An Apple A Day

A recent article in the NY Times caught my eye. I couldn’t have agreed more, and also less. Titled “Let’s (Not) Get Physicals”, it was a reflection on the problems with conventional routine physical exams. http://www.nytimes.com/2012/06/03/sunday-review/lets-not-get-physicals.html?pagewanted=all

The time-honored tradition has been for a thoughtful patient to see her/his doctor for an annual exam. The article discussed several of the screening tests that have been the foundation of the annual exam routine. Many of these have been shown to be ineffective. Ineffective screening tests are worse than just a waste of time and money, as they lead to other needless tests and procedures. The procedures, the next steps looking to identify or treat the “disease” that is not there or does not need to be treated, usually create their own problems. The end result is that the patient has been harmed by this well-intentioned effort. Bear in mind that dumping procedural screenings is nothing new. Annual chest Xrays, anyone? We used to do that not so terribly long ago.

That was the agreeing part. My disagreement is based on the definition of what is done. From my experience it is certain that an appropriately directed annual health assessment is wise. That is true, even excluding the simple technology of a couple of blood tests. I see people every day who are so vitamin deficient that it shows up in simple blood tests from a conventional lab. But forgetting that, dumping all the post 19th century technology, there is ample, easily accessed and useful evidence of what needs to be changed to better a person’s health.

Taking to patients about how they feel, what they eat, their exercise patterns, how they are managing the stress of their lives, etc., tells me a lot. With that information, I can help them improve the quality of their day to day lives and avoid developing the most common diseases in our society (e.g., heart disease and diabetes). The risks of talking to a patient, looking over a three day diet record, reviewing his/her use of supplements/medications and conducting a simple physical exam are close to nothing.

Another shadow, looming over this discussion, is that doctors know that patients don’t change their habits. You can never get them (you) to change their diet or exercise. They won’t work to learn how to manage stress better. Docs know that. As you know very well, docs are wrong.

A child can learn to read and write without any help. but it will take a long, long time and incredible determination. When a doctor tells a patient that they should get more exercise, eat better, stop smoking or whatever, without providing the specific steps to achieve those formidable goals, almost no one is successful. The patient feels like a failure and the doctor’s negative expectations are confirmed.

What my colleagues do not know and what perpetuates this vicious cycle of hopelessness is HOW to help patients make changes. Medical school lasts four years. After that we have to get at least one year more of training, with most of us taking three or more. In all of that, there is little emphasis on the benefits of changing lifestyle and none on how to help patients make changes. When I earned a national level soccer coaching license I received some of my most valuable medical education. That was how I learned the nuts and bolts of helping people make changes. That has made a huge difference for me, and more importantly, for my patients.

If my colleagues were taught more about healthy lifestyle, low-tech examination and how to actually help patients make changes, annual exams would be powerfully positive health and life-enhancing experiences.

Who is that in the photo? It is Joseph Bell, MD. He was the inspiration for Sherlock Holmes. One of Conan Doyle’s medical school professor’s, Bell was renowned for his remarkable insight into his patients, based purely on his skills of observation and thoughtful deduction. He might be an even better model for physicians today than in his own time.

I hope that, respecting tradition, you have dedicated yourselves to creating some better health habits in this New Year. I also hope that you are going about that in a joyful way, understanding that doing the right things will help you enjoy your life more. Also, pursuing good health habits should be fun, not tedious and just “good for you”. Sure, sometimes it takes a little while before you start noticing the benefits, so a little discipline is needed to establish your new habits. Other times, you feel better right away. Instantaneously or gradually, disease-reducing, longevity-promoting or not, do it because you will feel better. This newsletter is a map, guiding you along the most direct path towards a better life. Change is not just a matter of will-power. Going about it the right way makes it much easier, and markedly increases your chances of success.

I am in an exercise focus right now. Admittedly, some of that is because of the time I spent during the last month working at the Olympic Marathon Trials and attending a sports nutrition conference, but more importantly, a lot of new data is coming out that is very interesting and will be useful to you. In this blog I will soon post some thoughts about some physical training specifics. The purpose will be to make your exercise more efficient and more effective.

Making changes

The idea of making changes in the New Year is easy fodder for comedians. Everyone talks about it, but no one really accomplishes anything. That’s right and it’s also very wrong.

In the Northern Hemisphere, where most of us live, the New Year roughly marks the return of the sun. The days start to become longer and warming weather will follow. Greeting the New Year with hope and new ideas has been the tradition as far back as we can trace human cultural history. I think this tradition would have died out long ago if every attempt were met by failure. On the contrary, every day I see patients successfully change their lives for the better, not just at the New Year. You should be optimistic about making changes.

Change doesn’t happen simply by rolling out of bed on New Year’s Day, although that IS a necessary first step. To ensure success, you need to develop a plan.

Self-Assessment

The dark, cold months of the year are traditionally a time of reflection, a time of the inner life. Figuring out where you are is essential to creating a map to get you where you want to be.

I cannot overemphasize how important an honest and thorough self-assessment is when you are trying to make changes. Your self-assessment must be as objective as you can make it. An inaccurate assessment inevitably carries the seeds of failure. If you think you are in better shape than you really are, the training for that April marathon WILL injure you. You might think you aren’t eating well enough when your lack of exercise or poor stress-management is the bigger issue.

We usually perceive some problems clearly, but others we think are bigger than they really are, while still others are invisible to our own eyes. Trying to sort things out by yourself can be a lot like painting a self portrait without a mirror, or maybe having only a distorted, funhouse mirror to look at. This is the reason so many people find the help of a professional useful. A professional can identify problems and solutions you might not recognize or know about. A professional should have learned from the experience of many patients and can use that accumulated wisdom to guide you. Seeking the advice of family and friends can also be helpful at times.

Reflection is an inward, ideally a meditative, process. In keeping with that inwardness we should start from the inside, meditating on who we are and who we want to become. Following is a list of some areas to consider:

Essential health habits

Drink Enough Water

Exercise Almost Every Day

Eat Well

Take Your Supplements

Avoid The Things That Make You Sick

Get Enough Sleep

Be Involved in Your Community

Have A Healthy Sex Life

Remember That Attitude Is Important

Spirituality/Life purpose

Goal Setting

After you sort out where you are, you can create an image of where you want to be and construct a map to get you there. Deciding that you want to be younger is not going to work anymore than deciding you want to be taller or win the lottery. Make your goals achievable! That is the first step in goal setting.

In a more subtle way, deciding that you want to be stronger or thinner or calmer won’t work either. There is an art to creating goals that will help you achieve success.

Second Step - Goals Must Be Specific

If you set a goal but don’t have a path to follow towards the goal, or you don’t know when you are there, you won’t ever get there. For example, you decide that you want to lose weight. You then must sort out how you are going to do that and how you are going to measure it. Let’s say you determined that, for you, the keys to improved health are to increase your activity and change your diet by eating more vegetables and cutting out soda and alcohol.

You could begin by tracking your activity level for a week, either by timing yourself, or better still, wearing a pedometer. Then, as you set about implementing the changes, you have clear evidence and incentive by simply reading the numbers.

The same applies to your diet. You could decide that you will eat some vegetables at every meal, including two servings at lunch and dinner with a leafy green salad every night. You also determine to limit yourself to no more than one alcoholic drink and one soda a week. All you have to do is look at your plate and into your drinking glass to learn whether you are reaching your goals.

I have a couple of comments about weight loss as a goal. First, it is not a particularly health oriented goal, so I don’t like it much. As long as you are sort of close to “normal”, other factors (especially physical fitness) are much more important than the reading on the scale. There is some evidence that, as long as you are physically fit (i.e., good aerobic capacity and strength), obesity might not be a risk factor for death, disease or feeling poorly. The scale does not tell you what you are made of, your body composition. Most people who do a lot of strength training are overweight on the charts, but have low body fat. Increased levels of body fat are more risky than similar increases in body weight. Many people find that improving their diet and exercise pattern does not change their weight as much as it changes how they feel, their physical capacity and how their clothes fit. Muscle is denser than fat, so patients usually tell me their clothes are fitting looser even when their weight has not changed significantly.

Third Step - Early Success

To maintain and build on a change we need positive feedback. If you try to do too much, feel horrible while doing it and feel worse the next day, how likely are you to try it again?

Creating those specific, achievable goals helps you set in motion a positive feedback cycle. You met your goal. What you did made you feel better. You felt good because you met your goal. You then want to keep it going. It is vital to let yourself feel good about your accomplishment. CELEBRATE YOUR SUCCESSES!

Short-term vs Long-term Goals

Tied closely to the concept of early success is the distinction between short and long-term goals. If you are only going to be satisfied when you have gone all the way from couch potato to triathlete, you are going to be unhappy for a long time and probably never going to become a triathlete.

Short-term goals are the steps on your path. Long-term goals are the destinations to where the path leads you. If you think only about the beach, you are going to get lost on the path through the jungle.

Taking Action

Implementing your strategy requires determination, but it also demands gentleness. Living with a drill sergeant is not going to work, especially if YOU are the drill sergeant. For some patients I need to be a cheerleader, doing everything I can to convince them of the need for change and applauding their positive steps. For many others, particularly those who are less healthy than they used to be because of age, illness or they just let themselves go, I have to work hard to reign in their over-enthusiasm.

Particularly with exercise, it is very easy to do too much too fast. The consequence is often an injury, and the time then needed for recovery often sets the patient further back than she/he was to begin with. You will make the fastest progress by going slow. When increasing physical activity, I tell all but the youngest, strongest patients to increase EITHER intensity or duration by 10% a week.

The other side of it is that changing several problem areas in your life at the same time can be very good and a highly successful approach. Diet changes in particular are often most successful when they are dramatic. You feel better quickly and that experience helps you do more. As you feel the benefit, your commitment will be stronger and you will have more energy to do more to feel better still.

The greatest wisdom is in simply paying attention to how you feel and adjusting accordingly.

Failure

The road of excess leads to the palace of wisdom - William Blake

Failure is good. It is good because we have to make mistakes to learn. When I see a patient who has not implemented my recommendations I always want to know why. Actually I have to understand why they failed, in order to help them go further. Problem-solving is an inevitable part of doing anything new. If I recommend swimming for a patient with back trouble as the best exercise for her condition, but she can’t swim, what is the point? If a patient has not been using the breathing exercise I recommended because he did not understand it, I need to make it clearer.

The only real mistakes are those that we do not learn from. Mistakes teach us how to correct our course before we get way off track. If you haven’t made mistakes, you haven’t been trying.

This video talk is exceptional. You will find it interesting and surprising. The presentation style is very cool and the information is accurate, overlooked and extremely important.

Pooh-poohing Mind-Body Interaction

I surprise patients some times when I tell them that I do not believe in what is often called “mind-body interaction”. My explanation, though, convinces them not to run away and look for a different doctor. The idea that thoughts affect the body and physical disease alters emotions is right, but also very wrong. This concept falsely splits us apart.

The truth is that the brain is in the body. Every time I look at my books, there it is. The same was always true in anatomy lab, as well as looking at MRIs and CT scans. Despite this incontestable fact, there are those who view habits of thought as entirely divorced from biochemistry and physical health.

The problem starts on the medical side. A doctor tells a patient that the tests are normal. Therefore, there is no problem or the problem is 100% emotional. Go away and fix yourself. This ignores the limitations of our testing and allows us to abdicate our response to provide help. We fall into this trap out of ignorance at times, deluding ourselves into believing that thoughts are not biochemical, produced by and creating our physiology. We know better. MRIs show that the physical structure of our brains change after going through psychological counseling. Proteins, hormones, immune factors, and alterations in the levels of a broad range of the compounds normally found in our blood, can all have subtle and lethally dramatic impacts on our brains’ ability to function, including thoughts and feelings.

On the patient side, recognizing the importance of right thinking tends to lead to blaming the victims of suffering, including themselves, for getting sick. Thoughts and feelings are supposed to be all powerful from this view point.

My experience is entirely at odds with both of these limited perspectives.

Regardless of whatever spiritual radiance/vitality we manifest, our bodies always break down. The Law of Entropy applies to everything in the material world. You can do a lot to make your life healthier and better, but not forever. Responding to an influenza infection, your body will work as hard as it can to create massive quantities of immune factors to save its/your life. Those immune factors make you feel tired and alter your brain and thinking.

Honestly, I can not figure out how to separate mind and brain enough to determine which is changing the other. In reality they are one, influencing and influenced by everything. Managing stress, thereby improving the quality of your life, is an excellent idea if you have cancer, heart trouble, depression, any other disease, or even if you are well. Meditating increases telomere length, and then probably how long you will live. Being angry cuts off the blood supply to your heart and kills far too many people every day.

This is not New Age, airy fairy, trivial or simply about living a beautiful life. It is quite predictably a matter of life and death. The only part that is unpredictable is the due date.

Building on that perspective -

Sudden cardiac death risk and emotion
Considering the effects of emotion on physical health, death is about as meaningful an outcome as one might imagine.

Swedish investigators recently determined to do something about what we know (BRAVO!). They took 362 patients who had been discharged from the hospital after a heart attack or a procedure to increase blood flow to the heart, and randomly assigned them to usual care with or without twenty sessions (2 hours) of small group cognitive therapy focusing on stress management. Patients in the counseling group were over 40% less likely to have any cardiovascular event (like a heart attack) and 28% less likely to die for any reason. It is notable that these effects were seen despite an absence of differences in the traditionally recognized risk factors (cholesterol levels, cigarettes, etc) between the groups.

Scientifically, this extremely impressive result should be confirmed but as far as those of us living in the real world, it is absolutely certain that if you do not want to die from heart disease or at least live as long as possible, you MUST become a master at stress management.

Preventing Sudden Cardiac Death

Women are less prone to heart attacks than men, but just barely. Unfortunately, the symptoms they suffer are often not as easily recognizable as caused by their hearts, and often they have fewer symptoms. We have much less research on women and heart disease than we have on men.

Sudden Cardiac Death (SCD) is much more common in men than in women. You probably know of someone “who just dropped dead” one day unexpectedly. Usually this is a surprise, coming out of the blue in the sense that most victims of SCD have not been diagnosed with coronary heart disease. However, it turns out that a lack of diagnosis does not mean absence of disease. At autopsy, the hearts of SCD victims usually show evidence of previously unrecognized coronary heart disease, suggesting that some of them ignored or did not recognize symptoms caused by their heart trouble. Others, especially women and diabetics, are prone to unusual symptoms and might not even have any pain.

What are the usual symptoms? Crushing left sided chest pain “like an elephant sitting on my chest”. The pain can extend to the left arm or jaw. Physical activity, emotional upset and eating can worsen the pain. The heart will often beat rapidly or irregularly. Shortness of breath, sweating and dizziness are also common symptoms. Of course, each of these can have other causes, but you should not assume that the cause is minor.

Prevention is always the best idea, and studies of SCD are giving us useful ideas. Fortunately, the major risk factors for SCD are the same in women as in men. Harvard investigators dug into data collected from 1984 - 2010 in the Nurse’s Health Study to learn what factors might lead to SCD. What they found is really exciting, because it confirms that we are not so powerless against SCD as we had thought.

They found that following a healthy lifestyle dramatically reduced the risk of SCD. The factors they considered were avoiding smoking, keeping weight down, averaging more than 30 minutes of exercise daily, and eating a Mediterranean type diet (lots of veggies, nuts, beans, fruit, fish, whole grains and moderate alcohol). Women who did one of these right cut their risk of SCD in half. Add another and the risk was down 60%. Following three of these four wise health practices lowered risk by two thirds and a clean sweep of all four lowered risk of SCD by a dramatic 92%. Looking at the data the other way around, they found that fully 81% of the Sudden Cardiac Deaths were attributable to lifestyle factors.