Sunday, June 27, 2010

medication vs. lifestyle changes

This is a great article by Dr. David Katz, borrowed from

I recently saw a patient who, like many others before her, had decided it was time to get serious about her health. She wanted my help with better nutrition, weight loss and modifying her risk factors for chronic disease. Making such assessment in the customary ways, I was fully convinced she was motivated, serious and committed.
Unfortunately, in between visits with me, my patient had a primary care appointment that went rather badly. Apparently disgusted that the patient was not taking a recommended medication, this primary care doctor derided the value of lifestyle interventions and told the patient, "It won't be my fault if you leave here and have a heart attack!" She also, apparently, summed up the possibility that weight loss might not fully reflect body fat loss (and muscle gain) as "bull!" I recently learned of all this when the patient called me, confused and distraught.
With my patient's permission, I hope to speak soon with my colleague and attempt a meeting of the minds. For the time being, though, we have a situation nicely summed up by Cool Hand Luke: "What we've got here is a failure to communicate." Apparently, Luke had just left his doctor's office.
My patient did, indeed, have chronic disease risk factors, including slightly elevated blood pressure and cholesterol, along with early signs of diabetes risk. She is well aware of this, having addressed it with her primary care provider on prior occasions. She had been prescribed medication for lowering her cholesterol, but had not tolerated it well. She came to see me to explore other options.
Those other options are readily available. The American Heart Association, the National Heart, Lung, and Blood Institute and the National Cholesterol Education Program all recommend lifestyle changes -- diet, exercise and weight control -- as the primary approach to cholesterol lowering. The method is referred to as "therapeutic lifestyle changes," or TLC.
The American Diabetes Association places an emphasis on TLC for both diabetes prevention and management, although in the case of management, medication is used as well. The Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (I have always felt their name could do with a makeover!) also front-loads with TLC as the first and best method for controlling elevated blood pressure.
The dietary recommendations of these diverse groups -- and, for that matter, the American Cancer Society -- are noteworthy for overlap. By and large, the emphasis is on foods that are close to nature, minimally processed and rich in nutrient value: vegetables, fruits, beans, lentils, whole grains, nuts, seeds, lean meats and fish, eggs, low-fat dairy. Regular physical activity at a moderate level, and the weight control that generally results from eating well and being active, are common recommendations as well.
Evidence that this basic approach is effective when truly followed is decisive. Studies such as the Lyon-Diet Heart Study have shown that a Mediterranean diet based on the foods above lowers the risk of heart attack in high risk individuals by as much as 70 percent. The Dietary Approaches to Stop Hypertension (DASH) studies have shown that a mostly plant-based diet with low- or non-fat dairy can lower blood pressure as effectively, and more safely, than medication.
The Diabetes Prevention Program showed that lifestyle was twice as effective as the drug metformin in preventing diabetes in high-risk individuals, reducing its occurrence by 58 percent. The Portfolio Diet study by my friend, Dr. David Jenkins at the University of Toronto, proved the principle that diet can lower LDL cholesterol as effectively as statin drugs.
So, there is nothing at all radical -- particularly in a patient who is reticent about taking drugs -- in attempting to modify cardiometabolic risk with a lifestyle intervention.
My patient and I did exactly that, with gratifying results. Between her first visit and her follow-up, she had already lost six pounds by making sensible and sustainable changes to her diet and physical activity patterns. Her blood pressure was lower at follow-up as well; blood work is pending. Because she has been exercising vigorously, it is likely the six-pound weight loss does not fully reflect the loss of body fat, and gain of muscle. We will be doing a body composition test to verify this.
The primary care doc simply refuted all of my advice to the patient, rather than speaking with me. The result was a patient caught between competing medical opinions, and probably trusting both of them less as a result. TLC often doesn't work for lack of follow through; when adopted well, it works well. This patient was doing a great job and deserved encouragement, not discouragement. She got "bull!" from my colleague; from me, she gets: "You go, girl!"
There is no question in the scientific literature that body fat loss can greatly exceed weight loss in someone who is exercising and gaining muscle. My most noteworthy personal experience with this was on the TV show, Celebrity Fit Club, when I supervised weight loss in the over-450-pound comedian, Ralphie May. When the scale wasn't moving, despite Ralphie's diligent efforts, we used body composition analysis to track his progress -- and it showed a dramatic shift from body fat to muscle.
TLC is slower in its effects than medications such as statins, or antihypertensives. But it is ultimately both safer and more potent. Lifestyle can reduce chronic disease risk by 80 percent; no single drug comes close. I of course recommend medication use when TLC isn't getting the job done, for whatever reason.
As for this patient's risk of walking out the door and having a heart attack, I see that differently. We can think of medical danger as being too near a fire: there is the risk of getting burned. This patient, however, was walking briskly away from the fire. No immediate need to put on a suit of asbestos.
In my current practice -- labeled integrative care -- we are very accustomed to stating explicitly that the patient is the boss. We rely on a model for using evidence in treatment decisions called CARE, clinical applications of research evidence, that emphasizes five considerations: safety, effectiveness, quality of scientific evidence, available alternatives and patient preference. Each of these matters, and warrants discussion.
Doctors need to talk to their patients. We also need to talk to other doctors about the care of our patients, so patients are not left in a no (wo)man's land of conflicting opinion. In that divide, we've got a failure to communicate that could readily result in a more fundamental failure: the failure to meet the needs of our patients, and help them be well.

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