Lifestyle changes, cycling and normal…

Tonight, let’s talk a little about ‘normal.’

Nearly every weekend in the fall, during cyclocross season, I line up with a cadre of other men who look as though they desperately need to “eat a sandwich.” You look around for calm and all you see are ribs and hip bones poking through spandex. Seriously, these guys are ridiculously skinny. One of them tells me he drinks protein shakes to keep his weight above 135 pounds.

This is the weekend scene. It’s much different from what I see Monday through Friday at work.

Which is normal?

To explain where I’m going, let’s go under the tape for a spell. It’s a little circuitous, so allow me some leeway. I’ll get back to cycling and ‘normal’ at the end.

You well know that I am hell-bent on promoting the value of stacking together small lifestyle choices. If you followed me in the office for a day, you would might think…this is one scratched-up disc. “He says the same stuff over and over and over again.”

It’s true. The message is repetitive. In fact, my yearly follow-up patients often say I told them the same thing years ago. That’s the thing about recommending lifestyle changes: it’s time-tested.

To bolster my message, I’m always on the alert for studies that support the view that wellness sprouts from simple choices—not pills or procedures. Take this one from today: The British Medical Journal reports an analysis that says folks who eat real fish, not fish pills, have better outcomes. See what I mean? Simple stuff, not pills.

The problem with relying on evidence-based reasoning comes when studies don’t (seem to) support your view. Here, there is a choice: ignore the negative study or face the results head on.

The Look Ahead study:

Last week, as reported by theHeart.org, the Look Ahead trial was stopped because of futility. After analyzing five-year data, researchers concluded that a program of intensive lifestyle interventions in adult onset diabetics would not ever be able to reduce adverse cardiovascular outcomes, like heart attacks, strokes or death.

The study randomized overweight middle-aged diabetic patients to either an intensive lifestyle intervention program or standard education. Those on the intensive program had a lot of advantages: pre-packaged healthy meals, sessions with nutritionists and personal trainers and other ancillary health classes. Let’s just say this group was seriously encouraged to help themselves.

The results:

Yes, intensively prodding unhealthy patients resulted in statistically significant improvements in weight, fitness, levels of hemoglobin A1c (a measure of blood sugar control) and blood pressure.

But, no, these improvements did not result in fewer heart attacks, strokes or hospitalizations.

The spin:

The exerciser naysayers rejoiced. So did the establishment of ‘treaters’, who basically said…see…we told you all: lifestyle changes are not enough. Patients with lifestyle-acquired diabetes will need medicine and perhaps even stomach-stapling surgery.

My take:

This health blogger says not so fast establishment. Let’s take a closer look at what really happened in the study. How could significant improvements in fitness, weight and blood pressure fail to reduce outcomes?

Now I’m getting back to normal—and cycling.

The problem with the study was one of absolutes. Statistically significant–but tiny–improvements in weight loss left subjects still way overweight. Likewise, fitness improved but subjects were hardly fit; and blood pressure was reduced but the changes were paltry. In other words, the intensive intervention program barely changed these people. Though better, they were still a long way from toeing the line in a bike race or 10K.

My cardiology colleague and fellow blogger on theHeart.org, Dr. Melissa Walton-Shirley, captured the much-ado-about-doing-nothing study with panache: (emphasis mine)

At the beginning of the trial, “Rhonda” weighs 185 pounds. At the end of four years of “dieting and exercising,” she still weighs 175 pounds. Who in their right mind would think that’s really going to make much difference? She’s still overweight. She’s still diabetic….She looks nothing like the gaunt Paleolithic-appearing Dean Ornish, who hasn’t had a gram of fat in 40 years, and she doesn’t look like someone who drank the sugar-free Kool-Aid offered by Atkins…

…Let’s face it, 95% of type 2 diabetics could be cured if they achieved a weight that made their neighbors question if they were dying of something. In America, we are not socialized to accept a really healthy weight. Instead, we’ve been raised on the Hansel-and-Gretel diet, made to clean our plates or our drive-through wrappers until our fat little fingers are just plump enough to appease our penchant for a sedentary lifestyle and distaste for denying ourselves anything. The unpleasant fact is that the typical American smorgasbord has been far more effective than (terrorism) will ever be in destroying our population. Until we change our trial designs on diabetes and lifestyle and dietary changes, our country will continue to spiral downward into a sinkhole of debt and death. Healthcare reform will mean nothing and healthcare reform will do nothing until we “get it.”

You may think these words are harsh. I don’t. Blindness, amputations, dialysis, heart failure and impotence–from diabetes—that’s harsh.

So yes, cycling friends, your neighbors might think you are dying of something.

But to cure chronic diseases, like diabetes and heart disease, normal people are going to have to look a lot more like you. Indeed, you are the normal ones.

Dang it.

I’m still hungry. I want a sandwich.

JMM

9 comments

  1. Nice blog! Love to read your stories.
    Greets from the Netherlands

    JB van Rees
    Cardiology Trainee
    Leiden University Medical Center
    the Netherlands

  2. Thanks John, a very good read as always. I feel a little more normal now.
    But 135 is WELL beyond my large bony frame … I’ll settle for 160-165.

  3. So maybe insurance co.’s award those with a healthy weight and blood work! In this day and time I can’t understand how these data crunching insurance co’s can’t honestly and effectively encourage patients to adopt a healthier lifestyle. They have the technology but maybe there’s no enhanced earning potential in doing so. hhuummmm,,,

  4. As usual, I love your take on all the ‘spin’ and superhype and subhype. I saw that study, and as an overweight diabetic with CAD, I wanted to embrace it. But a part of me knew it had ‘red flags’ all over it! Thank you for sorting thru the emotional baggage many of us carry and laying it all right out there.

    As a retired NP, I knew what to teach my patients, I knew where they would resist, and I also know I use my own denial of disease to give myself permission to NOT do what I teach.

    I am printing your response to the misinterpretation of the study in BOLD print as my own daily reminder that at this stage, it really IS “all in my own hands!”

    Lynn

  5. John,

    I suspect you and your skinny cycling buddies didn’t get fit because their doctor told them so. They probably have their own inner motivation that drives them to stay healthy.

    The real message of the Look Ahead trial isn’t that weight loss isn’t good for you, it’s that our best efforts as physicians trying to intervene aren’t working. Maybe doctors shouldn’t be graded on office BMIs and hemoglobin A1C measures. Maybe we should be judicious about pouring resources into futile efforts to change hardened behavior habits. I’d welcome more research into motivating behavior changes, but at this point, we don’t seem to have the answers.

    I see no reason not to continue to preach healthy leaving in the office. We just need to be realistic about how well this works. Sometimes medications really are good for you.

    Jay

  6. Good stuff! Also a fellow cyclist, I went totally vegan several years ago and I severely limit processed foods. My motivation is fear of what I see the health…oops, I mean the sick care system becoming after serving it in for the past 35 years….oh yea, and I like to ride my bike fast. The other day someone(overweight, Db) in my office told me I looked frail, one of my colleagues who is at least 25 years my junior jumped in and said with conviction….don’t mess with Barbara, she’ll kick your butt! I think that says it all!

    1. Lisa,

      Thanks for saying. I had thought about your response while writing this post.

      You know that as an advocate for health-through-good-choices, I don’t think anorexia is anything but a serious disease. I also recognize that self-image issues are real.

      The thing that I wanted to emphasize is that our new normal has run amok. I was at a conference of primary care doctors this weekend. They were arguing about micro-managing sub-particles of cholesterol. I thought to myself: how many patients not at goal LDL/HDL are physically-fit and look like bike racers. .00001%

      When I was in Europe this summer it was as if a different species of human existed–at least compared to that which inhabits the South-eastern US.

      We need a new normal.

  7. Granted, it was a cheap shot. But so were most of the sharp criticims of your colleague. Boomers didn’t sign up for the clean your plate club. It was a government health initiative that was forced on us when we were in grade school. I could write a novel here and that rould be rude, so I’ll refrain. It doesn’t surprise me that the study failed to produce the desired outcome. Type of diabetes and obesity are much more complex than even most doctors want to believe. Weight has a similar genetic disposition as height, yet no one has ever said to me “if you would just grow another 5% of your height you can cure diabetes.” Even if I was able to lose enough weight to control my diabetes with diet and exercise, I would still be diabetic.

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