Give Credit Where It Is Due

Evidence based medicine, education, and preventative medicine are continually being promoted as the salvation of our Universal Health Care System. Interestingly enough, there seems to be very little Level 1 research showing that a “healthy” diet as we know it at present, will contribute to longevity. Ongoing debate on low carbohydrate diets versus low saturated fat diets seems to leave us no-where. When my patients went on very strict low fat diets in the past, I noticed their HDL would drop, and now I believe there is evidence that saturated fats are necessary for the metabolism of HDL (good cholesterol). We seem to be quite sure at this time that trans fats are bad and after many years of suggesting that diabetics don’t need to worry about sugars, we are once again back to limiting “refined” carbohydrates. We believe that exercise is good, but there is very little Level 1 research that I know of that shows exercise will significantly decrease bed utilization in our hospitals. Recent research now suggests that perhaps it is not so much what we are eating, but what we are not eating (like sufficient linoleic acid containing foods), that is doing us harm. I will defer all this to nutritional experts (welcoming comments!). Suffice it to say, all of the above is very confusing and requires effort on the part of the patient both to learn and initiate. Personally, in my practice, I always found it easier to get my patients to take a pill than read a label or work up a sweat!
The point I’m getting at is best made in the March issue of the journal “Atherosclerosis in Primary Care”. The feature article is titled “early benefits of statin therapy in lipid lowering trials” and goes on to show that many lipid lowering trials (Level 1) have shown that aggressive lipid lowering with a statin, reduces the incidence of MI’s in 90 days and strokes in two years. This is done supposedly by lowering LDL, improving the health of the intima, and an anti-inflammatory effect of the statin. Since this is good “evidence based medicine” why is it that our (physician) “educators” are still advocating life modifying approaches as first line therapy for high risk patients? Not long ago one of our leading educators suggested (in a medical journal) a conservative approach like this for a patient with five cardiovascular risk factors (high risk). Why shouldn’t we start with 80 mgs. of atorvastatin and at the same time institute the life style modifications? If the patient is the exception to the rule, and is a huge success with life style modifications, consideration can be given to decreasing or stopping medication. For patients that have an aversion to taking medications, this approach may even be an incentive for them to adopt a healthy life style.
The cost of Pharmaceuticals has increased faster than any other aspect of health care over the past twenty years. There is a definite push on the part of our educators to decrease the use of pharmaceuticals in our patients. We often hear statistics on all the hospital admissions and deaths that occur because of medications but is this because of error and mismanagement or from the medications themselves? To pass judgment, this must be balanced against the lives saved and hospital admissions prevented by these various medications. The statin group of medications, and most of our anti-hypertensive group of medications, have that information available to us. There is very little rational for delaying pharmaceutical interventions.
Statistics show that we as a society are getting more obese and less active in spite of efforts at education. We are reaping the results of fifty years of smoking, years of consuming transfats, and an increased pollution to our environment; and still the life expectancy of men and women in Alberta is ten years longer now than it was when I graduated in 1962. It is not because people eat healthier or exercise more. Perhaps if we, as a profession, didn’t join in the chorus of voices giving pharmaceuticals a “bad rap”, we wouldn’t have so many patients who are non-compliant with their medications.