From Dr. Fischer’s Case Files : Sometimes We Order Too Many Tests in Medicine

ICUIn my last post, I touched on the idea that sometimes ordering more tests in medicine actually leads to worse outcomes, and the counter-intuitive idea that staying healthy might, at times, be best served by NOT proactively looking for every possible medical problem. This is such a tough concept for most people to wrap their heads around that I thought a few real-life examples from my own “case files” might be helpful to better illustrate the point. I’ve changed the names and some details in order to protect privacy, but the stories below are taken from real patients that I’ve encountered over the years.

The Stress Test Gone Wrong

Bob was a healthy man in his mid 60s who was enjoying his retirement when a close friend of his unexpectedly dropped dead of a heart attack. Alarmed that the same might happen to him, Bob made an appointment with his doctor and requested that he have a stress test to check his heart out. Though all professional organizations have now weighed in against the practice of the “preventative” stress test in patients without any cardiac symptoms (because time and again studies have failed to show that they save any lives, and because of stories like the one that is about to follow), at the time this was a not unheard of practice, and so a stress test was scheduled.

Bob’s stress test showed an area of possible concern, so he was referred to a cardiologist, who scheduled him for a catheterization. This is a much more definitive test to look for coronary artery disease, in which a catheter is threaded through an artery and up into the heart, and then dye is injected in order to visualize the coronary arteries and see if any blockages are present. Fortunately for Bob, his coronary arteries turned out to be free of any important blockages – the area of concern on the stress test had been a “false positive”. Unfortunately for Bob, during the procedure he suffered a rare and devastating complication: a plaque in one of his arteries broke off and travelled to his kidneys, choking off their blood supply. He spent the rest of his life on dialysis and died a few years later due to complications from his kidney problems.

A Lethal Case of Non-Lethal Prostate Cancer

Joe was in his late fifties when a PSA (a blood test to check for prostate cancer) was found to be elevated during a routine exam. He was referred to a urologist who performed a biopsy which found a small spot of cancer on his prostate. It has become increasingly clear in recent years that small spots of prostate cancer like this are very common and often grow extremely slowly, such that they may take many decades before they start to cause any problems and therefore don’t always needs to be treated. But at the time of this story, it was the standard of care to always remove prostate cancer, and this is what was done. After reviewing the options. Joe elected to have a prostatectomy – an operation in which his prostate was surgically removed.

Unfortunately, even fairly routine surgery like this can sometimes go wrong. In Joe’s case, he developed a bloodstream infection after the surgery. He spent several weeks in the hospital getting IV antibiotics. The infection in his bloodstream allowed bacteria to get into his knee, and he developed a severe knee infection, which ultimately required him to get his knee replaced.

I met Joe about ten years after all of this occurred, when he was hospitalized again with what started out as a simple infection. Unfortunately, it didn’t stay contained, and again he developed a blood stream infection. Bacteria love prosthetic devices, and once the infection spread to his blood stream, it was only a matter of time before the artificial knee got infected again. There followed a very long hospital stay, involving multiple knee surgeries, weeks of IV antibiotics, and stays in the intensive care unit. Despite our best efforts, Joe ultimately succumbed to his various medical issues. The death certificate listed the cause of death as complications from a severe infection of the knee, but Joe’s demise actually began years earlier when his PSA was found to be elevated.

If the above stories seem frightening, I want to remind my readers that these are extreme examples. Most medical procedures are safe and very rarely lead to really bad outcomes like these. The point is not that we shouldn’t be doing cardiac catheterizations or treating prostate cancer. It’s that ALL decisions in medicine involve weighing the pros and cons of taking a particular path. The pros (“maybe we’ll find an early prostate cancer and my life will be saved”; “I’ll get a clean bill of cardiac health and sleep better”) are readily apparent to patients, whereas the downside is often more hidden.

We’ve all heard about that friend of a colleague who got lucky, was found to have disease x at a really early stage, and is doing great as a result. The story about the guy who died as a result of a long chain of events that started when he got treated for a cancer that might never have killed him doesn’t catch our imagination in the same way. But it should serve to remind us that things are rarely as clear-cut as we’d like them to be in medicine.

Do We Order Too Many Tests In Medicine?

080922-N-2688M-004I promised in a previous post that I would try to address the topic of the current drive to reduce medical testing, and the fact that it’s not solely motivated by money. In the past few years, the medical headlines have been full of controversy about recommendations to do fewer mammograms, to cut back on prostate cancer screening, or to do fewer MRIs.

The general reaction from the public has been very negative toward such moves. Most people assume that these steps are being taken to help the government and the insurance companies save money, and that their health may be jeopardized as a result.

Modern life is full of things that are counterintuitive. It should seem obvious, for example, that raising the minimum wage would help the working poor to obtain better lives – but in fact, many (perhaps most) economists think the opposite. Driving a hybrid car should seem like a no-brainer for reducing greenhouse gas emissions and helping the environment – but it in some circumstances it may not be. And it should seem perfectly obvious that ordering more medical tests will lead to more timely diagnoses of scary things, like hidden cancers, and thus save lives. Except that often times it may have the opposite effect.

How could this possibly be?

There are a number of factors to consider, but the most important one is: what are the odds of turning up a “false positive” result to the test, and what harm might accrue to the patient as a result?

Let’s imagine a fictitious scenario in which cancer of the pinky were ravaging the United States. Let’s further suppose that one of our brilliant scientists here in Rhode Island, at Brown University, comes up with a screening test for this cancer, called the “Pinkygram.”

Now consider the following scenario: Angela gets a pinkygram, which shows a suspicious spot. This leads to a biposy, which shows an early pinky cancer. This is removed, and she goes on to live a long healthy life. At the same time, her twin sister Barbara also gets a pinkygram, which shows a suspicious spot. This leads to a biopsy, which turns out to be benign, and she too goes on to live a long healthy life.

So far, giving our fictitious sisters their pinkygrams seems like a great idea. We did two tests, found two suspicious spots, and diagnosed one cancer. We saved one life (a huge positive) at the expense of putting Barbara through a scary, painful, and expensive medical procedure that didn’t result in adding any benefit to her health (a negative). But I think most people would take this trade-off. Had we not done the pinkygrams, Barbara would have been spared an unnecessary ordeal, but Angela might have died.

But what if for every Angela we find, there are a hundred Barbaras? Now we’re faced with a little bit of a tougher scenario. We are putting one-hundred women through an expensive, painful, risky procedure in order to save one life. But on the whole, this still seems like a good deal; one-hundred women have been put through a bad ordeal, which is very unfortunate, but in the long-run they are doing just fine, and we’ve saved Angela’s life. I think most people would still take this trade-off.

But now let’s suppose that one of those one-hundred women has a bad complication from their biopsy procedure. To make the example really clear, suppose that one of our Barbara’s has a severe allergic reaction to the anesthetic during her biopsy and dies on the table. So the “tally” now looks like this: one life saved (Angela, who might have died of pinky cancer but now won’t) but one death created (one of our Barbara’s, who would not have died of pinky cancer, but died from the procedure that was done to prove this) and 99 other Barbara’s who have been put through a great deal of pain, stress, anxiety, and financial expense. Now, on the whole, our pinkygrams have caused more harm than good.

This is precisely the sort of reasoning that led to a controversial suggestion a few years ago that women aged 40-50 not get as many mammograms. At the time, the suggestion led to a massive outcry from some breast cancer advocacy groups, and the recommendation was never put in place. And to be fair, the data is not so unambiguous as in our hypothetical pinky example above. It’s hard to do a full “cost/benefit” analysis of a test that is used on millions of women, because there are so many variable outcomes that may be over or undercounted. And breast cancer is understandably such an emotional disease for so many people, that a pure “cost/benefit” analysis can never give us a full picture of the situation. But there is no doubt that the majority of women aged 40-50 who have an abnormal mammogram will turn out to NOT have breast cancer, and also that some cancers diagnosed in this age group would probably not turn out to be fatal. The researchers who were suggesting we should not be doing mammograms on this group were not just being motivated by a desire to save the system money.

The right thing to do is not always clear cut, and the recommendation to do fewer mammograms may well have been the wrong one. My point is not that we should or should not be doing fewer mammograms on younger women. But rather that a reasonable person who is motivated only by a desire to help women be as healthy as possible can come down on either side of this question. And so it is with many of our medical tests.

And now, a word from some studies…

Journal_of_the_American_Medical_Association_first_issueGetting back to the topics of diet and nutrition, there have been a few interesting studies published of late.

In one, researchers at Tulane University put a group of overweight adults on either a low-carb diet or a low-fat diet and followed them for twelve months. As has consistently happened in similar prior studies, the low-carb folks lost more weight and had better improvements in a variety of health markers (notably HDL cholesterol and triglycerides) than did the folks in the low-fat group.

This supports my oft-repeated contention that low-carb diets are NOT bad for you, and in fact, are probably a better choice for most people than the standard “low-fat, low-calorie” diet that is typically recommended for weight loss and health.

In another study, JAMA published a “meta-analysis” in which they crunched together the data from 48 different randomized controlled trials on diet and weight loss. Their conclusion? “Significant weight loss was observed with any low-carbohydrate or low-fat diet. Weight loss differences between individual named diets were small. This supports the practice of recommending any diet that a patient will adhere to in order to lose weight.” [Although they did find a small edge to the low-carb diets in terms of maximum weight loss].

Which supports another important Dr. Fischer corollary: while I certainly promote low-carb diets and think they work better for most people most of the time, the best diet for any individual patient is the one they are most likely to follow.

Sandeep Jauhar on the Problems of American Medicine

UnknownA few years ago, I read a memoir entitled Intern by a doctor named Sandeep Jauhar. It is probably the most accurate and well-written description I’ve ever read about medical training, and if you are interested in what it is really like to be a medical resident, I highly recommend reading it.

Now, Dr. Jauhar has a new book out about the crisis of modern American healthcare and why so many physicians are dissatisfied. As I’ve said before, I don’t fit into that group – I still love what I do and think it’s a real privilege to be a physician. But the profession certainly has its problems, and we would do well to address them.

At any rate, I haven’t read Dr. Jauhar’s new book yet, but I did listen to an interview with him about it recently. It’s about 25 minutes and pretty interesting, so if you have the time, click here.

Lyme Disease, Part 3 – The Chronic Lyme Controversy

Adult_deer_tickIn my last two posts I discussed the basic facts of Lyme disease, including how it is transmitted, how to protect yourself from it, what symptoms it causes, how it is diagnosed, and how it is treated.

Lyme disease however has a more controversial side. It would take far more than a single blog post to discuss it, but I want to touch on this topic because it is something that comes up frequently and which understandably causes a lot of confusion amongst the public at large. I think it would be easiest to continue our discussion in Q&A format:

Q: I’ve heard that people can develop “Chronic Lyme Disease” in which they are infected forever. Is this true?

A: The short answer is that, to the best of our knowledge, no. The idea of “Chronic Lyme Disease” is not accepted by mainstream medical opinion, though there is a very vocal minority out there that do believe in it, and I think it would be rash to completely dismiss their concerns.

There is no doubt that many people who are affected by Lyme disease continue to suffer from a variety of ailments even after they are treated. Common complaints include fatigue, joint pains, a feeling of being “foggy”, and headaches.

Many studies have looked into why this is, and there are a number of theories about this phenomenon (more on this in a moment). One of those theories is that some patients develop “Chronic Lyme” in which the infection is not cleared despite antibiotics. To date however, no large-scale credible study has been able to demonstrate the existence of such a condition. To the best of our ability to tell, patients who have been treated with antibiotics do seem to be rid of the bacteria that causes Lyme disease. The mainstream view is rather that these patients have “Post-Lyme Disease Syndrome”. In other words, they are not chronically infected with Lyme, but rather they have cleared the infection but continue to suffer from symptoms that they acquired during their illness.

Q: If my symptoms are not due to Chronic Lyme Disease, what could it be?

A: This is a tougher question to answer, and the truth is that we aren’t certain. But there are a number of plausible explanations.

For one thing, it may be that the infection cleared up, but left some long-term damage to the body before doing so.

Another may be that going through a bout of Lyme disease creates an autoimmune response in some people. This is a phenomenon that is known to occur in other illnesses – for example, certain intestinal infections can set off autoimmune arthritis in people who are predisposed – so it wouldn’t be out of the question that the same thing is happening here.

Another important point is that having had Lyme disease doesn’t prevent one from developing other medical problems. There is a tendency once someone has had Lyme to hang a lot of symptoms on it. But it is perfectly possible to have Lyme, recover fully, and coincidentally develop another illness such as a thyroid problem, or arthritis, or celiac disease not long after. A person who has been treated for Lyme and is continuing to not feel well therefore should have a reasonable workup to exclude other possible illnesses. I’ve seen important diagnoses go missed because of the assumption that all of a patient’s symptoms were attributable to Lyme.

It should also be pointed out that there have always been people who just don’t feel very well. The medical literature has been full of cases of intractable fatigue, aches, and other symptoms for literally thousands of years. The diagnosis given to such people often depends on the time and place in which they live. Freud for example wrote entire books about performing psychotherapy on people with many of the same symptoms that we see today in post-Lyme disease syndrome – this was in Vienna in the late 1800s, a time and place where Lyme disease didn’t exist at all – attributing them to “neurosis”. In the 1950s, it was common for people with fatigue and aches to be labelled as having “Chronic Brucella,” a rare intestinal infection. My point is not that people who are suffering from these symptoms don’t have something “real” or that Lyme disease isn’t playing a role in many cases. It’s just that even if we could completely eradicate Lyme disease from the face of the earth, there would still be some people with these symptoms.

Lastly, it has to be acknowledged that maybe Chronic Lyme Disease does exist after all. The fact that so far the studies don’t seem to support the existence of this syndrome doesn’t mean for certain that it doesn’t exist.         
  
Q: I’ve heard of “Lyme Clinics” that treat Chronic Lyme disease with long-term antibiotics. What do you think of this?

A: This is really the crux of the matter. There wouldn’t as much contention between those who believe in Chronic Lyme Disease and those who don’t if it weren’t for this point. If you believe that Lyme can become a chronic infection, then it makes perfect sense that a very long course of antibiotics may cure it. If you don’t, then giving a prolonged course of antibiotics is not going to help. Even worse, long-term courses of antibiotics can cause very dangerous side effects, including life-threatening bowel infections, nervous system damage, kidney failure, and death. Exposing patients to such risks without any provable benefit violates the core precept to “first, do no harm” that physicians are sworn to uphold.

I’m perfectly willing to admit that there’s a lot we don’t know about Lyme disease. I’m perfectly willing to admit that there are many people who continue to be bothered by symptoms even after completing treatment for Lyme disease. I’m even willing to admit that perhaps we will someday discover that Chronic Lyme infections really do exist. But on the point of long-term antibiotics I draw a much firmer line.

To date, there have been several randomized controlled studies done comparing long-term antibiotics to placebo in patients who have post-Lyme/Chronic Lyme type of symptoms. They have all come to the same conclusion: there is no sustained benefit to a course of long-term antibiotics. (References here, here, and here.) The people who got the antibiotics either had no improvement at all compared with the people getting placebo, or else just a very slight and minor one that did not last once the antibiotics were stopped. Needless to say, the people getting the antibiotics had more side effects and complications.

Given this fact, most doctors – myself included – do not feel that it is appropriate to treat patients with long-term or repeated rounds of antibiotics for this condition.

Q: So does this mean that people with “Post-Lyme” or “Chronic Lyme” disease are doomed?

A: No. Many patients with long-term post-Lyme symptoms do eventually get better – I’ve seen people who have suffered for months or even years with this issue gradually get back to the point of living a normal life. But for a small number of patients symptoms will persist for a long time, perhaps indefinitely.

I think it fair to say that, at this point, nobody on either side of this debate knows with complete certainty why this is. This fact is very frustrating, and hopefully in the future this is something that science will figure out. In the meantime, if you think you are having ongoing symptoms after a bout of Lyme disease, it’s best to discuss this with your doctor.  

Lyme Disease, part 2

LymeCTIn my last post, I gave some background about the history of Lyme disease, how it’s transmitted, and how to protect yourself from catching it. Today, I want to discuss exactly what Lyme disease does to your body, and how it’s diagnosed and treated.

I think it would be easiest to do this in question and answer format, so here goes.

Q: Help! I got bit by a tick yesterday and today I have a rash! Is it Lyme disease?

A: Probably not. Recall from last post that it takes about 24 hours of a tick being attached to your body to transmit disease. Secondly, if you are infected with Lyme disease, it takes about a week after the bite before symptoms of Lyme disease appear. It is not uncommon to have a small red rash at the spot of a tick bite for a day or two after being bitten, similar to what you might find with other bug bites. This is an inflammatory reaction to being bitten by a bug, not Lyme disease itself. Needless to say though, if you have any doubts go see a doctor.

Q: What are the first symptoms of Lyme disease?

A: The most common is a “bullseye” rash, which looks something like this:

Bullseye_Lyme_Disease_Rash

This develops about a week to 10 days after an infection. It can be accompanied by mild flu-like symptoms (fever, aches, fatigue). Unfortunately, the rash doesn’t always look so textbook, and there are a small percentage of people who don’t develop the rash at all. If you think you’ve been bitten by a tick and see any of these symptoms about a week later, go see a doctor! This is the stage of Lyme disease that is most easily treatable. Almost everyone who gets a few weeks of oral antibiotics at this point will make a full recovery.

Q: I’m not sure about the rash I have, and neither is my doctor. Can’t you order a blood test to tell for sure if I have Lyme?

A: This is a crucial point that I can’t stress enough: there is no test that can diagnose Lyme disease at an early stage! Let me repeat that: if you think you have had Lyme disease for less than several months, a blood test is completely useless! Why is this? Because the best (though certainly imperfect) test we have for Lyme is a blood test for antibodies to the Lyme bacteria, not for the presence of the bacteria itself. It takes at least six weeks after you are infected for your body to start making these antibodies, so it is completely expected that early in the course of a Lyme infection you will have a negative test result.

Here’s a true story to demonstrate how dangerous this point is. I once saw a patient who had been bitten by a tick. About a week later he developed a rash and fever, so he called his doctor’s office and left a message with the receptionist asking that he be tested for Lyme disease. The test was ordered and came back negative. Therefore the patient felt reassured that he was safe, and so he didn’t follow up on it any further. He then came to see me a few months later, extremely sick with a classic case of advanced Lyme disease. In truth, the fault for this was not just with the patient – his original doctor probably should have asked more questions before just ordering the test (though to be fair to her, we doctors are very busy and sometimes messages get garbled in translation). But the fact remains that nobody is more responsible for your own health than you are, and it’s a really bad idea to play doctor to yourself. So let me stress this again: if you think you might have Lyme disease, go see your healthcare practitioner and let them make the decision about what tests, if any, are appropriate to order.

Q: What if I don’t get prompt treatment for Lyme?

A: Lyme is a disease that works in stages. The initial stage of rash and flu-like symptoms lasts a few weeks at most and then will go away on it’s own, even without treatment. For a significant percentage of people this will be the end of the issue, and they will have no further problems. However, many people who are not treated will advance to later stage Lyme disease. This can be varied in its manifestations, but in general includes three main types of health issues:

    1) Neurological ailments – these can include meningitis (an inflammation of the tissues lining the brain that causes fevers and severe headache), neurologic palsies (most commonly Bell’s Palsy), and an encephalopathy (a subtle impairment of thinking).

    2) Cardiac issues – these occur when the bacteria infects the heart, causing disturbances of the heart’s electrical impulses. This can lead to a dangerously slow heart rate.

    3) Arthritis – the infection can cause severe pain and swelling in many joints, most commonly in the knee.

At these stages, antibody tests should be markedly positive. Therefore, a positive test IN TANDEM with any of the above symptoms can help make the diagnosis. If the test is negative, on the other hand, it strongly argues that there is another cause for the symptoms. (Every one of the above symptoms can be caused by a number of other diseases too).

At this point in the infection, things become much more difficult to treat. Patients will need several weeks of intravenous antibiotics. Fortunately, most will make a full recovery. However, a significant minority will take a long time to feel fully better, and an unlucky few will be plagued by long-term symptoms (to be discussed more in my next post).

Q: I feel a bit sluggish. I got a Lyme antibody test and it was positive. This means that I have Lyme disease, correct?

A: Not necessarily. As with all blood tests, a Lyme antibody test can be falsely positive. The diagnosis of Lyme disease is pretty clear cut when the antibody test is markedly positive in a person who has symptoms that are classic for Lyme (such as severe knee arthritis, or a nervous system palsy). But studies have shown that many people with no symptoms of Lyme can occasionally have a positive antibody test. I will discuss this topic in more detail in my next post, because this is a major part of the controversy over what has been called “Chronic Lyme Disease” by some people.

Let’s Talk About Lyme Disease

Limes_whole_and_halvedI’m going to take a break from my nutritional and fitness ramblings to get back to a more “medical” type of topic: Lyme disease.

Rhode Island is at the center of the Lyme epidemic. We have more cases of Lyme per capita here than any other state in the country, and right now is the peak of Lyme season. Accordingly, I see and treat a lot of Lyme this time of year. It’s a disease about which a lot of confusion exists, and about which there is a lot of fear and controversy, so I thought it would be helpful to dedicate some time to discussing it.

First off, some background. Lyme disease got it’s name because it was discovered during the 1970s when there was an outbreak in the town of Old Lyme, Connecticut. At that time there was a cluster of young people (many of them children) coming down with an unusual type of arthritis. They came to their doctors with fatigue and swollen joints, amongst other symptoms, and many were initially diagnosed with Juvenille Rheumatoid Arthritis. Eventually it become apparent that there were simply too many patients coming in with these symptoms for it to be an autoimmune disease, and after a few years of detective work, the truth – that the disease is caused by a bacteria known as Borrelia burgdorferi which is transmitted by the bite of a deer tick – was discovered.

It is very possible that Lyme disease existed in some form prior to the 1970s. However, the prevailing theory is that changes in the usage of land led to it’s introduction en masse into the population around that time. In the decades after World War II, large swaths of land in New England (and other parts of the country) that had previously been plowed farmland were converted into suburban developments, and in many cases woods and trees were allowed to grow back. This created a situation in which large numbers of people were now living in proximity to deer and the ticks that feed on them, thus creating the conditions for Lyme disease to be introduced into the population at large.

Whether it is because of the continued encroachment of humans into the habitat of deer or because of increased public awareness and better diagnostic techniques, there is no question that Lyme disease has grown significantly in prevalence since it was first discovered, with possibly several hundred thousand cases annually in the United States.

The single best way to protect yourself against Lyme disease is to not get bitten by a deer tick. This means that if you are going into areas of woods or tall grass, you should wear protective clothing and an insect repellent with DEET in it. You should also do a full body tick check and take a shower immediately after coming indoors. If you do find a tick, promptly remove it, as described here. A tick that is attached to your body for only a brief time cannot transmit Lyme disease to you. In fact, most estimates are that a tick needs to be attached for at least 24 hours before it can transmit the disease, so even after getting bitten by a tick you have a big window of time in which to protect yourself against a disease transmission. For a full discussion of tick avoidance, I recommend clicking here.

I’m going to stop there for now, so as to not overload you. We’ve discussed the history of Lyme disease and how it is spread and can be prevented. In my next post, I’ll go into specifics about what symptoms Lyme disease causes, how it can be diagnosed, and how it is treated. Then I’ll probably use a third post to discuss the big controversy surrounding Lyme disease, namely the concept of “Chronic Lyme Disease,” and why this very term has created a contentious debate between certain patient advocacy groups on the one side, and doctors and researchers on the other.

Which Fats Are Healthiest?

olives-20224_640It seems that I’ve generated an international following, because a reader from Thailand contacted me to suggest that, since I’m advocating that people eat more fat, it would be useful to do a post on what types of fats are healthiest.

True, the reader from Thailand happens to be my brother. But still. A global empire has to start somewhere.

There are definitely differences between the fats. Most folks are familiar with the concept of “healthy fats”, and I do think a quick rundown of how the different fat types fit into a healthy diet could be helpful. So here goes a quick review, in order from best to worst:

The Healthy Fats – Stuff these down your throat in great quantity and sing a song of praise to the Gods.

These include olive oil, fatty fish (salmon, herring, mackerel), avocados, and nuts. If you notice, these are all staples of the so-called “Mediterranean diet” that has become popular in recent years. The other unifying theme here is that these are all naturally occurring fats that have been part of the human diet for a long time, and that come from either plant or fish-based sources. A pretty good body of evidence suggests that not only are these fats not bad for you, but that they actively promote better health. You should eat as much of these types of fats as you wish.
 
The Neutral Fats – Don’t be afraid to eat these.

I put saturated fats from animal products in this category. This includes egg yolks, dairy products, and meat. As I’ve pointed out in prior posts, these fats have been demonized for a long time, but the evidence that they are really bad for us is scant at best. It is true that a diet high in these does often lead to elevated cholesterol levels, but it raises both the so-called “good” (HDL) and “bad” (LDL) cholesterol about equally, so it’s probably a wash as to overall cardiac risk. Despite six decades of trying to prove that these fats are deadly, no study to my mind has convincingly done so. We have some early epidemiological studies suggesting that diets high in these fats lead to heart disease, but epidemiological studies are notoriously prone to flaws, and I could cite just as many such studies that do NOT show any association between eating these fats and heart problems. To cite just one example, the two countries in Europe with the highest consumption of saturated fat (that would be France and Switzerland, respectively), are also the two countries in Europe with the least heart disease.

A word of suggestion here: most cows in the United States are fed grains such as corn. Many have raised the point that cows are naturally meant to graze on grass, and that they are leaner and healthier when they do so. Corn is used instead because it is cheaper than grass and it fattens the cows up more quickly. It is now well established that products from grass-fed cows (meat, cheese, butter) are higher in Omega-3 fatty acids (a particularly healthy type of fat) than products from corn or grain-fed cows. It is therefore likely that these products are healthier. If you can afford them, consuming grass-fed beef and dairy is probably a good choice.

One final fat that I would throw into this category is coconut oil. This is a naturally occurring saturated fat that looks very similar in appearance to shortening. You may recall that in the 1980s, this was a very maligned type of fat, and there were warnings left and right about how deadly it was. Indeed, at the time, many mass produced bakery goods were made with coconut oil. Within a few years, coconut oil all but disappeared from the mass produced supply chain, often replaced by the supposedly healthier vegetable shortenings and hydrogenated vegetable oils (more on these shortly). Well, it turns out that coconut oil is not as bad as was thought at the time. True, it is a saturated fat. But again, it is a naturally occurring one, and there have been studies in the past few years showing that coconut oil has an overall favorable effect on HDL to LDL ratios and may also have some anti-inflammatory properties. If you google “coconut oil”, you’ll find a lot of web sites claiming that it cures everything from acne to Alzheimer’s disease. I wouldn’t quite go that far. There’s no credible evidence that I know of that Coconut oil is some type of wonder drug. But if you accept – as I do, and many others are coming to – that saturated fats are a normal part of the human diet and not the public enemy they’ve been made out to be, then coconut oil is an inexpensive and versatile oil to include in your diet.

If there is one constant theme to this category it is this: these are saturated fats that occur in nature and that have been part of the human diet for a very, very, long time. They may not be the healthiest fats, but our bodies are probably well adapted to digest these and there is little evidence that they are overtly harmful.
 
The Fats of Dubious Value – Be cautious. The jury is still out.

I include most of the vegetable oils that form the backbone of the American diet here: corn oil, peanut oil, soy oil, safflower oil, etc. For a long time these have been pushed as “heart healthy” because they come from plant sources and are naturally unsaturated. They also tend to be high in polyunsaturated fatty acids, which are thought, possibly, to be protective against heart disease.

The problem with these fats is that they are mostly relatively new introductions to the human diet. Many of them didn’t even exist until the last 50-60 years. Not surprisingly, we are now turning up some research on them that suggests they may not be as healthy as we once though. For one, they are very high in omega-6 fatty acids (which are pro-inflammatory) and low in omega-3 fatty acids (which are anti-inflammatory), and we now believe that diets high in omega-6 and low in omega-3 have their own set of health risks. There is also evidence that, at least in lab animals, some of these oils may promote the growth of cancer cells.

There are a lot of websites out there dedicated to the proposition that these oils are pure evil. I’m not prepared to go that far. I think the jury is still out on these, and perhaps some of them will turn out to have a role in a healthful diet. But I think it’s best to take a cautious attitude toward them.

A final note: of these types of oils, probably the healthiest is Canola oil, which contains some fairly good stuff, including omega 3 fatty acids. There are some website out there dedicated to the proposition that Canola oil is terrible for you, but I’ve yet to see any really compelling evidence for this, and I think most nutritionists agree that, aside from Olive Oil, it’s perhaps the healthiest of the vegetable oils.
 
The Evil Fats – Run from these.

Without a doubt, the worst fats are the ones that are high in so-called trans-fatty acids. I won’t bore you with a chemistry lesson, but essentially there are two major types of carbon-hydrogen bonds in organic molecules: trans bonds and cis bonds. Virtually all of the bonds found in fats that humans naturally eat (olive oil, nuts, egg yolks, butter, steak, milk, fish, and so forth) are cis bonds. Trans-fats are only found in industrially manufactured products. So until just a few decades ago, human beings ingested virtually no fats containing trans bonds. It should not be surprising then that these turn out to be just terrible for us. Research has now linked trans-fatty acids to almost every disease known to man, including heart disease and cancer.

Where are these evil trans-fatty acids found? In any oil that has the word “hydrogenated” in it. Hydrogenated and partially-hydrogenated oils are oils that have a bunch of hydrogen ions shot into them via an industrial process. This results in a cheap oil that is solid at room temperature and that takes years to spoil. Needless to say, fast food restaurants and manufacturers of packaged foods love these types of oil. You shouldn’t.

Here’s an important tip for you: a few years ago, trans-fatty acids deservedly began to get really bad press. A lot of companies have now gone out of their way to advertise their products as “trans-fat free”. Be very wary of products that make this claim. It is perfectly legal to advertise your product as “trans-fat free” if it has only a small amount of trans-fat per serving. A lot of companies have sneakily cut their serving size down in order to exploit this fact. For example, let’s imagine a company that used to sell a box of 20 cookies, each of which contained a half gram of trans fat. Suppose they used to list a serving size on the nutrition label as two cookies (i.e. 10 servings per box), which would equal one gram of trans-fat per serving. Now the same company might sell the exact same box of 20 cookies, with the exact same recipe, but label a single cookie as one serving (so now 20 servings per box). With each serving now containing only half a gram of trans-fat, they are allowed to round down and advertise the cookie as “trans-fat free”. Same company, same cookie, same trans-fat levels, but by an accounting trick they can now advertise their product as “healthy”.

Don’t be fooled. If the word “hydrogenated” appears anywhere on the ingredient list, the food has trans-fats in it, and you should run.

And how, exactly, did all of these trans-fats get into our diet? Well, for one thing, money certainly drove the process. As discussed previously, hydrogenated oils are cheap to make and can last for years, so manufacturers of mass-produced food have found it very profitable to use these. But another reason they became so popular is that they had the backing of many scientists and nutritionists. After all, it was reasoned in the 1960s, 70s, and 80s, if saturated fats are killing people, it would be just great to remove them from the food supply and replace them with a “heart healthy” product like partially-hydrogenated vegetable oil. Oops.

Which brings me to one of Dr. Fischer’s iron-clad rules of nutrition: if a food sounds like it was manufactured in a lab in New Jersey, or is something that your great-grandmother wouldn’t have recognized in her pantry, it’s probably not going to turn out to be good for you.

Fitness: Putting It All Together

Ford_assembly_line_-_1913In my last two posts, I’ve discussed why exercise alone won’t do much to help you lose weight (but is still very good for just about every other measure of health you have) and why you don’t need to spend a lot of time working out each day to get into shape.

In this post, I’d like to tie all of this together, so we can outline the principles of a good fitness plan. Let’s call this Dr. Fischer’s four criteria of fitness:

1) Don’t view exercise as something that is separate from the rest of your life.

If you think about it, the idea of “working out” is pretty new. For most of human history, people didn’t think about “exercise” at all. They stayed fit by walking, farming, doing physical labor, and the like. Now that we live in an age where it’s possible to sit behind a computer all day, drive everywhere, and take an elevator instead of stairs, we’ve suddenly become crazed with the idea that physical activity doesn’t count unless it’s done on an expensive contraption while wearing spandex.

Rid yourself of this idea. The basics of staying fit are to simply live in a way that is more active. Walk places instead of driving. Take the stairs instead of the elevator. Get up and stretch or walk around your desk every few minutes at work. Play ball with your kids or do some work around the yard or the house.

Make small bursts of regular activity a part of your every day. This should be the foundation of your fitness plan.

2) Do exercise that you enjoy. If you don’t enjoy any exercise, at least do exercise that is brief.

One of the reasons that I am a proponent of low-carb diets is that I think people have an easier time sticking to them. This is a common theme with me. As a primary care physician, I am always looking for the most effective treatment that my patients are actually likely to follow. Exercise is no exception.

Therefore, try to build your fitness plan around an activity that you actually enjoy doing. Many people love running and if you’re one of them, great. Keep it up. But if you aren’t, don’t try to force it. Find another form of fitness that you do actually enjoy, such as swimming, dancing, lifting weights, playing basketball, or whatever else you can imagine. It’s more important to find an activity you are going to stick with than it is to find the “perfect” form of exercise that you will quit after a few weeks.

If you have neither the time nor the inclination to engage in any activity on a regular basis, do a high-intensity interval training workout at least three times a week. As pointed out in my last post, these can take as little as four minutes. Everyone should be able to at least find that much time for exercise in their life.

3) Try to get at least one high-intensity interval workout in each week.

If you fit into the category from the last paragraph (hate all exercise and are doing a few high-intensity interval workouts a week), you are already covered on this point and can skip ahead.

If you are into a more “traditional” form of working out, such as jogging or doing cardio at the gym, at least vary it up by doing one high-intensity interval workout a week instead. This will allow you to mix things up a little, and will challenge your body with a different form of cardiovascular fitness, which (as outlined in last weeks’ post) has been shown to have numerous health benefits.

4) Don’t focus only on “cardio”

For a long time, the conventional wisdom was that “aerobic” exercises such as jogging, swimming, or biking were “cardio” friendly and good for the heart, whereas muscle building activities such as lifting weights or doing push-ups were just for vanity and strength.

In fact, we’ve learned in recent years that both types of exercise are good for the heart. Indeed, numerous studies have shown that older people with more muscle mass are healthier and live longer than those who have less muscle mass. So don’t completely ignore “muscle building” activities. If you are a runner for example, make it a point once or twice a week to spend a few minutes lifting weights or doing some push-ups and chin-ups.

It is perfectly okay to combine this point with the third one. For example, it would be okay to run three times a week, and then have a fourth exercise day consisting of a high-intensity interval routine of lifting weights or doing body-weight exercises.

That’s it. Stick with the above four criteria and you will be able to get into (or stay in) great shape without an insurmountable amount of effort.

How might someone put all four of these criteria together? Well, there are an infinite number of ways really. But to give an example, let me take you through the routine that I personally used this week:

    Sunday – took a long bike ride with my son.

    Monday- did a Tabata of jumping jacks: 20 seconds of jumping jacks followed by 10 seconds of rest, repeated 8 times, for four minutes of total workout time.

    Tuesday – no formal exercise, but I did take a walk in the evening

    Wednesday – did a high-intensity interval workout as follows: 15 squats, then 10 pushups, then 5 pull-ups, followed by 30 seconds of rest. I repeated this as many times as I could during a ten minute span.

    Thursday – no formal exercise. But I did do work around the house, including lugging a few air conditioners up from the basement and installing them.

    Friday – 25 minutes of straight-up cardio activity on an elliptical machine

Aside from all of the above, there were also plenty of brief walks, stretching at my desk, and chasing my kids around the yard.

Note that for the six days of Sunday through Friday, I included all four of the criteria written about above:

    1) Plenty of casual “non-exercise” physical activity (walks, house work)

    2) Some longer workouts that I enjoy (riding my bike, doing the elliptical)

    3) A few high-intensity interval workouts (Tabata jumping jacks on Monday and a body-weight circuit on Wednesday)

    4) At least one “strength training” day (body weight circuit on Wednesday)

Will my workout routine next week look identical to what’s above? No. But it will certainly fulfill all of my criteria for good fitness again.

You Can Get a Great Workout in Just Four Minutes a Day

StopwatchIn my last post, I wrote about why exercise is unlikely to help you lose a lot of weight. But I also pointed out that for almost every other important health metric (heart health, bone/joint health, mood, libido, stamina, longevity), it is a crucial part of your preventative health plan.

I also wrote last time of the patient who wants to achieve all of their weight loss by “working it off” at the gym. That’s one conversation that comes up frequently in my clinic. But another conversation that I often have goes like this:

Me: “Are you doing anything for exercise these days?”

Patient: “No. I just don’t have the time.”

Well, I have some great news for you this week: it actually takes very little time to get into better shape.

VERY little.

For most of the past few decades, the common advice has been to do extended workouts and to make sure to incorporate “cardio” activities such as jogging or biking into your workout plan. This has been great for gym owners, personal trainers, and the rest of the fitness industry, but not so much for the average person who really doesn’t want to (or can’t) spend 45 minutes a day in the gym.

So let me burst another myth: you don’t need to spend long times at the gym or do “cardio” activity to get in great shape.

In recent years, new research has emerged which has shown the benefits of something called High Intensity Interval Training (or HIIT). The basic idea of HIIT is to do brief periods of exercise during which one alternates between maximum intensity and moderate intensity.

Let me give an example to illustrate. The “traditional” way of running to get fit might include jogging for 30 or 40 minutes several times a week. The HIIT way of running to get fit would look something like this: run as fast you possibly can for thirty seconds, then walk for a minute and a half. Repeat times 5 for a total workout of ten minutes.

Studies have shown that working out in just this manner results in impressive improvements in blood pressure, cholesterol, body fat, glucose, and cardiovascular health. Doing just a few HIIT workouts a week can lead to the same health benefits as working out in the more traditional way.

In the face of this knowledge, whole new fitness industries have sprung up around High Intensity Interval Training. CrossFit, is probably the best known example of this, and for those who need an organized activity to get in shape, I highly recommend the CrossFit box here in Providence.

For those of you who prefer to workout at home, I will discuss some more specifics about how to apply the principles of HIIT and devise a workout plan you can live with in my next post.

For now however, I want to make one last point so that I won’t be accused of false advertising in the title of my post, and so that you will never again have the excuse that “I don’t have time to exercise.”

Just how far can you take the idea of High Intensity Interval Training? Well, some years back, a trainer for the Japanese Olympic skating team developed a FOUR MINUTE workout routine, that goes like this: do whatever activity you want (he initially used cycling on a stationary bike, but routines have since been developed using sprints, pushups, jumping jacks, and just about anything else you can imagine) as hard as you possibly can for twenty seconds; then rest for ten seconds. Repeat a total of 8 times, for a 4 minute total. A scientist named Dr. Tabata studied these athletes and determined that doing only this routine four times a week led to almost as much fitness improvement as found in athletes working out for an hour or more a day.

You can read more about the so-called “Tabata protocol” here.

Now go get moving.