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Report Favors Cholesterol Drugs, But Doctors Say Diet Is Effective

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Report Favors Cholesterol Drugs, But Doctors Say Diet Is Effective

By THOMAS M. BURTON
Staff Reporter of THE WALL STREET JOURNAL
 

A government panel wants 36 million Americans to take cholesterol pills like Lipitor and Zocor for the rest of their lives. So whatever happened to starting with a better diet?

While these "statin" cholesterol drugs are powerful and potentially life-saving, their side effects in people taking them over a lifetime haven't been determined. Nevertheless, powerful institutional realities, ranging from how doctors practice to how pharmaceutical companies market drugs and insurers pay, have converged to elevate drugs over diet.

1New Government Cholesterol Standards Would Triple Number of Prescriptions (May 16)

"If people make significant enough dietary and lifestyle changes, 70% or more of this at-risk group can lower their cholesterol levels enough without drugs," says Michael F. Roizen, a University of Chicago internist and co-author of "The RealAge Diet."

Research shows that some seriously ill heart patients have actually reversed coronary disease with a low-fat menu including dishes like risotto with corn and red peppers, or angel-hair pasta with tomato and basil. Many people on such diets avoided heart bypass surgery and angioplasty altogether. Of course, some patients truly need cholesterol drugs, and other people wouldn't give up butter if it was killing them.

The authors of the much-publicized government cholesterol report last month did recommend dietary changes. But physicians like Dr. Roizen feel the report didn't push hard enough. It recommended a diet like the American Heart Association's "Step II" 30%-fat diet, which includes foods like chicken, fish and olive oil. The report didn't recommend more stringent, and even vegetarian, diets for sicker people with higher risk factors or advanced coronary artery disease. "Nobody thinks those diets can be applied to the general population," says Peter J. Savage, acting director of epidemiology at the National Heart, Lung and Blood Institute, which appointed the government panel.

Ironically, one factor favoring the use of drugs is a consumer-oriented phenomenon: Many insurers now grade doctors' performances and dole out monetary bonuses and penalties based on measuring and improving patients' cholesterol levels. And the fastest and easiest way for doctors to lower cholesterol is to prescribe a powerful statin like Pfizer Inc.'s Lipitor. "Insurance provides all kinds of incentives for that behavior," says Dr. Roizen. "You get a bonus payment that is about 20% of what you are otherwise paid for care."

Moreover, doctors are typically paid for spending about 30 minutes for a first visit, and 12 to 15 minutes for a follow-up. A physical exam and medical history easily eat up the time, leaving little or no time for doctors to give instructions on preparing, say, a week's worth of cardiac-healthy meals. "Even if physicians have the training, they don't have the time," says Dean Ornish, an internist at the University of California at San Francisco best known for his program of dietary and lifestyle training.

Most doctors don't have the dietary knowledge. "Physicians aren't so well-versed in it, so they haven't spent as much effort in dietary control as they might," says David P. Faxon, president-elect of the American Heart Association and University of Chicago cardiologist.

At most, doctors usually hand out a list of "good" and "bad" foods and tell patients to try to follow it for a month before taking drugs. But there is often little instruction on preparing dishes or on lower-fat alternatives if a patient's cholesterol remains too high.

Drug companies also help set the tone in doctors' offices. They enlist doctors as consultants, even at smaller community hospitals. They pay for medical conferences like the recent American College of Cardiology meeting in Orlando, Fla. Pfizer was the leading sponsor there, forking over $822,000 for the meeting and handing out Lipitor-logo bags to thousands. Drug salesmen visit doctors' offices, sometimes weekly, paying for pizza lunches and treating physicians to dinner. It all adds up to a coziness that makes prescribing drugs feel like the norm.

Another advantage that drugs have over diet is that insurers pay for drugs but generally won't cover dietary counseling. UnitedHealth Group Inc. says that big employers don't request coverage for dietary education. The Minnetonka, Minn., insurer, though, has a telephone hotline and a Web site with cholesterol and dietary information. Aetna Inc., of Hartford, Conn., says it won't pay for dietary instruction unless a doctor recommends it. It also provides videos for "high-risk" cardiac patients to help with things like stress management.

Insurers "tend to pay for treatment much faster than for prevention," says Gary N. Wilner, head of cardiopulmonary wellness at Northwestern University. "Is enough being done on dietary education? Obviously not."

That is slowly changing. Highmark Blue Cross & Blue Shield in Pittsburgh, with 2.9 million insured, pays for the $7,200, 12-week Dean Ornish program. So far, 1,500 patients have participated. Instead of getting an operation, seriously ill patients already diagnosed as heart-bypass candidates learn meditation and Dr. Ornish's heart-disease "reversal" diet, including the corn-pepper risotto and tomato-basil pasta dishes.

The diet is strictly vegetarian and doesn't allow extra olive oil, peanut oil and other oils with saturated fat. Skeptics say most people can't adhere to it. Highmark says that 85% of its participants did. Dr. Ornish notes that he supports a less-spartan low-fat diet for qualified patients, and prescribes statin drugs for people who don't respond to moderate dietary changes and choose not to pursue the stricter "reversal" diet.

Highmark says it has saved about $17,000 a patient by avoiding bypass operations and angioplasty procedures, and that patients' angina declined by 57%. After 12 weeks, the average cholesterol of patients in the Ornish program fell 11%, to 174.0 from 196.1. Dr. Ornish and colleagues reported in a 1998 Journal of the American Medical Association article that diagnostic images showed participating patients had 7.9% less blood-flow blockage on average after five years, while other patients' blockage advanced an average 28%. Also, LDL, or "bad," cholesterol, fell about 40% after one year. (Critics have noted this was a small study, with only 20 patients in the program.)

Similarly, Dr. Roizen and the University of Chicago have an $1,800 daylong program to teach lifestyle, diet and exercise improvements. But the program draws mostly affluent people, such as executives looking for more-healthful menus on their Learjets, since few insurers -- as with the Ornish program -- cover the cost.

"Why have we gotten to the point in American medicine where it's considered radical for people to exercise, eat a healthy diet, manage stress and stop smoking?" asks Dr. Ornish. "To assume that people won't change is self-fulfilling."

Write to Thomas M. Burton at tom.burton@wsj.com²

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