Preventive Medicine Column
Dr. David L. Katz
As you likely know, a new set of guidelines for the use of lipid-lowering drugs to prevent heart disease was issued recently with considerable fanfare, and then set off a firestorm of controversy. The old approach relied heavily on levels of LDL cholesterol, while the new approach relies on a calculation of overall cardiac risk that leaves LDL out of the mix altogether. At stake are statin prescriptions for millions of us.
As a physician specializing in Preventive Medicine, with a long-standing interest in cardiac risk modification specifically, it makes sense for me to weigh in here. So here you go: the answer may not matter a lot, because it’s the wrong question.
Until now, I have held back from entering this fray for two reasons, one lesser and one greater. The lesser reason is that we really don’t yet know the right answer. If it were truly clear exactly what criteria for statin use were best, there would be no controversy in the first place. There appear to be strengths and weaknesses to both sets of criteria, the old and the new. Either way, it’s clear that statins- which in fact are rather good drugs– can and do save lives when prescribed judiciously, both by lowering lipid levels and other mechanisms, such as reducing inflammation. The debate is all about what “judiciously” really means, and what is most judicious.
Frankly, I don’t think anyone knows for sure yet. To know with genuine certainty, we would need to randomize thousands of people to statin prescription by the old method, and thousands more to statin prescription by the new method, and see which group had less heart disease and premature death over time. Until or unless that is done – don’t hold your breath – we have competing expert opinions with no clear basis in empirical evidence to declare a winner.
The greater reason for my reticence though, as noted, is that I think it’s the wrong question. The right question is: how can a society look on passively at a situation that invites tens of millions of its citizens (no matter what criteria are used) to take a drug to fix what feet and forks could fix better, at lower cost, more universally, and absent the risk of side effects?
Statins really are good drugs, and under the conditions that now prevail, they do indeed save lives. And yes, alas, tens of millions of us are candidates for them. But such conditions need not prevail, and should not prevail. Why do we let them prevail?
As far as I’m concerned, the entire debate about statins is part of our societal static. It’s a background noise of cultural misdirection that favors the conflated interests of Big Food and Big Pharma, while ignoring the compelling, consistent, signal of what lifestyle as medicine could do for us all.
We could prevent all those heart attacks, and more, without putting statins in the drinking water. We could add years to life, and life to years, and save rather than spend money doing it– if lifestyle were our preferred medicine. The signal has been there for literal decades that minimally 80% of all heart disease could be eliminated by lifestyle means readily at our disposal. There is a strong case that, but for rare anomalies, heart disease as we know it could be virtually eradicated by those same lifestyle means. And the same lifestyle medicine that could do this job would slash our risk for every other bad outcome as well, while enhancing energy, cultivating vitality, and contributing to overall quality of life. And unlike our statins, we could share these benefits with those we love.
But for the most part, we as individuals, and collectively as a culture, seem deaf to this signal. We watch our peers and parents succumb to heart disease, and wring our hands. We fret over the same fate overtaking us- and our children. We get prescriptions for drugs we wish we didn’t have to take, worry about serious side effects, suffer through minor ones, grumble about co-pays, and implicate ourselves in the unmanageable burden of “health” care costs.
And so our debate about statins, seemingly so important, plays out in the static of the status quo. No matter who wins the debate about statin indications, we the people- the tens of millions of people who, either way, are missing the signal and will wind up taking drugs to fix what lifestyle could fix better- lose.
Dr. David L. Katz