A friend of mine had a bad reaction to a heart medicine, dropping her blood pressure to as low as 76/49 as a result. She was feeling understandably dizzy but didn’t want to go to the ER so she asked me if there was anything she could do at home to help raise her blood pressure. I recommended that she drink a large volume of water and take some salt tablets. She had no salt in pill form, and didn’t want to take it straight out of the shaker so asked if there was any other way to get the salt in. I asked her to describe the contents of her refrigerator and pantry, and made a mental note of what I thought had the highest salt content.
My friend thought that potato chips might do the trick, and was surprised when I told her that she had something almost ten times saltier at her disposal. Four ounces of prosciutto contained almost 2g of sodium, an entire day’s worth of salt! So she dutifully consumed the sliced meat, washing it down with about a liter of water. Two hours later she was back up to 98/66 and six hours later her blood pressure had returned to a healthy 116/83.
This was a rare case where a “high salt diet” had its benefits. In the case of ham versus hypotension, ham won… and saved my friend a costly, and unnecessary ER visit. Let’s hear it for deli meat!
One would think that happiness and healing are inextricably linked in healthcare, but the Happy Hospitalist (HH) raises an interesting question: is modern medicine’s emphasis on patient satisfaction (and shared decision-making) sacrificing our quality of care? A recent study found that patients who preferred their physicians to take the lead in their medical decision-making had shorter, less costly hospital stays.
HH argues that if physicians are expected to perform like airline pilots, reliably choosing/performing the best course of action for those depending on them, then patients should behave like passengers. In other words, passengers don’t tell the pilot how to fly the plane, nor should patients override a physician’s clinical judgment with personal preferences.
I think this analogy misses the mark because patients are rarely interested in making decisions about how a physician accomplishes her task, but rather which tasks she undertakes. Flight passengers aren’t interested in quibbling about the timing of landing gear, they are interested in the selection of their destination city. And so they should be.
While there may be a correlation between physician-led decision-making and shorter hospital stays, I’m not convinced that this translates to improved care quality. For the study subjects, discharge could have been delayed because the “empowered” patients insisted on ensuring that a home care plan was in place before they left the hospital. Or perhaps they wanted to get their prescriptions filled before going home (knowing that they couldn’t get to their home pharmacy over the weekend)? The study did not assess whether or not the discharge delays reduced readmission rates, nor did it seek to determine the cause of prolonged stays. This study alone is insufficient to draw any conclusions about the relative value of the patient empowerment movement on health outcomes.
While I certainly empathize with HH about the excessive focus on patient satisfaction surveys over true quality care, I strongly believe that an educated, participatory patient is our best ally in the practice of good medicine. There are simply too many cogs and wheels turning at once in the healthcare system to be able to ensure that the right care is provided at the right time, every time. We need all the help we can get to monitor our care plans in order to avoid medical errors, compliance problems and missed opportunities.
If you see something, say something. That principle applies to healthcare as much as it does to flight safety.
This weekend I accidentally stepped way outside my comfort zone. A friend of mine had invited me to compete in the Primal Games – an event that she described as a “fun time for all fitness levels with some guys dressed up as cave men.” Sounded innocent enough. And it appealed to my sense of whimsy, so I signed up without a second thought. A couple of weeks prior to the event I decided to do a little more research and discovered that this competition *might* be a bit more challenging than I had originally thought. The event website was somewhat vague, but alluded to things like “Atlas balls,” climbing over walls, obstacle trail run, military crawls, and medicine ball tosses. Hmmm. I’d never attempted to scale a wall in my life, nor was I too thrilled about the idea of hoisting around beach-ball-sized cement objects. I was getting nervous.
I soon discovered that my nervousness was more than well-founded. As I arrived at the event, the temperature was rising above 90 degrees Fahrenheit as I was greeted by shirtless male competitors (see photo above). Apparently, almost everyone at the Primal Games was on a team of some sort already, and many had prepared for the event for over a year (mostly at CrossFit gyms). As I gingerly approached the registration tent a well-muscled woman wrote a number in permanent marker on my arm and calf. I was branded and there was no turning back, so I decided to spend some time watching the other athletes warm up. I was astonished by some of their capabilities.
Take this guy for example (photo at left). He was able to hurdle the “women’s wall” that I struggled to scale and climb over. I stood there, staring aghast at the fellow like some kind of animal in headlights. I realized that I belonged on the sidelines as a spectator, not a competitor – but alas, I was in it for the duration.
The women at the event were only slightly less intimidating. Some looked like Olympic weight lifters, others were lean, mean, muscle machines. Very few were as old as I was. My fantasies of a day tossing water balloons back and forth with people in spandex and super-hero capes were fading fast.
And so the games began – three individual events arranged in heats, requiring a whole lot of “hurry up and wait.” My first challenge was a 1.5 mile trail run with obstacles. The distance seemed fairly innocuous so I took off at full tilt when they blew the air horn for my group. About a half-mile in I began passing members of the group that started ahead of mine. I wondered if I had misjudged my pace, but figured I’d deal with that later. I navigated jumping over some hay bales (no problem for a former dairy farmer), threw myself into the Army low-crawl and bolted across a boardwalk to come into the finishing stretch. And that is when I hit the wall. Literally.
I had never scaled a wall in my life and apparently there’s some technique to it. I ran up to the 6-foot obstacle, jumped up and grabbed the ledge and then hung there like some kind of limp towel. Nope, that was definitely not the right way to do it. Race officials tried to explain more successful strategies to me as I failed to scale the wall in a second embarrassing attempt. I opted for the penalty Burpees and crawled under the wall… only to face the next, slightly shorter wall. There was no way around it this time – I had to do it. A miss was a disqualification on the shorter wall.
Panting, sweating, and wearing all black in the midday sun, I somehow muscled my way over the short wall in the least elegant way known. I jogged ahead to the water slide, took a hard dive onto my chest and bolted to the finish line with no energy to spare. That performance was good enough for an 11th place finish in my age group (the “Masters women” – which hardly seemed a fair category title considering my lack of mastery of this challenge!)
The second event appeared deceptively straight forward. I had three minutes to launch 6 medicine balls backwards over a wall. But for every 7 feet closer to the wall you got, you had to do increasing numbers of penalty Burpees. I figured I’d be pretty good at this since I’m built more like a water buffalo than a gazelle, but no dice. This event was 70% technique, and figuring out how to get the ball to make the correct-shaped arc (so it cleared the wall) had a steep learning curve. Even the strongest-looking women often missed the wall because their ball ended up going straight up and down instead of backwards. I opted to get as close to the wall as possible and just “gut out” the high reps of Burpees.
I was relieved to see a familiar face in the crowd as I approached my med ball toss challenge. The owner of my home gym had arrived, video phone in hand, to memorialize my event. She was my only fan, and asked if I’d mind if she yelled out encouragements during my event. I agreed hesitantly, both nervous about the permanency of the video that was being made of my potential “flailings” and unsure if her shouts would induce panic or perseverance. Luckily for me it turned out to be the latter. And here’s the video to prove it:
The final event was a true soul-sucker. I watched some of the men compete, and they made it look easy. It was a combination of cement (aka Atlas) ball carries (up and down a field) and tire rope pulls. Again, as a “water buffalo” I figured I’d have an advantage on this one, but here is where I crumbled. As they started the timer, I ran out to the end of the tire pull rope and started dragging it towards myself, hand-over-hand. The weight of the tractor tire was startling, and it moved at about 1/5 the speed of the men’s pulls as I realized that this event was MUCH harder than it looked. I finally got the tire across the line and had to drag it back to the start. I was the slowest in my heat and could tell this wasn’t going to go well.
And then the race official pointed to the Atlas ball that I needed to pick up and put on my shoulder. I had never even touched one before. I squatted down, got my arms under it and used my quads to get it on my lap. The weight (75lbs) took my breath away. I knew there was no way I was going to be able to get this thing up and down the field and I lost heart. Somehow I managed to muscle it up to my shoulder, where it perched on my clavicle ominously. I started taking steps across the field. The weight was crushing. I marveled at the women in lanes next to me who were managing to make it down the field. Time stood still in the 95 degree heat with no shade and no relief anywhere in site.
By some miracle I got that ball all the way up and back, and made it through the next tire pull. Then back to the start again where the official instructed me to pick up the same Atlas ball and do a second lap. I felt the will drain out of my body. There was just no way I could do it. I struggled to get it on my shoulder again and made it on my third attempt but then got about 20 feet down the field and dropped the ball. I tried to get it up again but couldn’t. I tried to carry it like a baby in front of me but it broke through my arm hold. I asked the official if I could take a penalty and get a lighter ball. Nope. That was not an option. So I spent the last few minutes in a futile effort to move the ball down the field and then finally the merciful timer signaled the end of the heat. I was the only woman who couldn’t get the ball back the second time.
And it was at that point that the infamous words of Dirty Harry Callahan came to me, “A man’s gotta know his limitations.” I had certainly found mine, and the humble pie was bitter-sweet. On the one hand, I was pretty amazed that I had not given up and gone home at any of several understandable points during the day. On the other, I was keenly aware of my physical limitations – and had to bow the knee to the truly gifted athletes who won the day. Would I do this again? Hmmm. Ask me once my cuts and bruises are healed. All I can say is that other competitions seem less frightening now, and maybe that’s the best gift that the Primal Games has given me.
In the future when I’m asked to join friends for a half-marathon or similarly grueling event, all I need to ask is, “does it include Atlas balls?” And if the answer is, “no” then I’m in! Thanks to the Primal Games my comfort zone has permanently expanded. I hope you’ll join me in the zone sometime, my friends! Misery loves company, after all.
I was raised by a health food zealot, and have been “eating clean” for most of my life. I have been an editor of a peer-reviewed nutrition and obesity journal, a food critic, and a dairy farmer. I am passionate about food – but I am also passionate about science. And I have to tell you, that for measurable health benefits, how much you eat is more important than what you eat.
I know this is controversial, and I’m certainly not saying that we should throw out all our leafy green veggies and grilled chicken and chow down on a diet of Twinkies and beer. But what I am saying is that the relative importance of food volume versus food quality has been misrepresented. We are focusing too much on specific nutrients and not enough on total caloric intake. I’d guess that what we eat is about 10% of the obesity problem, and how much we eat is 90% of the problem, but we spend 90% of our time talking about changing and improving what we eat rather than portion control strategies.
2. Measurable health benefits occur from weight loss as small as 5-10% of total body weight. You don’t need to be a bikini model to achieve the health benefits of weight loss. You can decrease your blood pressure, sugar, and cholesterol with modest weight losses. In my opinion, leanness under about 25% body fat (for women) is mostly an aesthetic choice, not one of medical necessity.
4. It matters more to lose weight, than it matters how you do it.Head-to-head studies of one diet versus another have repeatedly shown minimal differences in health benefits between the diet groups. The benefits occur from the weight loss, not from the manner in which it was lost.
This is all good news. Americans can achieve healthier outcomes with less effort than generally believed. Regular exercise, and a calorie-controlled diet (rather than rigidly controlling the macro and micro nutrients) are all that is required to substantially reduce the risk of many costly and unpleasant diseases. If you want to further optimize your health by eating a diet rich in fruits and veggies, whole grains, low-fat dairy, healthy fats, and lean protein please do so! But better to be a normal weight than obese due to eating too much of that healthy diet.
The bottom line is that you don’t have to give up eating the things you like, you just have to eat less of them. Even Olympian Carmelita Jeter eats Hostess cup cakes occasionally. And she’s the fastest woman in the world!
P.S. This blog post was inspired by a Twitter conversation with @Judith_Graham who said that the complicated issue of what to eat was too difficult to address in 140 character exchanges. Thank you, Judith!
P.P.S. Also, I’ve been thinking a lot about well-meaning but misguided (IMO) health policy issues raised by mayor Bloomberg’s ban on Big Gulps and the AMA’s endorsement of soda taxes. Bloomberg was pointing in the right direction (the size of the soda, not the soda itself was the problem), but I don’t believe you can regulate good behavior. Education and personal responsibility are the way to go.
I am one of the 50% who feels that this policy will not be effective. In short, this is why:
1. You can become obese by eating and drinking almost anything in excess. Targeting sugary beverages is reductio ad absurdum. Did America become fat simply because of an excess supply of sugary fluids on grocery shelves? What about the super-sizing of our food portions, the change in workforce physical requirements, the advent of cars, escalators, healthy food “deserts” in poor neighborhoods, video games, and cutting gym class from schools?
Holding Coca Cola, et al. responsible for our own over-consumption of calories is both unfair and tantamount to spitting into the wind – something bad is going to come back at us. Consumers can easily get around the soda tax by buying sweet alternatives – which may have even more calories than soda. (Caramel latte anyone?) And then what? Are we really going to play public policy, food and beverage whack-a-mole?
Carmelita Jeter's Shopping Cart
2. You can be thin and fit while eating and drinking almost anything. Obviously nutrition science has shown that a diet rich in fresh fruits and veggies, lean meats, low-fat dairy, whole grains, and healthy fats is the best for our health. However, please consider that the world’s fastest woman, Olympian Carmelita Jeter, eats Hostess cup cakes, Teddy Grahams, Welch’s grape juice, whole milk, and Gatorade. How do I know? Because she posted a photo of her shopping cart on Twitter (see image to the left). I obviously have no idea how much of this she eats – or when she eats it – but if the world’s fastest woman is powered (to some degree) by “Twinkies” then I think we should all think twice about demonizing certain foods/beverages in our anti-obesity fervor.
3. You can’t regulate good behavior. Human behaviors that may lead to obesity are simply too complex to regulate. Who would want to live in a world where government becomes the de facto “Nutrisystem” for its citizens, mailing out pre-packaged, ingredient-controlled meals to 312 million people per day, three times a day, seven days a week? While that may save the post office from its imminent demise, we can neither afford to do that, nor do we need to.
People who believe that policy should drive behavior point to smoking bans that have cut down on smoking rates. While I agree that small improvements have been made in reducing smoking rates, roughly one in four people still smoke (depending on your source, this number could be as low as one-in-five), and one in every five deaths is still attributed to cigarette smoking. Hardly a resounding victory, alas.
But beyond the fact that policy changes (and the billions we’ve spent enacting and enforcing them) have resulted in a disappointing decrease in smoking rates, is the issue that cigarettes and food ingredients (such as sugar) are not analogous substances. While there is no safe minimum amount of cigarette smoke, our bodies need salt, glucose, and fat to survive. They cannot be cut out of our diet completely – nor should they. And the only way to force people to optimize their intake is to enact Draconian measures.
So instead of starting a food-fight, it’s important to accept the complexities associated with this particular health scourge and promote a broader, more-nuanced approach to wellness incentives. We have to attack this problem from the ground up, because a top-down approach requires our government to become an invasive, food and exercise nanny.
The good news is that one-third of Americans are not overweight or obese, despite our current “toxic” food/inactive lifestyle environment. Perhaps these thinner folks can be ambassadors for the rest of us, and reveal their secrets of healthy living despite our current limitations. Even with our best efforts, we need to understand that (like smokers) we will always have a segment of the population that is overweight or obese.
And as for the Olympians among us – they help to illustrate that obsessing over every morsel of food or cup of soda that we consume is not the way forward. Sorry AMA, I’m with Carmelita on this one.
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