Preventing Heart Disease: What We Thought We Knew Is Wrong

The word is out.  I first learned about it in a “Sound Medicine” interview last July with science writer Sharon Begley, a follow-up to an article she had written in April. In it she discussed research showing that giving statins to healthy people to lower their cholesterol does not help to prevent a first heart attack.  It turns out that cholesterol numbers are not a good predictor of heart attack risk and that lowering your cholesterol is unlikely to improve your odds.  (See my post, “Statins – Whoops!”)

More recently, Drs. Stephen Sinatra and Jonny Bowden were on “Dr. Oz” discussing the new approach and promoting their new book, The Great Cholesterol Myth:  Why Lowering Cholesterol Won’t Prevent Heart Disease and the Statin-Free Plan That Will.  Here is a synopsis by Dr. Joseph Raffaele:

“Dr. Sinatra explains that cholesterol is a vital substance, necessary for the proper functioning of our bodies. To name just a few: it keeps our cells flexible, is essential for hormone production, and is turned into vitamin D in the skin.  He believes it has been vilified as the cause of heart disease because of a longstanding misinterpretation of the studies often cited to support its role.  He rightly states that about half the people who have high cholesterol never get a heart attack and half who do have a heart attack have normal cholesterol.  The message is clear:  total cholesterol, the number we’ve all been obsessing about for the past few decades, is meaningless.  It’s not the cause of heart disease.”

If cholesterol numbers don’t matter, what does? Cholesterol is still in the picture but the issue is the particle size of your LDL cholesterol.  Small LDL particles are more likely to get into arterial walls and cause inflammation.  Inflammation is now thought to be a contributing factor in many illnesses, not just heart disease.  Obesity, insulin resistance, and a diet high in sugar and processed carbohydrates are factors that contribute to this condition.  Sinatra and Bowden recommend an anti-inflammatory diet with plenty of fruits and vegetables.  They note that only one group of patients has been shown to be helped by statins: middle-aged men who have already had one heart attack. 

“New Thinking on Heart Disease Prevention,” a blog post by Dr. Ryan Sweeney, provides a clear and concise summary of the new approach.  In addition to particle size and inflammation, Dr. Sweeney names oxidative stress as a factor contributing to heart disease.  The summary at the end includes the names of the tests that are needed to monitor the three factors:  CRP-hs, Homocysteine, Oxidized HDL and LDL, and LDL subtractions (for particle size).

In his blog post about the Dr. Oz show mentioned above, Dr. Joseph Raffaele takes all three doctors to task for not mentioning the benefits of hormone therapy in reducing the risk of heart disease for women who take it.  

“What if I told you there is natural therapy that reduces your risk of having a cardiovascular event by 41% and your chance of dying of any cause by 27%, while also being free of any of the side effects commonly seen with statins?   Would you take it?  In addition to heart disease prevention, this therapy’s common “side effects” include a reduction in hot flashes, vaginal dryness, depression, brain fog, insomnia, and vaginal dryness.  Serious “side effects” include a 23% reduction in breast cancer (yes, reduction) and improved bone density. If you are a menopausal woman between 50 and 60 years old, you can expect all these benefits from estrogen replacement.”

So here’s the situation:  millions of patients are currently taking statins with no benefit to their health and some potential hazards.  Statins can cause muscle weakness and memory loss,  as well as other physical and cognitive problems.  For a more extensive list of possible side effects take a look at “How Statins Really Work Explains Why They Don’t Really Work” by MIT scientist Stephanie Seneff.  All of us are paying for this useless and possibly harmful treatment through our insurance premiums and our taxes.  We will also be paying to treat whatever damage is done to patients who take statins.  At the same time, the use of hormone therapy, which has repeatedly been shown to reduce the risk of heart disease and to be safe for most women, is being discouraged by Medicare and insurance companies.  I have been on hormone therapy for thirty-three years, half my life, and I consider myself amazingly lucky.

7 Things I Try to Do to Stay Healthy

1. Drink juice; commercial tomato juice is an especially good choice.  A large study has shown that people who drink juice several times a week are 76% less likely to get Alzheimer's disease.  Recent research from Finland has linked tomato products with a reduced risk of stroke because of their lycopene content.  Store-bought sauce, paste, and juice are are concentrated and have more lycopene than fresh tomatoes.

2. Look up, not at my feet, especially when going up or down stairs.  This encourages my brain to use my sense of balance, a tip from Dr. Michael Merzenich, the neuroscience behind PositScience, which produced the Brain Fitness Program and other brain games.  As an added benefit, looking up is supposed to improve your mood.

3. Know my blood pressure.  I take mine at home but there are machines in pharmacies and lots of other public places.  For an accurate reading you should sit quietly for a few minutes beforehand.  At doctors' offices, staff members often skip this step so that my normally lowish numbers are high instead.  I wonder how many people end up unnecessarily taking blood pressure medication as a result of situations like this.

4. Use a heart rate monitor for cardio workouts.  Until you know what your cardiovascular system can do, how can you tell whether you're working too hard or not enough? How do you know what particular type of workout will be effective for you?  You get the answers to these questions by trying different routines and watching what your heart rate does in each situation.  (I never took notes, but that's probably not a bad idea.)  In my case, there is a sweet spot at about 80-85% of maximum heart rate, somewhere in the vicinity of 130 beats per minute,  where I'm working just hard enough.  (Maximum heart rate = 220 - 66, my age, = 154 x .85 = 131.)  I also like knowing my resting heart rate.  If I'm doing a new routine and resting heart rate goes up, I'm not getting enough of a cardio workout.

5. Take care of small problems right away.  If I get a little cut or a torn cuticle I immediately put a band-aid and antiseptic on it so that it will heal quickly.  If a faucet starts to drip I call the plumber.  Any trouble sign that I ignore or push to the back of my mind will lead to anxiety and a worse situation in the future.

6. Practice empathy; keep in mind that there is a person at the other end of any transaction.  This is not for the sake of altruism but because behaving this way gets me through exasperating situations more easily.  If I give someone a hard time I end up feeling bad myself.  Also, you never know when you're going to pick up a valuable new insight.

7. Be an honest moral bookkeeper.  If I've made a mistake I try to acknowledge it.  Ongoing avoidance and denial sap energy from the rest of life.  Letting go of illusions about yourself can be a great relief.

Fatter Body, Slower Brain: Two New Studies

Putting on extra pounds may damage your mental, as well as your physical, fitness but overweight middle-aged people who follow a program of high-intensity interval training can lose weight and improve their cognitive functioning.  These are the implications of two recent small studies, one headed by Timothy Verstynen, PhD of Carnegie Mellon, the other by Dr. Anil Nigam of the University of Montreal and the Montreal Heart Institute.  

In the Carnegie Mellon study, researchers examined the brains of 29 adults using functional magnetic resonance imaging.  The subjects’ body mass index scores ranged from normal to obese.  In the overweight and obese subjects there was evidence of hyper-connectivity in parts relating to memory and decision-making, indicating that the brain needed to work harder in those individuals.  These parts functioned normally in people of average weight.  The obese subjects also needed more effort to perform a decision-making task.  “As people put on unhealthy amounts of weight, the body’s energy systems begin to degrade and you can start to see the negative effect on brain circuitry, particularly areas that are important for controlling impulsive behaviors,” according to Verstynen.  The key factor seems to be inflammation, which interferes with the body’s communication system.

The Canadian research involved six subjects in their late 40’s with body mass index numbers in the “overweight” range.  Dr. Nigam said, “We worked with six adults who all followed a four-month program of twice weekly interval training on stationary bicycles and twice weekly resistance training.  Cognitive function, VO₂max and brain oxygenation during exercise testing revealed that the participants/ cognitive functions had greatly improved thanks to the exercise.”  VO₂max refers to the maximum amount of oxygen that a person’s body can use during intense exercise; it is an indicator of cardio-vascular fitness and aerobic endurance.  Participants in the study lost inches around the waist and reduced body weight but they also significantly improved performance on cognitive tasks, such as remembering pairs of numbers and symbols.

These studies suggest that exercise allows the body to recover mental as well as physical functioning, even in middle age.  Based on the descriptions I’ve read there wasn’t a huge time commitment, just four sessions per week, but the exercise was at a fairly intense level, interval training and weights.  A leisurely walk might not have the same effect on the brain, though it probably helps the body.

Colds

On Saturdays during the winter when I was five or six years old I was taken to the doctor for cold shots.  Sixty years later, a cure for the common cold remains as elusive as ever and I am wondering what was in those shots.  These days I don’t get many colds, which is typical for the over-fifty crowd.  The rhinoviruses that cause colds, though many, are limited in number.  After fifty years of two or more colds per year my body has developed immunity to lots of them. 

For the most part, I have acquired my cold resistance the hard way, one cold at a time, but I’ve also learned some helpful strategies.  When we had colds as children, my brothers and I were sent to school, business as usual, unless we had a fever.  These days, when I first get a sore throat, I immediately try to slow down in order to let my immune system do its work.  I prepare meals and do some regular activities, including a little exercise, but no strenuous workouts.  The most important parts of my strategy are to take zinc lozenges (Cold-Eeze) and to sleep extra hours, probably a long nap in the afternoon in addition to 7-8 hours at night.  If I can do this, very often the threatened cold goes away without any further symptoms.  

When I was younger, colds used to last for a miserable week or ten days of sore throat, sneezing, and coughing, often succeeded by lingering chest congestion.  Sometimes all that would be followed by secondary infections that could drag on for weeks.  These days, once in a great while, I get a cold that really knocks me sideways – but it never lasts more than a couple of days.  This happened to me last week.  On Wednesday I got a sore throat and started taking zinc lozenges and resting.  By Thursday I was sneezing but I felt OK.  Friday I was totally wiped out – my sinuses hurt, my teeth all ached in unison, my throat was raw – and I spent most of the day sleeping.  When I woke up Saturday morning, it had pretty much all gone by, though I felt a little as if I had been in a fight, and today (Sunday)  it is hard to believe that it even happened.

Why do I get shorter, nastier colds? Apparently, it’s because my immune system now is stronger than it was when I was younger.  As Jennifer Ackerman points out, cold symptoms are caused not by the virus but by the action of the immune system in fighting it off.  The more powerful the response, the worse you feel.  The trade-off, I believe, is that the cold gets knocked out of your system much faster so that you spend more days feeling good and have a reduced risk of secondary infections.

Medical science has learned a lot about colds in recent years.  It seems that genetic variations may cause some people to get more colds than others.  Also, the more years your parents owned their own home before you were 18, the less likely you are to get a lot of colds during your lifetime.  The key here is stress, which can reduce the ability of the immune system to regulate inflammation, leaving the body more vulnerable to disease.  Important research in this area has been done by Sheldon Cohen at Carnegie Mellon University.  Coldwise, my destiny may have been forged in early childhood.  My parents never owned their own home – we lived in a place provided by the church where my father was rector – and there was always plenty of stress.  As for the cure for the common cold, we’re still waiting.

How to Make a Thick, Fluffy Protein Smoothie: Breville vs. Vitamix

Chocolate Protein Smoothie

I'm not a big eater and I don't consume a lot of meat.  Without supplements I probably wouldn't get enough protein, so I have a smoothie with whey protein powder every day.  This is no great hardship because today's blenders make it easy to whirl up a concoction with the taste and consistency of a milk shake.  The basic recipe takes protein powder (chocolate or vanilla), milk, and ice.  With vanilla smoothies I add frozen fruit (so less ice) and half a banana; with chocolate I add a couple of small peppermint patties, crushed.

I've had a series of Breville blenders, which are quite good.  They're well made, quiet, and have a special smoothie setting that produces an ideal thick, creamy result.  The downside is dealing with Breville.  Their customer support is uneven, to say the least, and ordering parts can be difficult.  (When I wanted to get a new rubber ring, I was told I'd have to buy a whole new container, $50 please.)  So, when the most recent Breville died, I decided to get a Vitamix.  Vitamix blenders are well known for their outstanding quality, but that comes at a price, about $500 in my case.  On the other hand, the machine I bought has a seven-year warranty; $500/7=$71, the annual cost of owning a Vitamix.  A $200 Breville that lasted 2.5 years would have an annual cost of $80.  Buying fewer machines is easier for me and better for the environment, so I went for it.

So far I'm impressed with the Vitamix.  It came with good instructions and a very nice cookbook demonstrating the full range of its capabilities.  The only distinct negative was that the smoothies weren't as good.  They tend to be watery and to have a grainy, icy texture.  I called Vitamix Customer Support and the representative advised me to turn the machine to the highest speed and leave it there for a couple of minutes.  I tried that and the results were no better.

At that point I started to analyze the problem: what was the Breville doing that the Vitamix wasn't?  The Breville's smoothie cycle automatically alternates between pulsing and blending for a few seconds for a total of one full minute.  Sometimes I had to do a second one-minute cycle but not always.  The advantage of this method is that it gets a lot of air into the mixture but, because the blades aren't continuously running and getting hot, it doesn't melt the ice.

With the Vitamix (and probably other blenders as well) you can simulate this process by pulsing a few times and then processing 10 seconds or more.  When I'm making two drinks I pulse 15 times and process for a count of 25. I repeat these steps until the surface of the mixture looks shiny rather than grainy.  I tend to get better results if I add the ice in two stages. When I'm using frozen fruit, I do everything but the ice first and mix then add the ice and repeat. If the ingredients stop rotating, I stop the machine, pick up the container and shake it from side to side to get rid of air bubbles.  It takes a little longer and you can't just push a button and walk away but it does produce a thick, fluffy, delicious smoothie.

Update: Two new smoothie recipes with anti-cancer ingredients appear here and here. Healthy drinks without the terrible taste.

Should I Be Taking This? 6

The most important information you should know about Cymbalta:

Antidepressants can increase suicidal thoughts and behaviors in children, teens, and young adults. Suicide is a known risk of depression and some other psychiatric disorders. Call your doctor right away if you have new or worsening depression symptoms, unusual changes in behavior, or thoughts of suicide. Be especially observant within the first few months of treatment or after a change in dose. Approved only for adults 18 and over.

Cymbalta^® (duloxetine HCl) is not for everyone. Do not take Cymbalta if you:

• have recently taken a type of antidepressant called a monoamine oxidase inhibitor (MAOI) or Mellaril^® (thioridazine)
• have uncontrolled narrow-angle glaucoma (increased eye pressure)

Before taking Cymbalta, talk with your healthcare provider:

• about all your medical conditions, including kidney or liver problems, glaucoma, diabetes, seizures, or if you have bipolar disorder. Cymbalta may worsen a type of glaucoma or diabetes
• about all your prescription and nonprescription medicines. A potentially life-threatening condition has been reported when Cymbalta was taken with certain drugs for migraine, mood, or psychotic disorders
• if you are taking NSAID pain relievers, aspirin, or blood thinners. Use with Cymbalta may increase bleeding risk
• about your alcohol use
• about your blood pressure. Cymbalta can increase your blood pressure. Your healthcare provider should check your blood pressure prior to and while taking Cymbalta
• if you are pregnant or plan to become pregnant during therapy, or are breast-feeding

While taking Cymbalta, talk to your healthcare provider right away:

• if you have itching, right upper-belly pain, dark urine, yellow skin/eyes, or unexplained flu-like symptoms, which may be signs of liver problems. Severe liver problems, sometimes fatal, have been reported
• if you have high fever, confusion and stiff muscles, which may be symptoms of a potentially life-threatening condition
• if you have skin blisters, serious or peeling rash, hives, mouth sores, or any other allergic reaction. These may be serious, possibly life-threatening, skin reactions
• if you experience dizziness or fainting upon standing. This tends to occur in the first week or when increasing the dose, but may occur at any time during treatment
• before you stop Cymbalta or change your dose
• if you experience headache, weakness, confusion, problems concentrating, memory problems, or feel unsteady, which may be signs of low sodium levels
• if you develop problems with urine flow

Most common side effects of Cymbalta (this is not a complete list):

• nausea, dry mouth, sleepiness, fatigue, constipation, dizziness, decreased appetite, and increased sweating

You are encouraged to report negative side effects of Prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.

Other safety information about Cymbalta:

• Cymbalta may cause sleepiness and dizziness. Until you know how Cymbalta affects you, you should not drive a car or operate hazardous machinery.
• People age 65 and older who took Cymbalta reported more falls, some resulting in serious injuries.

How to take Cymbalta:

Take Cymbalta exactly as directed by your healthcare provider. Cymbalta should be taken by mouth. Do not open, break or chew capsule; it must be swallowed whole. Cymbalta can be taken with or without food.
Cymbalta is available by prescription only.
See Prescribing Information, including Boxed Warning about antidepressants and risk of suicide, and Medication Guide.

Cymbalta is indicated for the treatment of major depressive disorder (MDD). The efficacy of Cymbalta was established in four short-term and one maintenance trial in adults.

Cymbalta is indicated for the treatment of generalized anxiety disorder (GAD). The efficacy of Cymbalta was established in three short-term and one maintenance trial in adults.

Cymbalta is indicated for the management of diabetic peripheral neuropathic pain and fibromyalgia.

Cymbalta is indicated for the management of chronic musculoskeletal pain due to chronic osteoarthritis pain and chronic low back pain.

The Only Rule

As a young child growing up in the 1950’s, I used to believe that there were lots of rules. Years later, with decades of life experience behind me, I have decided that there is only one rule that counts: PAY ATTENTION. In the natural world, attention and alertness are qualities that keep animals safe. While a wild creature loses the ability to notice and approaching predator or to find food and shelter, its days are numbered. Here in the developed world we have able-bodied people walking into walls or in front of cars because they are totally engrossed in their cell phones.

The other day I saw a pleasant sight. A young mother was walking down the street with her little boy, holding him by the hand. Then I noticed that her other hand was holding a cell phone to the side of her head as she continued a conversation. Was the little boy aware that he was being ignored? A recent article cites studies showing that children take more risks when they’re not being watched. Over the past five years, the number of unintentional injuries to children under five has sharply increased after years of decline. Some researchers believe that this change may be related to texting while parenting.

Many people believe that they are proficient multitaskers but most of them are wrong. Research has shown that only about 2.5% of the population can juggle several activities at once; “our brains are wired for ‘selective attention’ and can focus on only one thing at a time.”A driver talking on a cell phone may actually not see another car up ahead. In a column entitled “Yes, Sell All My Stocks. No, the 3:15 From JFK. And Get Me Mr. Sister.” Jared Sandberg tells a series of hilarious and unsettling anecdotes illustrating the hazards of multitasking.One marketing firm actually sent direct mail offers to 4000 nuns with the greeting, “Dear Mr. Sister.”>

The effects of divided attention are also apparent in the medical care business. The connection between doctor and patient is central to the healing process but that relationship is now being curtailed to fifteen-minute meetings devoted to reviewing test results and prescribing drugs. The radiologist who told me I might have breast cancer did not turn off his cell phone during our conversation and it rang once while we talked. Maybe that was part of the reason why I asked for a second opinion (rightly, as it turned out). If I’m having a routine physical and the doctor gets an urgent call, I don’t mind waiting for a few minutes, but what could be more important than telling someone that they might have a fatal illness?

The following incident was reported in the 10/6/12 issue of the Bloomington Herald-Times.  Auto technician Tracy Grubb was driving home along a rural road and noticed a man lying on the ground next to his truck near the side of the road.  By stopping and offering help, he probably saved the life of William Fox, who had suffered an allergic reaction from a bee sting.  Grubb later noted that about 30 cars had driven past while he was waiting for the ambulance.  He said, “I don’t feel that I done anything special or anything.  I was just paying attention while I was driving.”

Finnish Study: “Eat Your Tomatoes, Preferably Processed.”

A few years back I read about a study showing that people who drank fruit and vegetable juice three or more times per week were 76 percent less likely to develop Alzheimer’s disease than people who drank juice less than once per week.  Since my mother died of Alzheimer’s, drinking juice seemed like a sensible thing to do.  We bought a juicer and started making fruit and vegetable juice a couple of times a week, as I described in a blog post.  We have fruit juice for breakfast and vegetable juice (mixed with commercial low-salt tomato juice) for lunch or dinner.  Since then, we don’t seem to get sick very much and, when we do, we get over it quickly.  Coincidence? Maybe.

Now it turns out that the tomato juice part may also help to protect us from stroke.  A Finnish study of 1031 men has shown that those with the highest levels of lycopene had a 55% lower risk of stroke than those with the lowest levels.  Tomatoes are the best source of lycopene and processed tomato products, especially tomato sauce and tomato juice, have 7-10 times the amount of lycopene found in a single tomato.

Exercise Is Powerful - but the Body is Slow

Ten years ago I began to get pains in my shoulders and upper arms.  I started lifting heavier weights and the pains went away.  Fifteen years ago I would get out of breath from going upstairs.  That doesn’t happen anymore.  These days, at the age of 66, I do a brisk 33-minute cardio routine that feels challenging but not exhausting.  I also do jumping jacks and plyo, which I started only a couple of years ago.  Recently my feet, which had given trouble for years, have started to improve.  Is it the impact exercise I have been doing? Who knows? 

Exercise can accomplish truly amazing things.  If it were a drug, everyone would want to take it.  It’s safe (apart from the occasional injury), doesn’t interact with foods or medications, and has lots of collateral benefits, like counteracting depression and improving sleep.  The downside to exercise is that it requires actual work.  Being in good condition at my age is a luxury; spending 8-9 hours a week working out is the way I pay for it.  (Side note:  When I first starting trying to get into shape I used to exercise 12 hours a week doing a less intense routine.  By gradually increasing the difficulty of my workouts I’ve been able to cut back the time while still improving my condition.) 

I started this personal fitness project twelve years ago as a way of avoiding statins, which my doctor had recommended because of my high cholesterol.  In those days, when I would work out on the cross trainer, my heart rate would max out at 125 beats per minute and I would never break a sweat.  I think that my muscles simply weren’t strong enough to work any harder.  Later on I started taking a protein supplement and proteolytic enzymes and gradually found that I could do more.  Technology has accustomed us to believe that results should be instant and life should be user-friendly but that’s not the way the body works.  The human body has its priorities (mainly ensuring its own survival and comfort) and it is not going to be rushed.  If you’re older and have a slow metabolism like me, that’s true in spades.  When I start a new exercise program I don't expect to see results for at least a month.  If there are no changes after 6 weeks, I conclude that I'm on the wrong program and try something else.  To work into P90X so that I could finally do all the classes (mostly) took 2-3 years.  It has taken 12 years to get to my present level of fitness. 

One of the unfair aspects of exercise is that some people have to work a lot harder than others in order to see results.  I am naturally muscular and strong so you would think I could do less.  Instead, I have a physique that you really have to hammer on in order to see results.  (I suspect that may be true of muscular people in general.)  Walking, even brisk walking, and swimming do absolutely nothing for me and, with the cross trainer, my heart rate needs to be over 80% of maximum in order for me to maintain my current condition.  In order to see improvement I need to be working near the upper edge of what I can do.  It’s a delicate balance:  too much and it’s tiring and too hard on my body, too little and I put on weight and feel sluggish. 

Developing a fitness routine is a process of self-discovery:  it’s important to try different types of exercise to find out what works for you.  It takes time, persistence, and patience but the potential rewards are huge:  feeling better than you ever have in your life and being totally comfortable in your own body.

Predictive Health and Health Coaches

About a year ago, in a post entitled “Let’s Rediscover Preventive Health Care,” I wrote about how health coaches could play an important role in helping to create a health care system that would be more effective, better suited to individual needs, and less expensive.  I recently read a review of a new book, Predictive Health: How We Can Reinvent Medicine to Extend Our Best Years by Kenneth Brigham and Michael M. E. Johns.The authors are the founders of the Emory-Georgia Tech Predictive Health Institute which practices “personalized medicine, combining genomics with the study of how proteins and other molecules act in the body. “

The Institute, financed by private foundations, uses “the latest biological tests, including measures of body fat, bone density, circulatory function, physical fitness, and brain function.”  Four ‘biomarkers’ are thought to be especially significant in predicting future health:  inflammation, oxidative stress, immunity, and regenerative capacity.  After data on each patient has been collected she or he works with a health coach on an individualized plan that involves diet, exercise, and medical care.

I wanted to know more about the program so I went into the Emory website and found an interview with Kenneth Brigham, director of the Institute.  Brigham describes America as having a “disease care non-system” with a vertical relationship between doctor and patient that doesn’t work.  He cites studies showing that “half of the people who see doctors don’t do what the doctors tell them to do.”  At the Institute, health partners (health coaches) engage in a horizontal relationship with patients;   they seek to inform patients and to encourage them as they work toward their individual goals.  Of course, the bottom line is money.  We all know that the present system is unsustainable, but will the PHI program save money in the long run? The Institute hopes to collect data to show that the approach is cost effective so that it can be adopted on a larger scale.

Health coaches could play an important role in enhancing quality of life and preventing illness.  Under our current system doctors see so many patients per day that it is impossible for them to know each person well.  The emphasis now is on ordering tests and prescribing medications rather than attaining a holistic view of the individual.  By contrast, health coaches could get to know patients personally and follow their progress on a regular basis.  Doctors primarily seek to identify and treat disease.  Health coaches could observe characteristics like balance, posture, muscle tone, and flexibility that can contribute to later health problems.  They could then pass along valuable insights to doctors in order give them a more complete picture of each patient.  They could also help patients understand more about their own bodies and participate directly in their own health care.

Here in Indiana we currently have an ideal opportunity to try out this new approach.  Indiana University is about to establish two Schools of Public Health, one in Bloomington, the other in Indianapolis.  The Bloomington School will be the successor to the current School of Health, Physical Education, and Recreation, which has a well-regarded program in kinesiology.  Why not use this occasion to try a cooperative program between the Department of Kinesiology and the IU Med School to train health coaches?

Make Yourself Uncomfortable: Learning a New Skill

This blog has now been around for over a year and is getting pretty long.  As a result, some worthwhile posts that new visitors might actually want to read are hard to find because they are buried several layers down.  In order not to tax their patience unduly I’ve decided to create a website, “the no body’s perfect archive,” that will have a rotating featured post from the past stock, a navigation system by topic with access to all posts, and, later on, some new cool features.  I’ve done websites before, though not recently, so I already knew basic HTML but I had assiduously avoided learning CSS.  To add to the pain, my HTML editor was HotMetalPro, now extinct and too obsolete to be of any use. 

I started off with SiteSpinner, an inexpensive and not-too-bad program, but it limited my access to HTML.  So it was on to Dreamweaver.  Since Adobe doesn’t provide a manual for this software (!#@%!!), I ordered Janine Warner’s Dreamweaver for Dummies right along with it.  The book was good except that it didn’t have any exercises to work through and, without knowing CSS, I still had trouble wrapping my brain around DW.  So I’ve spent parts of the past couple of months learning CSS from two good books, one by David Sawyer McFarland, the other by Eric Meyer.  

This has all brought me back to thinking about the experience of learning a new skill.  As I worked on CSS this summer, I was aware of four basic phases.  I started off feeling hopeful and confident (“This won’t be too tough – I can learn it in a couple of weeks!).  Then I hit a wall.  Procedures got more complicated and I couldn’t actually do anything with the new stuff I had learned (“Maybe I should quit.”)  A while later I found that I could actually start doing some CSS on my own, apart from the exercises in the book (“The fog is beginning to break.”).  The final phase, where I am now, is where the whole thing sort of makes sense, I can do a fair amount, but I need a whole lot more practice.  How hard it must be for young children, who have to do this kind of thing all day, every day, little hands struggling to wield a crayon or use a pair of scissors for the first time.  It’s awkward, time-consuming and, for an adult, embarrassing too.  No wonder we avoid situations like this!

But making yourself uncomfortable by learning a new skill provides some benefits (over and above having the skill itself). According to proponents of the new theory of neuroplasticity, activities that force you to focus your attention, that get you out of your comfort zone, are good for the health of the brain.  Michael Merzenich, who founded the brain-game company Posit Science, believes that learning a new language in old age can help the brain’s attentional system stay sharp (Norman Doidge, MD, The Brain that Changes Itself, 86-87).  Other scientists have demonstrated that learning can prolong the life of neurons (Doidge, 252).  If you do physical exercise too, you get an added bonus because exercise can stimulate the growth of new neurons.  So I feel a little better about the weeks of drudgery learning CSS.  I’ll keep you posted about the website.

Update, same day:  Just listened to "Brain Exercise," an episode of the public television show "Life Part 2," which had an excellent discussion about which activities help the brain as we age and the relative strengths and weaknesses of older and younger brains.  It turns out that older people have the edge when it comes to making important decisions and seeing the big picture, though they may miss some details.

Why Losing Weight Is So Difficult

I recently came across a good article by science writer Sharon Begley that appeared in the January/February Saturday Evening Post for this year.  The piece, entitled “Lose Weight for Good!”, says that medical science is finally accepting what many of us have known all along:  that losing weight can be a complicated, difficult process, and that no two people will succeed at it in the same way.  If you don’t have time to read the whole article, at least scroll down to the “Easy Rules for a Stay-Slim Life” at the end; some of them are not what you would expect.

This started me thinking about why it took decades to get my weight down to its present, OK level (145 lb.) and to get into better shape.  There were several factors not mentioned in the article that were obstacles for me and undoubtedly are for others as well.

        1.  Thyroid Problems.  I was diagnosed with hypothyroidism as a teenager but nobody followed up on this in a systematic way until decades later.  In addition, thyroid disease was evaluated differently in the mid-twentieth century than it is today, though some medical operatives haven’t caught up with the new thinking yet.  When I look at the current report on my blood work from the lab it gives .5 to 4.90 uIU/ml as the normal range.  This is wrong:  the correct range is .4 to 2.0.  In the 1950’s and 60’s patients with readings in the 2.1 and above range were regarded as normal; today they would be treated for hypothyroidism.  Low thyroid levels are associated with slowed-down metabolism and fatigue.  Personally, I have found that if my thyroid level is too low it is impossible to lose weight no matter how little I eat or how much I exercise.  It used to be extremely frustrating when people would say that I must not be trying hard enough!

        2.  Stress.  During early adulthood I was under stress pretty much constantly.  Grad school is a high-anxiety situation for a lot of people but it is supposed to lead to a professional career.  During the 1970’s it was tough for many of us to find and keep jobs; it was as though grad school never ended.  Recent research has shown that stress is linked not only to mood disorders like depression and anxiety, but also to metabolic disorders, including obesity.  

        3.  Weak Muscles.  In gym classes in high school other students could do pull-ups; I could not.  In my twenties and thirties my muscles were so weak that I couldn’t do a single push-up.  Why was this and why didn’t anyone ever notice that a solid-looking person like me had such poor muscle tone? Here again, people with hypothyroidism can have weak muscles.  Also, my lifestyle during that period was very sedentary – I mostly sat around reading – and I probably wasn’t getting enough protein.  I wasn’t a big meat-eater and my body didn’t seem to be that good at processing the protein I did give it.   

     The good news is that all of this was totally reversible.  I now drink protein shakes and eat protein bars to get my levels to 70-100 grams per day.  I probably need at least that much because my body is unusually muscular, according to the body composition scale I use.  These days I can do forty or more push-ups, thank you Tony Horton.  So far, I can only do assisted pull-ups, but I’m working on that.  If your muscles are weak you can’t get a good workout.  If you can’t get a good workout you won’t be able to burn many calories. 

        4.  Problem Feet.  When I started doing more serious exercise in the 1990’s I began to notice little pains on the sides of my feet.  This led to my getting orthotics, a story I have told in the post “Respect the Feet.”  If I hadn’t gotten my feet fixed, I wouldn’t be able to survive the heavy-duty workouts I do today; the stress on my feet, knees, and hips would have been too much.  I often wonder how many hip and knee replacements could have been avoided if those patients had gotten their feet looked at early on.

In spite of the hassles and frustrations, getting into shape has ultimately been a process of self-discovery.  At this point I know my body very well, how far I can push it, when I should pull back.  At the age of 66, I feel more comfortable in my own skin than I ever have in my life.

It’s Not the Annual Physical, It’s the Tests

My primary care provider is a fine doctor; she is intelligent, kind, and a good listener; I enjoy talking with her when I have my annual physical each year.  What I dread are the tests, not because I mind being punctured or scanned or even having a certain amount of my time wasted, but because they sometimes force me to fend off unwanted medical interventions. 

Twelve years ago, when a previous doctor offered statins to lower my cholesterol, I said that I would try diet and exercise instead.  Diet and exercise worked, end of discussion.  A couple of years later when a bone scan revealed osteopenia (low bone density), Fosamax was pressed upon me.  I have never broken a bone and I think there is still a lot that medical science doesn’t know about bone quality so I said, “No, thanks.”  My doctor was a little offended.

The real fun started two years ago when a radiologist looking at my current mammogram thought he saw signs that might indicate cancer and recommended a biopsy.  (See the whole story in “Mammograms and the Cost Conundrum,” 8/22/2011.)  In my family cancer is almost unheard of and I am generally quite healthy so I opted for a second opinion, a move that clearly annoyed him.  The second radiologist found nothing wrong and still hasn’t.

This year the issue was heart disease, a matter I take very seriously because strokes and heart attacks are what kill most people in my family.  My PCP thought she heard a heart murmur so she sent me for an echocardiogram.  My doctor said it might be nothing:  apparently in very fit people a strong, vigorous heartbeat can sound like something wrong.  So I went for an echocardiogram.  As a side note, the technician took my blood pressure while I was sitting up talking to him.  When I saw on the screen that it was 140 over 80-something I said, “That’s much too high, let’s do it again.”  I lay quietly for a few minutes and my bp came out 118 over 63, still higher than my true number of 106/58, but at least within the normal range.  I’ve noticed a lot of medical personnel doing this:  not letting you sit quietly for a few minutes before taking your blood pressure.  Surely they know that the reading won’t be accurate; most people’s bp is higher in a doctor’s office and this just makes it worse. 

A doctor in Indianapolis read the echo and sent back a report saying that I had a “’pseudonormal’ filling pattern of the left ventricle for age (Stage 2 diastolic dysfunction).”  My PCP asked me to see a cardiologist.  My first move was to pick up a copy of the report from her office and try to learn more about what it meant.  According to several online sources, Stage 2 diastolic dysfunction is when you get shortness of breath, chest pain, and exercise intolerance.  This sounded like my father a few years before his death; it did not sound like me, with my P90X and cardio workouts.  

So I went to the cardiologist, a man widely respected for his medical expertise and his philanthropic work.  I was a little intimidated by his reputation and worried that perhaps there really was something wrong with my heart after all.  His waiting room was reassuring.  There were beautiful photographs on the wall (his work?) and a friendly receptionist.  In the examination room was his medical degree, from a university I had also attended (at the same time, it turned out).  The cardiologist was my age and a fitness buff like me.  He listened to pulses from head to foot, prodded my abs, and told me he didn’t hear a heart murmur.  Of the report he said, “I don’t know where he got this!”  Of my list of supplements he said that some of them probably weren’t doing me any good but there was nothing that would hurt me.  His recommendation:  “Don’t change a thing; just keep doing what you’re doing.” 

Need to Know: Obesity as a Threat to Our Future

On Friday evenings I often watch a program called Need to Know on public television.  This week’s episode, hosted by Scott Simon, dealt with the problem of obesity, first on the personal level, with the story of 10-year-old Carla, then on the public policy level, when Ross Hammond of the Brookings Institution was interviewed.  Carla, who lives in the South Bronx with her parents, is overweight and has been told that she is at risk for developing diabetes, an illness that runs in her family and has already killed one of her relatives.   

Children like Carla who live in low-income, predominantly minority neighborhoods have a one-out-of-two chance of developing diabetes at some point during their lifetimes, according to Dr. Alan Shapiro of the Children’s Health Fund.  Nationwide, children today have a one in three chance of getting the disease.  Correspondent and producer Sarah Schenck follows Carla as she enrolls in a health and fitness class and then proceeds to pass on what she has learned about diet and exercise to her parents.  In neighborhoods like Carla’s, sometimes called “food deserts,” nutritious food is scarce and expensive, while fast food is plentiful.  Opportunities to exercise outdoors are also limited.  Carla, a highly motivated and unusually articulate young person, seems to be making good progress toward her goals.

In the second part of the show host Scott Simon talked with Ross Hammond, a Senior Fellow at the Brookings Institution who is also on the editorial board of the journal Childhood Obesity.  As Carla’s story had illustrated, Hammond emphasizes that obesity has complex causes, including biology, the brain, and the person’s physical and social environment.  For this reason “it is very difficult to think of a single solution that will work for everyone.”  Instead, it is important to coordinate a variety of approaches to attack this urgent problem.   

According to Hammond, medical care for the overweight and obese can cost as much as 100% more than that for people of normal weight.  It is estimated that care for this group now accounts for 21% of all medical spending.  Obese patients require larger beds and special equipment in emergency rooms.  (I would add that very overweight patients in nursing homes will have the same needs over longer periods of time and that additional staff will probably be required as well:  think what it would take to turn a 400-pound patient over in bed!)  The best role for government, according to Hammond, is “helping to provide a playing field in which people can make appropriate choices and choose for themselves healthy options and have those healthy options be just as available, affordable, and convenient as unhealthy options.”  He calls obesity “a huge threat to our country.”

More Imponderables

Medical professionals generally would like people to take better care of themselves, to take more responsibility for their own health.  You can’t take responsibility unless you know the facts of the situation, yet some doctors and hospitals continue to place obstacles in the paths of patients seeking access to their own medical information.  I understand that privacy concerns necessitate the signing of a waiver and I have no objection to showing a picture ID, but even then my request is sometimes denied.  When a patient has had blood work, the actual numbers should be shown to him or her.  Some doctors provide interpretations of the tests rather the results themselves.  I remember the letters I used to get from one doctor, IN ALL CAPS, like a bulletin from the front lines.  Sharing and discussing the facts encourages cooperation between medical personnel and patients and may help to prevent erroneous diagnoses and the unnecessary treatments that result from them.

Recent discoveries in genomics have opened up new worlds of complexity in the study of the human body and made it even clearer than before that each of us is unique.  In spite of this, medical institutions in this country persist in trying to standardize treatment for all individuals in a particular category.  Medicare, which pays for my drugs, would like me to get off Premarin, which I’ve taken for more than thirty years and get on Estradiol, a newer and less tested medication.  They would also like me to swap the Synthroid I take for hypothyroidism for a generic.  (I tried a generic once before and it didn’t work the same.)  If a patient doesn’t follow orders when using a prescribed treatment, doctors call it “non-compliance.”  What should we call it when institutions want to take patients off prescribed medications that they have used successfully for years?  
   

Related Posts:  
"Please Give Me My Test Results (Not Just An Interpretation)"
"Humana, I Want My Premarin!"
 "Humana, I Want My Premarin!" sequel