Pills, Pills, Pills (Or Not): Is It Up to You?

by Shana Montrose

The Diagnosis
Close your eyes and imagine a person with high cholesterol. Did you imagine a 20-something, white, middle-class woman, who eats kale, has low blood-pressure and doesn’t weigh enough to donate blood? Neither did I.

I didn’t know my cholesterol was being checked until my doctor ordered a second blood test, this time requiring a 12-hour fast. Not believing I was a candidate for high cholesterol, I suggested the lab results had been thrown off by a wine-and-cheese party I’d hosted just days prior.

A nurse called with the results. She said my cholesterol had progressively increased over the past few months and that the doctor had written a Lipitor prescription. I asked her about benefits and risks associated with the recommended medication and she referred me to Google. I was begging for information and felt shut out of my own care.

I decided to take matters into my own hands by trying lifestyle changes before committing to medication. I had medical motivations, but I was also looking at the problem from a public health perspective. I wanted to see how hard it was to change behavior – starting with myself. I gave myself six months.  In that time, I eliminated high-cholesterol foods, exercised more and took vitamin supplements: omega-3 fish oils, CO-Q10, and niacin.

I should note that this experiment was conducted under rather ideal conditions. There was a Whole Foods in my neighborhood, I had access to a gym through my work, and I could afford to buy vitamins despite having found little research to justify their purchase. I seek not to diminish the reality that resource-strained populations operate under much less ideal conditions than my own personal laboratory—not to mention that I am a statistically insignificant sample size of one.

I asked her about benefits and risks associated with the recommended medication and she referred me to Google. I was begging for information and felt shut out of my own care.

The Plan
I increased my workouts by 1-2 days a week. I also started taking vitamin supplements morning and evening. But the biggest change was diet. I stopped eating cheese and red meat; making small allowances, feta in a Greek salad for example. I ate chicken until I saw Food Inc., and then eliminated that as well.

I began eating a lot more fish. I relied on beans and rice to feel full and to quell my ongoing craving for Mexican food (without diving into a beef and cheese enchilada). I also reduced my intake of butters, oils and fried food. My peers were surprised when I explained I had high cholesterol, but I found the more I told people, the easier it was to stick to the diet.

The Results
You can see the results of my cholesterol tests below. My intervention (diet, exercise, supplements), indicated by the red dotted line, began in November of 2011 following a steady increase in my cholesterol over six months.  In the first two months of my lifestyle changes, I reduced my cholesterol to below “baseline” (May 2011). Within six months I reduced my cholesterol to the optimal zone (the green space below 200 Mg/dL).

Cholesterol Results

Under 200 milligrams per deciliter of blood (mg/dL) is considered optimal, 200-239 mg/dL is borderline high and 240 mg/dL is considered high. A person with this level has more than twice the risk of coronary heart disease as someone whose cholesterol is below 200 mg/dL.

Perspective
A statistically significant sample would obviously yield different results. Lifestyle changes do not affect everyone the same way and lipid panel numbers are not always accurate indicators of effort. Other factors, such as genetics and co-morbidities are not to be ignored. I won’t claim that there is a universal solution, but in some cases lifestyle changes really can make a difference–for me, it was worth a try.

If  I had been 30 years older, if I had other health conditions, if I was unable to exercise, if I could not afford and find time to prepare healthy meals, if I had three jobs and four kids, maybe I would have chosen medication. The point is that I wanted to have a choice. In a “doctors-know-best” culture, many people do not demand information and do not take their health into their own hands. We can’t talk about personal responsibility without giving people the tools to be responsible.

Analysis
Explaining lab results, health determinants and treatment options may take 15 minutes longer than the 15 seconds it takes to write a script. In our litigious society, a physician may wish to protect himself against a lawsuit by practicing “defensive medicine.” It is easier to prove non-compliance to a medication regimen than non-adherence to a lifestyle-change plan.

As a consumer of healthcare and a student of health policy, I hope to see the development of shared-decision making to inform patients of their options and empower them to be more responsible for their health. I would have happily signed a waiver saying I understood the risk of refusing drug treatment and that I had been properly educated in how to manage my risk factors through exercise, diet, and supplements.

My insurance company should be thrilled at the money I saved from not filling prescriptions—and those savings should be shared with the doctor who took time to explain my options. It would also be wise for my insurance to cover future lipid panels and to discount a gym membership.

I want to engage in shared decision making motivated by achieving good health. I want my insurance company to use payment incentives to promote proper screening and prevention. We need to continue realigning incentives so everyone in the system – payer, provider and patient – is empowered to improve health and reduce cost. Shared decision making is a great start.

_____________________________
Shana Montrose is a former Health and Human Services Emerging Leader. She is starting an MPH program at the Harvard School of Public Health this fall.

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6 thoughts on “Pills, Pills, Pills (Or Not): Is It Up to You?

  1. Alexia says:

    Great blog Shana. I am a true believer in life changes versus medication. And I do hope that our health care system starts moving to a joint decision-making approach. I would be interested in seeing if one of your changes would have had as much of an impact as all combined. For example, if you did not take the supplements, did not exercise more, but changed your diet. I foresee more research in the making!

  2. Great article Shana! I would call my doctor out if he or she did not personally call me to explain abnormal lab results, especially when wanting to start treatment (medical or lifestyle). Moreover, referring a patient to google for research on adverse effects is malpractice and completely unprofessional, in my opinion.

    Unfortunately, many doctors deal with highly unmotivated patients all the time and easily slip into a routine of heading straight for the Rx pad. We aren’t adequately trained in motivating patients for lifestyle interventions (honestly, we’re not trained in that at all), and as you point out in your article – those extra 15 minutes needed to explain and motivate a patient aren’t reimbursed! That’s not to make excuses for physicians, but it’s a complicated and broken system that still doesn’t reward the things it should – though improvements are (slowly) coming.

    Ultimately, I’d say start looking for a new doctor, or at least educate the one you have on the sub-par care he or she provided you…

  3. jacob schor says:

    Shana,

    It’s nice to see those numbers move so nicely, good job. I suspect that not everyone will bring as much diligence as you did to a project like this. Still it’s nice to see what can happen when someone does everything right.

    I took minor exception when reading this section though:

    ” In that time, I eliminated high-cholesterol foods, exercised more and took vitamin supplements: omega-3 fish oils, CO-Q10, and niacin.
    I should note that this experiment was conducted under rather ideal conditions. There was a Whole Foods in my neighborhood, I had access to a gym through my work, and I could afford to buy vitamins despite having found little research to justify their purchase. I seek not to diminish the reality that resource-strained populations operate under much less ideal conditions than my own personal laboratory—not to mention that I am a statistically insignificant sample size of one.”

    Surely, at some point in your schooling someone taught you how to do literature searches using PubMed?

    Let’s take a quick look and see if there is any research on these vitamins you took.

    go to:
    http://www.pubmed.gov

    search 1: “Cholesterol AND fish oil”
    2,636 citations to published papers in medical and scientific journals of which 1559 are on humans and 544 are randomized controlled clinical trials (RCTs).

    search 2: “ubiquinone and cholesterol” has 580 citations, and 61 RCTs

    search 3 “Niacin and cholesterol” has 1,395 citations and 215 clinical trials…

    Whole Foods and other sellers of supplements are prevented by FDA rules from directly linking a supplement to medical information… if they did, that would mean the stores were selling unlicensed drugs, that is things to treat disease. Thus you won’t find the information in the stores as readily as you will in the library, in this case using pubmed, we searched the National Library of Medicine.

    to keep all of this in perspective though, a search on ‘lipitor and cholesterol’ gives more citations than fish oil and cholesterol, a total of 2,740 citations of which 767 are randomized controlled trials. Though one must also factor in the fact that the majority of this lipitor research was paid for and conducted by the companies that will gain from selling the lipitor, there is more published data on it.

    • I think you’re both right to some degree about the data for these things, as 2 of them are shown to be beneficial (and are routinely prescribed in best clinical practice), and 1 has not been shown beneficial to this point:

      Search #1 turns up 274 human studies in core clinical journals, which is not surprising as this is one supplement known to have a solid body of research showing efficacy. In fact, clinical guidelines for heart disease over the past few years have stated that fish oil should be a routine part of management.

      Search #2 only turns up 28 human studies in core clinical journals, and not a single one answers Shana’s question (most are about the relationship of the enzyme to statin-associated myopathy). Removing the core clinical journals qualifier expands the results to 343, but still didn’t provide a clear answer based on my review of the most recent articles. So, for this supplement, despite an initial large number of hits on pubmed, the evidence isn’t there.

      Search #3 has 329 human studies in core clinical journals, and is routinely prescribed by physicians to increase HDL and lower triglycerides based on its proven efficacy.

      Just a reminder that a large number of hits on pubmed doesn’t necessarily mean something is efficacious, and just because something is considered a supplement or natural doesn’t mean physicians aren’t prescribing or recommending it!

  4. raxxq says:

    This is a very interesting experiment and analysis. I have thought about what a high cholesterol diagnosis might mean for me, as I have a family history of high cholesterol and heart disease. Unfortunately for women, the majority of first line medications used to treat high cholesterol are incompatible with pregnancy and breastfeeding. When I had a physical prior to my pregnancy I asked why the doctor was not ordering the standard blood tests (including a cholesterol test). She said that if they found high cholesterol they would not treat it if I was planning to get pregnant. Does this mean that as a woman, I have to choose between my long term physical health and my ability to have healthy children? At the time I didn’t give it much thought, but reading your piece has brought these questions back to me. It is good to know that for those with the option, diet and lifestyle changes can make a difference.

    Like Braden, I would be highly unsatisfied with a “google it” response to a question seeking additional information about a health issue. Granted, I would also likely seek a second opinion from a specialist. I wonder, as you did your research, did you use any websites such as patientslikeme.com to connect with other young people (or anyone) who was attempting alternative treatment?

  5. Shana says:

    In 2002, the CDC and the NIH conducted the Diabetes Prevention Program (DPP), a 27-center randomized clinical trial that studied more than 3,200 adults who were 25 years or older and who were at increased risk of developing type 2 diabetes. The DPP evaluated the effectiveness of the following ways to prevent or delay type 2 diabetes:

    1) intensive lifestyle modification (healthy diet, moderate physical activity of 30 minutes a day 5 days a week)
    2) standard care plus the drug metformin
    3) standard care plus placebo (a pill that has no effect).

    What were the major findings of the DPP?

    This was the first major clinical trial of Americans at high risk for type 2 diabetes to show that lifestyle changes in diet and exercise and losing a little weight can prevent or delay the disease. Participants who made lifestyle changes reduced their risk of getting type 2 diabetes by 58 percent. Participants with standard care plus metformin reduced their risk for getting type 2 diabetes by 31 percent.

    Thanks to Eliot Fishman for pointing out this study. More information here:
    http://www.cdc.gov/diabetes/news/docs/dpp.htm

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