The Simvastatin Story

This week the FDA released new guidelines in regards to the use of the very common medication, simvastatin, which is used to lower cholesterol and thereby decreasing the risk of heart attack and stroke.  The reason for the guidelines change was due to new information that has been received from their Adverse Event Reporting System.  They found that there was an increased incidence of problems with muscles at the highest dose, 80 mg.  The incidence for this was much higher during the first year that a patient took the drug and was much more so in combination with certain other medications.  The most common are the calcium channel blockers used to control high blood pressure (diltiazem, verapamil).  They recommend that no more than 20 mg of simvastatin be taken in combination with these drugs and 20 mg with a similar medication, amlodipine.

Simvastatin 80 mg pill

You may ask, if there are serious risks to taking this medication, why wasn't it just pulled off of the market?  The reason is that for many people the risk of not taking the medication is higher than the risk of taking it.  In the last twenty five years, the incidence of heart disease has decreased dramatically.  Most researchers feel that it is due to the beneficial effects of the statin medications.  Their effects on the liver and on muscle tissue is well known.  When it is watched for and monitored, the medication is safe.  Simvastatin in particular is useful because it is the only statin on the market that is both potent and available in a generic form.  In my opnion, lovastatin and fluvastatin have more incidence of muscle pains.  Pravastatin is quite safe, has fewer muscle problems but is not very potent.  Basically, three options remain: Crestor, Lipitor and Vytorin.  Crestor and Lipitor will both be quite a bit more expensive.  The incidence of muscle problems is likely to be lower but the potential still exists.  Vytorin is simvastatin, together with a medication called ezetimide (Zetia).  It works by blocking the absorption of cholesterol in the intestines.  It shows great reductions in cholesterol levels but there is some debate over whether that translates into fewer cardiovascular events (heart attacks).

Where does this leave you?  It depends on your individual situation.  Step one is to estimate your cardiovascular risk.  If you have known vascular disease (atherosclerosis-partial blockage in any of your arteries), it is imperative that your LDL, bad cholesterol, be less than 100 mg/dl.  This is unlikely to be achieved by diet alone. A statin drug has the best data in regards to lowering your future risk.  If you have diabetes you fall into that same risk category.  If neither of the two are present, go to the Framingham Risk Calculator (click here) and if your risk is above 10%, you should be on a statin.   If it is lower you need to ask yourself if you are truly doing everything you can in regards to diet and exercise to ensure that you remain healthy.   Healthy living is preferable to medications any day of the week as long as the proper levels are attained.

If you need to take a statin medication, the good news is that if you have been taking simvastatin at 40 mg or less and are doing well on it, there is no concern about staying on that dose.  If you take 80 mg of simvastatin or you are also taking any of the medications that interact with it, you should discuss this with your physician.  For a detailed summary from the FDA and a list of all medications that can interact with simvastatin (click here).  If you have any questions, feel free to ask in the comments.  I'll be happy to respond.  Remember, these medications are there only to assist your own efforts in eating right and getting plenty of exercise.  They do not take their place.  Let's just simply be healthy!

Walking on The High Wire

Have you ever seen the person at the circus that walks on the tightrope?  The amazing ones can even ride a bike across while balancing balls, plates, boxes and other items.  It requires inner strength and great balance.  Similarly, our physical health can only be maximized if we are in balance in all the areas of our life.  If one area is neglected, it will affect the others.  I believe that we must be aware and nurture our health not only physically, but also, mentally, emotionally, financially and spiritually.  Let me touch on each of these, going in to more depth in future posts.

Mental Health:
We think of our youth as the years of our education but that is when it begins, not when it ends.  Keeping our brain active is important to maintain alertness, awareness and to ward off problems with our memory.  As our population ages we are seeing more and more of our family and friends develop dementia.  The scientific community has looked at all sorts of drugs and even herbal remedies to aid the brain.  None have been shown to be very significant.  However, one study in particular caught my eye.  Those patients who exercised their brain (puzzles, games, speaking a foreign language, playing a musical instrument) had a seven fold decreased risk of developing Alzheimer's Dementia than those who did not.  In addition, those who are stimulated to learn and grow mentally are more apt to read this blog and other sources of health.  Information is power.  In regards to your health, it is the power to make healthy choices and meaningful changes.

Emotional Health:
Our emotional state has a huge bearing on our physical health.  The stress from strained relationships can produce anxiety which is not just mental, but biochemical.  When we are under stress, signals from our brain are sent to the adrenal gland which is stimulated to produce epinephrine (adrenaline).  This courses through the blood stream, causing all sorts of effects.  Most noticeably are those of the heart, making it speed up, contract harder and even causing skipped beats or extra beats.  We can feel sweaty, dizzy and lightheaded.  It takes up so much energy, that it leaves us tired and exhausted.  Our immune system is taxed and we are left more vulnerable to colds and infections.  Often, patients will come in and tell me all of their physical symptoms and complaints but no one wants to admit that it could be caused by emotional stress.  It is much easier to be given a pill than to be told to work on improving relationships.  I recently saw a woman who has had many complaints over the last year.  She is currently doing relatively well and we have developed a strong enough relationship and understanding that I felt that I needed to discuss her family stresses in more detail.  I told her, "I fear that the stress of your relationship with your husband is having adverse consequences on your health."  Tearfully, she acknowledged that she felt trapped in the relationship and didn't even like going home after work.  We talked of ways to get help for them both, and though I certainly didn't solve any of her problems, she left with an understanding of how that stress was affecting her health and is now better able to focus her energies on the cause rather than on the symptoms.

Financial Health:
Living within our means provides a peace of mind that is priceless.  If we stay out of debt, we will not have to wonder if we need to choose to pay the mortgage or for a prescription.  Financial worries can be all consuming and cause the same stresses and health consequences as outlined in the preceding paragraph.  I realize that we all have different circumstances and some are left to struggle financially due to no fault of their own.  However, most of us can manage our resources better than we currently do.  We don't often think of how that impacts our health, but it most certainly does.  From a more global perspective, it has been shown that the best way to improve the health of a nation is not to pour more money into health care but to work on eliminating poverty.  We are much more able to take care of our physical health when we don't have to spend all of our energy on providing the very basic necessities of life.  Getting as much education as possible opens the doors of opportunity and ties in to our mental health as stated above.  Better jobs often have better health care benefits as well.

Spiritual Health:
The belief in a higher power, though not universal, is certainly pervasive in our world.  It brings hope to the depressed and provides an individual with a feeling of purpose in life.  Religious texts, such as the Bible, are full of examples of the power of faith to heal and to be healed.  When a loved one has passed away, those who have a strong religious connection often have stronger support groups and cope better.  As a physician, I have found great strength in being able to acknowledge a patient's belief and to support them as they may struggle with a serious illness.  I feel I can better help them cope with their disease by understanding their beliefs. There have been scientific studies showing the actual merit of prayer.  In fact, I pray for my patient's doctor each and every day.

All of these areas are important and must be balanced to achieve optimal physical health.  Each of us may have more work to do in one area than another.  When you are on the high wire of health, remember to keep all your burdens balanced!

Good Rays or Bad?

One of the key elements to our health is maintaining balance.  Just about anything, taken to an extreme can have bad consequences.  It is important to utilize one of our greatest, but often neglected, God given gifts: common sense.  No where is this better exemplified than in how we deal with sun exposure.

We have learned that excess sun causes skin cancer.  In the form of melanoma, it can be a rapidly progressive, deadly disease.  The medical community has gotten the word out.  Stay out of the sun.  Use sunscreen.  Protect yourself.  This is all true.

Now, shutting yourself inside all day and avoiding the sun's rays at any cost is not necessarily a good thing.  When the sun is out we all feel a little better.  Just as it awakens our plants and helps them to grow, it has been shown to decrease our propensity to depression and lift our moods.

There is one are of our health that the sun is essential to our metabolism.  It has to do with calcium.  Calcium keeps our bones strong.  It triggers our muscles to contract.  Without it, our heart could not pump.  It is very tightly regulated in our blood stream.  One of the ways in which this happens is through Vitamin D.  There are several sources of vitamin D in our diet but the active form which helps us absorb calcium, is formed through an enzyme that requires sunlight through the skin.  Without vitamin D our body does not function well.  I am finding in my own practice of medicine many, many people who have low Vitamin D levels.  When I was in medical school, I was taught to consider Vitamin D deficiency in mostly older patients with thin bones who never get outside.  We now live in a society where we go all day long without being outside.  Instead of walking or biking to work, we drive.  We sit all day long in buildings whether at work or at school.  When we arrive home, we rush to the computer to talk to our friends on facebook or write on our blogs!  We need more sun.

Sun exposure is bad, you say.  In excess, of course it is.  Just 10-15 minutes of sun exposure, three days a week is sufficient to maintain adequate levels of vitamin D.  Grab a hat, wear your sun screen but get outside and enjoy those rays.  Remember, keep everything in balance.

A Salty Study

I received an email recently from a patient wanting to know what to do in regards to salt intake in light of a study which was released this month from the Journal of the American Medical Association.  There has been long standing consensus that too much salt in the diet raises blood pressure.  High blood pressure (hypertension) indisputably increases the risk of both heart attacks and strokes.  The study looked at a group of people for eight years and followed them till they were 49 years old.  The Centers for Disease Control made a public statement expressing concern over the study's findings and reiterated their support of the stand of the World Health Organization and the American Heart Association that sodium be limited to 1500-2300 mg a day.  Interestingly, the Salt Institute, was the lone organization that hailed the study.

One of my big concerns about the study is how young the patients were.  The chance of dying of heart disease before the age of fifty is quite low.  The fact that they could measure a statistically significant difference surprises me.  It makes me wonder if those who died had preexisting heart disease.  They would be much more likely to be on low salt diets because that is what their doctors would have told them to do in order to minimize their risk.  If that were the case, it would not be salt restriction which caused them to have more adverse events, but rather their underlying heart disease.

Tropical fruit high in potassium with no salt!

Some of the best information we have in regards to sodium restriction come from studies done in relation to the DASH (dietary approaches to stop hypertension) diet.  It is sponsored by the National Institutes of Health (NIH).  Recent studies are summarized on their website at www.dashdiet.org.  Some years back I came across a study from a remote pacific island.  The population that lived there did not have access to processed foods.  The amount of sodium in their diet was exceedingly low and the amount of potassium was quite high due to a high intake of the native tropical fruits and vegetables.  The astonishing finding to me was that they did not find one single person with high blood pressure.  Not one!  I would have thought that someone would have had a genetic aberration that would have caused their blood pressure to be high.  To me, this study stands as a testimony of what eating the right foods will do for us.  Remember, if it sounds too good to be true, it usually is.  Leave the salt in the cupboard.

Make Every Step Count

"I don't have time for exercise."  I hear this all the time.  Most people, frankly, can make time to exercise.  It won't be found because there is always something that will fill a void.  Time for exercise has to be made.  I do know of some people, that truly have no time for exercise.  Some work two jobs or who care for elderly parents who are not well.  Exercising with small children is difficult also.  How is one to do it?

First, make every step count.  Go buy a pedometer (step counter).  They are rather inexpensive and can be found at most sporting good stores.  It is worn at the waist and will activate every time a step is taken.  Sufficient activity for one day is 10,000 steps.  Wear one around for a day and see how many steps you take.  See how many steps you need to make up and find ways of increasing them.  Park in a far corner of the lot wherever you go.  Take the stairs instead of the elevator.  It has been years since I have used the elevator at the hospital.  Take your dog for a walk.  Take a friend for a walk.  Take a bag lunch to work and go for a walk while you eat it.  Every step counts but you've got to take them.

What do you do during your down time?  Instead of going to a movie, go to the park.  Eat at a restaurant in an interesting area of town so that you can take a stroll afterwards.  When was the last time you have been dancing?  It is fun and burns those calories.  If you are going to sit and play a video game, then for goodness sake, get the Wii fit or one of the dance programs that makes you get up and move.  Walk over to your neighbor's house.  Go to the mall, but park on the other side.  Don't take the escalators but find the stairs.  In everything you do ask yourself, "How can I make every step count?"


Track your progress.  This will make you accountable to yourself.  Just this week I spoke with an 89 year old who told me that over the last 15 years he has biked over 40,000 miles.  This is a frail, old man.  He is not breaking any records for speed.  I have no doubt, though, that it has kept him alive.  By keeping track of your progress, you will find that you will naturally do small things to increase your activity.  If you only need to climb one flight of stairs to get to work, you may decide to go up two or three flights and then go back down to your level.  If you work on the 45th floor of a building, you may get off on the 40th floor and walk up the remaining five flights.  Make every step count.

The Buddy System

Like a group of boy scouts on a mountain adventure, to safely ascend the peak of good health it is helpful to have someone at your side.  A partner gives you a reason to show up at the gym when the alarm goes off, the air is cold and the bed is warm.  A partner helps you stay on track.  Your "buddy" may be an exercise class.  It might be a family member.  It could even be your dog who needs to talk a walk.  Being accountable to others transforms desire into resolve; good intentions into a way of life.

Staying on track with health is like walking on the straight and narrow path.  If we can't stay on it, we need to at least cross over it as often as possible.  A buddy helps to get us back on the wagon.  They will cheer for us when we are doing well, comfort us when times are hard and encourage us when we want to quit.  It can be as difficult to forge good habits as it is to break bad ones. Just as Alcoholics Anonymous uses mentors to keep a drunk dry, a mentor can also keep you going.  It has been shown that it generally takes twelve weeks of persistent effort to forge a good habit.  The hardest aspect of healthy living is to take a healthy choice and repeat it again and again and again.  It would be so much easier if we could exercise just one week out of a month and reap the same rewards.  Our bodies don't respond that way.  Consistency is the key.  I came across an article that found that Olympic level swimmers were studied as to their level of physical fitness at the peak of their exercise routine and then followed after stopping.  It only took six weeks for them to get out of shape.


A little competition never hurts either. Choosing a friend who is just a little better than you can do wonders.  Set a goal together.  Sign up for a walk or a run.  Support your favorite charity.  Buy yourself a bathing suit that is two sizes too small in the winter and pay for a summer vacation.  Upcoming weddings, reunions and other occasions can serve as goals to keep you going as well.  If you make the goal with a buddy, it will keep you going even on days when you may need to exercise on your own.  Do what works for you, but having a partner will keep healthy living a priority in your life.

Move That Body

Fifteen years ago there were two states that had obesity rates over 20%. Currently all states but two have such rates.  As a society we are getting bigger and bigger and bigger.  Much of that has to do with how and what we eat (see my previous posts) but the biggest reason in my mind is that we are getting more and more sedentary.  Most of us live in neighborhoods where it is impossible to walk to the store.  Very few of us take public transportation that would require us to walk to and from a bus stop or train station.  Most jobs are now desk jobs.  Many jobs that require physical activity have now become automated.  Even farming is not as physical as it once was.  We have machines that do most of the work for us.  When I was a child, we spent most of the day outside playing.  There are currently many children that spend all of their free time in front of either a television or computer screen.  Physical education at school has been cut back in many districts.  The combination of a diet that is full of foods requiring very little metabolism with a life style that does very little to activate our metabolism, adds up to caloric excess.  Our body is only too happy to store it away as fat and the weight comes on.

I came across an astounding statistic a few years back.  There is a group of people followed by the UCLA medical center who have lost about 100 pounds a piece and have kept it off.  The researchers were eager to try and find out what characteristics these people had in common.  They could only find two.  First, they all ate breakfast.  Second, they all exercised on average one hour per day for at least five days a week.  I'll talk about the first point in a later post but it is the second one that I want to stress.  This kind of exercise requires a complete life change and priority adjustment.  Those who try to find time to exercise, don't.  Time for exercise is not found, it is made.  It is only after exercise becomes a priority that big changes occur.  Anyone who has watched, "The Biggest Loser" can attest that the winners have all learned how to work out hard.  The ones who go home and don't keep up their routine regain weight.  Those who have changed their life for good, keep it off.

I have seen patients lose 10-20 pounds through watching their diet better but the only ones that I have seen lose 40-100 pounds are the ones who made exercise a priority.  Diet alone will fail because at a certain point of calorie restriction the body will just shut off metabolism.  Exercise is needed to keep it going.  I recently saw a 93 year old patient who is doing wonderfully well.  She remains active, her mind is sharp and is a delight to be around.  I don't think that it is any coincidence that her only complaint to me that day was that the "CURVES" in her neighborhood closed down.  When I asked if she found other ways to exercise, she slapped me on the shoulder and said, "of course!"


I know that I am not proposing anything that everyone doesn't already know.  It is not a lack of knowledge that keeps us back, it is motivation.  In the weeks to come I hope to inspire you a little more by sharing my thoughts on why exercise is so important, how it keeps us healthy, ways to begin exercising and helpful hints to keep it up and keep it going.  Tune in and keep moving!