Wednesday, September 26, 2012

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?

Wednesday, September 19, 2012

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.

Wednesday, September 12, 2012

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.

Saturday, September 1, 2012

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.”