Most physicians will be thrust into the role of patient or caregiver at some point during their careers. Unfortunately, it’s not until this occurs that many become fully aware of the finer points of excellent care and communication. Take for example, the simple act of reporting test results to a patient. We do this every day, but may not realize that how we frame the information is as important as the data themselves.
I came to realize this on a recent hospital visit when I was in the role of healthcare proxy for a loved one with heart disease. Not only did various physicians present information with different degrees of optimism, but individual doctors presented things differently on different days… depending on (I guess) how tired/hurried they were. Consider these different messages with the same ejection fraction (EF – a measure of heart pump strength) and angiogram (heart vessel imaging) test results:
Doctor 1: “I wish I had better news. The EF is lower than we thought. It is low because of your previous massive heart attack.”
Doctor 2: “Although your EF is impaired, there’s a lot that can be done to improve pump function with medications.”
Doctor 1 (different day): “On the other hand, the EF might be temporarily low because of your recent flu infection. It’s possible it will bounce back in a couple of months and you’ll be back to your usual self.”
Doctor 2: “I’m not worried about your chest pain because we know it’s caused by small vessel disease. Your angiogram showed that all your main heart arteries are wide open. The pain is not dangerous, though I’m sure it’s annoying.”
Doctor 1: “Chest pain is always serious. You never know when it could be the big one.”
Doctor 3: “It’s hard to interpret EF because some people live long and productive lives with low EFs, and others are quite impaired with only a small dip in pump function.”
Doctor 2: “Sure there are medications we can try to improve your EF, but I doubt you’ll tolerate them because your blood pressure is kind of low.”
Doctor 3: “Don’t worry about the EF, it will correct on its own once we get your rhythm controlled. This is an electrical problem, not plumbing.”
All of this emotional whiplash caused by the same test results… due to different physicians’ interpretations of prognosis and treatment options. What can be done? First of all, we physicians need to take a deep breath and realize how our words affect our patients. They are scared and vulnerable, and they are looking to us for hope… and when there is real hope, why not emphasize it? There is no need to focus on the worst-case scenarios until we are well and truly in their midst.
I believe that being a good clinician is not just about giving patients factual information, but also about presenting data with kindness. Sometimes, as I’ve discovered with my own loved one, it’s not as important what you say, as how you say it.
It is estimated that in seven years from now, half of all Americans will suffer from one or more chronic diseases, a majority of which are weight related. The American Medical Association recently declared that obesity itself is a disease. Obesity advocacy groups say that this move will lead to better health outcomes by providing more treatment options, preventative programs and education, as well as better reimbursement for treating individuals fighting obesity.
But what do patients need to know about weight loss? The good news is that a medically healthy weight does not require a very low percent body fat.
Weight loss for health – not for appearance – comes with a different (and in many cases much less demanding) set of recommendations. So for the purposes of this blog post, I’ll focus on key evidence-based advice for patients at risk for weight related disease…
1. You don’t need to lose that much weight to realize substantial health benefits.
A five to ten percent loss of body weight can lower risk for heart disease and other killers. For obese patients, even a modest weight reduction can have significant health benefits. An eleven pound reduction in weight leads to a fifty-eight percent decrease in the chance of developing diabetes. Even just losing two pounds reduces the risk of diabetes by sixteen percent.
2. Most people who succeed at losing weight (and keeping it off) do so with a combination of diet and exercise.
According to the National Weight Control Registry (NWCR) (a database of more than ten thousand Americans who have successfully kept at least 30 pounds off for a year or more):
- Ninety-eight percent of Registry participants report that they modified their food intake in some way to lose weight.
- Ninety-four percent increased their physical activity.
3. Walking is the most common form of exercise reported by successful weight loss subjects.
According to the NWCR, their study participants’ most frequently reported form of activity was walking. That’s not to say that other forms of activity (such as interval and strength training) aren’t an important part of a healthy lifestyle, but it is encouraging to know that brisk walking is a simple, affordable, and easily accessible place to start for most people.
4. Exercise itself (even without weight loss) is one of the most powerful preventive health interventions available.
Physical exercise has been shown to reduce blood pressure; decrease the risk for type 2 diabetes, strokes, certain types of cancer, and heart disease; improve arthritis symptoms and sleep disorders, and reduce erectile dysfunction, anxiety and depression. No pill or procedure can come close to providing all these amazing health benefits.
5. Diet is more important than exercise for shedding pounds of fat.
As I often tell my patients, “You can’t outrun your mouth.” Which means – you can eat far more calories in a short period of time than you can ever hope to burn with exercise. For this reason, diet plays a larger role in weight loss than exercise.
6. It’s more important to lose fat than to lose it by following a particular diet.
If diet is so important for losing weight, the next logical question is “Which diet is best?” Interestingly, the answer may be – whichever one you’ll stick to. Now, of course there are some diets that are more nutritionally sound than others – but the benefits of fat loss are so great, that health benefits are achieved even on relatively “unhealthy” diets. In a landmark diet comparison study, Michael Dansinger showed that study participants achieved similar benefits (such as improved cholesterol profiles, blood pressure, and inflammatory markers) from adhering to any of four vastly different diet regimes ranging from low fat, high carb to low carb, high fat.
7. The healthiest diets limit refined carbohydrate and animal fat intake, while maximizing fruit, vegetable, and healthy fats and protein.
I’ve just argued that a variety of diets work if you stick to them, and adherence is the key to fat loss, and even modest amounts of fat loss can have substantial health benefits. So does it really matter which diet you choose? In the long run, yes. Research has shown that there are some common nutritional principles that result in optimal health. The key ones are:
- Avoid refined carbohydrates as much as possible (such as sugar, fructose, and white flour/rice products). Unrefined carbs (such as whole grains, flax, oatmeal, brown rice, quinoa, berries, and cruciferous veggies) are an important part of a healthy diet.
- Avoid animal fats (trans fats). Healthy fats such as olive, fish and nut oils are preferable.
- Eat a diet rich in fiber, fruits and vegetables.
- Choose lean protein sources, including beans, eggs, chicken, fish, pork, yogurt, and fish.
- Limit alcohol intake and opt for water as your main source of hydration fluid.
8. Aim to lose 1 pound per week.
Cutting out approximately 500 calories from your daily caloric needs (established with a calorie calculator or by personal trial-and-error) is about as much as people can tolerate comfortably over periods of time. Diet adherence decreases as deficits exceed 500 calories per day.
9. The optimal, minimal amount of exercise for the average American adult is about one hour of moderate intensity exercise each day.
There is some disagreement on optimal exercise duration – some groups recommend half an hour per day (American College of Sports Medicine), others (such as the Institute of Medicine) a full hour. A review of the various positions and guidelines is available here. In terms of types of activity, there is general consensus that strength training twice a week should be added to moderate daily aerobic activity for best results.
10. You probably don’t need to take any vitamin or nutrition supplements.
Contrary to popular belief, most Americans (even with their sub-optimal eating habits) meet all of their basic dietary requirements with food intake. Non FDA-approved weight loss supplements have not been found to provide lasting benefits for weight loss and are generally ineffective and sometimes dangerous.
Weight loss drugs and surgical procedures may be effective last resorts for those who have failed to achieve results with diet and exercise. New prescription anti-obesity drugs and FDA-approved over-the-counter options are effective at helping patients shed extra pounds, but often come with unwanted side effects such as anal leakage and adverse cardiac events.
In conclusion, obesity underlies most of America’s chronic disease burden but can be reversed with modest weight loss through diet and exercise modifications. Patient adoption of long-term lifestyle changes are challenged by economic factors (e.g. healthy food “deserts” in inner cities), sedentary lifestyles, poor urban planning, excessive fast food and sugary beverage consumption, increasing portion sizes, and high tech conveniences that reduce energy expenditure, among other factors.
Patients are more likely to begin weight loss programs if recommended to do so by their physician, though studies suggest that they take advice more seriously if their physician is not overweight or obese herself. In our efforts to treat obesity, it may be especially important to lead by example.
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!
When you sit quietly, your heart slips into the slower, steady pace known as your resting heart rate. A new study suggests that an increase in this rate over time may be a signal of heart trouble ahead.
Your heart rate changes from minute to minute. It depends on whether you are standing up or lying down, moving around or sitting still, stressed or relaxed. Your resting heart rate, though, tends to be stable from day to day. The usual range for resting heart rate is anywhere between 60 and 90 beats per minute. Above 90 is considered high.
Many factors influence resting heart rate. Genes play a role. Aging tends to speed it up. Regular exercise tends to slow it down. (In his prime, champion cyclist Lance Armstrong had a resting heart rate of just 32 beats per minute.) Stress, medications, and medical conditions also influence the heart rate.
In today’s Journal of the American Medical Association, researchers from Norway report Read more »
*This blog post was originally published at Harvard Health Blog*
Dear Endurance Athletes,
Accept an apology in advance. You have endured so much from me.
Let’s at least start by agreeing that I can’t control the data.
Yes, you guessed it. There is unfortunately more bad news pertaining to the deleterious effects of endurance exercise on the human heart.
Again, I am sorry. Maybe re-phrasing the previous sentence will soften the blow. How about this: “Yet another study on endurance athletes suggests that exercise, like everything else in life, has an upper limit.”
Here goes, buckle up. Read more »
*This blog post was originally published at Dr John M*