Statin therapy is the de facto standard of care to reduce risk of heart disease, despite rhetoric in medical guidelines to initially address diet and exercise. Doctors prescribe statins to reduce total and LDL serum cholesterol–now considered to be rather weak risk factors for heart disease. This past month new recommendations to increase the target population for statin therapy triggered an uproar. Halleluiah. Finally some push back from the medical community.
Total cholesterol levels should never have been more than a screening tool. With a prediction rate of about 50%, this “gold standard” predicts heart disease about as well as a flip of a coin. Some clinicians quote studies estimating 50-75% of individuals suffering a heart attack have cholesterol levels within normal range. Many people with elevated cholesterol levels have no evidence of heart disease. New standards do away with draconian LDL-cholesterol targets –targets that a leading cardiologist described as “pulled out of thin air”.
IF NOT CHOLESTEROL, WHAT ELSE?
Current detractors to the cholesterol hypothesis range from science writer, Gary Taubes to Dr. Mercola and the spacedoc, Duane Graveline. Their words range from caution to alarm and haven’t stopped statins from being the most prescribed drug class of all time. Despite the fact that standard medical care recommends that patients work with diet and exercise first, patients are prescribed statins as soon as their elevated cholesterol levels don’t respond to mere lip service regarding diet and exercise. Most of my clients who come to see me to “reduce cholesterol” or other heart disease risks are already on statins– and often a slew of other medications as well.
The sad truth is that the pharmaceutical industry wags the dog. Too much medical care hinges on use of the prescription pad. The profit driven insurance reimbursement market allots little time for much else. In the meantime, statins accumulate a growing list of side effects, from elevated liver enzymes to muscle pain and loss of memory. More recently statins are linked to elevated blood glucose levels and diabetes. How can a medication so widely prescribed and so celebrated by physicians be taken by so many patients and carry so much baggage?
FOCUS ON METABOLIC HEALTH
The core of the problem remains that we do not offer patients enough nutrition support from qualified professionals. One size fits all dietary guidelines are misguided. Health care workers routinely offer patients pre-printed diet sheets that focus more on what we think we know about the disease than what is important to the patient. Medicare does not cover nutrition counseling for any diagnosis related to heart disease and most private insurance companies follow suit. In addition, most researchers and health care professionals confuse cause and effect.
Conventional thinking assumes obesity causes heart disease. In truth, the metabolic mess that increases risk of heart disease also increases central body fat. Despite newly gained reimbursement for treating obesity, the effort is less than what it could be.
DOES IT MATTER WHO PROVIDES NUTRITION COUNSELING?
First, new diagnostic guidelines recognize obesity as a disease and everyone is obsessed with the ‘obesity epidemic’. But why limit nutrition support to only the obese? We should be assessing metabolic health at every body size, not just those patients who sport a large enough BMI. Appropriate diet and exercise support addresses both metabolic health, risk of excessive fat gain, and risk of heart disease.
Secondly, only doctors, physician assistants, and nurse practitioners are eligible to be directly reimbursed for treating obesity. How much real counseling will be done in an already too short office visit? Most nurses are required to take only one semester of nutrition. Many surveys that find many doctors readily admit they feel unprepared.
Lastly, distribution of standard diet sheets and information pamphlets by health care professionals offer little more than a band aid. I laugh (and cry) at the feeble efforts offered by even the most celebrated health care delivery systems. We belong to Kaiser and I have personally received a letter recommending that I follow the enclosed diet plan and make an appointment to see my doctor in six months. Patients deserve better
THE PROCESS IS THE OUTCOME
Effective nutrition counseling does more than tell people what to eat. Sophisticated nutrition support focuses more on the process, mostly because the process is the outcome. People learn what approach works for them by experiencing how their diet impacts how they feel, how their body metabolizes energy and how their diet impacts specific bio markers including blood pressure, blood glucose levels, and lipid values. More critically effective nutrition counseling helps a patient figure out an approach to food that works in their life. Maybe we should take some of that money spent on statins and use it differently. Here are a few ideas for Medicare, private insurers, every health care provider and patient:
- Advocate for reimbursement of medical nutrition therapy visits with qualified nutritionists and dietitians.
- Stop paying so much attention to the scale and shift your focus to improving metabolic health.
- Recognize that the process is just as important as the outcome–mostly because the process is the outcome.
- Stop pretending information is enough to change behavior. Help patients address what really matters: bridging the gap between knowledge and behavior.