Most people who get a heart attack have serum cholesterol levels that are “OK”. Their blood pressure levels are also “OK”. Furthermore, they are not particularly overweight or sedentary, and do not smoke heavily, if at all. If that seems contradictory in the light of contemporary concerns about cholesterol, then it is time to re-examine the issue.
High serum cholesterol, high blood pressure, obesity, smoking, sedentary living, diabetes, and probably stress, are important risk factors for heart disease — the quintessential disease of the turn of the century.
The more of these risk factors that an individual has, the more likely he (or she, after menopause) is to get a heart attack. But people with only one or two of these risk factors do get heart attacks, and since there are so many more of these people than there are people with many risk factors, there will be an absolutely greater number of heart attacks among them.
Let us look at it another way. Assuming that most people wear their seat belts, it is inevitable that the people who die in motor vehicle accidents will, in most cases, be wearing their seat belts. An individual who is not wearing a seat belt is more likely to die in an accident than an individual who is wearing one, but there will be, let us hope, relatively few such individuals.
Which brings us to the point: it is change in the behaviour of the population as a whole that will bring the results that we want, but it is up to each and every individual to make that change happen. By wearing our seat belts, we are going to save the lives of a dozen or so people in the coming year. A small act by half a million people is needed in order to change the fate of a tiny minority, but the only way to save those dozen lives is for each of us to wear our seat belt.
The same logic applies to cholesterol. If the average person whose cholesterol is OK reduces his or her cholesterol, we will prevent twice as many heart attacks.
This is the “population approach” to contemporary health problems, and in the modern era it is the most meaningful and cost-effective way to respond to the challenge of heart disease, cancer, hypertension, diabetes, AIDS, accidents and other so-called lifestyle diseases. The alternative is the high risk approach, which would mean, to continue the seat belt example, seeking out the bad drivers in our midst and asking them to wear their seat belts. This is obviously a less effective approach; but for a number of increasingly irrelevant reasons, it is the favoured approach under prevailing health care systems.
The main reason is that doctors have been trained to promote health by looking for problems that need treatment. Drug companies have spent millions to develop those treatments, and they have to turn a profit. And so it is that we have been caught up in a “testing” frenzy to see who is in need of treatment.
Millions of dollars are going down the drain every year on stress electrocardiograms for business executives. Annual chest x-rays are routine, even though they provide no benefits and are probably increasing the incidence of cancer. Fat, sedentary diabetics are spending their money on blood sugar tests, when paying gym fees would make more sense. And of course, everybody is anxiously checking their cholesterol to see if it is high, and then rushing out to buy statins if it is.
None of this is going to make any difference to the health of the people of the Caribbean, but powerful interests are involved. Hospitals cater to thousands of executives doing annual medical check-ups. No executive in his right mind would spend thousands of dollars on a procedure that brings no obvious corporate benefits, but then health has never been a matter of logic. People want reassurance that they are not about to die, rather than programmes that will make them healthier and more productive.
This is not to say that testing is unnecessary. The problem is the reason for the tests. Every individual should know his or her cholesterol level, but only because such knowledge is one aspect of the assumption of personal responsibility for overall health.
Checking one’s cholesterol level without looking after one’s health is virtually useless. In most people it will not be particularly high. Even if it is a bit high, and you are otherwise in very good health, then it probably does not matter. If it is normal and you are in poor condition, you will still get that heart attack, if it is due.
Geoffrey B. Frankson is a medical doctor and Director of the Wellness Centre in Trinidad
