It can't be easy to be president. Your zone of privacy is so very small — and we want to know everything. Given that context, it seems obnoxious to stand in judgment of the president's having recently undergone a physical exam [PDF]. Or the nature in which the leader of the free world had his colon scanned for tumors. Or to chew over his blood lipid profile the way one would the latest Zogby polling data. 

But the president has embraced best practices as one of his goals for the reform of health care — frequently referencing Mayo Clinic as a shining example, in fact. That is nothing if not worthy, given the enormous waste generated within American health care because of screenings and treatments that hold cultural favor and are masterfully marketed and that must surely hold totemic status within related medical specialties, but which, alas, are not supported by evidence. Too bad his personal physicians appear to have missed the troubling disconnect between their practices over the weekend and the president's policy proposals.

Start with the annual physical itself. You could argue that an annual physical of the nation's chief executive is as much of a political gesture as it is medical, as it inspires confidence in the physical well being of our head of state, which is no small accomplishment. So this is perhaps the least troubling static generated by the news that the president is given a once-over every year. But the fact remains that people pay attention to the sight of the president having an annual checkup; it is an implicit endorsement of the process. 

And yet. Unfortunately, the United States Preventive Services Task Force, the scientific body that garnered so much attention last year for delivering the unwelcome news that annual mammograms for women in their 40s should be an individual decision as opposed to an automatic requirement, has maintained since 1996 that annual physical exams do not keep people healthier.

"The 10-member Task Force," states what is surely now a yellowing press release, "rejected the traditional emphasis on a standardized annual physical examination as an effective tool for improving the health of patients. Instead, they emphasized that the content and the frequency of the periodic health exam need to be tailored to the age, health risks and preferences of each patient."

The bad and the good
The history of annual physicals is a perfect amalgamation of the bad and the good in how medicine is practiced today. Bad: They were created for nonmedical (insurance) purposes. Good: They encourage people to maintain a regular relationship with a primary-care physician. But there remains little empirical justification for compulsory sessions of having a person in a lab coat listen to your breath, peer into your ear, or deliver talismanic poundings upon your knee with an expensive rectangular hammer. That is all surely placebo —  all fine and well if doctors are bored and care is cheap. But as we all well know, that's hardly the deal anymore. 

The checkup wasn't all a waste of taxpayer dollars. The president was encouraged — and, more important, at the knee of a medical professional in whom he has placed his trust — to knock it off with the smoking. (Apparently he is an "occasional" smoker.) There is surely no medical intervention with more potential for diminishing future illness than that simple conversation. He was also reminded to continue to think of his health, to keep up with exercise, and watch his portions. These are all well and good. 

But over the weekend Obama was given a virtual colonoscopy, a procedure that as of last February is no longer paid for by Medicare. He was also chided for an LDL above 130 (his was 138), a marker that would have been viewed as entirely reasonable prior to the creation of blockbuster lipid controlling medications and the tightening of officially acceptable blood-level recommendations that mysteriously followed. These two interventions strike at the heart of the sort of problems driving up the cost of medicine in our country, and which health-care reform will have to address if we are to salvage a system of care that is both scientifically defensible and financially solvent. Tomorrow: the problem with "fly-through" colon exams. Today: the perplexing demonization of LDL. 

If you read Wednesday's Second Opinion post, you are familiar with the fact that the demonizing of LDL cholesterol is simplistic in the extreme. LDL cholesterol is actually a disparate array of particles, the big ones benign, the small ones bad, and thus not an especially good predictor of heart disease, given that it's the big ones that drive up the count the most. It is, however, controllable with medications, some of the biggest-selling medications of all time, in fact. 

A battle of numbers
So it isn't surprising that the LDL message has increasingly become a battle of numbers, rather than foods, and the numbers have been driven lower and lower.  Just 10 years ago, an LDL below 160 (milligrams per deciliter of blood) was considered acceptable for people such as the president, people without heart disease. After the National Cholesterol Education Panel’s updates in 2001, the target LDL for healthy people with multiple risk factors dropped to 130, and in 2004, another round of NCEP updates pushed the LDL goal from 100 to 70 for those with heart disease, from 130 to 100 for those with multiple risk factors, and told everyone else to keep our LDL below 130. Which iswhy Obama is being encouraged to lower his LDL through diet.

The problem is, if you do not reduce your LDL through diet, you are often then directed toward statins, and as a result of this process, the segment of the country in need of lowering LDL by way of drugs has become a great-cross section of society. Half of all Americans over 35 — nearly 100 million people — have an LDL like president's. of 130 or more. Treating them all with drugs would cost the system $300 billion annually, according to  Douglas Bremner MD, a researcher and physician at Emory University and author of "Before You Take That Pill."

And it wouldn't necessarily make us any healthier. Research suggests that statins are effective in those with heart disease, but vastly overrated for everyone else. A landmark study known as WOSCOPS tested the statin Pravachol; the results were  published in the New England Journal of Medicine in 1995. Its subjects, 6,600 high risk men in Western Scotland, represented the quintessential candidate for heart disease: Half of them were smokers and all were guys with supposedly-perilous LDL levels averaging 191.

“The relative benefit was a 30 percent reduction in heart attacks,” say Jon Abramson, MD, author of "Overdosed America." “But the absolute benefit was that you had to treat 50 high-risk men for five years to prevent one coronary event.” 

An Air Force study of statins known as AFCAPS/TexCAPS and which was published in JAMA in 1998 studied 6,600 moderately at-risk men (LDL averaging 150). It also found the drugs were capable of improving your risk by a third. But that only meant they prevented heart disease, over the course of five years, in two out every 50 people who had taken them. 

Another inconsistency
The current trend of using statins to push LDL lower than ever — a task often requiring multiple pills from multiple drug makers — has uncovered another inconsistency to the LDL hypothesis. If reducing LDL is good, reducing LDL even lower should be better right?

Wrong. Even in heart patients, the population supposedly helped by aggressive chemically induced LDL reductions, the evidence does not support the notion that the human body recognizes a dose-response relationship to the lowering of LDL, and the risk of having a heart attack. According to an influential review written by three Veterans Administration researchers with no ties to the drug industry, and which was published in the Annals of Internal Medicine in 2006, when it comes to pushing LDL below 130 in patients with or without heart disease — such as the president — there is no evidence “the degree to which LDL cholesterol responds to a statin independently predicts the degree of cardiovascular risk reduction.”

Even dietary interventions have muddled the case for the dangers of LDL. The Mediterranean Diet, for instance, is routinely touted as proof that replacing saturated fat and processed food with healthy fats and fresh foods prevents heart disease. But thanks to a large study of the diet conducted in France known as the Lyon Heart Trial, we know the diet’s effect on HDL and LDL cholesterol has little to do with it. 

“At the end of the study,” says Abramson “both groups’ LDL cholesterol levels were the same. The benefits weren’t mediated through lowering of cholesterol.”

Freelancer Paul Scott of Rochester writes frequently about health and fitness for various media. Susan Perry will return March 8.