by Shana Montrose
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.
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.
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).
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.
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.