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February 28, 2011Access to your doctor
March 1, 2011What do you think of the value of nutrition in preventing and treating coronary disease?
It is intuitive that a good diet and lifestyle should reduce one’s risk of coronary disease. Indeed this is always the first thing I advise patients when I see them. However it should be realized that the reduction in cardiovascular risk from dietary changes is often fairly modest. My own experience, and results from observational studies, would suggest that a very aggressive dietary intervention, such as switching from a high fat diet to one considered “heart healthy,” improves cholesterol control only by about 5-10%. For most patients I see with coronary disease, they need to get their cholesterol down by 30% or more for optimal risk control. Yet many people try to delude themselves into thinking they don’t need cholesterol lowering medications because they will change to a healthy diet.
It isn’t that having a healthy diet is not important; it certainly is. Diet is always step one and likely has benefits beyond what physicians like myself measure on the lipid panel: e.g. vitamin intake, nutrients, other cholesterol particles such as chylomicrons, and many other benefits. Every major guideline emphasizes the importance of a healthy diet for minimizing your disease risk. However its benefit on the lipid panel is relatively modest. The lipid panel is by no means a perfect tool but it is quite predictive of cardiovascular disease risk. For most people with established coronary disease, medications are required to lower the LDL to the guideline-suggested target. I would venture that these medications are necessary for a good number of patients without coronary disease as well, at least those who are intermediate or high-risk for coronary disease.
What do you think? Do you think medications are over-prescribed for cholesterol control? Do physicians do a good job of explaining the need for medications?
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2 Comments
understanding nutrition for the average person tends to fall into two categories: tastes good, doesn't taste good. speaking for myself, i followed those guidelines for many years until recently. I can't say i'm middle aged, only 34 this year, but i have noticed over the last couple of years that my body isn't as hardy or strong as it once was. recently this has led me to evaluate the foods i am eating. (as a collateral benefit, i am also paying closer attention to the foods that my child is being offered.) i know little about coronary disease, other than that it is a term used to describe a condition that some people (including my deceased grandfather) are, or have been, afflicted with. oh, and that it is something you don't want to get. that is about the extent of my knowledge of the condition…but i do know i don't want it. and this is where my recent evaluation comes in. also, to answer your first question, i think nutrition is THE keystone in the acquisition or prevention and treatment of coronary disease. understanding what you are eating, where and how it was grown, handled and delivered is pretty important. for the most part people don't consider one or any of these facts either because acquisition of the information is inconvenient, they are selectively ignorant for the sake of convenience, and/or there is little choice for healthy alternatives. there are food choices that one can make in their local grocer that can mean the difference between healthy and non-healthy – which equates to a healthier heart, body and soul.
i don't believe there is such a thing as "over-prescribed" unless a doctor is doing it to appease the company that produces the drug and there is something to gain from it aside from patient health and longevity. in terms of cholesterol drugs, if the patient needs immediate help and the doctor has determined that the patient would benefit from a certain prescription then there should be no issue.
those are my two cents.
Good comments anonymous. I think you especially have a good point in emphasizing prevention. Better to have a healthy diet and lots of physical activity early in life and avoid disease later, rather than need to make the lifestyle changes after something has happened.
I can't speak for all doctors and there is always a lot of doctor-bashing in the media, but I generally find drug rep visits interesting. They do want me to prescribe their drug OF COURSE. However they try to sell it usually just by presenting their data, and info on the mode of action and side effects. There are no kickbacks, free trips etc, the usual perk is a free lunch that is wolfed down in a limited span of time (I often go back to the hospital on my lunch hour). As a doctor it is my responsibility to evaluate the medication independently (you need reviews from other sources and to look at the data yourself) before changing my practice to prescribe the drug. But rep visits I think do play a useful role – you hear about new products from them earlier than you would otherwise.