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Monday, December 12, 2011

How to lose weight, lower your blood pressure, have better cholesterol and live longer, all without me nagging about it

There are various things that appear to be good for people. These include maintaining a normal weight, or losing weight if a person is fat, drinking some alcohol, but not too much, quitting smoking and exercising. Doctors as a whole also believe that lowering cholesterol levels is good, and at my recent update in internal medicine course there was some good data that suggested that drinking coffee is a good thing! Controlling blood pressure is also very important.

Being obese is bad in a number on ways, increasing risk of getting cancer, increasing osteoarthritis of the knees, which in turn is responsible for quite a bit of suffering and death, and increasing blood pressure and heart disease. Diet changes can help, but unlike much of what I have believed, there is no particular diet that is better than other diets for everybody. One study looked at people attempting to lose weight using either a low fat or a low carbohydrate diet. The low carb diets are exemplified by the Atkins  and the "zone" diet, which are rich or unlimited in proteins, even fatty meats, but strictly control the amount of carbohydrates a person eats. When a person does not take in carbohydrates, such as breads or rice or pasta, or sugary foods, that person will begin to use proteins as fuel and produce ketones which have the effect of suppressing appetite. The low fat diet, on the other hand, has been ingrained in us for decades, and belief in its healthful properties has resulted in reduced fat everything, from milk to potato chips.  Although many people can lose weight faster with the low carbohydrate diet, after 10 years both types of diet are equally effective.

A study out of the United Kingdom demonstrated an average reduction in lifespan in moderately obese patients of 3 years. This means that a 5 foot 2 inch woman over the weight of 165lbs could expect to live 3 years less than if she were normal weight, up to about 130lbs.  Her life span would be 10 years less than expected were she 220 lbs. A person could expect to lose 1 pound a week of weight by either eating 500 calories less or exercising the amount it would take to use up 500 calories. On a stationary bike a person consumes about 500 calories exercising hard for 45 minutes, and heavy people use more energy to do the same amount of exercise as skinny people. It is more effective to both exercise and reduce calorie intake because the body can reduce its energy expenditures if it thinks it is starving, and conversely inactive people often find it hard to avoid inattentive overeating.

Drinking no alcohol at all appears to be associated with a shorter life, though long term controlled trials of alcohol drinking are totally impractical, so the evidence is not unassailable. There are many bad health outcomes associated with heavier drinking, more than 3 drinks a day for men and over 1 drink a day for women, but even heavy drinking statistically may be better than none at all! (Obviously this is only meaningful for populations, since an individual can drink him or herself to death and individuals do regularly do this.) Women who drink anything at all have a higher risk of breast cancer, but it is heart disease, not breast cancer that is the major killer of women, by a long shot, and drinking definitely appears to lengthen a woman's life.

Cigarette smoking has almost nothing, in fact I can safely say absolutely nothing, to recommend it as far as health goes. OK, I can imagine some scenarios in which cigarette smoking has probably saved someone's life. Perhaps once someone leaned over to pick up a cigarette and just barely missed being hit by a bullet, or avoided being bitten by a malaria carrying mosquito due to being surrounded by cigarette smoke, but in regular life cigarettes do cause heart disease, strokes, vascular disease, lung disease and cancers of many sorts.  The CDC reports that 1 in 5 deaths in the USA is attributable to cigarette smoking. Physicians are not very good at getting people to stop smoking, but there are various medications, including Chantix, budeprion and nicotine products that can significantly reduce cravings for cigarettes with very few side effects.

A gradual decrease in the amount of exercise that Americans regularly engage in is mostly responsible for our devastating epidemic of obesity which will lead to health care costs that we cannot even begin to imagine at this point. As little as 30 minutes of exercise a day for 5 or 6 days of the week can make a significant improvement in many health outcomes, ranging from preventing Alzheimer's disease to preventing heart attacks.

Elevated cholesterol levels, especially certain types of cholesterol, such as the LDL (low density lipoprotein) is associated with increased deaths from vascular disease such as heart attack and stroke. In some cases it may be a marker of bad health behaviors and bad heredity, but it also appears to be causative, and lowering cholesterol with lifestyle changes, weight loss or medications of certain types does reduce risk of these diseases. The most effective medications to reduce cholesterol are the statins (at least as far as we know) and every year another study shows that being on statins is good for some new thing. This information should be viewed critically since statins are hugely big business for pharmaceutical companies, but even I, a skeptic, admit that using these drugs (things like atorvastatin (lipitor) and simvastatin) probably saves lives, especially in those at high risk for early or recurrent coronary artery disease. Statins can, and often do, cause muscle pain and cramping, and combined with certain other drugs can lead to muscle breakdown due to interactions. In general, though, they are probably as safe as many over the counter drugs and herbal preparations.

Coffee, in the nurse's health study and in other well regarded studies, decaf or regular, and in large amounts, reduces risk of developing diabetes, improves diabetes control and reduces progression of fatty liver disease or hepatitis C to endstage liver disease. This is big. The effect is not tiny either, and if coffee were a new pharmaceutical it could be marketed for this indication. It would probably cost upwards of $20 a cup, though. Researchers have looked for negative consequences of coffee drinking for years and have failed to find any that are significant, other than that coffee can give one heartburn or a sour stomach.

Blood pressure should generally remain below 130/80, though medication treatment may not be indicated until the numbers go over 140/90 and the very old may do better with slightly higher numbers. There are a myriad of medications that work for this, but chief among them are mild diuretics, especially the generic pill chlorthalidone which has been around for decades. Ace inhibitors such as lisinopril are also very effective, and calcium channel blockers can be powerful. Sometimes combinations of these drugs are necessary. 

Diabetes is very common now and by 2030 is estimated to afflict 1 in 10 Americans. We could turn this around by changing our lifestyles to decrease obesity, but that isn't happening, so in the not too distant future, a sizable proportion of all patient visits will have something to do with diabetes. Good control of blood sugars with pills or insulin can decrease risk of complications such as heart disease, loss of sensation, blindness and kidney failure. Treating a patient with diabetes follows some pretty detailed guidelines laid out by the American Diabetes Association, and involves control of blood pressure, blood sugar, cholesterol and screening for early signs of complications.

Looking at the paragraphs above, it becomes clear to me that it is going to be really hard for primary care doctors to instruct their patients in all of the good things they should be doing to live longer and healthier, and I also note that many of the things that I've mentioned are things that I am not that good at telling patients how to do. I'm not great at getting patients to lose weight or exercise, though I think I do a pretty good talk. I can only get a patient to quit smoking if she already plans to do it. I can do the diabetes stuff pretty well, I think, but it sometimes gets forgotten as I focus on what the patient really wants me to help them with, such as some kind of acute or chronic suffering that they are experiencing. I haven't yet tried to get patients to drink more coffee. That may be easier, though having them drink it without cream and sugar may be tricky. High blood pressure treatment is sort of my bread and butter, but it is a task without much thanks since patients usually do not feel better on medications and don't notice the condition at all until someone measures it.

So what I was thinking is that maybe I shouldn't be doing all of this stuff. Maybe I don't need to be the nag, especially since I am not that good at it. I prefer to be the good cop, which means I desperately need a bad cop, or at least a charismatic motivator. What is so special about me as a doc that I need to do all of this counseling? Other people might be better at it and wouldn't need the broad training that I have to accomplish a good 90% of the stuff I laid out. Posters, TV commercials and education in schools could much more effectively beat into peoples' consciousness the importance of diet and exercise and not smoking or quitting. Exercise and life coaches can be awesome motivators. The alcohol industry could be tapped for the funds to advertise the health effects of moderate alcohol, and I bet they would do a darn good job of making the point that alcohol is good for us. Some level of industry/public health cooperation could make sure that this didn't move into the realm of "a little is good so more is better." Diabetes treatment, at the level of periodic visits and medication adjustments, is much better done by a multidisciplinary team, including nurses and pharmacists, and not heavily dependent on physician input. Much of control of blood pressure could be done after home monitoring by a nurse or a pharmacist with a decision flow chart for which drugs to use, and I honestly think they would probably do a better job than I would. If things got dicey, the patient could come to me and I could sort things out. Cholesterol would be the same issue. The drugs to treat cholesterol are pretty limited, and with a fingerstick test at the pharmacy of at my office, medications could be prescribed per a protocol and the patient could be monitored until the dose was correct. Pharmacists can certainly monitor for drug interactions, at least as well as I can. What about the patients who don't want to do all of these good things? I applaud them--not everyone should be a sheep. As the good cop, I doubt I would be much more effective than my somewhat less extravagantly educated colleagues at convincing them to toe the line. If it was really important, I could of course give it a try.

If much of this public health and protocol driven medicine were not my job, I would have more time to sit down with a patient with complex medical and psychosocial issues and work with them to come up with solutions to problems. I could diagnose their fascinating and disabling diseases, inject their swollen joints, see them the same day they called in with a cough and a fever or blood in their bowels or vomiting or a suspicious lump. I could be a doctor, not a cross between an accountant and a mother hen. I, and my colleagues, could begin to see clearly towards being able to take care of the genuine needs of the scads of patients already in need of primary care, and those who will, if all goes well, be insured by 2014.

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