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WORK HARDER OR DIET MORE

Somebody once said there are two kinds of people: Those who divide people into two types and those who don't.

To me, there are people who accept the idea of preventive medicine, and there are people who think I'm trying to kill them. Either they understand that disease and pain are lurking around the corner waiting to pounce on us all, and believe that I can do something to fend the bad guys off, or they think that doctors are evil capitalist pawns of the drug companies who are trying to induce life-threatening side effects with expensive pills.

Now because I have a paranoid streak and, on my bad days, fall into the second category, I tend to view preventive recommendations with some skepticism. I don't think we need to be happy puppy dogs gazing adoringly at medical opinion leaders who take a lot of money from big corporations.

Nonetheless, I have to endorse some new cholesterol guidelines published by the government's National Cholesterol Education Program (NCEP). These are revisions that cover some data from clinical trials published over the last few years. And it turns out that very aggressive cholesterol control is important in certain situations.

Now the background for this is that heart attacks and strokes are huge problems for Americans. "We are the veal," as the bumper sticker says: quasi-obese, sitting in little cubicles all day while well meaning co-workers feed us doughnuts. It costs money to exercise, and sitting still looking at a computer screen all day can pay big bucks.

The best thing would be for us all to go out for 12 hours a day and feed the animals, toss around bales of hay and hammer the fences back together, like our ancestors used to. But that ain't happening anytime soon.

So medicine treats the side effects of modern affluence. We make Lipitor so you can eat hamburgers. That's how I see it. So back to cholesterol. NCEP guidelines continue to be very complicated, to the point that I sometimes have to use a computer program to figure out what a patient's goal cholesterol should be. You can check out one of these calculators at www.intmed.mcw.
edu/clincalc/chol.html; the site gives you what may be a frightening estimate of your 10-year risk of heart disease.

So you should probably talk to your doctor about your specific goal, though as always I encourage you to learn as much as you can about your health issues.

But what's new in the guidelines is that for high-risk patients, the goal LDL cholesterol (the bad cholesterol) should probably be 70, lower than what we thought before. And in general, if you've had a heart attack, you should probably be on a "statin" cholesterol-lowering drug no matter what your cholesterol is.

People worry about the side effects of the statins; muscle aching is the most common. Statins decrease the level of Coenzyme Q10 in the body, and a few small studies have suggested that this might prevent and treat these muscle aches. And Coenzyme Q10 is probably good for your heart anyway.

But keep in mind that when we make these cholesterol recommendations, we're including the side effects in our calculations. So if you take 100 people and give them the medication, and 100 people and don't give it to them, the 100 with the medication will live longer, including all the side effects that might happen.

It's like going to the slot machines -- if there's a lucky machine that pays off frequently, you want that one, right? Cholesterol lowering is the lucky slot machine.

Even in elderly patients with heart disease, it turns out that aggressive lowering of LDL cholesterol is a good idea. The elderly have a much higher risk of heart attacks, so the benefits of lowering cholesterol turn out to be important.

So just like we compensate for the cold winters with central heating, and compensate for modern American nomadic job behavior with long distance phone calls, we need to compensate for the bad side of modern labor saving machinery and food abundance. At least until we all become triathletes or subsistence farmers.

Dr. Mike Merrill is an internist practicing in Buffalo. His column appears every other week on this page. E-mail your comments to him at driconoclast@yahoo.com.

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