When to Question Your Doctor: A Cautionary Tale

Most people are in awe of physicians.  Medical doctors are smart, well educated, and devote their working lives to helping others.  The least we can do, it would seem, is not to add unnecessary complication to their already-overstressed schedules by disagreeing with them.  The current New England Journal of Medicine has an important article, “SpeakingUp — When Doctors Navigate Medical Hierarchy,” by Ranjana Srivastava of the Monash Medical Center in Australia. 

It turns out that not only patients are intimidated by physicians; doctors are also intimidated by other doctors so that they do not always speak up when they sense that something is wrong.  Medical professionals are especially loath to interrogate those whom they perceive as outranking them in the medical profession’s pecking order.  Srivastava, an oncologist, was unwilling to express her sense of uneasiness about a patient to the surgeon about to operate on him.  Her account of the incident and its consequences is honest and moving.  
  
The message I took away from this article is this:  if something bothers you, speak up.  Be respectful, ask reasonable questions, but don’t keep silent.  To this I would add:  if the doctor becomes annoyed or brushes your reservations aside, get a second opinion.

Abdominal Migraines

My paternal grandmother would sometimes get abdominal pain severe enough to send her to the emergency room.  She had a number of exploratory surgeries that turned up nothing until finally, in her seventies or eighties, she said, “No more surgeries.”  My father used to get migraine headaches.  I don’t get those, but once in a great while (about every seven years) I get an abdominal migraine.  Usually at night after a big meal, maybe under stressful circumstances, I will get painful spasms below my navel (about 7 on a scale of 1 to 10), accompanied by sweating, vomiting, and diarrhea until my whole system is cleared out.  After that the pain continues; I can’t keep down any food or liquid; and of course I can’t sleep.

In 1989 that happened and I went to the emergency room.  That time I was lucky because the doctor there knew what this was.  He checked a few things, had an x-ray taken, and sent me home with pain medication.  He didn’t tell me the name of the condition; I found that out later for myself.  I stayed in bed the next day and after that I was fine.  Seven years later it happened again and I called my regular doctor.  I said, “I know what this is.  Please give me something for the pain and I’ll be OK in a day or two.”  My doctor was skeptical and wanted to be extra cautious.  She had me check into the hospital and lined up a surgeon.  The hospital ran various tests, found nothing, and let me go after a couple of days.  The next time, just as the pain was starting, I took a generic Pepcid AC (famotidine) and the pain stopped in its tracks: apparently this is the right thing to do.

Many doctors believe that only children get abdominal migraines but this seems to be wrong.  I get them, my grandmother probably did too, and I know at least one other adult who does.  In adults an abdominal migraine is probably mistaken for a stomach virus or food poisoning.  For people who get them often it probably makes sense to carry the pills around, just in case.

I get various kinds of muscle spasms too.  The best fix for these is to wet a washcloth with the hottest water you can stand and press it against the knotted up area.  Sometimes this has to be done a couple of times but after that the muscle will relax.  I’ve read that muscle spasms can be caused by deficiencies in any of various minerals.  I take potassium, magnesium, and calcium and the blood tests for these indicate that I’m where I should be.  Evidently this is just part of my genetic inheritance.

The Latest on Stilbestrol

In today’s paper I read about the Melnick sisters, whose suit against Eli Lilly and Company went to trial this week.  The sisters charge that a Lilly product, diethylstilbestrol (DES), which was given to their mother during four of her pregnancies, caused their breast cancers.  DES was given to pregnant women in the 1940’s and 50’s to prevent miscarriage.  It was later taken off the market when it was found to cause a rare type of vaginal cancer in the daughters of women who had taken the medication.  It was also found not to prevent miscarriage.

The circumstantial aspects of the Melnick case are compelling.  Four of the daughters developed breast cancer in their forties after their mother took DES during those pregnancies.  A fifth daughter, who did not receive in utero exposure to the drug, has not had cancer.  On the other hand, the pregnancies took place during the 1950’s; medical records no longer exist; and Lilly was not the only company that produced stilbestrol.  In addition, the prescribing doctor failed to follow Lilly’s recommendations, which called for using the drug after three or more consecutive miscarriages.  The Melnicks’ mother evidently did not have successive miscarriages.  

In “Stilbestrol and Me” I discussed my own experience with DES.  My mother’s doctor prescribed the drug after my would-have-been older brother was born a “blue baby” and died soon after, not really a miscarriage at all but a heart problem in the child.  DES is a good illustration of “The Twenty Year Rule.”  An apparently successful new technology appears; the medical profession gets excited and applies it to many patients.  Twenty years later (from the ‘50s to the ‘70s in the case of DES) unpleasant or dangerous side effects become evident and the medical profession backs off en masse.  You would think these experiences would lead all of us to be more cautious before trying out the latest thing on our irreplaceable bodies.

Update 1/10/2013:  Eli LIlly settled its case with the Melnick sisters for an undisclosed amount.  Lilly stated that, while it did not believe that its medication had caused the Melnicks' illnesses, the settlement was in its best interest.

“Dear CDC: BMI ≠ Body Fat”

Happy New Year!  Another year, another study apparently proving that being a little overweight is fine and may even reduce your risk of dying, as compared with being thinner.  This one, from the Centers for Disease Control and Prevention, re-analyzes data from 97 studies involving nearly three million people from various countries.  The study, which is being published in the Journal of the American Medical Association, has been widely publicized.  I counted two articles in the New York Times and one in the Wall Street Journal plus coverage on radio, TV, and the Internet.

This is the most recent illustration of “the obesity paradox,” the fact that, although excess weight is a factor in cardiovascular disease, obese patients with heart disease tend to live longer than those with no excess weight.  I would argue that the root of this “paradox” is in the definition of obesity.  When you used a flawed measuring device, you get incorrect results and BMI, which used as the index of fitness in all these studies, is seriously flawed, as I explained in my post, “What’s Wrong With BMI.”  

BMI is a ratio of weight to height:  multiply your weight in pounds by 4.88, then divide it by your height in inches, squared.  Anyone with a BMI over 25 is considered overweight; anyone over 30 is classified as obese.  This means that people who are fatter than average (unhealthy) are lumped together with people who are more muscular than average (very healthy).  Under this system, a person the same height and weight as Tony Horton would be treated as equally fit even if he had never exercised a day in his life!  Measuring the percentage of body fat for each individual would provide a more accurate picture of the situation.  Lots of people know that there are problems with BMI.  Melinda Beck’s article in the WSJ alludes to this.  A number of her readers know it too, as indicated by some of the comments on the article.  So why did the CDC use it in this case? The answer is that it is easier and cheaper to use existing data and the existing data all use BMI.

As a federal agency under the Department of Health and Human Services, the CDC is looked upon as a leader in the fields of science and health.  When it continues to use and endorse BMI as a measure of good physical condition, it sets an example that others follow, which does a disservice to all of us.  In my doctor’s office my weight is measured on a BMI scale.  I ask my doctor why there is no body fat scale and she says that BMI is the current standard.  As long as this continues, there will be no data on body fat for anyone to study unless they do original studies themselves.  Fortunately, some of this research is being done.  A Mayo clinic study found that people of normal weight can be at greater risk of heart disease if the levels of body fat are high.

The timing of this new study and the ensuing publicity could hardly be more damaging.  Scientists at the CDC are surely aware that fat people who lose weight through appropriate diet and exercise (not illness) will lower their blood pressure, reduce their blood sugar, and improve their cholesterol readings, all of which will contribute to better health.  At the beginning of a new year many people are pre-disposed to turn over a new leaf.  Instead of encouraging people to cultivate better habits, the CDC puts its imprimatur on the perverse message that it’s OK to be fat.

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.