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Cognitive dissonance is the confusion we experience when we attempt to meld two contradictory ideas. Americans who are concerned with their health are reeling from cognitive dissonance: obesity, high blood pressure, diabetes, and high blood cholesterol are epidemic threats to our lives, yet America is graying so rapidly that nothing can save the Social Security and Medicare funds from collapse. This chapter and many that follow will teach you how to filter the pronouncements of authorities that relate to your health. With a few skills and rules, the exercise is far less tenuous than that which we undertake every day in every other arena. After all, most health pronouncements are offered as “science,” and science is quantifiable. The challenge is not that the terminology is unfamiliar; the terminology the media has learned to spew is now parlance. The challenge is in knowing how to discern the “science” in the cacophony so that you can ask if the pronouncement is meaningful to you. I will teach this with some of the most familiar “scares of the week.” Getting Comfortable in Your Cholesterol There is no question that blood “cholesterol” is a “risk factor.” But it’s not much of a risk factor. If you have no extraordinary family history, yet you have extra­ ordinarily high low-density lipoprotein (LDL) cholesterol and low high-density lipoprotein (HDL) cholesterol, it will cost you a year or two of life expectancy. Nearly all who are labeled “high cholesterol” are far from the extreme and have minimal risk. Nearly all labeled “high cholesterol” are contending with a reducchapter Risky Business Cholesterol, Blood Sugar, and Blood Pressure three 34 | cholesterol , blood sugar, and blood pressure tion in life expectancy of months. Do you think a reduction of months of life expectancy is meaningful, or even measurable? There is no question that the “statin” family of drugs can lower cholesterol. There is no question that these drugs advantage members of families with a particular genetic disease that causes heart attacks (myocardial infarctions) when very young. There is no question that lowering cholesterol in patients who have already suffered a myocardial infarction will result in a very small though measurable decrease in the likelihood that they will suffer another myocardial infarction and a smaller, barely measurable increase in their survival. This is termed “secondary prevention,” or preventing recurrent disease. However, there is a serious question as to whether statin treatment affords any meaningful advantage to all the rest of us who have not suffered a myocardial infarction. Can we recruit science to answer that most relevant question, or even assuage the doubt? Are statins useful for the primary prevention of heart disease? Consider the following scientific protocol. A program was set up to screen the blood cholesterol of healthy men age forty-five to sixty-four. Of those with high cholesterol, 6,595 agreed to participate in a five-year, randomized placebocontrolled trial of pravastatin, the “statin” marketed under the brand name Pravachol by the Bristol-Myers Squibb Pharmaceutical Company, which funded the trial. That means that every morning for the five years, these men took a pill. For 3,302 men, that pill contained 40 mg of pravastatin, and for the remainder the morning pill contained a pharmacologically inert substance, a placebo. The main results are presented in Table 1. This pivotal study was published in the New England Journal of Medicine in 1995. It is called the West of Scotland Study because it was a multicenter study conducted by a consortium of investigators, the West of Scotland Coronary Prevention Study Group. It remains the most compelling study for all who argue that statins are important for the “primary prevention” of cardiac disease. The result elevated statins to the forefront in public-health policy considerations. It has driven statins to the forefront in recommendations by advisory panels of such organizations at the American Heart Association. Thanks to the fallout from this study, Americans know that cholesterol is bad and statins are good. Questioning the credo is heresy . There are parallels to the fashion in which the results of the trials of CABG surgery (see chapter 2) have gained such influence that the efficacy of CABG is an American “truth.” Just as we debunked the CABG “truth,” we must decide if science compels us, the well people, toward cholesterol screening and treatment if our cholesterol level is said to be “high.” Let’s examine the table from the bottom up. Pravachol (in high dose) saved [3.14.246...

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