Saturday, August 16, 2008


Today at Fat Doctor's blog, she has a post about a patient who seems to firmly believe that his high cholesterol will have no impact on his life, and that not only does he refuse treatment but he feels "sorry that [she has] been duped." By clicking on the link on her blog, you can visit the website of a physician who uses the term in the title frequently and always in all caps. I'm not going to put his link here because, frankly, I don't want to give his site any more traffic. If you want to visit, go to FD's blog and click her link. Basically, he promotes not exercising, eating tons of red meat, and pretty much doing whatever you want, so long as you take his "cheap" supplements.

Now, does this patient have the right to believe whatever he wants? Of course. If he wanted to believe that little aliens in his bloodstream were doing battle with the bad cholesterol with argon laser beams, he has that right. Does the patient have the right to refuse intervention? Absolutely. Cholesterol-lowering drugs are not benign therapies. Statins can cause rhabdomyolysis, most cholesterol meds can cause elevated liver transaminases, most (if not all) can cause GI upset, and of course, they all cost money. Without insurance, Lipitor can cost $100 per month (I'm having a hard time finding a good estimate online, so forgive me if that is inaccurate). There will always be patients who don't want what Western medicine offers, and that's okay.

The problem is that this guy claims to be a kind of maverick doctor hero, set against the pseudo-science of mainstream medicine, offering treatments that only he knows about. For example, he claims that only low cholesterol is unhealthy and that even the American Heart Association agrees. He says that patients with low cholesterol can be just as prone to heart disease as those with high. You know what? I don't have exact numbers, but it's true that patients with low cholesterol and no known, accepted risk factors can have heart attacks. It's also true that people with high cholesterol may never have a heart attack. Finally, it is true that other factors are involved that we don't know much (or anything) about. Homocysteine is one; the "pattern" of LDL is another; apolipoprotein subtype ratio is yet another. Cholesterol level is not the only predictor of heart disease.

Yet, total cholesterol, LDL and HDL levels are all well-correlated with cardiovascular disease in multiple, multiple studies. There may be a lot to this picture we don't fully understand, but we do widely accept that elevated total cholesterol and LDL and/or a low HDL level puts you at risk for heart disease. We do have good study data that shows that lowering LDL and raising HDL reduces risk of heart attack and death even in those who had a previous heart attack. It's a risk reduction, not a guarantee, not a promise of no future heart attacks, but a better chance for not having another one. And, though I cannot get the AHA website to load for me today, I'm pretty sure their guidelines for cholesterol have not changed since last month when I was on neurology and we followed their guidelines for lowering cholesterol.

One problem with evidence-based medicine (of which I am only a novice at best) is that we can only say what the evidence tells us. If we don't have a study, then we can't say yea or nay. When the Women's Health Initiative shocked everyone a few years ago by showing increased cardiovascular events in women on hormone replacement therapy, the best available evidence at the time was to stop all HRT. Now, the picture is much muddier, as more and more studies try to tease apart the risks and benefits of HRT. What does the evidence tell us? It's really hard to say. All I know conclusively is that HRT lowers symptoms of menopause. So, ob/gyns prescribe it for that. Who knows about the increased risk breast cancer or heart disease or DVT or decreased risk of colon cancer? Is it worth it to increase the risk of breast cancer to decrease the risk of colon? Who knows? (I'm obviously no expert in HRT, and I will leave a more detailed discussion to those who are).

Another problem with evidence-based medicine relates to the studies. One study says that drinking 1 glass of alcohol daily lowers your risk of heart attacks, so the media gets excited and tells people to drink. Then, the next study says it's red wine, not just alcohol. The next says the level is 2 drinks for men. The next says it's so many per week, and if you don't drink that much, then just don't bother. Some studies don't show a benefit to drinking at all, or point out the liver toxicity and risk for dependence. We have different studies that advocate, in turn, low-fat, high-fat, Mediterranean, Atkins, South Beach, low-salt, low-meat, high-meat, low-carb, high-carb, low-protein, high-protein diets. Everyone was shocked recently that the Atkins diet wasn't shown to increase cholesterol. A Mediterranean diet (lots of olive oil) has been shown to be more favorable than the tradition low-fat AHA diet in some studies.

But I digress.

This guy's website is a hodgepodge of truth, incorrect facts, and flat-out lies. Truth: drinking 8 glasses of water per day is a healthcare myth. In terms of hydration, you can get enough water from food and other liquids (even coffee, tea, and soda) to keep you hydrated. Lies & half-truths: the AHA warns that low cholesterol can lead to the deadliest kind of stroke known as the "massive stroke". First, I don't remember learning about the "massive stroke" when they taught us about ischemic versus hemorrhagic, cardioembolic versus large-vessel, etc. Second, is he referring to total cholesterol, or to HDL?

My final problem with this guy's site, before I quit reading it because I was so angry, was right at the top. Next to his link "Find Out What Your Doctor's Not Telling You" is a link "Recommended Products". Here's the key to this guy: he's selling all the supplements he recommends. It's his website that the link goes to. His proprietary "NATURAL HORMONE THERAPY" will only cost you $29.95 for one month, the same price for his "ULTIMATE DAILY SUPPORT". I'm sure he would argue that this is no different than any other doctor prescribing Lipitor, because everything costs money. Sorry, bud, but Pfizer wasn't knocking on my door to give me a big paycheck every time I wrote a script for atorvastatin on neurology (and often, we used the generic simvastatin unless there was a reason to use Lipitor specifically). $0 in my pocket versus $30 in his from the sale of his supplement. (Of course, there are doctors who are getting $$$ from drug companies to hawk products, and shame on them, too).

There's a pretty fine line between a "physician" and a "quack". Those who do their best, slog away learning the best available data, try to read a JAMA or two at the gym, go to CME conferences, and generally try to stay afloat the most recent data represent the current ideal of American medicine. Western medicine doesn't have all the answers. Some of our treatments don't work, and others will be outdated in 5 years. It could be that in 20 years we'll look back and laugh at our current understanding of cholesterol metabolism and atherogenesis. I'm hoping that our knowledge in medicine will be much more personalized by then, so we can more accurately assess a person's risk for bad outcome from a disease and tailor a therapy just to them. For example, the recent PSA outcry has people wondering, how can we tell which men have a favorable, non-lethal tumor, and which have an aggressive tumor which needs removal?

But there's still a difference between trying to keep abreast of the best medical advice, and making up your own "science" in order to sell a vitamin supplement. When drug companies do this, we cry foul, and many patients are wise to this scheme. Unfortunately, when doctors do this, patients may be unaware. It's one thing to buck traditional medical science and point out its many flaws; it's another entirely to just start making stuff up on your own so you can sell books and pills.

And yet, I'm still bothered. I guess I need to believe that in medicine, we're not perfect, but we're doing the best we can. Guys like this exploit the weak points of medicine and rub it in our faces by using inflammatory language. It's rather like a schoolyard bully singing "nyah, nyah, nyah-nyaaaaah, nyah". You can look at it for what it is, you can cover your ears and say "go away!", you can know fully that it's just a stupid song, "a tale told by an idiot, full of sound and fury, signifying nothing"--and yet that song still gets under your skin. Sometimes, when I acknowledge just how much we don't know, and how limited science actually is, I feel like there are fewer differences between "physicians" and "quacks" than I would like to admit.

I just hope that as our science gets better, the gap between the two gets wider.


Fat Doctor said...

Excellent points (and not just that you agree with me that he's a scary quack). I wonder if by saying that low cholesterol is dangerous, he's referring to the fact that super low LDL (below 30) may be associated with intracranial hemorrhage. Seriously, I doubt he's done any reading lately, so I don't think that's what he meant.

Tiny Shrink said...

That's another possibility with the low LDL that I hadn't thought of. He's so vague, though, that who knows exactly? And how often are statins THAT effective and lower somebody's LDL to <30?

Oooh, that guy got me all riled up!