  Are people being helped if they lower heart disease risk by taking statins but raise their risk of developing diabetes?

Possible explanations of the data

  • Doctor effect – are doctors advocating medication over healthy lifestyles?  It is easier and takes less time.
  • Patient effect – are patients interpreting taking statins as a free pass to keep the same lifestyle they had before medication?  Again taking a pill a day is easier than maintaining a healthy lifestyle.

The truth is probably a little bit of both.

How does this affect my practice?

I’m a strong proponent of preventing disease.  We prevent heart disease by not smoking, controlling blood pressure and reducing the Low Density Lipoproteins that clog our arteries with statins.  Central to this, and what I recommend with or without medication is lifestyle – a healthy and active one!  Doing so may avoid the need for medication or allow us to use a lower dose – reducing side effects!

What we don’t know from this study is if people had an increase in heart attacks despite their lower overall cholesterol levels – meaning the increase in calories, fat and weight offset the benefit of taking a statin.  Or, did the statin allow people to safely lead a more permissive lifestyle?  Can you have your steak if you have your statin too?

The study did show an increase in diabetes  – presumably related to the weight gain in the statin users.  They consumed about 250 calories a day more in 2010 than in 2000 – which can lead to almost 10 pounds a year in weight gain!

So when I discuss taking statins with my patients, I always frame it as a component of a plan to reduce the risk of heart disease.  If diet and exercise reduce risk enough, medication can be stopped and risk reassessed.  Even if lifestyle does not reduce risk enough to stop medication, it may minimize the need for dosage increases.

For those that do not alter their lifestyle, they run the risk of developing diabetes.  While statins will reduce some of the risk of heart disease, diabetes carries its own risks – kidney, nerve and eye damage – which statins won’t protect against.

My role as an Internist is to look at a person as  a whole – evaluate all their risks and how they relate to each other.  So this study serves as an example that we can treat a singular problem, but if that is our whole focus, we lose sight of the person and may not truly improve their health.

The path to wellness begins with a proper diagnosis

The “new” cholesterol guidelines – what’s really the issue?

For decades people and doctors have been obsessed with cholesterol levels.  Books have been written, diets promoted, medications prescribed – all with the purpose of getting your cholesterol to “goal”.  You get your labs done and your doctor tells you your cholesterol is high.  You are instructed to eat a low-fat diet, exercise more and possibly start a medication.  Often you are not sure which numbers are high, or what they mean.  But you know that high cholesterol is a bad thing, and so you try to follow the doctor’s advice and lower your cholesterol.  
11/12/13 was a unique date – not only the second to last sequential month/day/year in our lifetimes; it is also the day the American College of Cardiology (ACC) and American Heart Association (AHA) released new guidelines for cholesterol management that recommend treating high cholesterol but not to any specific number.
This represents a change in over a decade of “goal oriented” recommendations which specified a level of bad cholesterol (LDL) to aim for, using multiple medications if needed to get there.
New Guidelines for Cholesterol:
  • Aim for cholesterol to be reduced by half
  • Only use a statin medication
  • Not necessary to add other medications if you don’t get quite there
Why were these changes recommended?
The theory behind the changes is that the guideline committee felt there wasn’t strong enough evidence supporting a specific target.  For example, if a person’s LDL cholesterol is reduced from 195 to 95, is there any real additional benefit in getting to the previous high risk goal of 70? Or is 95 good enough?
So what are the recommendations?
People are broken down into 2 risk groups in terms of deciding if a statin should be used
  1. High Risk:  people with a prior heart attack, bypass surgery, a stent or diabetes should take statins.  Statins are also recommended for those with very high LDL cholesterol (>190)
  2. Future Risk:  those whose 10 year risk of a heart attack is 7.5% or greater.  This number is calculated with a risk calculator that uses cholesterol, weight, blood pressure, smoking and other factors to come up with your number.
The High Risk group is not a  major change in terms of starting treatment.  The change is not recommending a target value for the LDL cholesterol.
The Future Risk group is different – the previous recommendations used a higher 10 year risk 15-20% before starting a statin.
Besides statin therapy, lifestyle changes are a cornerstone of the new recommendations:
  • No smoking
  • A health body weight
  • Exercise
  • A diet with lots of vegetables, fruits and lean protein
Controversy
Not all doctors agree that the 10-year risk is the best guide for starting treatment – why not lifetime risk?  There also have been questions about the risk calculator itself – the formula used appears to overestimate risk – including more people needing treatment than may truly benefit.  In addition, several of the members of the guideline committee quit due to disagreement on the direction the committee was going with their recommendations.  The remaining committee members only considered evidence from very specific types of trials, ignoring other trials that made compelling arguments but did not meet their standard of evidence.  The committee also chose not to include other markers of cardiovascular disease such as LDL particle number, Apolipoprotein B, PLAC testing and LDL particle size.
So how will this affect MY practice?
I think the guidelines are an opportunity to talk to people about their real diagnosis – their risk of cardiovascular disease.  As I have told many patients – to a certain extent, I don’t care what your cholesterol is, I care about you having a heart attack or stroke.  Cholesterol is a marker of how much artery clogging gunk is in your system.  There are several studies that show that the standard cholesterol profile underestimates cardiac risk.  I think that using the LDL particle number (LDL-p) is a better marker for assessing that risk.  If we reduce your LDL-p, your risk for cardiovascular disease goes down.  Statins are a tool (a very powerful one) to reduce cardiovascular disease risk.
I’m also not a fan of 10 year risk as a cutoff for starting treatment – I prefer lifetime risk, as the process that blocks your arteries is ongoing.  If we know 20 years before you have a heart attack that the risk is there, why wait until a heart attack is only 10 years away to start reducing risk?
How do I assess risk?
Risk can be estimated with a good history, a physical and testing.
History:
  • Prior heart attack, stroke or known cardiovascular disease?
  • Family history of heart attack or stroke – a male relative under age 55 or a female under age 65
  • Diabetes
  • High Blood Pressure
  • Smoking
Physical:
  • weight
  • waist size – belly weight is riskier than just being overweight
  • blood pressure
  • leg swelling
Diagnostic Testing
  • Cholesterol Assessment
    • there are several tests for this besides the standard cholesterol (called LDL-c) test which I will be reviewing in a future article in detail.  There have been several studies that show that other tests like LDL particle number (LDL-p) are better predictors of risk.
    • LDL cholesterol particle number (NMR Lipoprofile)
    • Apolipoprotein B (ApoB)
    • LP(a)
    • PLAC testing
    • Cholesterol particle size
  • C-reactive protein
  • Glucose
Once we put together your history, physical and test results we can have a discussion not about your LDL number, but your real diagnosis – your risk of cardiovascular disease.  The goal of that discussion is to reduce your risk of having a heart attack or stroke.
How can we reduce risk?
  • Blood pressure control
  • No smoking
  • Maintain a healthy body weight
  • Control diabetes
  • Being physically active
  • Control cholesterol
So the benefit of the new guidelines is they can inspire a conversation that leads to a proper diagnosis – not treating a number, but treating cardiovascular risk.

The path to Wellness begins with a proper Diagnosis