Dr John M

cardiac electrophysiologist, cyclist, learner

CW: Athletes teaching heart rhythm doctors?

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What could competitive athletes teach a group of heart rhythm specialists?

Cyclists, runners and yes, even triathletes, know something that we wizards too often forget. I’ll tell you what it is in good time. Keep reading.

I just returned from a giant gathering of heart rhythm doctors. It was, as all national meetings are, an incredible learning experience. You come back motivated and ready for action. (The cycling equivalent would be watching tapes of Paris-Roubaix before a big crit. For tri-peeps, think of the Dave Scott/Mark Allen duel in Kona. Seriously, that was an epic battle of inflammation.)

Sub Q ICD

My Heart Rhythm Society really knows how to put on a show. They recruit wonderful speakers, accept exciting scientific papers and hold too-numerous-to-count practical sessions for us regular docs. And…as an industry-intensive specialty, all the latest innovative technology is available for hands-on exploration. Just walk up to a booth and in seconds you are holding a futuristic ICD—one without leads in blood vessels!

But for all the glitz, I continue to be disappointed in the lack of interest in my passion—the advocacy of healthy living through good choices. Athletes understand this well, but us tech-heavy doctors, not so much.

I found not one abstract, poster or oral presentation on the importance of fitness, healthy lifestyle and what smart people like to call primordial prevention. Heart rhythm doctors crave news about burning, installing and medicating a disease that’s already happened. It’s ironic that much of what I treat day in and day out may have been prevented.

An athlete wouldn’t think about not exercising every day. You punish yourself for eating a cookie. You like sleep because it makes for better muscle recovery. Some athletes even have rules about drinking Coke: I’ve heard nutjob cyclists who allow themselves a cold Coke only when two criteria are met: after a hard-fought bike race or after a three-hour training ride.

Lots of small choices pay big dividends.

I saw this patient recently (a former athlete gone soft with birthdays) who has been introduced to middle age by the new onset of atrial fibrillation. I saw her for consideration of catheter ablation. Really? That fast? Not in my practice. My patients get the lecture before this:

That's a lot of burns!

She has done well managing her disease: she cut down on caffeine and alcohol, improved her sleep hygiene, carved out time for exercise and now focuses on avoiding last-minute cram sessions for projects. Her arrhythmia has improved without medicines and based on these good choices, an invasive procedure was wiped off the table. Granted, it doesn’t always work this nicely. But sometimes it does. This blawger’s opinion is that doctors too often underestimate the value of athletic lifestyle choices. Rather, we do the easy and evidence-based thing: pull out the prescription pad or recommend procedures.

Imagine the effects on public health if young people implemented this patient’s strategy. Remember, the same behaviors that prevent atrial fibrillation also lower blood pressure, control blood sugar, modulate cholesterol, improve cognition, prevent cancer and even help the environment. It’s a tired analogy to invoke auto maintenance; but it’s true. Electrical disorders frequently result from years of poor body maintenance.

Though we heart rhythm doctors bask in technology and worship engineering prowess, we must remember that we are still doctors. We have the capital to influence our patients’ decisions. We aren’t their moms, but we can be their teachers.

Athletes do the little things. They know the benefits of good preparation and long-term maintenance of the only body they will ever have. As an athletic doctor, I want to teach my patients that. I want to write about it. I love technology, and the fury of medicine, but I also love it when I don’t have to use it.

JMM

CW: When old (primordial) news makes big news.

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It’s 2012 already. Time flies; doesn’t it?

It seems like just yesterday when…

I started this business more than two decades ago. A time when cell phones hadn’t even graced James Bond movies; we got up to change the channel on TV and the world health concern of the moment was a Hunger Games-like scenario induced by a US-USSR confrontation. That was a long time ago indeed.

Let’s think back to medical school lessons circa 1985. One of the first tenets we learned was that hardening of the arteries led to heart disease, and this slow steady process begins in childhood.

Though Medicine has come a long way in the past two decades, I’m left wondering what it means that major journals continue to publish–and major heart meetings still feature–trials that retell the long-known and obvious story of how heart disease takes hold.

Specifically, I ask myself how it is news that making basic healthy lifestyle choices in childhood pays huge dividends later in life? Is it really that stunning to read in this Circulation study from Finland that kids with the highest scores in the AHA’s big seven features of health had better blood pressure, less obesity and more pristine carotid arteries as adults?

Here’s another of the featured presentations at this week’s ACC. As outlined in this theHeart.org piece, researchers from Detroit boldly conclude:

“Lowering LDL [bad cholesterol] early in life has the potential to reduce coronary heart disease to a far greater extent than starting treatment later in life—the current standard practice.”

Imagine…those with lower levels of bad cholesterol since childhood did better as adults. (Of course, the most interesting question here is whether achieving low cholesterol levels with drugs equals just having it because of exercise, diet and good genes. My hunch: don’t bet that the means achieve the same ends.)

This throwback stuff reminds me of my old collection of ties. What’s old always seems to come back around again. Gosh folks, the idea that eating too much (even chocolate) and moving too little causes heart disease is ancient. I just can’t remember basic common sense studies like these two garnering this much attention in years past. Maybe it wasn’t an issue when kids still had daily gym class, personal computers barely existed and heart docs were too busy studying Swan-Ganz catheters as treatment for heart attacks.

But times have changed. Smart people, no check that, really smart people are starting to use really complicated terms for the basic program. Masters of the obvious call daily exercise, smart food choices, good sleep hygiene and an upbeat optimistic attitude, ‘the program’, or ‘the plan’. Academic types now have named ze plan: ‘primordial’ prevention.

Until recently, most of us thought about only two kinds of prevention of heart disease, primary and secondary. Secondary prevention means treating all the risk factors of heart disease after a patient has suffered an event. Things like prescribing statins, beta-blockers, ACE-inhibitors and aspirin; treating high blood pressure and maximizing LDL levels are all strategies known to reduce the chance of a second heart event. Similarly, primary prevention implies treating the same conditions in an effort to prevent the first cardiac event.

Primordial prevention comes before all this. Overqualified heart doctors call such strategies, ‘upstream’ treatment. In real words: to primordially prevent heart disease entails taking basic actions (move, eat less, sleep and smile) to prevent the causes (of the causes) of hardening of the arteries. Primeval maneuvers, or ‘small choices made every day,’ beginning in childhood, slow the onset of diabetes, high blood pressure and elevated cholesterol—the main diseases that cause heart disease.

Just like we learned way back when. Like Mr Berra said:

”It’s déjà vu all over again.”

In conclusion, I’ll leave with this final thought: Perhaps we need more scientific inquiry into effective and novel means to incent folks to embrace primordial prevention. Solutions here will be tough, as they will require cooperation on many fronts. Wisdom from doctors forms only a small part of the solution. Positive changes will have to happen at the community and economic level. (I know; the bike path argument sounds progressive.) To replicate healthy communities like San Luis Obispo, Boulder and Hamburg Germany on a grand scale won’t be easy. For if it was, heart docs would have more time to blog.

JMM

Saying No to the Polypill

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The tweet said that experts were debating the merits of a polypill? I had to click that link.

Yes. I was right; there were actually “eminent” cardiologists suggesting that a pill containing 4 different medicines (a statin, aspirin, beta-blocker and an ACE-inhibitor) “might change the face of cardiovascular medicine.”

The direct quote from Dr Salim Yusef, one of the most eminent heart doctors, went like this:

“We have to think of the polypill not as a pill, but as part of a strategy to completely change our approach to prevention,” said Yusuf. “Instead of saying lifestyle first and drugs next, why don’t we say that drugs are the basis, then get the patients contemplating prevention, and then get them to modify their lifestyle. Maybe that will work, because the reverse strategy hasn’t.”

Maybe it was jet lag?

Sometimes I wonder how it would be if I were really smart. Would having all that brain power blur the fact that a pill would never be better for our hearts than going to bed on time, eating less food, treating people kindly, and carving out 20-30 minutes a day to simulate chasing food down, like our ancestors did before there were triathlons and personal trainers?

Don’t get me wrong; if you have heart disease, like many of my ICD patients, there is little doubt that those four medicines—along with a healthy lifestyle—will prolong your life. Smart people call this secondary prevention. I call it “the plan,” or “the program.”

But if you don’t have heart disease, the best way to avoid getting it is so simple, so easy to understand and so not up to your doctor.

That’s it, I am taking a stand: put me down as strongly against the idea of a polypill, regardless of the p-values.

Put this B-student down for not giving up on the idea that pills should never be the basis of preventing heart disease. Call it mean if you will, but I believe that people, not doctors, can make the greatest impact on reducing the burden of heart disease.

JMM

Disclosure: I wrote this piece shortly after participating in an amazingly uplifting two-hour cyclocross practice. That, my friends, can be called bias.

Reference: Experts debate merits of polypill, by Michael O’Riordan, www.theHeart.org.

 

Happiness: the fourth leg of heart health

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He was dressed causally in jeans, a loosely collared shirt and a near perfect tan, as if it was happily acquired outdoors, not in a tanning booth.

This Monday morning on GMA, Dan Buettner, a member of the crazed ultra-endurance cycling fraternity sat before millions of viewers, with the perfectly coiffed George Stephanopoulus, and proclaimed the tenets of happiness.  As if they were previously unknown.

Since heart disease is most often related to inflamed arteries, sticky platelets and adrenaline-sensitive rogue cardiac cells, it seems the soothing-ness of happiness is a highly pertinent topic. Along with good food, good movement, and good sleep, being happy forms the fourth leg of heart health.

Mr Buettner is accumulating fame and fortune pointing out the obvious. Of this I am a fan.  Like good doctors, he is providing simple messages.

Here is a sampler of some of his advice:

On being happy at work:  He says to make sure you have a work buddy—a best friend. Cultivating healthy relationships at work makes us happier.  Cardiologists and general surgeons take this to heart.  Wink.

Since a common complaint about work is the commute, he suggests living close to work. A 2 mile commute through a city park is better than a 2 hour criterium-in-a-car. Regularly shouting to yourself, about the unfocused driver ahead, “Shoot that gap, idiot,” probaly isn’t that good for one’s arteries.

On socializing: And this one is a shocker: Mr Buettner recommends socializing seven hours per day. In this realm, health-care workers are in a sweet-spot. This should be great news to current nursing and medical students.  Moreover, the young should be happier–as they are capable of doubling their socializing time by ‘e-socializing’ at the same time as they socialize in person.

On picking friends; ‘Friending’ happy people is best.  Like the REM hit, Shiny Happy People…holding hands, laughing, singing, spreading love around, probably counters the signing of pre-authorization forms, the ‘talking’ to cubicle people and the farce of quality measures where everyone reaches 100% by placing a sticker in a chart, signifying that some core measure was done.  Oops, that wasn’t very friendly.

On neighborhoods: Mr Buettner suggests living in a neighborhood with sidewalks. Those with jobs devoid of significant socializing will need sidewalks to make their daily quota. It’s funny how atrial fibrillation and coronary disease easily penetrate the security measures of gated neighborhoods.

On money matters: It seems that those who save, pay down debt, and live within their means are happier than those who consume. Thoreau said this too, but he didn’t seem all that shiny or happy—just wise.  Isn’t he saying, “Be careful what you own or it will own you.”  Isn’t that as obvious as don’t smoke or over-eat?

To women, on picking a mate: He suggests women are happier with men who are more oriented to family than riches. No comment needed here.

To those who love pets: (He is a best-seller for a reason.)  Dog ownership makes one happier. “There is something about petting a dog,” he says. Last week, upon entering the patient’s room, the yippie dog almost got loose on the cardiac ward.  He was a certified therapy dog, I was told, as if I missed that journal article.  (The hospital rocks, who knew that dogs were MRSA-free.)

On liking yourself:  He suggests building a personal shrine in your home. A place where you can post pictures, diplomas, and awards. “Hey, don’t throw that third place Ohio Valley Cyclocross plaque away.”  A shrine to yourself; he didn’t say start a blog, did he?

Like living heart-healthy, living a ‘happy’ life requires seeing, and then doing the obvious.

Unfortunately, in this era of much, contentment is often well camouflaged.

In aiding others pick a better mate, in highlighting sidewalks over gates, in encouraging collegiality at work, and in promoting Thoreau-istic living, Mr Buettner helps the fight against heart disease.  This should make him happy and heart healthy.

As long as he doesn’t get AF from those 15,000 miles rides.

JMM

Liquid plumber, Pacman and Heart disease…The Anacetrapib story

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It beats 100,000 times per day. It pumps liters of blood per minute. If it stops, you stop, in about six seconds. For the human heart to contract this reliably, without hiccups, it requires a steady stream of nutrients. A healthy heart has clean pipes.

There are two ways to keep pipes clear of blockage.

Option A: Not put stuff in them that would block them off. For most, in this land of plenty, this isn’t really a viable strategy.

Option B: Periodically clean the debris out.

Presently, in cardiology, pipe cleaning is the territory of the “squishers.’ Mechanically, they squish blockages, suck debris out, and prop the pipe open with metal cages called stents.

But in the future, perhaps as early as 2015, pipe-cleaning may be the province of spectacled biochemists, rather than quarterback-like interventional cardiologists.

Such chemical unclogging, call it the “liquid plumber” method, was the big story from this week’s AHA meeting.

The magic pill’s name is anacetrapib. It is an experimental HDL (good) cholesterol-increasing drug, developed by Merck. I use the term magic, because the impact on HDL levels is like magic. Exercise, previously known as the best way to increase HDL, can raise levels 5-20%. Anacetrapib resulted in a 138% rise in HDL. As icing on the cake, it also lowered LDL (bad) cholesterol by 40%.

Why is this so exciting? It isn’t squishing, burning, or shocking; it’s a pill. How could a pill be that cool?

Here’s why.

HDL is thought to be good cholesterol because it acts as a scavenger—like in Pacman.  HDL removes plaque-building bad cholesterol from the artery wall and transports it to the liver, for processing. More HDL particles is like having more Pacman. (Is it a coincidence that Pacman turns thirty this year?)

Science is funny though. Just because high HDL levels are good, doesn’t mean that raising their levels with a chemical will also be good. In 2006, Pfizer found this out the hard way, when their HDL-raising drug (torcetrapib) flopped. Yes, Pfizer’s pill increased HDL, like it was supposed to, but it also increased the risk of heart attack and death (ouch). It was an 800 million dollar debacle.

Although in the same chemical class, Merck’s drug, anacetrapib, is felt to be different than Pfizer’s, torcetrapib.  Opposite to its predecessor, in the preliminary (1600 patient) DEFINE trial, anacetrapib did not increase blood pressure or the risk of heart attack.  In fact, as a secondary endpoint there were fewer cardiac procedures in the ‘liquid-plumber’ (anacetrapib) group.

Ironically, I was on my trainer, exercising, raising my HDL, when my interventional cardiology colleague called me back.  I had called him for his take.

He was serious, when he bemoaned that if this pans out like some predict, Merck’s version of liquid plumber may put him out of work.

Looks like we will find out in a few years.  A 30,000 patient randomized controlled trial of adding anacetrapib versus placebo to atorvastatin is set to begin enrolling patients.

It is exciting news, but for advocates of exercise, the message is worrisome.  A pill is better than exercise.  That one will be hard to swallow.

JMM

Good journalistic pieces on the DEFINE trial are at:
Ron Winslow’s WSJ story.
Larry Husten’s Cardiobrief blog
h/t to Will and William for the Pacman and Liquid plumber reference.

Get smart

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As if we need more evidence that schools should bring back daily gym class.

Researchers at the University of Illinois studied 9-10 year-old children with MRIs (no radiation exposure), VO2 treadmill testing, and memory evaluations.

Their findings should spank those in the educational elite who give regular gym class only lip service.

“Dr M, you are an electrophysiologist, you took zero education classes and thus, you don’t know squat about educating children.”  That may be true, but I understand science, and am on the front lines of America’a struggle with fatness, which we are decidedly losing. So let me tell you about this important experiment.

Here’s what happened. First, the kid’s fitness was quantified by treadmill exercise tests. Maximum oxygen uptake cannot be faked. Then, they had head MRIs to measure the volume of the hippocampus—a funny-sounding name for a part of the brain that is known to be important in memory and learning (and some think hyper-activity.)  Finally, for the not-so-fun part: the kids underwent memory testing.

There were three important findings:

  • Physically-fit kids had significantly larger hippocampal volumes.
  • More physically-fit kids had stronger relational memory skills. In other words, they learned better.
  • Importantly, on statistical analysis the link between physical fitness and better memory revealed that hippocampal volume was the key element.

These findings are both believable, and important from a public health standpoint.

It has been previously shown in animal studies that aerobic exercise increases cell proliferation in the hippocampus. And in elderly humans, recent evidence suggests aerobic fitness is associated with larger hippocampal volume and superior memory performance.  And now we have real data in children.  The researchers give us the following conclusion: “The(se) findings are the first to indicate that aerobic fitness may relate to the structure and function of the preadolescent human brain.”

As a cyclist who witnesses the sadness of genetic limitations all the time, I found this quote from the senior author very intriguing (emphasis mine),

The study suggests that taking steps to increase childhood physical activity could have a significant effect on brain development, Kramer said.

“We knew that experience and environmental factors and socioeconomic status all impact brain development,” he said.

“If you get some lousy genes from your parents, you can’t really fix that, and it’s not easy to do something about your economic status. But here’s something that we can do something about,” Kramer said. 

Taking on fatness will require the collaboration of many facets of society. Educators will have a prominent role.  Hopefully, studies like this one will help debunk the common myth that there isn’t time for regular gym class.

“Kids, we have gym everyday; it will make us smarter.”

JMM

Statins are so misunderstood…

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The medical assistant who checked the patient in tells me,

“Dr Mandrola, this guy had coronary artery disease since the 1980’s.  He is 90 years-old now, and his only medicines are that statin and aspirin.” 

One of the more common questions that arises in cardiology is whether a person should take a statin drug. Despite the fact that statins are the most widely studied drug in the history of mankind, there remains widespread misinformation on their use.

Such angst was on full display in the comment section of a recent post from the well known medical blog, KevinMD.  Dr Eric Van de Graaff, a cardiologist and blogger, submitted a very informative and well written piece on the use of statins for the prevention of stroke and heart disease.  (A must read for doctors and patients alike.)

Dr Van De Graaff made many salient points. First, he tells us about the enormity of the science behind the use of statins. No drug has been studied more. He correctly said that in high-risk patients, especially those who have already been diagnosed with blood vessel disease, statins are unequivocally beneficial.

Dr Van De Graaff knows that just saying that statins are scientifically proven to benefit high-risk patients will not be enough for the throngs of nay-sayers, especially those who offer their products to sell.  Thus, he goes on to point out how these drugs were proven successful. In easy to understand language, he explains that the studies (of 120,000 patients) proving statin’s benefits were of the highest scientific rigor: they were prospective, randomized, controlled, and double-blinded.

Even after this fair and balanced piece on statins, the comments illustrate the public’s tremendous misinformation on statins. We read that doctors overly rely on medicines, and we under-emphasize prevention. (They should ask my overweight patients.)  Even a doctor commented, “I’ve read much of the evidence and I am not convinced.” In her psychiatry practice, she had three patients with possible statin side effects, so she is dismissing the data from 120,000.  Yet another doctor who had a unrecognized statin related side effect admonishes us to “consider ramifications of the most important enzyme pathways in our bodies.”  

Confusing the public with medical misinformation really fires me up. And even more inflammatory is that many entrepreneurs use such misinformation for personal gain.

I have written about statins in the past, and as long as the shark-cartlage-for-health-dot-com-like sites continue to spread misinformation, or, the anecdotal reports of this side effect or that side effect speak louder than the truth, I will be motivated to write.

In an effort to spread the truth about prevention of heart disease, I give you this list of statin-facts…

  1. Making good lifestyle choices are the most important means of preventing heart disease. Eating well, sleeping well and exercising daily should be a given. Good doctors will tell you this, but they shouldn’t need to.
  2. Drugs, procedures or surgery should never replace good lifestyle choices. Taking a statin to counteract cheetos is utter nonsense.
  3. Statin drugs lower cholesterol levels, but this is not likely the primary mechanism of cardiovascular benefit. They are vascular anti-inflammatory agents that work at the blood vessel wall. 
  4. In patient’s with high a risk of heart disease (those with risk-factors like genetic predisposition, diabetes, high blood pressure or smoking), or in patients who have had a vascular event (stent, heart attack or stroke), statins are scientifically proven to be beneficial. The science behind this is second to none.
  5. Even though science proves the benefit of statins in the secondary prevention of vascular events, it does not mean they are devoid of adverse effects. It just means that the side effects are greatly outweighed by the reduction of events (in 120,000 patients.) 
  6. These same trials showed that the side effects of statins were very similar to those of placebo.  Do the nay-sayers tell patients this?
  7. Adverse effects of statins are rarely if ever life-threatening. However, the disease which statins prevent, heart attack and stroke, are definitely life-threatening.
  8. Statin side effects are real, and they are clearly higher than what is reported in the literature. Sometimes they can be mitigated by changing to a different statin, but more often than not, they are a class effect, and these patients cannot take them.
  9. Whether statins reduce CV risk in patients whose only risk factor is a high cholesterol is not clear. Low risk patients have such low event rates, that is hard to show a benefit of any therapy. Statin-enlightened doctors know this. Patients could ask, “Doc, high cholesterol is my only risk, do you really think a statin will alter my long-term outlook?”
  10. If changes in one’s well being are noted after starting a statin, the drug should be considered as a culprit. This is why there is a doctor-patient relationship, and why doctors should have the time needed to listen to the patient’s story.
  11. When reading about your health consider potential conflicts of interest. We all know about big pharma’s conflicts: they make more money if they sell more statins. To me, such conflicts are self-evident and understood. However, the entrepreneurial nay-sayers are also conflicted. Bashing science-based medicine is a fertile field of business. The statin-bashers will frequently have a newsletter, book, diet or supplement to sell you. Conflicts. Be aware.
  12. Doctors do not financially benefit from prescribing statins. We can’t even use pens with industry logos anymore. Doctors recommend statins because we know that the small risk of an adverse effect is out-weighed by the proven benefit. And as a rule, the higher the risk of an event the more the benefit. 
  13. I believe in patient choice. Patients can choose to forego the benefit of statins, just like they can forego any medical therapy. 

Doctors wish there was no need for drugs.  We wish you hadn’t had a heart attack, but since your endothelium has proven to be susceptible, our goal is to prevent another event.  In addition to good lifestyle choices, a statin drug will clearly decrease your risk.

Sore muscles are unfortunate, but not as much as a heart attack or stroke.

JMM

If I was Surgeon General…

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I would follow the lead of our country’s first Mom.

This is serious folks.

We, as an American society, need to solve the obesity crisis.  Not just for our physical health, but for our country’s financial stability.

Reducing the spiraling costs of health care is wanted by all.  So far, prevention of the diseases which contribute most to our health care costs, (heart disease, cancer and orthopedic issues, to name just a few) has been given only lip service, by our future supplier of health care–the American government.

It turns out that the mechanisms to reduce our most costly ailments are the same as those that mitigate obesity. It is like simple math. (If a=b, and b=c, than a=c.)  If lifestyle choices reduce obesity, and less obesity means less consumption of health care for heart disease and cancer, than better lifestyle choices means less health care consumption.  Bunches less.  It is for this reason, that I believe the most productive way to reduce health care expenditures is to reduce obesity.

Right now, the government and third-party payers are using other means to wrestle the rising costs of health care.  Dr Berwick and his like-minded academics from cocoons like Cambridge plan to reduce costs by rationing care.  Presently, we have the increasingly used covert rationing techniques, like using “doctors in cubicles” who, without seeing the patient, deny tests and procedures.   But soon, there will be no way to avoid overt rationing.   Others think that reducing doctors’ compensation will reduce costs. It will, but the price of this strategy will be reducing access to care for the majority. WItness the VA healthcare system. 

My vision is that we can conquer the obesity epidemic.  Doing so will improve our country’s health, productivity and likely lead us out of the health care morass.

Here are a few components of my plan…

First, some important assumptions:

  • High calorie food and drink are not going away.  Fast-food restaurants with drive-thrus are here to stay.  Coke, Pepsi and the infinite concoctions of sweetened fluids are staying as well. Very easy access to high-calorie inexpensive food is a certainty in the future. 
  • Automation in the work place will continue to make it more difficult to burn calories at work.  The professor and the judge are right about this. 
  • We will continue our evolution into a car-dominated society.  Outside of the unusual places where vegetarians and granola-munching dominate, like Boulder and Bend, it will become increasingly harder to navigate by foot or bike.
  • Society is unlikely to tax junk food like we do for cigarettes.  Although, the benefits of financially discouraging junk food consumption seems obvious, implementing such a tax is implausible and politically untenable.  For example, which foods get labeled junk and which do not, would prove to be a circus.  Baked chips versus regular chips, dark chocolate versus milk chocolate are just two of many vexing examples.  Further, the influence of our snack-food companies, like Coke, Pepsi and Frito-Lay would surely unleash their political fury against such a “regressive” tax, as they would call it.
  • Public education campaigns can work.   The benefits of eliminating smoking in public places has taken hold even in the heart of a tobacco growing community, Glasgow, KY.  I believe with enough effort, reducing fat-creating behaviors is achievable.   

These assumptions provide the background in which we will have to work out solutions.  A multi-prong attack on fatness will be needed.  (Please, feel free to add another prong.)

Prong 1:  Hit em early.

Generational change will be needed.  As such, changing fat-creating behaviors needs to start early.  Pediatric leaders will need to make obesity education and treatment as high a priority as vaccinations.  Excessive calorie intake needs to be targeted at a young age, like measles mumps and other infectious diseases. Surely, obesity is worse than pink eye.  For example, kids naturally stop eating when they are full–this behavior needs to be carried forward, aggressively.

Prong 2:  Educational reform.

Educational leaders need to passionately move forward in teaching children about the new world of available calories and challenges to finding places and time for exercise.  No longer should lip-service be paid to gym and nutrition classes.  Physical education should morph into exercise time.  Invoking the excuse that there is not enough time in a school day for exercise needs to be banished.  Oodles of data show that exercise actually enhances learning.  Junk food should be removed from schools.  There is plenty of room for fame and fortune for those who can make inroads here.  Maybe even a Nobel prize.

Prong 3:   In treating obesity, adult doctors are guilty of passivity.

Simply saying to a patient, “try and lose weight,” is woefully inadequate.  Adult doctors need to be much more aggressive in their approach to fatness.  A high BMI is a high BMI. It is hard data that should be frankly discussed, like blood pressure, blood sugar and testosterone levels.  And, I am not just talking about Kentucky-level obesity, even “bike-jersey” fatness needs to be discussed.  Are you fat?  Put a bike jersey on and look in the mirror.  The answer will be obvious.

Lowering the threshold of discussing fatness is critically important, as catching any disease in its early stages makes therapy easier.  Obesity is no exception.

Prong 4:  A massive public-service campaign needs to emerge.

So far, we have the pediatricians, educators and adult doctors on board.  Now we need the government.  Give the rationing a break for a moment, and let’s work on preventing the diseases which really impact our medical system. With the fury of the “got Milk” campaign, healthcare leaders need to convince Americans (especially in places like Manchester, KY) that drinking sugary drinks, eating fat-laden snack foods and not finding a place and time each day to exercise is dangerous. “You don’t exercise?…Holy cow, that’s bad,” should be our country’s new mind-set.

Here would be one slogan,  “Exercise every day you eat!” 

Prong 5:  Reward objective evidence of wellness and fitness.

Although it would be controversial, it seems self-evident that thinness and fitness should be rewarded.  Twenty years ago, I remember that the sponsor of the Indy half-marathon–an insurance company–offered a discount for those that ran a certain time.  Drastic times call for drastic measures, and so it seems that those with normal BMI’s should pay less.  Sorry if this sounds prejudicial or caustic, but incentives are an important motivator, and none better than money.

Prong 6:  Not finding a place or time for regular exercise needs to be unacceptable.

The message is that we no longer live in a world where kids walk to school and people burn calories at work.  It is a new world, where food is available everywhere. We are not devolving our cities backwards for pedestrian or bike traffic. Therefore, like brushing our teeth and hair are societal norms, so should finding time and a place to exercise.

Implementing such a radical new paradigm will require children.  Children can mold adult behaviors.  They brought us old folks Facebook and texting, so surely they can bring us the new social norm of daily life with exercise.  Our new America will need to look at those that run, ride or walk as the mainstream rather than the fringe.

Business leaders can also help with this new norm.  Forward thinking companies should encourage such a new paradigm.  Many already do.  Our new paradigm of exercise and eating right is good for business as well.

Such a message will take time and persistence, but it is possible.  Isn’t it? 

JMM

Medical innovation cannot cure fatness…

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Possessing great intelligence is not a guarantee for being right.

Judges and professors are surely smart, but the quagmire that is the obesity epidemic can fell the smartest of the smart.  So it is when a professor of public policy and a famous federal circuit judge, author and senior lecturer at the University of Chicago wax prophetically on the topic of obesity in America.

In an opinion piece in Saturday’s WSJ, these two academics correctly point out many important truisms on the obesity problem.  As they eloquently say, society has advanced to the point that regular life burns fewer calories.  That’s obvious.  Not only do people burn fewer calories at work, as they argue, but more importantly, except in health oases like Boulder Co or Bend Or, suburbia makes it challenging to safely commute anywhere without an automobile.  In my representative middle American city it would be unsafe for me to ride or walk to work.  Likewise, my child could not walk or ride safely to school.

On the other side of the obesity equation (the calorie intake side), they also correctly point to the decreasing costs of high calorie food.  Correct again.  The middle of the grocery store–that portion of the store with the highest amount of high fructose corn syrup and inflammatory trans-fat–is increasingly less expensive.  The dollar/calorie ratio is clearly decreasing.

Furthermore, in pointing out the obvious observation: as education on the importance of diet and exercise in controlling obesity has increased, so has the weight of Americans, they argue correctly that lack of knowledge is not the problem.  America knows about obesity.

They also debunk the simplistic myth that taxing junk food will help; as taxing over-indulgence in calories is impossible.

So far, so good.  The professor and the judge are three for three.  But in the last inning of the close game, where it really matters, they strike out with the bases loaded.  I had to read their conclusions numerous times, as it was with great disbelief that such a cogent piece from incredible minds could conclude in such wrongness.

After all their rightness, the professor and the judge conclude that medical innovation may be the most promising solution to the obesity problem.  They make two outrageous conclusions.  (Not counting the false analogy that obesity-related behavior is like HIV-related behavior.)  
  • They argue that medical research will devise a way to minimize the effects of obesity.  Their words speak for themselves.

    • True, if R&D led to better treatment or even prevention of the diseases that obesity gives rise to or exacerbates, including heart disease, joint problems, surgical complications, and especially diabetes, this would reduce the incentive to lose weight. But if most of the adverse health consequences of obesity were eliminated, obesity would cease to be an issue, except perhaps from an aesthetic or emotional standpoint.

  • To illustrate medical innovation, they cite the example of Vivus’s obesity wonder-pill, Qnexa (they misspelled it ‘Onexa’).  Yet, two weeks ago, an FDA panel of experts recommended against approving this pill.   It seems “instant willpower” in a pill comes with the potential for depression, arrhythmias and birth defects.  Such adverse effects were cited as the primary reason for recommending against approval.

At the risk of being considered myopic, it is impossible for me to imagine that we can medically innovate our way out of the obesity problem.  Carrying excessive body fat will always be detrimental to our organs and joints.  Saying that modern medicine can some day eliminate the adverse effects of obesity is simply ludicrous. Any judge or professor who would like to know more about the obesity problem should spend a week or so in a cardiologist’s office.  The wrongness of their present notion would quickly become evident.

Stapling the stomach or taking pills to change brain chemistry are not now, nor never will be the answer to fatness. The solution to obesity is not in medical innovation, but rather in a complete societal paradigm shift.

In solving our fat crisis, a Mom is substantially closer to the treasure than two powerful academics.

JMM

Wonder pill versus good choices…

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I need help.  In dealing with obesity as a medical problem, that is.

I am pretty solid at arrhythmia management, but as an obesity doctor, not so much.  If I was the teacher, and my obese patients were the students, I would surely be fired for poor student test performance. At least, if the core measure was the patient’s BMI.  (But since I live in Kentucky, there would surely need to be a correction factor.)

If a student does poorly on an achievement test, is it the student’s or the teacher’s fault? If the obese patient does not lose weight, is it the doctor’s or the patient’s fault?

Today, in the NEJM, I read about Arena pharmaceutical’s attempt at creating the new “wonder pill” for obesity.  Lorcaserin is a novel serotonin re-uptake inhibitor which acts primarily in the brain centers that control hunger and satiety.  Theoretically, it provides a patient with the good sense not to eat too often, and as the skinny farmer advises, leave the table before you are stuffed.

Although, Locarserin had no major adverse effects, the weight loss was modest, up to 5-10% of body weight.  Thirty pounds is only the prologue for the 300 pound patient.

So, now we may have another pill for fatness.  Like we do for tiredness, and the low sex drive of male middle-agedness.

The study conclusion is worded with scientific precision.  The researchers say, in conjunction with behavioral modification, the drug was effective in weight loss  What people hear, though, and the drug manufacturer are really saying is: take this pill and be thin.

Cynicism is knocking at my door, and I am trying to ignore it.

It is clearly true that obesity is one of the developed world’s most important medical problems.  Paradoxically, while the fury of modern medicine has lowered death rates from heart disease and cancer, the obesity epidemic continues unabated.  The more sophisticated we become as a society, the fatter we get.

As a doctor of the heart, it is crystal clear that lifestyle choices lie at the heart of health. No disease is more preventable by lifestyle choices than heart disease.  And these same lifestyle choices work on obesity as well.  Call it being on “the program.”  Not a diet, the program is a simple concept: finding the groove of enough exercise, wise food choices and adequate rest.

I own only one belt.  It is thick leather.  At times, as I am human, the white-chocolate-chip brownies in the doctor’s lounge get the best of me.  If this behavior persists with any regularity the belt feels tighter.  Thick leather belts do not stretch. The tighter belt says, pedal a little longer and cut smaller pieces of brownie. Doing so restores equilibrium.  But if I deny too much the result is grumpiness. The pattern is repetitive.

This simple formula is the problem.

However, the notion that obesity is simply an imbalance of the equation, calories-in, calories-burned, is not in vogue.  It seems, by saying to the patient, eat less (really, it is sadly amazing how few calories a sedentary middle-aged human needs) and move more, you are at risk of being perceived as judgmental, incurious and even aloof.

If on the other hand you talk about enhanced receptor sensitivities in hunger centers that may be inhibited by sophisticated chemicals, you are smart, and a sensitive doctor.  The obese patient may conclude that poor lifestyle choices are not their fault, rather a chemical imbalance in the brain.  (And maybe this will be proven so.)

I don’t think we should persecute the obese. Malfeasance is bad for the heart.  Nor am I against novel pharmaceuticals or innovative surgery.  But taking a pill or having surgery (that someone else pays for) will always be easier than saying no to white-chocolate-chip brownies.

As we advance in medical technology, the simplicity of making a series of good choices should not be overshadowed by the science of receptor inhibition in the brain.

Surely, doctors should emphasize the program more.

JMM

In heart health, we need more than just education…

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Everyone knows that the heart health of Americans is dismal. Obesity, diabetes, and high blood pressure are all on the rise.

For now, technological advances in cardiac care continue to maintain, or in some cases, lower the death rate from heart disease. Squishing blockages, ablating abnormal heart tissue, and installing cardiac devices have successfully kept the abysmal lifestyle habits of so many at bay. Despite all the fury of modern technology–or maybe because of it–many continue to fail miserably on the front end, that is prevention.

This WSJ piece, from a noted Ivy league prevention expert, purports vascular age as another means to tell patients of their poor blood vessel health.  On a positive note, this piece educates us on the role of the blood vessel, particularly the seemingly inert, but highly susceptible to inflammation inner lining, known as the endothelium. Correctly proclaiming the endothelium as the crux of heart health is a good thing.

Also, telling an unhealthy 40 year old that he has the artery health of a 64 year old is certainly a novel idea that is more elegant and maybe a bit more eye-opening than just telling him he is fat, out of shape and now has diabetes. As far as educating goes, the vascular age thing is quite good, but it is still only education, not motivation.

In 2010, can anyone American not know about heart healthy behaviors?  Education on heart disease is ubiquitous;  even substituted for smart policy decisions, like Louisville’s chief doctor who opposed banning toxic trans-fats in favor of educating the public on their danger.

As is the case with most able-bodied, non-dabbling electrophysiologists, I can ablate SVT, Atrial Flutter, and implant pacemakers and ICDs with greater than 95% efficacy.  Even PAF can be successfully eliminated two-thirds of the time.  Yet, despite trying hard (really hard), I fail more than 90% of the time to get patients to change their heart healthy behaviors.  Nine in ten patients return just as fat and sedentary as they were at the time of my previous lecture on heart health.

In heart health, getting people to know is not the issue, rather the issue is in implementation of the plan. The treasure at the end of the rainbow, is a mechanism or strategy that affects people’s lifestyle choices.  Somehow, something. or someone needs to find a way to motivate people to change their lifestyle.  This is the holy grail of heart health.  The solution is before us in clear view.

Politicians, MPAs, MPHs and the like all talk about health care savings of this plan or that plan, but can you imagine the savings if there was a major change in population behavior. Imagine the savings if masses of people stopped smoking, started carving out time for 30 minutes of exercise, leaving the table still able to walk upright, and going to bed on time.  Imagine the health of our youth if we had mandatory gym class every day, healthy food in the cafeteria and healthy parent role models.

Imagine…

But how?

JMM