By Anne V. PAC · Comments (0)

Knee pain is perhaps the most commonly expressed joint pain in the over 40 population that patients discuss with me in the clinic. What to do about the problem can be challenging for people.

Osteoarthritis is a wearing down of the cartilage in the knee joint, usually from overactivity over a life time. It is often aggravated by prior sports injuries when young, as well as being overweight. It is said that more than 27 million people in the US have osteoarthritis, with the knee being the most prominent joint affected.

Many people have enough destruction of the knee joint that a knee replacement is the only choice left due to extreme pain and immobility.

Most people however, are best treated with less major therapies, including physical therapy and arthroscopic surgery. Arthroscopic surgery is performed by an orthopedic specialist and involves inserting a tiny tube into the knee joint. Through this fiberoptic tube, the different components of the knee can be seen and sometimes repaired.

While many people have arthroscopic surgery for their knee problems, there have been several trials suggesting this does not really give a person much benefit for treatment of OA of the knees. Physical therapy has been shown to relieve the pain of OA, but an optimal treatment regimen has yet to be standardized.

Researchers recently collated data from 48 different studies in which PT was compared to other non-exercise interventions for OA of the knees. It was found that the most beneficial treatment included a physical therapy program consisting of aerobic and resistance exercise with specific target at quadriceps (thigh) strengthening, supervised 3 times weekly for at least 4 weeks.

What does this mean for you if you have OA of the knee?

The idea of exercise to improve your already aching and painful knee, may seem like something you do not want to do. Perhaps you think surgery is the easier route, but now there is data to indicate that this is not going to be beneficial for you.

While going to physical therapy 3 times weekly may present some obstacles for you, such as time and money; there are often ways to deal with these issues.

The flip side to not doing PT is the cost of not exercising because of pain, with the resulting impact on your health. Additionally, most of us can skip a few extra things we do in the course of a week, and save that money for the PT session. Most PT offices open early and stay open late to accomodate people with rigid work schedules.

Ask your provider about physical therapy if you have OA of the knee, before going the route of surgery. Most reputable orthopedic surgeons will suggest this first, before doing arthroscopic surgery. Working hard to improve your knees will pay off well in the long run!

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March was the designated month for colon cancer awareness; and what could be more timely than news of a new method for screening awaiting approval by the FDA. The American Cancer Society states that over 140,000 new diagnosis of colon cancer occurred in 2011 alone, with up to 49,000 deaths. Similar statistics noted for 2013 and are expected for 2014.

If you are over 50, or have a family history of colon cancer; your medical provider has most likely spoken with you regarding the importance of a colonoscopy. This is an important conversation given the above statistics.

In the event you have studiously avoided any talk with friends or family regarding this often dreaded procedure; I will take a moment to review it for you! Polyps are the usual precursors to colon cancer, and when discovered early and removed; can prevent cancer from occurring. Colonoscopy is the best way for this to happen, often called “the gold standard” for colon cancer detection.

Colonoscopy is a procedure where a long tube with a fiberoptic lens at the end in inserted moved upwards through your large bowel to the end, where the appendix is or was. The specialist is looking at the walls of your large bowel, searching for abnormalities. If any are found, the area can be biopsied or a polyp removed through tools inserted through a channel of the endoscope.

Sounds lovely, right! Thankfully, you are usually asleep for this procedure. As you can imagine however, your bowel walls must be clean so that abnormalities are not hidden by waste-that would be stool. The colonoscopy is actually the easier part, it is the cleaning process that can be more challenging.

Having worked for over 10 years for the division of Gastroenterology at Duke Medical Center, I am well aware of the benefits of colonoscopy. I observed and assisted with hundreds of colonoscopies, and I am a major advocate for this procedure. In the hands of an experienced colonoscopist, it is extremely safe.

In my role as a medical provider, I have instructed countless patients regarding the ease at which this procedure is often done. What I did not realize, despite many conversations with people; is how loathsome the clean out can be! When I personally experienced this, I understood clearly, the reluctance with which many people approach this procedure!

This new test is potentially an exciting screening tool for low risk people to use, possibly in place of colonoscopy. It detects the presence of DNA, or genetic code, shed by polyps and cancers into the stool. It is potentially far more accurate than stool guiaic testing, which only tests for the presence of blood in the stool.

Co-author for this study, Dr. Steven Itzkowitz, also director to the fellowship training program at The Icbahn Medical School at Mount Sinai; excitedly states what a breakthrough this test is. “That kind of result is really unprecedented for a non-invasive stool based screening” speaking of the 90% accuracy the study found with test subjects.

Better yet, this test is done in the privacy of your home! Before you get too excited, this test is not yet available for wide spread use. So if you have been holding out hope for a more comfortable test, one is on the way!

Do not hold out for this test though, if you are experiencing blood in stool, a persistent change in the size or shape of stool, abdominal,pelvic or rectal pain. These may all be signs of colon cancer and need immediate evaluation, especially if you have a family history of colon or rectal cancer.

As a medical provider, I recommend routine screening and feel it is easily tolerated. However as a person who now undergoes these invasive routine screens, I fully understand the reluctance!

Hopefully you will get a 10 year reprieve as I did, if there are no polyps!


For years and even decades, research and guidelines on prevention and treatment for various diseases and conditions have been studied almost exclusively in men, then applied to women. This environment of medical research is now changing and the new stroke guidelines issued by the American Heart Assoc. and American Stroke Assoc. reflect this.

Stroke is now the 3rd leading cause for death in women, with over 55,000 more deaths in women than in men occurring annually. The new guidelines are intended to reduce this incidence and hopefully help prevent more strokes in women by increasing awareness of symptoms  and risk factors for both patient and medical providers.

First, lets review what a stroke is. A stroke occurs when the blood supply to a portion of the brain is interrupted either by a clot, or by bleeding. These types of stroke are called embolic or thrombotic, and hemorrhagic. A stroke caused by a blood clot occurs when a clot lodges in a blood vessel within the brain, having traveled there or forming at the site.  A hemorrhagic stroke occurs when a blood vessel ruptures and bleeds into the brain space, either from a weakening in the blood vessel wall or from trauma.

Both situations cause the brain that is supplied by the blood vessel that is now damaged, to die. A stroke can give a variety of symptoms, depending on what part of the brain the damage occurs in. Some of the symptoms of stroke can include:

  • loss of  balance, or use of arms and legs, weakness
  • confusion
  • visual loss or change, trouble speaking or finding the words you want
  • numbness or tingling of face, arms or legs
  • facial drooping, slurring of words, trouble eating
  • a sudden severe headache

It is important to get to an ER immediately if you feel you or someone you know may be having a stroke, as immediate help can prevent the long term impairment from a stroke and prevent death of brain tissue.

The new guidelines are now recognizing conditions that are either unique to women or occur more frequently in women. These risk factors include:

  • Use of hormone replacement therapy and oral contraceptives
  • presence of migraine with aura
  • history of pre eclampsia in a prior pregnancy (high blood pressure during pregnancy)
  • history of central retinal vein occlusion (blood clot to the vein supplying the nerve of the eye)
  • atrial fibrillation which occurs more commonly in women than in men

Other risk factors applicable to both men and women include:

  • hypertension
  • diabetes
  • high cholesterol
  • nicotine use
  • inactivity
  • obesity
  • a blood clotting disorder
  • having a family  history of stroke
  • having high blood pressure, diabetes and high cholesterol AND smoking is very high risk.
  • excessive alcohol use and use of some recreational drugs

Discussing your risk factors with your medical provider will help guide any specific treatment or lifestyle changes that are most important for you. A DASH diet low in sodium has been found in studies to reduce the risk of stroke.

It is key that you stop smoking especially if you are taking a hormone preparation at any age. Additionally, smoking cessation will reduce your risk of stroke substantially,  if you develop diabetes or hypertension as well as high cholesterol.

You do have the power to reduce your risk of stroke by:

  • staying active
  • controlling weight
  • controlling blood pressure and glucose levels, as well as cholesterol
  • using alcohol in moderation, no nicotine!
  • You may want to discuss with your provider whether a low dose aspirin is appropriate for you.

Most importantly, knowing the signs and symptoms of a stroke and getting to qualified help such as a major medical center; can save your life.

For additional information on stroke, visit the AMA/ASA website!


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New Culprit in Memory Loss-Inflammation?

By Anne V. PAC · Comments Comments Off

Everyone becomes forgetful at some point in their lives, but when it occurs to someone already dealing with the symptoms of aging; dementia becomes the feared ailment.

Forgetfulness is one thing, dementia is a whole other beast. While there are some things you can do to avoid dementia, some of it is predetermined by genetics. Preserving your memory is as much as preserving your health.

It is all about inflammation. What we do and don’t do to our bodies and to our health, causes inflammation. Inflammation causes harm to our cells; it is unavoidable but definitely can be minimized.

Memory loss in the form of mild forgetfulness is a normal consequence of aging, as we do lose brain cells and volume over time. It is also a function of too much brain multitasking, so a thought or intention is not properly imprinted. In other words, doing too much at one time can crowd the brain circuits and make it difficult to remember, usually the lesser important thoughts.

There are also some medical conditions that can make memory harder to preserve. Think of your brain as a computer. If it does not get proper energy, it cannot work. It also needs a break once in a while in the form of sleep and relaxation.

Your brain needs oxygen, blood flow and glucose to work. If you are not breathing well, or you have a heart condition; your brain may not get what it needs. Usually there is enough glucose, so this is rarely an issue. It also needs the nutrients that nourish the nerves such as the B vitamins, fatty acids, even cholesterol! Thyroid hormone also is the metabolic booster for the body. If this is not in adequate supply, the engine can’t work as effectively.

Finally, there are our sex hormones that help with brain function. Both estrogen and testosterone help with brain function and memory. As these hormones decrease with aging, you may notice a decline in your memory abilities.

Inflammation is also felt to be a culprit in decreasing memory. Inflammation can come from a wide variety of sources including infections, arthritis, smoking, diabetes, hypertension to name a few. Excessive alcohol use is also detrimental mostly through poor nutrition.

So it would stand to reason that improving your memory, or at least keeping it from worsening; would include proper healthy treatment of the medical conditions that cause inflammation. In addition, treating conditions that improve blood flow to the brain as well as oxygenation are key.

Exercise will improve your heart and your lungs, helping to deliver an abundant supply of oxygen and nutrients to your brain.

A healthy, well rounded diet with foods rich in Omega 3 fatty acids, and the B vitamins will support nerve health. Limiting alcohol which can damage the nerves is equally as important.

Avoiding poor sleep habits will help you to get a good nights sleep, allowing your brain to repair itself.

Managing your blood pressure and glucose metabolism with a healthy lifestyle and  medication if needed, will help keep inflammation of your system down.

When do you worry? When your memory issues are impacting your life.

You don’t have to wait until you forget what city you are in to have your memory be a problem. Decreased work performance can be an indicator of a problem, or repeatedly forgetting names of people in social situations. Suddenly no being able to complete a set of chores that normally you complete in a day. These can all be indicators of a health problem.

See your medical provider to get some labs done. You will want to get your thyroid level checked, may be Vitamin B12 especially if you are a vegetarian. Vitamin D level may also be useful. You may need to review any medications you are on, statin therapy for cholesterol can be a big culprit in affecting memory.

Lastly, hormone therapy may be indicated. For women at low risk for heart problems and breast cancer, hormone replacement therapy is very useful at helping to restore memory. For men with a low testosterone, replacement with this hormone can also help to restore memory and erase the fogginess that low testosterone can cause.

While inflammation is an unavoidable consequence of aging, there is a lot we can do to minimize the inflammation in our body. Living as healthy as you can helps your brain as well as the rest of your system.

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How can something so benign as body and face lotion, or shampoo cause serious harm?

Parabens. What?

Parabens are chemical preservatives added to lotions, cosmetic and shampoos to guard against bacterial growth and contamination. Sounds like a good additive, right? The problem is that these chemicals are also in a class called endocrine disruptors, and pathologists have discovered them in some breast cancer tissue.

An endocrine disruptor is a chemical, either man made or naturally occurring; that mimics a certain hormone. These chemicals can cause an inappropriate response by its target, or it can latch to a receptor making the actual hormone ineffectual.

Simply put, these are chemicals that interfere with the normal hormonal response of our body. Examples include compounds found in soy and certain vegetables that can interfere with the thyroid hormone. A diet high in these compounds can fool the body regarding the amount of thyroid hormone floating around the blood stream, causing the thyroid to become over or under active.

These parabens in lotions and toothpaste are weak estrogen mimics, causing increased cell growth in estrogen sensitive tissue, like our breasts. Another examples of an endocrine disruptor the chemical BPA, which is used to line cans and in plastic bottles. The amount of this chemical capable of leaching into the product it contains, is unknown. Increased amounts of this has raised concerns regarding behavioral and developmental issues for children as well as a developing fetus.

Whether you are menopausal or not, it is wise to check your beauty products for parabens, and perhaps chose a product without this additive. Additionally, switch from plastic bottles to glass or metal water bottles that can be refilled. This is better for the environment also! Limiting canned products will also reduce the sodium you consume which will help control blood pressure.

The EPA is more concerned about the amount of exposure we are all getting rather than this exposure coming from one place. Now that DDT has been eliminated from use, there is rarely one big exposure. It is more the slow, small, day to day use of these products that contain endocrine disruptors that may be harmful.

It seems that a few simple small changes may be worth while for health AND environmental reasons!

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Safety of Fibroid Surgery Questioned

By Anne V. PAC · Comments Comments Off

Every year, many women undergo treatment of their uterine fibroids. Many of them are menopausal, as this is the time fibroids can cause problems.

Up to 20% of women have fibroids at some time of their lives. These usually benign growths often occur in pregnancy and shrink after the uterus returns to its normal size. For some women however, they can continue to grow and become quite large. If there is rapid growth, concerns that a sarcoma are raised. A sarcoma is a rare cancer of the muscle cells within the uterine wall.

If you have one or more fibroids, you may experience heavier than normal menses as you approach menopause. This can be a nuisance, but it can also cause anemia. This anemia can impact your health with lack of energy as well as place a strain on your heart if the anemia is significant enough.

There is a wide range of treatments for fibroids, with the final treatment being a hysterectomy. This is usually the coarse of treatment if the anemia is persistent enough, and other treatments have not been successful at lessening the heaviness of the menses.

Many women are happy to have a hysterectomy after months or years of heavy menses and anemia. In the past, a hysterectomy was done exactly has you may be picturing it. An incision in the abdomen, removal and then stitches. A 6 week recovery follows at which you may not be able to work.

A new procedure has been utilized over the past several years that significantly reduces recovery time as it is not as invasive. It is called morcellation. This surgery allows the surgeon to remove the uterus and fibroids through a small incision near the belly button! This has been a tremendous advancement in hysterectomy for women, and the decreased recovery time has helped make the difficult decision of hysterectomy easier.

Your are probably wondering how this enlarge uteruse, sometimes the size of a football; can fit through a tiny opening.

The morcellation procedure involves cutting the removed parts into small peices and removing them as such. A spinning blade is sometimes used, and this is the potential cause of a serious problem.

If your fibroid has a small focus of cancer cells-a sarcoma, within it; this spinning blade can spread this cancer onto other organs within your abdomen. It is very rare that this happens, but it has.

A less lethal but equally serious complication can arise when benign fibroid tissue latches on the other organs, microscopically, and causes problems months and years post operatively.

How can you use this information? If you have fibroids and are considering a hysterectomy, talk to your gynecologist about your concerns regarding this procedure. Ask your surgeon if there have been any patients to experience this adverse outcome and what he or she can do the minimize the chance of post surgical problems. Make sure your surgeon is experienced and qualified to do a morcellation if this is the route you choose.

As with any surgery, there are risks and benefits and it is up to you and your surgeon the discuss and weigh these. This procedure has benefitted many women without any adverse outcomes, and it is still a good procedure in experienced hands.

Categories : Menopause Symptoms
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Escape the Code!

By Anne V. PAC · Comments (10)

Think it is impossible to escape your genetics? Are you destined and resigned to end up looking just like one of your parents, or Aunt Sally or Uncle Benny?

An interesting study looking at just that was recently released to the news. This research is centered on the genetic risk of breast cancer, and possible explanations for healthy members within clusters of families with strong histories of cancer.

Having a family history of  the BRCA1 and BRCA 2 gene mutation significantly increases a woman’s risk for developing breast cancer. This specific gene mutation is only responsible for some of the incidences of breast cancer. Researchers have been looking at other factors explaining this cluster of familial cancers. This has led to the exciting research regarding epigenetics!

It just may be possible to some degree, to escape your genetic code!

Genetic code is in all of our cells and it is the blueprint from which our cells, organs and bodies will work. Epigenetics is the machinery that actually turns on or turns off this blueprint. It can, and will determine what happens within your cells and your body.

Researchers and scientists are talking about something called methylation. This methylation process can prevent cancer from growing in certain situations, or help it to grow in other situations. It depends on the where in the body it is working, how much methylation is happening, and what is actually making it work.

It turns out that a decrease in the healthy methylation process may be responsible for aging. This decrease of healthy methylation can lead to hyper or hypomethlyation, which can then promote growth of cancer cells. This type of decrease is considered a somewhat natural process associated with normal aging. It then seems that certain life style habits can cause the wrong type of over methylation, leading to problems with glucose metabolism and also to cancer.

Getting back to the study I mentioned above. Unaffected women from high risk families with breast cancer were found to have different methylated blood cells when compared to affected family members. Researchers are not sure yet what this means, but it suggests a changed expression in the genetic code.

Another recent study regarding the incidence of breast cancer in British women revealed another surprising difference. White women residing in the UK were noted to have a higher incidence of breast cancer compared to South Asian women and black women, also residing in the UK. This difference was attributed to a higher consumption of alcohol and decreased amount of breast feeding by white women as compared to women of other ethnicity. When these habits were removed from the equation, the rate of breast cancer was equal throughout the different groups of women.

Diet has been shown to affect the expression of cells, specifically a diet low in folic acid is associated with gastrointestinal malignancies. Use of opiates, nicotine, and over use of alcohol have all shown  changes in cells leading to cancer through abnormal cell repair and DNA expression. This is the route believed to allow cancer cells to grow. Exercise has shown to elevated protective chemicals within our bodies which help prevent this abnormal methylation process.

Why are we talking about this? Researchers are beginning to identify the different affects healthy and unhealthy habits have on the incidence of disease. This empowers us to make decisions that allow us to take more control of our health and hopefully, longevity.

You may not be destined to develop diabetes or heart disease as you age, you may not be at risk for cancers. It may be possible to escape your genetic code by choosing certain habits that are beneficial to your epigenetics.

Think back on all the good advise from our mothers or fathers regarding healthy habits. Teachings such as eat your vegetables, get enough sleep, no drinking to excess or smoking at all; they were talking epigenetics!

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Making Your Resolutions Stick

By Anne V. PAC · Comments Comments Off

If you are someone who has great resolve with making changes, then fade with time; follow these suggestions that behavioral science researchers talk about!

1. Make a written contract with yourself regarding your intention and concrete plan regarding the change you want to make. This helps with memory and reduces forgetting!

2.Put something on the line, something important enough to you to motivate your committment. This will make it harder for you to back out of your plans. It can be a vacation you will reward yourself with, or it can be money.

3. Group your activities together. Meaning, allow yourself a pleasurable activity while you are engaging in your behavorial change activity. For instance, allow yourself to listen to music while you walk or run. This will encourage you to look forward to the habit change.

4. Enlist social support and help with the change. Get an exercise buddy if you are trying to start a new program. Get a mentor if you are trying to quit smoking, or give up unhealthy food. This will make you accountable to someone else, and encourage you to be true to your intentions.

Making changes can be hard, but getting your mind behind the change and creating new habits will keep you on track with the changes you want to make.

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If you are one of the 10% of people taking omega 3 fish oil capsules, you probably feel you are doing something positive to your health. After all, news information abounds with the health benefits of Omega 3 fish oil; and capsules have become the third most commonly taken supplement following multivitamins and calcium.

But are they really beneficial? More importantly, are they equal in health value to omega 3 rich containing foods?

Over the last 5 or more years, there have been numerous benefits of the Omega 3 fatty acids in fish discussed in the medical literature. They have been shown to have significant benefits to cardiovascular health, although the cause for this benefit is not clear.

Additional benefits attributed to omega 3 oils found in fish include:

  • possible improvement or prevention of dementia
  • reduction of inflammation
  • improvement in arthritis through inflammation reduction
  • thinning of blood can help prevent blood clots
  • prevention of heart arrhythmias, reduction of stroke, increased flexibility of blood vessels
  • reduction of risk of macular degeneration
  • can improve dry skin, hair and nails
  • may help with treatment of depression

Studies evaluating the health benefits of omega 3s have been conducted primarily looking at omega 3 fatty acids in foods such as fatty fish, flax seeds and walnuts. There have been some comparative studies evaluating whether omega 3 fish oil capsules are equivalent to  a diet high in omega 3s in reducing the risk of stroke and heart attack. It had generally been felt that these too sources of omega 3 are equal of benefit.

Several recent studies have called this healthy benefit of capsules into question. A recent Italian study did not show any improved benefit for participant taking omega 3 fish oil capsules in preventing heart attack and stroke compared to an equal group taking no supplements at all.

Should you take omega 3 fish oil capsules? There is no clear answer to this question yet. The current evidence would suggest that eating 2-3 serving weekly of fatty fish would be the most beneficial source of omega 3s. If you do not like fish, or if you are vegetarian; supplements may be a good option. The studies thus far have been small, and they have not looked at all the other healthy benefits of omega 3 supplements.

The important thing is to get a good brand that is purified. You should discuss dose with your provider as fish oil capsules can thin the blood and may not be right for you with certain medications. Generally however, 1 gm a day of purified Omega-3 fish oil capsules is the recommended dose. Higher doses are recommended for high triglycerides.

Omega 3 fish oil capsules can be a good addition to your supplements as you age in that it helps many body systems. The jury is still out however, as to whether they prevent certain cardiovascular disease. For this reason, they probably should not be substituted for a stronger medication to treat a significant heart condition!


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The Quandry of Cholesterol Medication

By Anne V. PAC · Comments Comments Off

The question of the benefit of cholesterol medication is a much talked about topic of discussion these days in health and medicine. There are two camps; those who follow the guidelines produced by experts after analysis of medical studies, and those who believe that these guidelines are polluted by the influence of pharmaceutical companies. There are traditional medical providers in both groups, but most nontraditional practitioners would opt for the second group.

You may wonder which group your medical provider belongs to. Many patients believe that physicians who prescribe these medications get a kick back from the drug companies for prescribing these medications.They are therefor leery of the actual need or benefit for themselves.

While it is true that many prescriptions for statin drugs, the class of drugs that can lower cholesterol, are written yearly; this is not because of a financial incentive.

Why so many statin drugs prescribed?

In 3 short words: the American diet! As a medical provider who regularly checks the cholesterol levels of patients, I am disheartened on how many abnormal lab results I see. I am convinced the number one reason for these elevations is the food choices people make. It is true that genetics play a role, but what you put in your mouth plays more of a role.

Not everyone with high cholesterol will have illness from this elevation. Medical research is trying to figure out what the differences are between people who develop heart disease from their elevated cholesterol and those that do not. Researcher do not have all the answers, and sometimes they argue amongst themselves as see with the newest guidelines and risk calculator tool!

What we do know is that a diet high in sugar and fatty meats, as well as highly processed foods, raises cholesterol. A diet low in these items and high in fruits and vegetables tends not to raise the cholesterol. Some people are more genetically predisposed to have high cholesterol. A bad diet can make this happen, whereas a more vegetarian or Mediterranean diet, will help to prevent cholesterol elevations.

We all need some degree of cholesterol, as this is used in cell repair and nerve health. Too much however, collects along the walls of the arteries as it has to go somewhere. Some cholesterol can be broken down and taken out of the body, but not all. Exercise can help with this breakdown, thereby lowering the cholesterol.

It is strongly felt and supported in medical research that cholesterol plaques in the artery walls are capable of growing until they rupture, causing a heart attack. This happens in many people but not all, and unfortunately we do not have the capability of predicting with accuracy who will have this happen. In some people it is a given, others it is more elusive a risk. So for now, medical providers have to go by the odds with their suggestion and recommendations regarding statin therapy.

But you do have some choices. You can decide to ignore the advise to take statins, and take a chance that you will not have a cardiac event; play the odds in other words. If you are wrong however, you may lose big time.

You can chose to address your lifestyle instead of take medication, or do both. Changing your diet profoundly and for good, as well as exercising may make the need for statins a moot point. For me, as a patient and medical provider, is the approach I recommend regardless of whether statin therapy is also used. A healthy diet can do so much more than just lower cholesterol.

So for now, if your medical provider is recommending statin therapy; it is not so they can get a kick back from the drug company. Most likely your cholesterol level is high enough and your risk factors numerous enough that you are at risk for a cardiac event. And now you have a choice: take the medicine, change your diet, do both or do neither and take your chances.

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