The February issue of Diabetes Health included an article titled “Diabetes Expert Offers Tips on Understanding and Preventing Heart Disease: Drugs are the Answer” by Alan Marcus, MD. The article emphasized the use of medication to control high blood pressure and cholesterol and to prevent heart disease in people with diabetes.
The article listed only three modifiable risk factors for cardiovascular disease: smoking, hypercholesterol-emia, and hypertension. Sedentary lifestyle should have been included. The American Heart Association has also added lack of physical activity as a fourth primary risk factor for cardiovascular disease (CAD). The Centers for Disease Control in the late 1980s stated that the impact of physical inactivity is at least equal to the impact of the original three factors. Furthermore, Dr. Carl Casperson of the CDC added that more Americans are affected by sedentary lifestyle than any of the other three risk factors. Consequently, many health organizations such as the American College of Sports Medicine, the American Cancer Society, the American Heart Association, and the American Diabetes Association advocate exercise as a preventive health measure.
Based on epidemiological studies conducted in the last 50 years, we know that the moderate levels of exercise, i.e. 30 minutes total per day, reduce the incidence and mortality of CAD by about half. This is a very potent effect. No medications rival this impact.
Low Stress Exercise
Exercise as easy as walking and gardening provide this protective effect. The activity doesn’t even have to be done in one 30 minute session as we once thought. As long as it totals 30 minutes daily, CAD risk is cut in half. Exercise has the added benefits of helping weight loss, retarding osteoporosis, enhancing self-esteem and self-confidence, reducing stress, and improving one’s sense of well-being. Exercise is even known to reduce several types of cancer, according to an article by Steve Blair in the Journal of American Medical Association, Nov. 1989. The information came from a study of 13,000 people. Again, drugs hardly rival the effects of consistent daily physical activity in producing these effects.
Drugs that help reduce blood pressure and LDL cholesterol have side effects. As Marcus points out, these include depression, increased risk of death, and impotence. Exercise does not have these effects. Quite the opposite.
Natural Methods First
Rather than place all the of the emphasis on drugs, many suggest a more comprehensive preventive approach. The “drugs only” approach contradicts the stepwise approach to treating hypertension advocated by the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (1993). This approach urges physicians to first use conservative strategies such as weight loss, exercise, smoking cessation, and sodium reduction in treating hypertension. If this response is inadequate, then the use of drugs is justified.
Emphasis on drugs as the first line of treatment removes the sense of accountability that everyone should have for their own health. Marcus’ view is widely held by physicians. This view has contributed to soaring healthcare costs. Until we educate the American public and determine effective strategies to make people more physically active, I fear that we will continue to see healthcare costs rise exorbitantly.
We know that lifestyle is the major cause of CAD and most of its risk factors. Pictures of soldiers in the two world wars clearly show how relatively lean men were in those eras. They didn’t achieve their leanness or protection from hypertension and hypercholesterolemia from drugs. They were physically active and actually consumed more calories than we do today.
Drugs have their place in medicine without question, but it seems dangerous and ill-advised to proclaim them as “the answer.”
Alan Marcus, MD, responds:
Kris Berg raises important issues and also states findings that should be accepted as part of the overall treatment of patients with hyperlipidemia or high cholesterol.
Exercise does play an important role in prevention of coronary artery disease and does indeed have a positive effect in increasing high density lipoproteins, and therefore does result in a lowering of the risk factors for heart attack. In fact, a one point increase in HDL results statistically in a three percent lowering of the chance of coronary artery disease in the individual.
Conservative Treatment May Not Be Enough
It is true that the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure recommends conservative strategies such as weight loss, exercise, smoking cessation, and sodium reduction as the first stage in treating hypertension. It should also be noted that in certain high risk groups, these conservative strategies will not result in success.
In terms of sodium reduction, Dr. Williams in his article in the New England Journal of Medicine stated that only 10% of hypertensive people are in fact responders in terms of lowering blood pressure in response to sodium reduction.
Other strategies such as weight loss, exercise, and smoking cessation are definately to be undertaken. However, it should not be viewed as the only treatment. The emphasis on drugs is placed on patients who have diabetes, and are therefore in a much higher risk area for having coronary artery disease than those who do not have this underlying metabolic disorder.
Medication Has Its Place
Diabetes often cannot be treated solely with exercise and diet. Medication is necessary and this may relate to the time of diagnosis or duration of the disease prior to diagnosis. At the time of the diagnosis of diabetes, 50% of these patients have demonstrable coronary lesions which unfortunately do not respond to conservative treatment strategies.
The justifiable and scientifically valid evolution of a more rigorous and aggressive indication for the primary and secondary prevention of coronary artery disease with lipid lowering therapy has been paralleled by accumulating evidence of the potency, safety, and tolerability of the HMG-Co-A reductase inhibitors. These agents assumed a key role as one of the major drug classes for the treatment of lipid disorders in patients who have failed to achieve target levels in spite of dietary modification.
These drugs, as well as others, figure prominently in the reduction of risk for patients whose lipid abnormalities remain refractory in the face of diet and exercise therapy. Rising healthcare costs as noted by Berg are, unfortunately, not the cost of medication but are related to the expense involved in treating the catastrophic outcomes of underlying coronary artery disease, namely stroke, heart attack, peripheral vascular disease, and amputation.
Soldiers Are Not a Good Example
Pictures of soldiers in world wars showing lean body masses may be very attractive; however, soldiers are usually in their second to third decade of life and unfortunately hyperlipidemia and coronary artery disease becomes evident in the fourth, fifth, and sixth decade of life. At that point, underlying metabolic disorders such as diabetes, hyperinsulinemia, and insulin resistance have taken a toll that cannot be reversed by conservative treatment alone.
Drugs have a place in medicine, but more importantly, they have a place in the prevention of disease, and their role in reducing the incidence of death from myocardial infarction has been clearly demonstrated by means of multiple studies that are now accepted as standards of care. Failure to treat a patient who has high-risk disease with medication that will result in a reduction of the incidence of death in the relatively near future is tantamount to poor treatment.
The Goal of Medicine
While the Hippocratic Oath states that we should do no harm, clearly the use of medication in the prevention of disease is not harming the patient, but actually treating and preventing illness. The first goal of medicine is the prevention of disease.
Alan O. Marcus, MD, FACP
So. Orange County Endocrinology