(The Boston Globe) -- So, go ahead. Gulp that pill of Lipitor or Pravachol or some other cholesterol-busting medicine. And then wash it down with a fat burger, swaddled in cheese, crowned with a dollop of mayonnaise. While you're at it, supersize the fries and the soft drink. After all, your cholesterol's under control, so surely your heart must be healthy, right?

Well, not quite.

In a society addicted to quick fixes, easy answers, and silver bullets, statin drugs -- which have revolutionized the regulation of cholesterol -- seem like salvation in a pill.

But a healthy heart does not live by a low cholesterol score alone.

Nor is a reading of 100 or 80 or even 60 for LDL cholesterol, the bad actor, license to tuck into a pint of rocky-road ice cream or a slab of steak smothered in butter.

Instead, heart specialists insist, patients leave themselves vulnerable to cardiovascular disease if they remain obese, diabetic, and hypertensive -- even if they manage to rein in their bad cholesterol. It is a reflection of the growing awareness that heart disease is a stunningly complex condition that cannot be blamed on any single underlying factor or cured by firing at any single target.

While statins reduce patients' cholesterol, they cannot prevent them from being overweight or diabetic, said Dr. David Waters, chief of cardiology at San Francisco General Hospital and a specialist in researching the cholesterol-lowering benefits of drugs. "The thing to do for those people is to teach them eating habits that will keep them from getting fat and diabetic." You can teach, but will anybody listen?

Accumulating evidence leaves researchers feeling pretty gloomy about the answer to that question. At the same moment when the power of statins is being hailed, the failure of diets and exercise to cinch America's expanding waistline has driven some specialists to despair.

"People want a magic bullet," said Michael Liebman, chief scientific officer of Windber Research Institute, a private Pennsylvania lab devoted to women's health issues, including cardiovascular fitness.

"They don't want to do the hard work of changing their meals or exercising. They'd rather take a pill." That explains, in part, why Lipitor is prescribed more than any other drug in the United States. And it costs plenty. A year's worth of low-dose statins runs about $900, maybe $1,000. That's only going to increase if doctors start following the recommendations of a landmark study released last week showing that the bigger the doses, the better the outcome.

Spending on statins will skyrocket further if they become the drug of choice for patients with even slightly elevated LDL -- or patients who want the drugs as a hedge against future health problems. There's no recommendation at the moment that most adults take the pills, but some specialists talk not so facetiously about placing statins in the drinking water, just like fluoride.

Still, that could come with a very real cost, and not just financially. Statins, like most drugs, have risks. For patients with dangerously high LDL and other cardiovascular complications, the slight risk of side effects from statins -- including muscle pain and liver damage -- seems like a risk worth absorbing.

"But the risk-benefit calculation changes as you dip deeper into the population, into those people who are less at risk of heart disease," said Michael F. Jacobson, executive director of the Center for Science in the Public Interest, a Washington-based nonprofit organization devoted to nutrition issues. "People will get less of a benefit. But the risk will remain the same. You're exposing them to a risk with less of a benefit." Which brings us back to exercise and diet.

To be sure, there are those patients who exercise relentlessly and count each calorie religiously, and yet their LDL cholesterol barely budges.

In their case, genetics dealt a lousy hand.

"I have lots of patients who are little skinny guys who exercise a lot, but genetically they just have high cholesterol and they need a statin to reduce it," Waters said. "If you have bad genes, there's not a lot you can do about your cholesterol in terms of exercise and diet." Then there's everybody else -- the people who could nudge their LDL toward acceptability by eating a little less, exercising a little more.

Even the most ardent advocates of lifestyle modification acknowledge that dietary changes don't typically result in dramatic changes in LDL. Still, a small reduction can matter a lot to patients whose LDL waffles between OK and marginally worrisome, with a reduction from, say, 110 to 90 proving meaningful.

"There's an incredible reliance on the statins and a tendency to use them as a crutch when a lot of people could achieve the same benefits using exercise and diet," said Dr. Eric Topol, chairman of the Department of Cardiovascular Medicine at the Cleveland Clinic. "The statin has actually given people more of a sense of being Teflon-coated from having a heart attack and stroke and dying prematurely. Many patients that I see, they think they're protected and they can continue a very poor lifestyle and that's an unfortunate thing." Part of the problem, Topol lamented, is that doctors and patients alike are too "LDL-centric," as he put it. It is an unhealthy fixation with a single measure of health, a disregarding of other vital metrics that provide insight to the vitality of the heart. What about blood pressure? What about weight? What about sugar levels in the blood?

"You may be able to get people's LDL cholesterol levels down, but they're still going to be at a relatively high risk for lots of other disorders," said Alice H. Lichtenstein, a professor at the Friedman School of Nutrition at Tufts University. "If this lower LDL score gives them a false sense of security, we're going to be exacerbating all of the other problems that can occur from being overweight or inactive. It's not dealing with the diabetes, it's not dealing with the joint problems, it's not dealing with the blood pressure." Only half-joking, Dr. Caroline Apovian has a suggestion for how to deal with those problems: "Maybe," said Apovian, the director of the Center for Nutrition and Weight Management at Boston Medical Center, "to deal with our world today, we need Lipitor and an antiobesity drug and Prozac in our water."

Copyright 2004 The Boston Globe. All rights reserved.