Bayesian Investor Blog

This is a tale of some differences between functional medicine and mainstream medicine in dealing with high cholesterol. Specifically, how I was treated at the California Center for Functional Medicine (CCFM) versus how I was treated at Kaiser.

Functional Medicine

I blogged about some of this in my Functional Medicine post.

My LDL cholesterol was on the high side for over a decade, and occasionally got above 200 when I briefly tried a diet that was high in saturated fat (the BulletProof diet).

Nobody has any particularly strong evidence about whether it’s harmful to get high cholesterol via eating butter and coconut oil. But with clear evidence that some high LDL levels are due to health problems, and much less evidence saying that high LDL levels are safe, I’ve been getting more concerned as my age increases and my heart attack risk therefore rises.

Before trying statins, CCFM looked for a variety of possible causes of my high cholesterol. They asked a bunch of questions that helped rule out mold. They found and fixed SIBO , Giardia, and high thallium levels. They asked enough about my diet and lifestyle to determine that I was already following the advice they would have given to handle those causes of high cholesterol.

They likely verified that I had no trouble with insulin resistance and that my mild thyroid problems were insufficient to explain the high cholesterol. Kaiser had the same information, potentially influencing their recommendations.

CCFM also looked at Apolipoprotein B, LDL-P, and CAC scores to verify that the LDL results were correctly identifying a real, although not unusual for my age, risk.

It was only after two years of finding and treating health problems that might contribute to high cholesterol that they decided to recommend that I take a low dose of statin (red yeast rice), with several other supplements such as Ubiquinol to offset statin side effects.

Ironically, I chose CCFM to see Chris Kresser, known for his fairly anti-statin stance in blog posts. Yet his hand-picked successor played a key role in convincing me to use a statin.

CCFM started me on a cautious dose of 2 capsules per day of Thorne’s Choleast-900. That reduced my Apolipoprotein B levels from 118 to 83, which is comfortably below the standard target of less than 90. I experienced a mild increase in headaches. Those subsided after a few months. I also felt some muscle weakness, enough to slow my hiking speed by at least 5%. This weakness may have partly gone away when I finished participating in the TRIIM-X trial after about 3 months on the statin. At any rate, these effects are hard for me to notice now.

Kaiser

In contrast, my Kaiser doctor looked at my age, total cholesterol, and LDL cholesterol levels, and decided those were sufficient reason to urge me to consider a statin. I’m guessing he’s fairly average for a Kaiser doctor, following a fairly standardized procedure.

He prescribed 20 mg dose of rosuvastatin (without mentioning any supplements that I should take with it).

CCFM recommended 10mg as a dose comparable to what I was getting with the red yeast rice. So I got the Kaiser doctor to prescribe a 10mg dose. I took that twice a day, following the instructions on the label. I felt a bit nervous about the ambiguity in the CCFM recommendation as to whether 10mg meant 10mg/day, or 10mg twice a day, but decided there was little risk in taking it twice a day.

I didn’t detect any obvious effects from switching to rosuvastatin. Hindsight tells me that’s because I was foolish enough to switch while recovering from COVID. I experienced some difficulty hiking uphill, making my overall hiking speed about 15% slower than I thought it should be, but I attributed that to lingering COVID effects.

I got blood test results: my Apolipoprotein B plunged to 50, and my total cholesterol dropped to 134. Dale Bredesen suggests keeping total cholesterol between 150 and 200.

There’s correlational evidence suggesting that the safest level is somewhat above 200. I presume the evidence from statin trials has convinced experts that the optimal level is lower than this, but there seems to be a fair amount of disagreement about how to translate that evidence into a good target.

Those numbers tell me that I got almost twice the statin effect that I was aiming for. I briefly switched back to red yeast rice in order to test my strength on one hike, then switched to 10mg/day of rosuvastatin. My hiking strength is almost back to normal.

I also experienced some weight gain on the higher dose, and I’m maybe losing it slowly now.

Analyzing the Differences

Does Kaiser’s approach save them money? It’s not obvious.

The short-term results are obviously cheaper for them. The CCFM testing took many hours of a nurse practitioner’s time, and a cost me a few thousand dollars.

In contrast, Kaiser’s approach has costs that show up much later. High doses of statins cause some people to develop diabetes. Muscle weakness due to higher than optimal statin doses likely contributes to a variety of expensive diseases, via reduced exercise.

My guess is that these long-term costs are small enough that Kaiser still has a slight financial incentive to be quick to prescribe a higher than optimal dose of statins at the first sign of high cholesterol. But I doubt that these financial incentives are strong or clear enough to be the main force here.

Kaiser could have done better simply by starting me on a lower dose and adjusting the dose based on blood tests. That’s maybe $100 for the testing, plus 10 to 20 minutes of a doctor’s time?

At least some of Kaiser’s tendency here seems to come from goals I respect less than them wanting to save money.

Maybe there’s some pressure from statin manufacturers? I doubt that statin manufacturers want patients to get overly high doses. But I expect their incentive to understate statin side effects generates pressures that behave a good deal like encouraging overly high doses.

Another factor might be doctors’ desire to look confident about their ability to select the best dose. I can easily imagine patients who wouldn’t notice any problems if they experienced what I experienced, and who would get annoyed if the initial dose had been too low, causing them to need an extra blood test and an extra interaction with a pharmacy.

Lastly, I wonder: is a key factor mainstream medicine’s focus on implementing whatever rules are backed by the most rigorous evidence?

We have a fair amount of evidence that our medical system makes mistakes like this. E.g. the odd insistence that second doses of COVID vaccines be given three weeks after the first, in spite of strong suspicions that prioritizing first doses when supplies were scarce would save lives.

Statin clinical trials are unlikely to find the minimum dose necessary for good results. As long as side effects are mild, drug companies are likely rewarded for erring on the side of high doses, since that’s more likely to produce evidence that the drug is effective.

Clinical trials tend to succeed based on lowering LDL levels (in which case stronger effects are assumed to be good, except where side effects are detected), or cardiovascular mortality (i.e. ignoring the possible trade-offs between cardiovascular deaths and deaths from other causes; the correlational evidence suggests that low cholesterol contributes to cancer).

These factors add up to clinical trial results that guide doctors to prescribe doses that err on the high side. And since there’s no funding source that is willing to generate more rigorous trials that would improve the dosing guidelines, that’s what a risk-averse doctor will follow.

Functional medicine providers are more willing to look at all the evidence, and do a little bit of extra reasoning.

P.S. My magnesium blood levels have been at the low end of normal for as long as I’ve been measuring them. CCFM suggested a bunch of tests that determined that I wasn’t absorbing magnesium very well, in spite of getting adequate amounts in my diet, and taking a bit more than the maximum recommended dose of supplements.

They gave me advice for better absorption, most importantly to cut down on the phytic acid that I get from seeds. I did that by replacing many of the nuts I eat with sprouted versions of those nuts. My magnesium levels are more normal now. I think it has improved my sleep, and lowered my heart rate (from the mid 50s to the upper 40s – that’s low enough that it’s hard to say whether the lower rate is better).

Added 2023-06-27: I got some feedback suggesting that Kaiser did a better job because the CCFM treatments were worthless.

I’m adding this to clarify that my primary purpose in seeking those treatments was to deal with fatigue. I have more energy now than before those treatments. My energy expenditure on hikes has increased from around 1400 to 1800 calories per week. That exercise is now limited mainly by available time, whereas before seeing CCFM it was limited more by my available energy. I’m guessing that the CCFM treatments explain at least half of that change.

I considered high cholesterol to be a minor issue that deserved lower priority than fatigue.