Sunday, February 7, 2010

Advanced Lipoprotein Testing and the Fallacy of "Average"

I use quite a bit to determined carb content of various foods now that I am tracking my blood sugar. I am prediabetic and like all good TYP'ers this is one more thing I am tracking to reduce my heart disease risk.

While at the site today I stumbled across a blog written by their so-called heart disease expert, Dr. Steve Parker, titled, "Advanced Lipoprotein Testing: Not Quite Ready for Prime Time" In it, Parker essentially said that advanced lipoprotein testing (ALT) such as that offered by NMR has, "never been shown that such testing offers any additional benefit over traditional risk factor assesement and management."

Now, I am certain that Dr. Parker is a very nice man who means well but for people like me and many others he is wrong - possibly dead wrong. It all has to do with applying common sense and the statistical fallacy of assuming what is good for the average person is good for all persons, more importantly, what is good for teh many is necessarily good for the one -YOU!

Dr. Parker starts with an argument that is perhaps the most powerful reason for using using ALT, "The Centers for Disease Control reports that half of all heart attacks occur in people with 'normal' cholesterol levels." If this is true (it is) one must come to the conclusion there must be some other factor besides standard lipid values (i.e. LDL, HDL, and Triglycerides) that can ferret out which person is likely to have a heart attack and which is not. Unfortunately, this is where Dr. Parker's deductive reasoning and intuition shut down. In fact, he contradicts himself based on an earlier blog he wrote praising ALT!

Here is the "killer" paragraph where Parker forgets all reasoning and statistical training he may have ever had.

"It's never been shown that such testing offers any additional benefit over traditional risk factor assesement and management. And all of the established clinical management guidelines utilize LDL cholesterol rather than LDL subfractions. Physicians know what to do with LDL cholesterol. We don't have evidence-based protocols that tell us what to do with these subfractions."

Let's dissect this statement to get to the truth.

1. It has never been shown that if I shoot myself out of a cannon wearing a parachute over Lake Michigan in February that I will die of exposure. What I do know is that a typical cannon with enough power to propel me from Wisconsin to Michigan (so I do not land over water) will kill me instantly and that even if shot from a lesser cannon with a parachute I will land far enough offshore that I will be unable to swim back in 36 degree water to safety. Sometimes one has to apply deductive reasoning. If I employ ALT and discover I have a dangerous lipoprotein subfraction such as Small LDL or Lipoprotein(a) (which I do) I am now in a better position to do something about it! I don't need a study to deduce this.

2. Just because "all of the established clinical management guidelines" use LDL and "Physicians know what to do with LDL cholesterol" does not mean I MUST be limited to antiquated methods applied by ignorant and behind-the-times physicians. I could go further and suggest Dr. Parker himself is ignorant. Many physicians DO know what to do with ALT and use it effectively to treat their patients using the most advanced technologies available.

3. The term "We don't have evidence-based protocols" is often shorthand for "I am too stupid or too lazy too engage in critical thinking so someone please tell me what to do." I do not need someone to do a study on taking common sense actions. I have high Lipoprotein (a) with an otherwise world-class lipid panel. My own physician (whom I fired) told me I was fine! If I had not done ALT I would not have discovered I had this independent risk factor for heart disease and would not be in a position to do something about it. I mean, c'mon, this is not rocket science!

4. The final and most crushing indictment of Dr. Parker's logic is the fallacy of extending information about statistical averages to an entire population. On average, a person with my traditional lipids (LDL, HDL, Triglycerides) would be in a low risk group - except I am among a few in this group who have high Lp(a). Yes, it might not be cost-effective to test EVERYONE for Lp(a). The cost of the test for everyone might not save enough lives to be cost-effective (this is the danger of national healthcare rules that rely on "evidence-based" medicine for the masses). BUT LET ME MAKE THIS CLEAR! I do not give a DAMN about the average guy - I care about ME! If I had followed "evidence-based" medicine and good old Dr. Parker's advice I might be dead. Instead I am proactively fighting my extraordinarily high Lp(a) - but only because I got the test and fought my insurance company to test my son (I won the battle and now my son knows 30 years before I did so he can take action even sooner).

So there it is. If you are a "good little soldier" willing to sacrifice your life for the "good of the many" and save a few bucks then great - more power to you. But, if you want to "pull out all the stops" to make certain you stay alive and your children live long lives then you will do everything possible to know your risks and take appropriate action.

No thanks Dr. Parker. I think I'll continue to track my lipoprotein sub-fractions using ALT. Just because most docs are stupid or lazy does not me I have to be. And, just because many people may not benefit from ALT does not mean ALL - specifically ME - won't benefit IMMENSELY. So, take your pick. Go with the flow or get aggressive. Practice Informed, Self-Directed Healthcare (ISH). Heck, it's your life. YOU decide!

Looking out for your heart health,


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