What's Wrong with Healthcare?

Thinking inside and outside of the healthcare box. After 41 years of family practice, what's happened to Canada's healthcare system?

Wednesday, March 15, 2006

Give Credit Where It Is Due

Evidence based medicine, education, and preventative medicine are continually being promoted as the salvation of our Universal Health Care System. Interestingly enough, there seems to be very little Level 1 research showing that a “healthy” diet as we know it at present, will contribute to longevity. Ongoing debate on low carbohydrate diets versus low saturated fat diets seems to leave us no-where. When my patients went on very strict low fat diets in the past, I noticed their HDL would drop, and now I believe there is evidence that saturated fats are necessary for the metabolism of HDL (good cholesterol). We seem to be quite sure at this time that trans fats are bad and after many years of suggesting that diabetics don’t need to worry about sugars, we are once again back to limiting “refined” carbohydrates. We believe that exercise is good, but there is very little Level 1 research that I know of that shows exercise will significantly decrease bed utilization in our hospitals. Recent research now suggests that perhaps it is not so much what we are eating, but what we are not eating (like sufficient linoleic acid containing foods), that is doing us harm. I will defer all this to nutritional experts (welcoming comments!). Suffice it to say, all of the above is very confusing and requires effort on the part of the patient both to learn and initiate. Personally, in my practice, I always found it easier to get my patients to take a pill than read a label or work up a sweat!
The point I’m getting at is best made in the March issue of the journal “Atherosclerosis in Primary Care”. The feature article is titled “early benefits of statin therapy in lipid lowering trials” and goes on to show that many lipid lowering trials (Level 1) have shown that aggressive lipid lowering with a statin, reduces the incidence of MI’s in 90 days and strokes in two years. This is done supposedly by lowering LDL, improving the health of the intima, and an anti-inflammatory effect of the statin. Since this is good “evidence based medicine” why is it that our (physician) “educators” are still advocating life modifying approaches as first line therapy for high risk patients? Not long ago one of our leading educators suggested (in a medical journal) a conservative approach like this for a patient with five cardiovascular risk factors (high risk). Why shouldn’t we start with 80 mgs. of atorvastatin and at the same time institute the life style modifications? If the patient is the exception to the rule, and is a huge success with life style modifications, consideration can be given to decreasing or stopping medication. For patients that have an aversion to taking medications, this approach may even be an incentive for them to adopt a healthy life style.
The cost of Pharmaceuticals has increased faster than any other aspect of health care over the past twenty years. There is a definite push on the part of our educators to decrease the use of pharmaceuticals in our patients. We often hear statistics on all the hospital admissions and deaths that occur because of medications but is this because of error and mismanagement or from the medications themselves? To pass judgment, this must be balanced against the lives saved and hospital admissions prevented by these various medications. The statin group of medications, and most of our anti-hypertensive group of medications, have that information available to us. There is very little rational for delaying pharmaceutical interventions.
Statistics show that we as a society are getting more obese and less active in spite of efforts at education. We are reaping the results of fifty years of smoking, years of consuming transfats, and an increased pollution to our environment; and still the life expectancy of men and women in Alberta is ten years longer now than it was when I graduated in 1962. It is not because people eat healthier or exercise more. Perhaps if we, as a profession, didn’t join in the chorus of voices giving pharmaceuticals a “bad rap”, we wouldn’t have so many patients who are non-compliant with their medications.


Blogger michie said...

It's interesting when people talk about nutrition and "level 1" evidence, especially regarding longevity... I'm not sure if what I've written below relates to what kind of "comment" you wanted regarding this, or if you just set off a ramble of my opinions Dad... Either way, here are my comments:

I’ve always had the motto: Once you eat what you should, you can eat what you want. That is, to satiety and no more. Accomplishing that goal is a whole other story. In an age of limited physical activity, our calorie requirements are less, and therefore we need to get our nutrient requirements with a smaller amount of food than if we were exercising. With greater physical activity, we can eat more food and hopefully fulfill our requirements better. Unfortunately most people don’t realize that eating what you should isn’t that difficult, and can be very yummy! I think this is mostly through ignorance and inexperience, something I was a victim of before I gained a certain level of knowledge and exposure in my current area of study and my extracurricular interest in the ‘optimal lifestyle’ for health.

On the topic of lifestyle and life extension… How important is life extension? The teenager that takes a drag on his or her first cigarette may not care that smoking could shorten their life substantially… until they’re 55 and only have 6 months to live and see everything over the next few years that they don’t want to miss. The family vacation they’ve been for the past 2 years, a family member’s graduation, the daughter’s wedding, the birth of their son’s first child… spring flowers!!! That being said, there probably is never ‘an ideal’ time to die.

So assuming that longevity IS important; the best science possible to predict these things is not set in stone. Yes, pharmaceutical companies can put people on this drug or that drug or no drug and see who dies and who lives over the next few years. That is pretty convincing. Nutritional science can examine the role of diet in life expectancy by looking at epidemiological studies, as well as some prospective cohort studies. I don’t have time to get into all the literature out there. I know that the body mass index has been associated with mortality, which I suppose is kind of an indirect measurement of nutritional status (a J-shaped curve with lowest mortality at BMI of 21-22 in a cohort of about 114 000 Americans, if memory serves me correctly). There have also been some studies showing that, for instance, the Mediterranean diet and low meat intake both seem to be positively associated with longevity.

Here is excerpt from an editorial in JAMA:
Diet, Lifestyle, and Longevity—The Next Steps? Eric B. Rimm, ScD; Meir J. Stampfer, MD, DrPH JAMA. 2004;292:1490-1492.
“In this issue of JAMA, Knoops and colleagues from the Netherlands, France, Spain, and Italy show that in European men and women aged 70 through 90 years adherence to a Mediterranean diet pattern, moderate alcohol consumption, nonsmoking status, and physical activity each were associated with a lower rate of all-cause mortality. Taken together, the combination was associated with a mortality rate of about one third that of those with none or only one of these protective factors. These healthful behaviors are not
extreme: for example, the physical activity criterion could be met by half an hour of walking daily.
Each of these factors was associated with lower mortality rates and combinations were particularly powerful. This work adds to a considerable body of previous studies with
remarkably similar conclusions. For example, Trichopoulou et al observed a comparable lower total mortality rate associated with a Mediterranean diet and moderate alcohol
consumption. Our group found that adherence to similar healthful lifestyle practices was associated with an 83% reduction in the rate of coronary disease, a 91% reduction in
diabetes in women, and a 71% reduction in colon cancer in men.”

Also, one can look at reducing levels of risk factors, chronic disease and to some extent mortality through diet. The Diabetes Prevention Trial showed that lifestyle/diet intervention worked better than metformin in preventing or delaying type 2 diabetes in those at risk (by 58% in lifestyle group vs. 31% in metformin group compared to non-intervention controls). Prevention of chronic disease logically delays death.

Caloric restriction has been shown to increase life expectancy in animal studies. These studies have pointed to many metabolic effects of life extension, including increasing endogenous antioxidant levels and reducing inflammation (i.e. “biomarkers of aging”), which are similar to the effects of diet and exercise, have also been shown to have positive effects in animal studies. Remember that in animal studies during caloric restriction, the animals tend to be given very strict, consistent and nutritionally complete diets (i.e. no “junk food”). This is unlike the free-living human situation in which caloric restriction may result in nutrient deficiencies, which in turn could reduce longevity (i.e. micronutrient deficiencies may even cause DNA damage, with one possible result being cancer).

Regarding reducing risk factors, is it true that if you reduce LDL cholesterol levels, increase HDL levels and decrease inflammation in an individual through proper nutrition and exercise, increase longevity could be increased? I think it’s clear that this is preventative of a heart attack and therefore results in that person living longer. I actually think that these risk factors are “health markers”, in other words they indicate a healthier overall person, whereas with pharmaceuticals you don’t know whether the drug is improving ‘overall’ health or just taking care of the symptom. It’s becoming clear that statin drugs seem to have multiple beneficial effects, however I would propose that certain diets can achieve similar effects on risk markers and MORE. With a healthy diet there’s no way of predicting all of the beneficial effects going on in the body. There are several clinical measures that we use to predict heart disease, but it’s possible that there are hundreds of physiological processes going on in concert that predispose a person to chronic disease. The effect of a drug on one or a few of these can be monitored, but what of the other effects? Nutrition/lifestyle likely improves ALL of these at once.

And finally, regarding life expectancy, some experts are now saying that due to the current obesity epidemic, there could potentially be “a decline in life expectancy in the United States in the 21st century” (NEJM 352;11, www.nejm.org, march 17, 2005). So not only are these people living with all sorts of side effects of obesity and the social stigma associated with it, but they will also die earlier!!! Society is a mess nutritionally right now…

This brings me to the most important result of a healthy lifestyle, in my opinion. This is improvement in the quality of life. My own personal experience is not science but a ‘testimonial,’ however I can tell you that my days are better when I have more energy and am feeling well than when I feel terrible, am in pain or am tired… I’m sure I could look up all the beneficial effects of lifestyle on quality of life, but I’ve already spent a lot of time writing this when I need to work on my thesis!

I feel that staying healthy while you are alive, if that’s a few years longer or not, is a worthy goal. It can be and must be fun in the meantime, because tomorrow you could get hit by a bus and none of this would have mattered!!! Although perhaps if you’d been optimally healthy, you would have been more alert and awake and noticed that bus coming! Ah, but I digress…

25/3/06 11:36 AM  
Blogger Al said...

"Society is a in a mess nutritionally right now" pretty well somes it up. So, in the short version you basically agree with me---"in spite of smoking, obesity, rising rates of diabetes, transfats, sitting on our duffs, etc, we are living longer AND I would venture to say, healthier (with better quality of life since most pharmaceutical studies look at medical events, hospitalizations, etc). As for "feeling better" within your self, I couldn't agree more. Pharmaceutical companies have been working on a "feel good" pill for many years since the market and demand for this would be incredible. Unfortunately,(or fortunately) anything coming out so far has had addictive properties and so has fallen into disfavour.
I support what you are saying and will buy much of it, but my point was that we as a society whine about the big bad drug companies and the cost of pharmaceuticals, but won't for the most part abide by the even rudimentary aspects of a healthy life style (as we know it)which is extremely cost effective.
I like your "after you eat what you should, eat what you want" with the "amount" caviat. Unfortunately, we are given too much of the DON'T phylosophy and not enough of the DO phylosophy.
Thanks for your comments.

25/3/06 12:15 PM  
Blogger michie said...

The drug companies may have help now for those who 'whine' about drug companies. Haha.

Check out:

Wonder Drug Inspires Deep, Unwavering Love Of Pharmaceutical Companies


25/3/06 3:32 PM  

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