Saturday, March 06, 2021

Little Fishes


Well, my doctors are at it again, trying to get me to take statins. So I've been going through what I went through ten years ago, browsing studies and reading Cochrane reviews and getting the lay of the land. American medicine is very aggressive about preventive statins. It's a maddening edge-case, for me: kind of a toss-up. On the one hand, the benefit is clear enough: if you put a thousand at-risk people on statins for five years, you'll prevent some 18 major cardiovascular episodes. But as far as I can tell, no one clearly understands why. The popular narrative of cholesterol "clogging" arteries is not what actually happens. And meanwhile, you've also put 982 people on a serious systemic drug for five years, without measurable benefit. I don't have confidence that these studies (all of which are underwritten by people who -- surprise! -- want to sell statins) are looking really carefully for long-term side-effects. I don't doubt that the research is conscientious, by its own lights. But its lights are not exactly mine. The balance has shifted slightly in favor of the pro-preventive-statins side, in the last ten years, but not much. I'm undecided.

But still, even given all the caveats, my cholesterol is outlandishly high, and probably indicates that I should do something about it. One thing, which I'm already undertaking, is to increase my (quite lame) cardio: I'm gradually going to double my modest daily walking time.  The other thing, of course, is my diet.

I have fixed a lot about my diet, in the past four years, but there's two big changes I've left for later: salt and saturated fat. Salt is a project I'm not willing to undertake yet. But I eat a lot of saturated fat at dinner: 100 grams of ground beef, and a densely-packed quarter cup (probably half a cup, unpacked) of ice cream. I have not had much luck tampering with those: I've partly been able to make all the other changes because I still able to look forward to gorging myself on saturated fat at dinner. But I think I'm going to take another, sustained shot at replacing the burger and ice cream with little fishes. Sardines, or herring, or whatever you call them. Little guys towards the bottom of the food chain. It needs to be canned, because no way am I taking on the burden of purchasing, storing, and prepping fresh fish every day. Not happening.

So. I'll have a lot of calories to spend -- upwards of 400 -- if I drop the burger and ice cream. I have a hard time picturing eating 400 calories of sardines. (Truth be told, I have a hard time picturing eating sardines at all) So at least it will be an "all you can eat" situation, which may placate the appetite demons somewhat.

We'll see. It's an experiment. If I can't do it -- if it leads to intolerable cravings and binges -- then I'll just accept that, resume the burger and ice cream, and go on my way: moving one blood lipid marker down is not worth putting the whole project at risk. Maybe I've done as much as I can: if so, that's all right. But I am going to make the attempt. Market day is Monday, so that's when I start.


Having to decide about the statins evoked an odd emotional crisis, which I'm still sorting out. My doctor ordered me to start taking them in a note on my online chart. It was not camouflaged as a suggestion, or a consultation. It was phrased simply as a command. This is a new-ish doctor for me, who is busy and rather rushed, who probably was not bearing in mind, or didn't know, or didn't care, that doctors have ordered me to take statins before and I have said no. 

I don't respond well to being ordered, when I think I ought to be consulted. As a white man with and advanced degree and a retirement stash, I'm greatly impressed with my own importance and dignity, and I expect everyone else to be too. 

At the same time, I score off the charts on those personality quizzes that assess agreeability. I prefer to avoid conflict. And I'm keenly aware that I want to stay on the good side of my health care people, because they have control of the pharmacopeia. If I'm dying of cancer someday I may want all the opium I can eat, and this is the doctor who will be deciding if I get it. I'm also aware (really I am!) that even thinking this thought wanders over the line into paranoia: I really doubt that many doctors are going to make that decision by pondering whether I was willing to take statins when they told me to. 

No, what's really operating here is a reluctance to accept my low status and vulnerability. Where my two options appear to be knuckling under and accepting that I'm powerless old man, hoping not to be stranded on the ice floe, with an ever-growing list of cumulatively debilitating daily medicines to take; or becoming one of those ridiculous superstitiously anti-medical cranks who refuse to go near a hospital when their appendix bursts. Comical, in any case. Nobody retains their dignity in the face of the Western way of doing medicine. Nobody retains their dignity in the face of age, in any case. And isn't it -- supposedly -- my goal to get rid of my dignity? Isn't my dignity precisely and exactly the source of my suffering? I thought abandoning my dignity was my life's project?

The fact is that this decision is trivial. If you did a study with fifty subjects, and a fifty-person control group, you would probably conclude that a) statins have no benefit and b) statins have no side-effects, either. You can't even see these effects in a small study. I may have opinions about the wisdom of setting standards for preventive drugs that result in the majority of the population eventually taking them, but -- that's another question, and not one in which the opinion of an IT guy / massage therapist / occasional poet weighs much.

So that much is clear. The decision is actually unimportant. What is important for me -- apparently -- is how I hold it, which stories I tell myself about it, and what state of mind they leave me in. The story of letting myself get pushed around is not going to be one that -- for instance -- inspires me to have a go at eating little fishes. The story of crotchety, shrill defiance, and insistence on my dignity, in defiance of due authority, may undergird the little fishes project, but it takes me that much further on the road to suspicion and isolation.  I'm already further down that road than I want to be.


Anyway. If any of you have helpful hints or suggestions about little fishes, please give them to me! My plan Monday is to plant myself by the canned fish and read labels and just try whatever they've got. 


Murr Brewster said...

I can eat a few little fishes if there's pizza under them. For the rest, my cholesterol is tol'able, but because I've suspected there's something wrong with my heart, I've gone the lower-inflammation route, myself. Which is why I originally quit eating wheat. I do not know whether to trust what I read on the subject, but here's one thing that happened: my life-long hummingbird pulse rate of around 88 beats/minute went down to about 76. That got my attention and it's been an easy switch to make.

Murr Brewster said...

Which, of course, is not what you asked. You put in a post like this you're going to get ALL KINDS of unsolicited advice.

Dale said...

Heh. That's fine! I don't eat wheat either, ordinarily, but that's just a consequence of doing the minimal-processing thing. I'd eat a wheat berry if it hopped onto my plate.

am said...

Years ago when I was told that my cholesterol was too high, I began eating a 14.75 oz can of pink salmon (630 calories) daily with the understanding that pink salmon would improve my cholesterol levels and is a good source of protein and calcium. A generous amount of canned pink salmon, rice and vegetables with tons of olive oil and salt makes a delicious satisfying meal. Canned pink salmon and olive oil rolled up in nori sheets, too. Salmon chowder. Canned albacore with rice and vegetables and tons of olive oil and salt. Big fish. Occasional fresh salmon or black cod.

Little fishes. I love sardines in olive oil. More expensive than salmon or tuna. I'm on a limited budget.

Then there's ground turkey. 200 grams is a serving for me. Inexpensive. Delicious. I buy it frozen. I used to eat generous amounts of hearty chili, homemade with ground turkey but can no longer tolerate tomatoes or anything spicy.

I no longer have my cholesterol tested because I have no desire to take a statin. Who knows if my cholesterol has remained high. I am otherwise unusually healthy for my age of 71.

Being Mortal, by Atul Gawande, convinced me to choose quality of life over length of life.

Dale said...

Huh! Turkey hadn't occurred to me. Thanks.

Definitely yes, to quality of life. If I do start taking the statins, and I do get muscle problems, out they go. I'm not inviting in anything that makes daily movement harder.

CassandraBeth said...

I hear you, Dale. Turkey is a good idea, also supplementing your little fish with occasional tuna or salmon. I like sardines, but can't imagine eating them every day. And I hear you about the statins. My total cholesterol is high, mainly because my "good" choesterol is off the charts, but the "bad" one is borderline. In Canada, when my doc does the math, I don't qualify as high risk... but honestly, I don't think anyone really knows. So far, no drugs for me. But when I read recently that the American Heart Association is recommending that all women have BP of 110/80 or less, 10 points lower than the current recommendation, my first thought was, "Another pharmaceutical goldmine." That will be another discussion, down the road. My husband has taken statins for years and years. He did have to switch kinds, but has had no ill effects, and enjoys a burger and fries. For what it's worth.

susie @ persimmon moon cottage said...

I used to have higher cholesterol than I do now and doctors tried me on several different statins. Every one that I tried made me ache so much all over that I wasn't able to even get around to do normal activities. I ached so badly it was like I had the flu. I'd be told to stop the statins, which I was happy to do, and within a week the aching in my muscles and flesh would stop. Every time a new statin came out I would give it a try with the same results. Then finally another new one came out and I got even sicker with that one. The doctor took me off them. I won't try them again. I believe for them to make me that sick when I took them, they were doing something to my body that wasn't good.

I think my doctor I have now is sensible and would question insisting that all women have a BP of 110/80 or less. When my blood pressure goes down to the low 120's I become very dizzy. I think insisting on that low of Blood Pressure is to get people to buy and use more blood pressure pills. The blood pressure pills I took for years were recalled for having an unintentional ingredient in them that caused cancer. That does not give me a feeling of confidence in some of our medications.

Sabine said...

There is familial high cholesterol in my family and I am the lucky one of three who has a relatively low, but still elevated, level. My siblings have been going through the roof for decades and have tried and suffered many types of statins with endless side effects and have both given up. I am taking a low dose statin because I am living with a carload of chronic illness risks which are all hammering down on my life expectancy like mad loonies. The reference range for acceptable cholesterol levels in my country varies quite a lot from the US range. That's another issue.

I have done a lot of reading on statins and on cholesterol and diet and I am not at all convinced that diet has any effect at all on our cholesterol levels. In fact, I have yet to find a definite convincing double blind etc. study with proof.
Have a read here:

Remember: cholesterol is an essential organic molecule that is used to seal our vessels (arteries, veins) to withstand stress, real physical stress. Hence, cholesterol levels during labour and childbirth are extremely high, simply to ensure that the physical strain of pushing etc. does not result in burst vessels.
It is not the enemy.
Food, on the other hand, can be.

I am vegetarian but (rarely) eat fish - mostly because I have trouble digesting this but also for environmental/climate change reasons. Ditto eggs, they just don't agree with me. These days, I think I am made up of vegetables and oatmeal, mostly. And black tea and fruit. And excellent bread. And some dairy.

Dale said...

Beth, yes, I remember him giving up on getting the numbers down by diet! I actually took statins for a while, many years ago, and tolerated them fine, so they're still on the table for me. But I'd rather be able to get a lipid panel and get a straight story out of it :-)

Susie (welcome!) yes -- some people have a really bad reaction to statins -- I've heard that from several readers, and my readership is not a very large sample.

Sabine, thanks! Yes, my understanding is that in some cases saturated fat intake does affect cholesterol, but in other cases it really doesn't. Dietary cholesterol appears, as your article says, to be a total red herring: it has basically nothing to do with blood cholesterol. There seems to be a lot of variability, and a lot of confounding factors (e.g. polyunsaturated fats bring down blood cholesterol, but probably actually make matters worse.) The "cholesterol is bad" story is nonsense. But a really high cholesterol number is still a marker to take seriously, I think: as long as you understand that it's a marker, and not the problem itself. I have evidence that I've been adding some visceral fat -- my waist is an inch larger than it was a year ago -- which suggests that I want to address my body composition a bit. So it's not just the cholesterol number that's giving me pause.

Thanks everyone! I really appreciate your comments & help!

Marly said...

Aren't you leaving out some tasty things that might help? Turmeric? Nuts and seeds? Persimmons? Etc. But fooling with diet and doing more exercise sounds good.

How much we still do not understand about the body is something we forget. And old advice sometimes turns out to be dead wrong, as when they made us (women, mostly) take calcium supplements (but no D3 or K2) for decades. There's such huge disagreement about amounts--1200 US for women my age, 500 WHO, 700 UK. Harvard's Chan School of Public Health says we take consume way too much calcium. And that's just one wee confusing example.

And surely baseline measurements for many things are individual, not standard, not median or average of a population. As a somewhat small person, I often wonder about that...