As I leafed through the mail yesterday, it occurred to me that those of you who are not physicians may be unaware of some of the small details that make up the lives of docs. One of these details is the daily postal bombardment. In addition to the usual assortment of underwear, outdoor furniture and clothing catalogues, in addition to the credit card offers, the pleas from charities, political campaigns and causes, in addition to the monthly bills, flyers and junk mail, doctors are on the receiving end of a stream of medically related mail, most of it unsolicited.
Each day brings invitations to continuing education seminars which are short on content and long on location. Learn about addiction medicine while lounging on the beach in Costa Rica. Absorb the intricacies of diabetes management aboard a cruise in the Mediterranean. None of it is cheap, so into the trash it goes. We get mail about hospital meetings, mail from the state medical board, mail from our malpractice carriers. We get updates to the PDR, the bible of currently available drugs and letters with red “attention” stickers that alert us to the fact that some new medication has been taken off the market or has suddenly shown a frightening side effect. But mostly, we get something we call “throw-away journals”.
Doctors subscribe to journals that reflect their interest and specialties, things like the New England Journal of Medicine, or (in my case) the International Journal of Obesity. Subscription journals are where the serious science lives and where authorities and researchers publish their scholarly work. But plowing through statistics and detailed controlled studies can become tedious and many doctors simply want to know what’s new in the treatment of the diseases they commonly see. Throw-away journals meet this need. These journals look a bit like subscription journals but are usually colorful and written in plain language. They have articles about the latest medicines and what’s new in the treatment of common problems. They often have pictures, sometimes on the cover, of horrendous rashes, skin ulcers and other gross conditions. Don’t ask me why. I guess someone thinks that doctors are attracted to lurid pictures. (Growing up, my kids sorted through the mail with trepidation lest they come across some of these). Docs don’t subscribe to throw-away journals. They just show up in our mail box. A lot of them.
Yesterday, along with many other medically related mailings, I received my copy of Internal Medicine News, a throw-away which is not into gross pictures and which I enjoy reading. As I leafed through it, I was struck by a simple fact. Medicine is being overtaken more and more by the diseases which stem from obesity. This is a fact which is rarely discussed. Overweight is still treated by most physicians as a peripheral issue to be addressed with a “by the way”. (As in: “by the way, you should lose weight”). But a glance at Internal Medicine News will tell you that overweight is central to disease and disability in this country. It is a warning, as clear as can be, that we are headed for financial and physical disaster if we continue to treat overweight as a trivial problem.
So, since I’m letting you in on the life of a doc, let me briefly recap the number of articles in the 45 or so pages of Internal Medicine News that relate to obesity.
Page 1: “Low Vitamin D Tied to Poor Prognosis in Breast Cancer”. A study in Toronto has showed that those women with low vitamin D levels when the diagnosis of breast cancer was made were more likely to have hi-grade cancers and to die of their cancers. Who has low vitamin D levels? Often, the overweight, because vitamin D gets trapped in their fat cells and can’t circulate in the blood as it’s supposed to. The study researcher notes this connection and then suggests that the study should be done again with subjects who are given Vitamin D replacement. My question: why not just get rid of the fat that’s trapping the vitamin D???
Page 10: “Redefine Diabetes to Lower Costs of Care”. A Georgetown medical professor suggests that we stop calling mildly elevated blood sugars ‘pre-diabetes’ and call any kind of blood sugar problem by its real name diabetes! I agree! We waste time with people when we tell them they are pre-diabetic. They simply have early diabetes and they need urgent lowering of blood sugar while they still have a working pancreas. Why do they have elevated blood sugar? Because they are overweight (90% of the time).
Page 21: “Diet Gaining Legitimacy as Potential Factor in Acne”. Turns out that what our mother’s said was true. Acne is worsened, or created, by what you eat. Various studies implicate, “milk, high-glucose-load diets, and low fiber/high saturated fat intake.” In other words: the SAD (standard American diet). The article goes on to report on the contrast between acne in our teens versus the “essentially zero” incidence in two non-Westernized populations who eat hunter-gatherer (Primarian) diets. These people not only eat “minimally processed plant and animal foods” but have low insulin levels. (see my post onThe Case Against Calories) . In a study done in Australia, 43 teens with acne were given either a low carb or a high carb diet. Guess what? The acne improved on the low carb diet AND the kids lost weight. Yet another endorsement for eating Primarian.
Page 29: “Screen for Geriatric Syndromes in Diabetic Elderly”. If you make it to old age with diabetes, here’s the list of problems you’ll face. An increased risk for dementia because of your microvascular disease, your experience with high and low sugars and all the medicine you’ve ingested. An increasing list of medications, all of which have their side effects. (One study showed that 14% of elderly diabetics were taking 10 or more drugs.) “Patients will be struggling to follow your instructions for additional medication..and some will not be able to afford all of these medications”, says the author. (Note from BB: lose weight now and don’t put it back on!). An increased risk of depression. More falls. Urinary incontinence. The disclaimer at the end of the article lets us know that the author received money from a drug company which makes diabetes medicine. Yes. They do make more money from people who take these medicines than from those who have lost weight, eat well and exercise.
Page 29 again: “Diabetes Linked to Risk, Not Cause, of Parkinson’s”. Want something else to worry about if your blood sugar is high? You’ve got a 34% higher risk of new-onset Parkinson’s.
Page 37: “Ratio of Sodium to Potassium Affects Cardiovascular Risk”. Hey! You know what? If you eat a lot more salt than potassium you’re going to have a lot more cardiac and vessel disease. People with the highest ratio of salt to potassium had a “highly significant 50% increased risk of a cardiovascular event” (read: heart attack or stroke). Why? Our ancient ancestors ate a diet high in potassium and had no access to added sodium. We’re built the same way, but we’ve reversed our intake. Again, the authors ponder the question: “Should we be looking into the use of salt substitutes in which sodium chloride is replaced by potassium???” This is just the kind of suggestion we’re always coming up with… add more of something good to a bad diet. Why not just eat Primarian?
Page 40: “Bariatric Surgery Leads to Bone Density Decrease”. Uh oh. Cutting your stomach in half and rerouting your intestines may not be the best idea in the world. Many patients who go in for gastric bypass start out with low vitamin D levels (see above), so already have a tendency toward weak bones. The bypass itself makes it harder to absorb nutrients and one of those is calcium. There also can be a problem absorbing the B vitamins and iron. It’s controversial, but bone loss may be an issue after this surgery. Just to finish up, let’s look at the ads in this journal. The drug ads tell us what medicines are common and are competing for market share. Remembering that the conditions associated with overweight and poor diet are high cholesterol, high blood pressure, high triglycerides, joint problems, reflux, high blood pressure, irritable bowel and diabetes, let’s look at the ads (I’ve included all of them and highlighted the ones related to weight):
Sixty percent of the ads in this journal relate to conditions that can be prevented or made dramatically better with weight loss and a healthy diet.
We as doctors have a choice to make. We can read our journals and see our patients. We can choose to ignore the connection between diet and health or, if we recognize the connection, we can choose to believe nihilistically that our patients are incapable of making real change. If that’s what we believe, why bother to counsel them on diet? Why tell them to lose weight? Why work on encouraging them to Refuse to Regain???
But you, readers, know the truth. Continue to give yourself the supreme gift of good health. Along with it, you will get some bonus gifts: an increased chance of longevity and of many more disease-free years. Add exercise and you will reduce your incidence of depression, raise your bone mass and prevent the muscle loss that leads to falls and fractures.
A Doc’s Life can be a strange one at times. We want to do what’s right for the patient and we have so many darned meds. They come in pretty packages and they’re brought to our attention by attractive, enthusiastic drug reps who often serve lunch along with their wares. And patients seem so happy to have their problems solved with a pink pill in a shiny wrapper. But we, like you, have to make a choice.
To quote a higher authority: "… I have set before you life and death, the blessing and the curse. So choose life in order that you may live, you and your descendants, (Deuteronomy 30:19). Each of us, both doc and non-doc alike must figure out exactly what that choice means.