Prevention works—tips for success. A serious appeal
Is prevention a fantasy, or the future of medicine?
The evidence tells us that true prevention works better than drugs, and lasts longer than surgery—but only if you do it. And that seems to be the problem—doing it. Despite the huge numbers of “diet—exercise—live right” articles in magazines and newspapers, most people talk the talk, but don’t walk the walk.
When many physicians talk about “prevention”, they really mean what they do—vaccinations, screening tests and giving drugs for coronary artery disease, hypertension, cholesterol and triglycerides to “prevent” heart attacks and detect cancer early. For instance, aspirin and statins are given for “primary prevention” of heart disease-the prevention of a first event in patients who are at risk. That’s not just lingo, it’s the point of view. While these measures may be huge advances, critically important, and save lives, some may be band-aids rather than a fundamental solution. An example of the difference is the Texas mandate for insurance companies to pay for screening for calcium and arterial plaque in arteries with CT scans* and ultrasound. These tests are really good for screening, are evidence-based and underused, but they do not change the prevalence of the problems of fatty deposits in arteries from scratch. Sure, they may identify arterial calcium/fatty deposits for future treatment. Lifestyle changes — nutrition, exercise, stress control, etc. — act in earlier steps, and are disease-modifying, two fundamental advantages in preventing and fighting illness. *if you discount radiation
Is prevention a myth in this world of multiple medications, scans, and procedures? Or is it simply a more rewarding, pleasant, effective, and fundamental way of life to complement such medical management?
When it comes time to change diet and lifestyle—“real” prevention—most doctors now assume it is hopeless, and the patient will not change at all. Even though lifestyle changes are listed first in all treatment guidelines for chronic illnesses, Docs still write the prescription during the initial visit, without bringing up diet. Sadly, they are right! Only 7% of Americans actually lead a preventive life. Most people will not change, some not even attempt it. So in recent years, there have been articles titled “PREVENTION IS A MYTH” in medical journals.
Perhaps too many people do want the prescriptions first… They gladly take the prescription, thinking it is an essential part of the visit. Yet in just a short period of time, often a few weeks, they stop taking the medication too! In fact, about half eventually stop. Is there any sense to this sequence?
Could their increased risk for disease be related, for instance, to double or triple cheeseburgers and fries, or prime rib, a box of cookies, all with the fat they contain paralyzing arteries for hours after being consumed? Or huge amounts of salt eaten throughout the day, every day? Or perhaps six sugary drinks every day that put on weight, leech calcium out of bones, and inflame the body’s cells? Some kids think that they are eating “vegetables” because they put ketchup on a paper-thin piece of iceburg lettuce in their burger! Most people either don’t want to hear it, or let it roll off.
The scientific basis for prevention is substantial, strong, and current
This past year there have been dozens of papers in medical journals that have conclusively shown that when people try to make healthy choices, they can succeed. Just doing the basics in small steps makes a big difference in their risk for chronic disease-strokes, heart attacks, thinning of bones, cancer… all reduced by large numbers. How about extending your life by up to 70%? Sound good?
In April, 2009 a report from Harvard Medical School reported that 90% of diabetes could be prevented by attention to 5 simple health habits. For each lifestyle factor corrected, the incidence of diabetes fell by 35%.
The following month on May 20, in the Journal of the American Medical Association (JAMA), it was reported that people with low fitness ratings had 40% higher risk for death from any cause, and 47% higher risk for cardiovascular disease. Adequate exercise (also called “physical activity” so people do not become frightened or paralyzed by what they should be doing) is grossly under-appreciated, under-rated, and under-used as a non-pharmaceutical means of treating common degenerative disorders of lifestyle. Increased activity alone may be as effective (or more so, in terms of multiple effects) as approved drugs and other methods of preventing and/or treating depression, diabetes, cardiovascular disease (including coronary artery disease, hypertension and stroke), breast, colorectal and other cancers, and cognitive disorders. The program Exercise is Medicine®, endorsed by the American College of Sportsmedicine, is a most significant positive step in the public interest.
In July, 2009, the Journal of Nutrition found that if you eat a healthy diet, you are likely to live longer. Surprise! This was a huge study from the National Cancer Institute, involving 350,886 participants in a National Institutes of Health/AARP data base.
And in July, JN’s sister publication, the American Journal of Clinical Nutrition, a Tufts University study showed that women who followed the Dietary Guidelines for Americans, which have been criticized as minimal and imperfect, enjoyed slower progression of coronary artery disease (hardening of the arteries).
The August 10, 2009 issue of the Archives of Internal Medicine described how just four simple healthy habits cut the risk of diabetes by 93%, heart disease by 81%, stroke by 50%, and cancer by 36%. But if you added vitamin D and calcium, according to a second release, you could drive cancer risk down over 60%. One executive in a cancer organization claimed 85%. Practicing 5 healthy habits would save well over 100,000 lives per year.
There are many more publications, and they all tell the same tale: the documented basis for simple nutrition and lifestyle advice to prevent chronic disease is startling. But is all this evidence getting people to act and change? No.
In this past year it was also found that 9% of the national health budget is used for complications of overweight and obesity. And all this excess weight drives diabetes and related conditions, such as metabolic syndrome and prediabetes, which have been rising at about 5% yearly. Right now, about 45% of our population qualifies for the term “metabolic syndrome” and it probably rises by the day. In fact, progress in extending life expectancy in other areas, such as smoking, is being wiped out by the obesity epidemic.
Diabetes was the subject of a special diabetes issue April 15, 2009, of the JAMA, with a notable discussion about the public health problem it poses. In December 2009, Diabetes Care, a major journal of the American Diabetes Association, published a paper concluding that diabetes will nearly double in the US in the next 25 years and the cost of treating it will almost triple—to $336 billion in 2007 dollars. That assumes obesity and overweight will continue afflicting about 65% of Americans, which is doubtful.
Good grief, is all this overwhelming, or what? What do we need to wake up? And it is just only a sample of the overall problem crushing us. If this continues, Americans are destined to become a country of invalids, medically dependent and care-needy. In addition, with a new health care system in place or not, we will inevitably become bankrupt soon if some major change does not occur. The answer lies not in more approvals for drugs, or expansions of “indications,” simply because drugs are not that effective for lowering prevalence rates of chronic disease, and may cause even greater dependence and expense. The proposal to give entire populations a “polypill” containing 5 cheap drugs, in part to neutralize poor lifestyle habits, is laudable but culturally embarrassing and only a crutch.
What is the answer, then?
We must strike at, and reverse, the basic cause—our poor lifestyle habits.
In specific conditions, the record of change is disappointing. The diets of patients with coronary artery disease remain poor one year after the initial diagnosis. Even worse, the diets of patients who undergo coronary artery bypass surgery actually grow more likely to deposit fat in arteries (atherogenic) during the year after their procedure, despite dietary advice. In other words, after undergoing a procedure which is a major life event, their diets get worse. Could it be that some post-operative heart patients then think, “now I’m fixed, so I can eat anything I want?” As Arnold used to say, they’ll “be back”.
As far as specific nutrients are concerned, Americans are also losing the battle to keep their intake and blood levels up to the minimum required to prevent disease, and failing horribly to bring them up to the amounts needed for optimum health. There are no better examples than fish oil and vitamin D, with multisystem, well proven benefits both in prevention and treatment of many diseases, all supported by a tsunami of papers in respected peer reviewed medical journals in the past several years. Both are seriously underused and undervalued. In fact, fish oil has been called a “polypill” itself with respect to disease prevention.
Nutrient inadequacies are not corrected by drugs-they are entirely different approaches, and not “competitors”
Many women in this country are taking medications called bisphosphonates and estrogen to treat conditions such as osteopenia, osteoporosis, and recurring fractures due to thinning of their bones. The purpose of these drugs is to replace insufficient bone mass. Surprisingly, while the package inserts for these medications recommend taking calcium and vitamin D, a significant number of women fail to do so, or take only a fraction of what they need. By not supplying the raw materials from which bone is made, they are greatly diminishing the drug’s effect, and defeating their purpose. The medication does not replace the need for the basic ingredients needed for more bone. Sometimes the simple, inexpensive, nutritional approach may be critical.
Think of this possible sequence for a moment. Suppose a woman was taking one of these drugs to increase her bone mass, but failed to take calcium and vitamin D. After a year or so, when her bone density test showed no improvement, her physician might give her a more potent medication, one that was more likely to have serious side effects… In this example, the problem was not a biphosphonate that had insufficient “strength”, but rather no raw materials for the biphosphonate she was taking to use.
In heart failure, not only is vitamin D of importance in causing problems, but micronutrient deficiencies have been known for decades. Back in July, 2001, a review in the Journal of the American College of Cardiology highlighted the problem. Eight years later, October 27, 2009, another paper in the same Journal about mineral deficiencies in heart failure called it an unmet need. Recurring hospitalizations for heart failure remains an unsolved problem. Many of the micronutrients of value are inexpensive, yet their potential in this lethal disease remains ignored.
Another example is potassium and magnesium balance. Not only are poor intakes of both common in Americans, but contribute to many diseases. Deficiencies in either are generally not detected using conventional blood levels of these ions, simply because the lion’s share is inside cells. Once blood levels become abnormal, there is usually a much greater problem than realized with the total amounts in the body. Both are extremely important in high blood pressure, heart failure, abnormal rhythms, nerve function, etc. Correction of inadequate intakes could affect public health significantly. Most times, the mild acidosis that concerns people, whether true or not, could easily be reversed by raising their potassium intake.
Contrast for a moment the reduction of risk for coronary artery disease of 85% through lifestyle changes, with the reduction of 40% using statin drugs. Compare the benefits of minimal extension of lifespan in heart disease using statin drugs, and the more significant lowering of mortality from all causes reaped after using the Mediterranean diet. Consider the steep rise in protective high density lipoproteins, “good cholesterol” or HDL, from exercise, fish oil and perhaps niacin, compared to the minimal to modest elevation from the use of some medications. There is no question statin drugs are valuable when needed, but giving them to the entire population to neutralize consequences of bad habits that lead to obesity, metabolic syndrome and high levels of inflammation may be unwise.
Reflections
Just as JFK asked about what we can do for our country, we must ask ourselves, “What are we willing to do for our own health?” This should be our question, rather than say “Doctor, make me thin/get rid of my diabetes” by magic (despite my sabotaging habits), with society subsidizing the (ineffective) process. Lifestyle modification, admittedly difficult at first, does not chalk up huge drug bills, one prescription after the other, each eventually abandoned. Lifestyle changes also require fewer tests to monitor whether medications are working, or for potential adverse drug reactions.
Positive lifestyle habit changes needn’t be large, or many. Just a couple of small steps in a positive direction can make a big difference. Commit and resolve to be healthy! A positive lifestyle leads to a healthy body and the mental depth to successfully deal with these demanding times.
To begin, commit to prevention—real prevention, on a personal level. Everyone already knows that poor lifestyle habits lead to chronic disease. But most people just want to get the quick fix—the “magic pill”, or surgery, get it covered on their insurance, and go back to their old habits. What they don’t realize is that the quick fix has another price—side effects, and after surgery, more surgery when the problem returns. And it typically does. What comes after heart stents? More stents, until there’s no room left in coronary arteries for additional stents—then bypass surgery. Wonder why?
Does it surprise you that 85% of cardiovascular disease, and over 90% of diabetes is preventable through what you eat and do every day? Little things certainly do matter.
Not only do good habits cut risk, but when medication and surgery are needed, being in shape helps assure a smooth, successful outcome with fewer complications.
We must also rid ourselves about the notion of the “quick fix.” We must realize there ain’t no quick fix. You’ve got to get light, and quit the chips, pork rinds, processed snacks, and volume eating. Most Americans don’t even know what the sensation of that light diet feel is, and how invigorating when they know the feeling of good health.
This month the American Heart Association advises health, not disease, after seeing 2009’s statistics…
The Annual Report of the American Heart Association will be published in their journal, Circulation, Jan 26, 2010. This traditional review of statistics about heart disease and stroke is, for 2010, being used to revisit the concept of cardiovascular health, rather than cardiovascular disease.
“The AHA is refocusing efforts on lifestyle factors that can prevent the development of cardiovascular disease in the first place, and some of the statistics in this document show us just how far we have to go…”
What to do
The solution: personal responsibility for our own health, trying to make improvements in small steps. Yes, it can be tough, but the reward is great. The power of what we can do together to help our health is awesome, according to a recent N Y Times Editorial.
The bottom line: It’s up to you. People only make changes when they really believe it is in their best interest.
For instance, learn about the Mediterranean-type diet. Despite walls of diet books, it is the only diet proven to extend life, in a most pleasant way. Risks for chronic degenerative diseases are significantly reduced by this diet. Forget about the fad diets, which are usually short on science, but long on claims and naked proclamations.
And best wishes for your program. In future editorials we will offer a list of important health changes that you can easily incorporate into your routine. Little by little.
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