Health for life

In recent years, the prescription of statin drugs to reduce cholesterol has soared through the roof.  Youve heard of them:  Lipitor (atorvastatin), Crestor (rosuvastatin), Zocor (simvastatin), and the like. The supposed benefits of these drugs, as your doctor will tell you, is that theyll reduce your cholesterol levels, hence lowering your risk of heart disease.  Im sure you all know by now how I feel about lowering cholesterol levels (see this)... but thats beside the point in todays discussion.  I will just say that statin drugs effectiveness may have been a bit overstated.  Today, though, Id like to focus on the dangers, or side effects, one may encounter in taking statins.

First, just a little information about how statin drugs work in the body.  Their main function is to block an enzyme called HMG CoA Reductase.  This is one of the enzymes that is involved in making cholesterol in the liver.  So through blocking this pathway, the drug has inhibited the bodys ability to make cholesterol molecules.  As a result, your blood cholesterol level goes down, your doctor is happy, and youre happy.  Weve finally won the battle against cholesterol!  Yeah... except cholesterol is needed in the body for all sorts of vital processes, like hormone production, vitamin D synthesis, cell membrane structure, and brain function, just to name a few.  Hopefully by the end of this, youll realize how ridiculous it is to think that blocking an important biochemical pathway like this one is a good idea.





Meet Dr. Duane Graveline.  Dr. Graveline is a family doctor with a high cholesterol level, who began taking statins several years ago.  Shortly after starting on statins, he suffered a serious and disturbing loss of memory, so he stopped taking the drug.  He had no further problems for a year while off statins, so his doctor persuaded him to begin taking them again.  That high cholesterol needed to be treated.  Shortly after returning to the meds, Dr. Graveline experienced a much worse episode of memory loss, during which he regressed into his teenage years, unable to recall his training as a doctor at all.  After getting off the statins, though, his memory returned again.  Interesting huh?  Well Dr. Graveline decided to tell his story by publishing a letter on a website called Peoples Pharmacy.  Almost immediately, he was flooded with letters from hundreds of other statin-takers who had experienced a similar problem.  Clearly, something about these drugs was causing serious impairment in the brain.

On a related note, there has been consistent data since the 1960s showing that people taking cholesterol-lowering drugs tend to die more frequently from violent deaths, such as car accidents, suicides, and shootings.  This information has largely been disregarded for lack of a plausible explanation.

But how about this... 25% of the cholesterol in the body is concentrated in the brain.  Until recently, we didnt understand the reason why, but new research by Dr. Frank Pfrieger shows that cholesterol is absolutely essential to neuronal communication in the brain.  Cholesterol is so important, in fact, that without it the brain would be almost entirely useless.  So, now we have a very plausible mechanism to explain the mysterious amnesia experienced by Dr. Graveline and others.  That also may explain the increase in car accidents; lapses in brain function lead to mistakes on the road.  Low cholesterol, not necessarily as a result of statins, has also been shown to lead to reduced serotonin levels in the brain.  Low serotonin is one of the key brain abnormalities involved in depression, and it has been linked to increased violence and aggression as well.  Heres an example of a study that linked low cholesterol levels to increases in school suspensions and expulsions.  According to the researchers, "the results of the current study are consistent with the majority of previous studies examining the associations between low cholesterol and various forms of aggression in adults."  Looks like its no accident that those with low cholesterol are more likely to be suicidal or violent.  Still think blocking pathways is a good idea?  Read on.

As I mentioned before, statin drugs act on the enzyme HMG CoA Reductase, inhibiting its action.  While this prevents cholesterol synthesis, it also prevents synthesis of another important molecule that shares the same biochemical pathway.  This molecule is known as coenzyme Q10 (CoQ10).  This vital substance is found in every cell in the body, and in particularly high concentrations in high-energy cells such as muscles, especially the muscle cells of the heart.  CoQ10 is an important part of ATP synthesis, meaning that it is needed for your body to turn food into useable energy.  If cells run out of ATP, they die... so yes, CoQ10 is seriously important.  Which cells did I say had the highest concentrations of CoQ10?  Ohh yes, cardiac muscle cells!  And what will happen if your cardiac muscle cells run out of CoQ10, along with ATP?  Heart failure.  Thats right, the medication that is supposed to be protecting your heart can cause heart failure.  Incidentally, while heart disease rates have actually been on the decline in America, there has been a recent sharp increase in congestive heart failure.  Theres no evidence to prove statins are causing this recent phenomenon, but its certainly an interesting coincidence.

You know, every time I write one of these blogs, I try my best to be as concise as possible so that I dont end up with something so long that nobody wants to read it.  But, here I am again with another research-paper-length post.  Anyway, in conclusion here, Id like to reiterate the problems with blocking the pathway that makes cholesterol.  Cholesterol is an important molecule with a number of vital functions in the body, not the least of which is to allow the brain to function.  Without it, the brain is useless.  Think about that (with your brain) next time you take your statin drug.  And dont forget about that whole car accidents, suicide, violence thing.  Low cholesterol levels, resulting from statins or not, increase your risk for depression.  Also, blocking the cholesterol pathway prevents CoQ10 production, which is vital to every cell in the body, especially heart cells.  Without it, youre at risk for heart failure (the irony kills me).

The take-home lesson:  While taking a statin drug will make your cholesterol numbers look better, at least in your doctors eyes, there are serious problems with inhibiting cholesterol synthesis.  Cholesterol is far more important throughout the body than most people give it credit for.  And while it may be a risk factor for heart disease in certain populations, it is not the true cause... where is the logic in treating the innocent risk factor??  Its clear to me that the path to health does not lie in working against your bodys natural mechanisms; we need cholesterol, not statins.

The way you prepare broccoli and related vegetables can alter their potentially cancer-fighting powers, new research shows.

Broccoli and other cruciferous vegetables are a good source of sulforaphane, a phytochemical (naturally occurring plant compound) that has shown strong anti-cancer properties in lab studies.

However, the enzyme myrosinase in broccoli is needed for sulforaphane to form. If the myrosinase is destroyed, sulforaphane cannot form.

Researchers compared boiled, microwaved and steamed broccoli, and found that steaming broccoli for up to five minutes was the best way to retain its myrosinase. Boiling and microwaving broccoli for one minute or less destroyed the majority of the enzyme, according to Elizabeth Jeffery, a researcher at University of Illinois at Urbana-Champaign.

Jeffery also found that if you do eat well-cooked broccoli, you can still get sulforaphane to form by adding raw foods containing myrosinase to your meal. Study participants ate a broccoli supplement with no active myrosinase. When some of them ate a second food with myrosinase, their blood and urine levels of sulforaphane were significantly higher than those who did not eat the second food with myrosinase.

The findings were presented Thursday at the annual meeting of the American Institute for Cancer Research in Bethesda, Md. Findings presented at medical meetings should be viewed as preliminary until published in a peer-reviewed journal.

"Mustard, radish, arugula, wasabi and other uncooked cruciferous vegetables such as coleslaw all contain myrosinase, and weve seen this can restore the formation of sulforaphane," Jeffery said in an institute news release.

Previous research has found that:

* Crushing or chopping garlic, and then waiting 10 to 15 minutes before exposing it to heat allows its inactive compounds to convert into the active, protective phytochemical known as allicin.
* Cooking tomatoes and other foods that contain lycopene allows our body to more easily absorb the beneficial phytochemical.
* Boiling vegetables for a long time means you lose water-soluble vitamins, such as vitamin C, folate and niacin that leach into the water.

"As were learning, food processing isnt just what happens to food before it reaches the grocery shelves," AICR associate director of nutrition programs Alice Bender said in the news release. "This research highlights that what you do in your kitchen can make those fruits and vegetables on your plate even more cancer-protective."

Your bronze plan ticket to health care?

Should patients be forced to reach a spending threshold before their insurance kicks in? At first glance, it makes sense, because health consumers "skin in the game" forces them to think twice before going to the emergency room for a sore throat, or an orthopedic surgeon for simple back pain.

Wharam and colleagues examine the science behind high deductible insurance in this just-written article in the New England Journal.

And the science says there is a lot we do not know.

Once insurance risk is monetized into premiums, policymakers as well as insurers are operating in the dark about calculating the right deduction for a given income level. One example is Cover Oregons $5000 deductible for persons who are at 200% to 400% of the federal poverty level. That means a family with a yearly income as low as $47,000 would have to spend more than 10% of their income on health care before seeing a dime of insurance coverage.

"Egads," says the DMCB.

Given that stark reality, the challenge is to figure out how an up-front deductible influences "buying behavior" once persons get sick. Unfortunately, most of the research out there is on the impact of relatively "small" amounts of out-of-pocket expenses on health care utilization, especially in low-income populations. The bad news is that lay-persons - who are unable to discern the difference between a simple headache vs. a brain tumor - tend to "indiscriminately" lower all utilization as their cost sharing goes up.

There has also been no research on the impact of high deductible plans on mortality or chronic condition control.

Concluding that the U.S. is "poorly prepared" for what will happen under Obamacares bronze high deductible plans, Wharam et al recommend there be more research on the topic.  Pending that, they suggest consumers be educated about their insurance purchases and be encouraged to chose low-deductible plans. They note that the star-crossed insurance exchanges (once theyre fixed) can be configured to help do that. When there is employer-based insurance, employers could be encouraged to make the deductibles more proportional to income. In addition, health savings accounts could also help.

While the authors dont use the words "population health management," they tap this discipline as one solution to this Obamacare problem. They point out that predictive modeling/risk stratification can be used to create "personalized" insurance designs that optimize high-risk patients access to care. Patients in these plans could have access to decision-aids and coaching that help them figure out when its a simple headache and then they should seek medical care.

In previous posts, the Disease Management Care Blog has repeatedly questioned the wisdom of a one-size-fits-all, top-down, blunt force and Ver 1.0 approach to measuring health care quality.  Thats why its glad to see that the New England Journal of Medicine agrees with the DMCB in this Perspective by Nancy Morden and colleagues on the topic of Accountable Prescribing.

The authors point out that while blood pressure should be less than 140/90, LDL cholesterol less than 100 in persons with a history of heart attack and A1c should be less than 7% in persons with diabetes, its clear that the cure can be more costly than the disease.

For many individuals with mild elevations in blood pressure, diet and exercise can be enough and, if that doesnt work, cheap water pills often work great.  Among persons with elevated cholesterol levels, inexpensive statin prescriptions can save lives. Metformin for diabetes has been around for decades and it a first line agent no matter what the A1c is.

As a result, they call for measuring and rewarding quality based on accountable prescribing that not only measures the numbers (blood pressure, blood cholesterol or diabetes control), but the percent of individuals receiving conservative or first line treatments.  While this approach would require an even more detailed databases/registries, its within reach of most commercial insurers and advanced electronic record systems.  We owe it to our patients to provide a tailored, bottom-up, nuanced and Ver. 2. approach to measuring health care quality.

Its also a concept that the population health and care management service providers could, with the right kind of clinical partners, lead.  This calls for a pilot program and, in the DMCBs humble opinion, the sooner, the better.

For a better idea of how this might work, check out this table.

Image from Wikipedia

Every Saturday, we post a piece from the CHG archives. This one is from January 2009.

A few weeks ago, we posed a question to CHG readers, asking what kind of posts y’all would like to see more of in 2009. Overwhelmingly, the response was: easy, one-dish meals that make excellent leftovers, posted alongside gratuitously good-looking pictures of George Clooney. (I may have added that last part.)

It was a challenge, but I think we may have come up with a few ideas, thus fulfilling your wildest frugal foodie dreams. (We’re also very modest.)

It’s a big internet out there, and there are several billion interpretations of “one-dish meal,” so our first step was narrowing the field. Here were our initial criteria: