A Sad Commentary on Modern Medicine.

[Slatts]

....... They have Glaxo reps buying them lunch and giving them results from Glaxo-sponsored studies (the public ones). I wouldn't call that "education", but it's a lot more than they know about health because they aren't in the business of "health", they're in the business of medicine.

Damn, that's about the most profound and insightful statement regarding the current "healthcare" situation. Pretty much sums it up right there.

[Jonathon Sullivan]

As a doctor and man of science, how are you satisfied with this?

I didn't say I was satisfied. What I said, in the interest of being forthright with the people I deeply respect on this forum, and in the interests of full disclosure, was that I took statins, and for reasons other than medical. For one thing, I have a whopping life insurance policy and sweet medical and disability coverage. They love to see my LDL in the "normal" range, and they pass that love on to my premiums. Yes, that's heinous. Yes, it pisses me off some. No, there's not much I can do about it, and as it would happen I have bigger battles to fight as a man and as a physician. So far, I have tolerated statins well: generic simvastatin is dirt cheap, my muscles don't hurt, my liver works, and my dick hasn't fallen off. It may turn out to have side effects, but like the supposed benefits on morbidity and mortality, those effects are weak. There are also side effects, theoretical or otherwise, to eating char-grilled meat, sucking nicotine lozenges, eating raw salt-pickled vegetables, taking daily aspirin, refusing to take antibiotics for a sore throat, snorting fluticasone for my seasonal allergies, popping acetaminophen for pain, spending too much time at my computer, sparring with guys half my age, working midnight shifts in the ER, and driving over the speed limit. But I do those things, too.

One might think all that makes me intellectually dishonest; so be it. I've been called worse, and I see worse, every day, in the practice of medicine. But science only informs my decisions, it doesn't make them*.

And I'd like to point out, in case it escaped anybody's attention, that while I may take a statin and an aspirin a day, I am NOT one of those people who rely on pills to "stay healthy," nor do I advocate such an approach for others. It is precisely that approach that has completely fucked up modern medicine, and will continue to do so for the foreseeable future.



*My wife makes them.

[Robert Callahan]

Years ago a doctor told me that in the early 1900s, heart attacks were so rare that doctors would drive miles to see such a case firsthand. This person's theory (and I don't know of any studies proving/disproving it) was of a correlation between homogenization of milk and the increased incidence of cardiac disease. This may be of interest to those consuming a gallon of milk a day.

Homogenization prevents "cream-top milk" separation, by breaking up and finely dispersing the milkfat. Fat is absorbed rather directly into the bloodstream with minimal de/recomposition. If I recall correctly, by the 1950s, autopsies on young soldiers showed considerable atherosclerosis -- and these were active folks who didn't sit around playing video games.

Pure speculation, but maybe the vast surface area of homogenized fat microparticles led to increased oxidation or other changes during transport and storage, and over time, adding such fats to the bloodstream caused free-radical irritation/inflammation of the vessel walls.

Note: the milk topic is unrelated to the debate over raw, non-Pasteurized milk. Homogenization of milk is purely a convenience/appearance issue that's generally presumed safe. For those interested in avoiding homogenized milk, "Cream-Top Milk" (non-homogenized) is available at health food stores such as the Whole Foods chain, and it seems a reasonable option for whole-milk GOMAD.

.... really?

[Mike C]

I didn't say I was satisfied. What I said, in the interest of being forthright with the people I deeply respect on this forum, and in the interests of full disclosure, was that I took statins, and for reasons other than medical. For one thing, I have a whopping life insurance policy and sweet medical and disability coverage. They love to see my LDL in the "normal" range, and they pass that love on to my premiums. Yes, that's heinous. Yes, it pisses me off some. No, there's not much I can do about it, and as it would happen I have bigger battles to fight as a man and as a physician. So far, I have tolerated statins well: generic simvastatin is dirt cheap, my muscles don't hurt, my liver works, and my dick hasn't fallen off. It may turn out to have side effects, but like the supposed benefits on morbidity and mortality, those effects are weak. There are also side effects, theoretical or otherwise, to eating char-grilled meat, sucking nicotine lozenges, eating raw salt-pickled vegetables, taking daily aspirin, refusing to take antibiotics for a sore throat, snorting fluticasone for my seasonal allergies, popping acetaminophen for pain, spending too much time at my computer, sparring with guys half my age, working midnight shifts in the ER, and driving over the speed limit. But I do those things, too.

One might think all that makes me intellectually dishonest; so be it. I've been called worse, and I see worse, every day, in the practice of medicine. But science only informs my decisions, it doesn't make them*.

And I'd like to point out, in case it escaped anybody's attention, that while I may take a statin and an aspirin a day, I am NOT one of those people who rely on pills to "stay healthy," nor do I advocate such an approach for others. It is precisely that approach that has completely fucked up modern medicine, and will continue to do so for the foreseeable future.



*My wife makes them.

Right...but his point is WHY is this genetic? Is weak arteries the genetic defect, or is it the overproduction of LDL that is the defect? Those two things should be dealt with very differently - I would imagine.

[mlentzner]

I'm at the point now that ANYTHING a doctor told me I would look up. As a group they have an annoying tendency to talk out of their ass.

[mlentzner]

Right...but his point is WHY is this genetic? Is weak arteries the genetic defect, or is it the overproduction of LDL that is the defect? Those two things should be dealt with very differently - I would imagine.

Familial high cholesterol is caused by poor LDL uptake in the liver - not overproduction. High LDL caused by metabolic syndrome *is* caused by overproduction of LDL resulting from systemic inflammation. LDL production is linked to immune response. Statins interfere with your body's ability to produce LDL in the first place. That's my understanding of it - take it with a grain of salt.

So there's two ways you can get high LDL, which are caused by different mechanisms. Statins would only be useful if the high cholesterol itself is the cause of cardiovascular disease. It has been theorized that the reason statins work (to a degree) is that they are a potent anti-inflammatory. That's why they jack up your body's recovery ability. But if you're a couch-ridden individual with CV disease then maybe that doesn't matter. Although with your immune system in la-la land maybe you'd be more prone to cancer (ahem).

In my own case, all my blood work is awesome except the LDL number. I have family members who've lived to ripe old ages with LDL levels that would make a cardiologist blanch. According to an endocrinologist I talked to (so take with a grain of salt) there has never been a study done on people with genetic high LDL and statins. If true, there's another good reason for me to avoid them.

[Jonathon Sullivan]

Right...but his point is WHY is this genetic?

You mean my hypercholesterolemia? Hell if I know. God hates me? I was a dick in a former life?

Or, more likely, because I was dealt out heterozygous for a polymorphism in ApoB or LDLR or some other gene I don't know anything about. Then again, I haven't been genotyped. But it's not dietary (my LDL levels are extremely high and diet-insensitive), and it is, in my case, definitely familial. Barring some sort of miasma that attacks me in my sleep, a genetic etiology seems likely.

If LDL is a marker of arterial damage requiring repair, is it not more accurate to say that you have genetically weak/sensitive/vulnerable artieries?

Who said LDL was a "marker of arterial damage?" Certainly not me. Who said there was anything wrong with my arteries? Certainly not me.

And if so, shouldn't the emphasis be on how to stop damaging the arteries? Taking a drug to reduce the amount of LDL seems foolish if the LDL is there for a reason - to heal damage.

Who said my arteries were being damaged? Certainly not me. Who said LDL was there to heal damage? Certainly not me.

Why are your LDL levels so high? To simply say "Its genetic" explains nothing.

Of course it does. Phenotype is always highly (and sometimes exclusively) influenced by genotype. The question isn't whether genetics is responsible for familial hypercholesterolemia, the question is whether we should do anything about it, and if so, what? These are damn good questions, and I think I've made clear that, as far as I'm concerned, nobody has dispositive evidence to answer them.

Or, it explains everything: you are supposed to have higher levels of LDL and its not a defect that requires fixing, just like my green eyes are not a defect that should be fixed to make them brown.

"Supposed to have?" This smacks vaguely of teleology. But let's put that aside. Neither the green eye phenotyp nor the genotype respnsible for it have been invoked (erroneously or otherwise) as a mechanism for disease. Hypercholesterolemia has--right or wrong. You're comparing apples and oranges. It is inarguably the case that some genetic variants do in fact cause disease, and some confer advantage, while others merely produce phenotypic variations that are more-or-less inconsequential. In some cases (sickle cell, certain cancers, cystic fibrosis, etc) the mechanism from gene to disease phenotype has been well established. In other cases--like cardiovascular disease, which is multifactorial--not so much.

All of which is a little beside the point, because the real issue is the widespread use of statins in the general patient population, most of whom do not have a familial form of hypercholesterolemia. For we certainly don't know whether it's valid to extrapolate the precocious cardiovascular disease seen in heterozygotes for this variant to the general population, said extrapolation being a component of the predominant lipid-cholesterol-plaque theory of coronary artery disease. And it's an even bigger leap to extrapolate that to the idea than a drug that lowers cholesterol in the general population will reduce the incidence of cardiovascular disease or cardiovascular events (stroke, MI) in that population.

And of course, even if elevated LDL was intrinsic to the pathophysiology and development of atheroscleroitic cardiovascular disease (rather than just a epipheonomenon), it is sheer stupid fuckery to assume that correcting that disease measure (LDL) alone, by giving a little pill, will be sufficient to reduce the incidence of that disease in a sedentary, Cheeto-munching, cigarette-smoking, so-fat-how-do-you-wipe-your ass population like the one infesting North America.

Sheer fuckery. But profitable. And doctors and patients can feel like they're doing something, when in fact they're not doing the most important things at all.

I trust I make myself obscure.

[FatButWeak]

Sully:

I am totally not attacking you. I understand what you gotta do and why. But as Mike points out, Im asking you why not address the underlying issue: what is wrong and what is causing it? If your LDL is high, it must be for a reason. What is that reason? Solve that and you solve your need for statins. To say its genetic fails to answer the question; its a dodge, not an answer.

I understand you may not have an answer, but if everyone insisted on answers, and if DOCTORS (ffs!) insisted on real answers to this question (Why is my LDL so high?"), we would get closer to solving the heart disease riddle.

[Jonathon Sullivan]

I am totally not attacking you. I understand what you gotta do and why. But as Mike points out, Im asking you why not address the underlying issue: what is wrong and what is causing it? If your LDL is high, it must be for a reason. What is that reason?

The reason in my case is that I have a genotype that predisposes me to have extremely high LDLs. The pathophysiological implications of this are not entirely clear to me. My doctor has elected to treat it. I have elected not to fight him on it.

Solve that and you solve your need for statins.

(Sigh.)If I could change my genotype, I'd be able to solve a lot of other problems, too, not least my lack of ten bajillion dollars, a Nobel Prize, and the endless supply of ass models that go with such accoutrements. And I had hoped to clarify that I'm entirely unconvinced that I do need statins. My doctor, my underwriters and my family are another matter.

To say its genetic fails to answer the question; its a dodge, not an answer.

No, I'm afraid I don't agree. I don't know the specific polymorphism involved in my case, but it is clear to me that my LDL is abnormally high because of my genetics. That is not a solution, but it is an answer. Moreover, it is an answer to a question ("Dear Jesus: why is my LDL so high? Don't you love me?") that really doesn't keep me up nights.

I understand you may not have an answer, but if everyone insisted on answers, and if DOCTORS (ffs!) insisted on real answers to this question (Why is my LDL so high?"), we would get closer to solving the heart disease riddle.

I'm not sure that's true, because, again, I'm entirely unconvinced that LDL--or any other single factor--is the key to this "riddle." You say you understand I may not have an answer, and then you say that everyone should insist on answers. I hope you do understand that some answers are harder to come by than others. Questions about living matter in general and multifactorial disease states in particular certainly tend to fall on the "Hard" end of the spectrum. Asking questions is important, but it is only step one. The beginning of wisdom.

An even deeper wisdom obtains when one groks that not all questions can, or need be, answered.

I think we're losing the point of this thread, which is a shame, because it's an important one.

[Carlos Daniel]

If Sully's LDL is sky high, has always been, doesn't vary according to diet and runs in the family I think it's fair to assume it's genetic in one way or another. If you want to know the exact gene and how it works, then it's another story.