Even though I don’t have an outpatient practice, I like to keep in touch with some of my patients after they’ve discharged from the rehab hospital. Jack is one of my very favorite success stories.
I met Jack in a small regional hospital in rural western America. He had been admitted with sudden onset weakness, and during the intake process, accurately described his daily evening cocktail habit. Unfortunately, this led the clinicians down the wrong diagnostic pathway, presuming that alcohol withdrawal seizures were the cause of his weakness (due to a presumed “post-ictal” state).
A brain MRI was unremarkable, and so a fairly high loading dose of anti-seizure medications were started. Poor Jack happened to be very sensitive to meds, and reacted with frank psychosis. Days later he was still not in his right mind, and so a rehab consult was requested for “encephalopathy due to alcohol withdrawal.”
When I met Jack, it was clear on first glance that… [click here to read the rest of the story] or go to this link:
My patient was an elderly farmer with severe vascular disease. He had advanced leg artery narrowing, had survived multiple heart attacks, and was admitted to the hospital after a large stroke. He was incredibly cheerful, vibrant, and optimistic. He had a very large, loving family who took turns attending to him, and encouraging him with each small improvement in his leg and arm strength. They knew his neurological exam better than his doctors.
I was amazed at his recovery, given the size and location of his stroke (and his advanced age), I had suspected that he would end up wheelchair bound. But he was determined to walk again and get back to his gardening as soon as possible. His children told me that he was very stubborn and was a true “fighter.” As their patriarch, he carefully questioned each of them about their goings on, making sure that they were each on track with grain harvesting plans, animal feedings, and various farm-related projects. His life had meaning and purpose, and the hospitalization was merely a change of venue for his daily instructions.
Because my patient was so motivated, I offered to bring him to his physical therapy session early one day. To my surprise, he firmly, but politely declined.
“I have an appointment with my family in my room.” he said.
I wondered if they were going to discuss advanced directives with an attorney, or something of similar seriousness.
“Oh, I see. Well we will come get you at the regular time then.” I smiled and left the room.
As I walked down the hall back towards the nurses station I recognized various members of his family proceeding towards his room, dressed in what appeared to be their “Sunday best.” There must have been at least 15 people in the group, ranging from tweens to adults. They were smiling and upbeat.
Minutes later I heard wondrous a capella choral sounds wafting from the patient’s room and filling an entire wing of the hospital. All motion ceased. Therapists stopped pushing wheelchairs, exercises paused, patients with walkers stood silent in the middle of sterile, tiled floors.
My patient had delayed his therapy session for something far more important – a live chorus of loving family, singing for him in a private exhibition that managed to touch us all.
The music I heard that day taught me a very important lesson. Some people know how to live their very best, wherever they are. Even a life-threatening condition in a hospital setting cannot dampen the human spirit.
May we all aspire to have such a spirit.
Photo Cred: Max S. Gerber
I learned a valuable lesson recently about how difficult it can be to make the correct diagnosis when you see a patient for a very short period of time. In the acute rehab setting I admit patients who are recovering from severe, life-altering brain events such as strokes, head injuries, and complex medical illnesses. It is challenging to know what these patients’ usual mental function was prior to their injuries, and so I rely on my knowledge of neuroanatomy, infectious disease, and pharmacology to guide my work up. However, I have learned that asking the patient’s family members about what they were like (in their healthier state) is extremely important as well. Personality quirks, likes and dislikes, and psychiatric history all offer clues to ongoing behavioral challenges and mental status changes.
This fact was never clearer than when I met an elderly gentleman with a new stroke. He was extremely drowsy, non-participatory, and was not oriented to anything but his name. The stroke had occurred in a part of the brain that does not affect cognition, so I began to wonder if he had an infection or was having a reaction to a medication. I carefully ruled out all possible sources of infection, and I combed through his medication list and removed any potentially sedating drugs. His mental status remained unchanged for several days. I then began to wonder if perhaps he was suffering from significant dementia at baseline, and that he was living at home with more help from his family than they had initially reported. The therapy team and I began to consider a transfer to a nursing home. The family was horrified by the idea.
As it turned out, his grandson shared with me that he believed that the patient was autistic. Because his grandpa was elderly, he grew up in a time where not much was known about autism, and diagnoses of the condition was rarely made. He was therefore never formally diagnosed, but had many of the textbook characteristics. His stroke, combined with a sudden transfer to an inpatient hospital setting, was very distressing for the patient, and he had shut down to protect himself from the mental anguish. The “dementia-like” behavior that we were witnessing was merely an acute psychological reaction.
Armed with this new information, the therapy team requested family members to be present during all sessions – to encourage participation and to provide comfort and normalization of the transition from home to hospital. The patient responded beautifully, and made remarkable gains in his ability to walk and participate in self care activities.
I apologized profusely to the family for our period of confusion about his diagnosis and care needs, and offered reassurance that we would do our very best to help him recover from his stroke so that he could go home directly from the hospital. He did in fact return home, and with a little extra help from his daughters, he is enjoying his usual projects and activities.
As for me, I will never presume dementia without careful family confirmation again.
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.