Fact or Fiction: high cholesterol

I recently received an interesting email:

"I was in for my annual physical two weeks ago and the letter you sent me said that my cholesterol reading had increased from 210 to 216 over the last year.  You said you wanted me to come back in 6 months to get retested.  My questions are:

1.       I take one 900 mg fish oil tablet a day - would it be beneficial to double that?

2.       Some of the "natural" remedy information indicates that cinnamon tablets are helpful - any thoughts on that?

3.       My wife wants me to take "Cholest-Off" which is advertised as an all-natural means of reducing LDL numbers - would that be worth trying?

4.       Any thoughts on the Juice Plus program and if that might help?

5.       I eat a fair amount of peanut butter at lunch and drink 2% milk most nights for dinner - is that a problem?

I am eliminating or reducing my favorite vices - brats and ice cream sandwiches - probably  a good thing no matter what my cholesterol number is."  Name Withheld

I thought this would serve as a good launching point to discuss cholesterol.  Let me first explain what cholesterol is, what it's function is and how it can cause problems.  

Cholesterol is basically blood fat.  It is made mostly in the liver and is used in the body to create the membranes that keep our cells intact.  There are many different components to it.  The most important to understand are the LDL (low density lipoprotein), the HDL (high density lipoproetein) and the TGs (triglycerides).  The LDL particles are the most atherogenic (meaning they cause blockages in the arteries).  When in excess, they will be deposited in the membrane of blood vessels and start an inflammatory process resulting eventually in build up or "plaques."  They are referred to as the "bad cholesterol."  HDL particles are like tiny little fat vacuums. They circulate and will take up the extra LDL and other fat particles keeping them from forming plaques.  The higher the HDL, the better off you are.  The triglycerides are particles that are less toxic than LDL particles but still harmful.  Together with fatty acids, they will also strain the body's metabolism and increase insulin resistance, which can lead to diabetes.  

The total cholesterol is the sum of the LDL and the HDL and 1/5 of the TG's.  We typically say that the total cholesterol should be less than 200 mg/dl.  However, that depends on the makeup of the other particles.  For example, I just saw a patient whose total cholesterol was 240 mg/dl.  That seems rather high but her HDL was outstanding at 135 mg/dl.  Her LDL and TGs were well within the normal range so her cholesterol  profile was perfectly normal.  I could only wish mine be so good.  We would like to see everyone above 40 mg/dl for the HDL.  As of yet there have been no good medications developed to increase the HDL.  Regular cardiovascular exercise remains the best way to increase it.  That and having good genes.  

The LDL is partly genetic but greatly influenced by the foods that we eat.  The culprits tend to be animal fats (red meat, bacon are the worse).  Butter and other oils which are solid at room temperature are also dangerous.  The LDL in low risk individuals should be under 130 mg/dl.  In higher risk patients it should be less than 100 mg/dl and even some studies show that driving it down to 70 mg/dl gives additional benefit.  Those at high risk are anyone who has had a heart blockage, those who have blood vessel disease elsewhere such as in the neck, brain or legs, and anyone who has diabetes.  I'll talk more about specific dietary recommendations in a future post.  

The triglycerides are the easiest to lower without medication.  They are increased by ingesting too much greasy food, alcohol and simple carbohydrates.  Sugared beverages are some of the worst culprits.  Even the simple carbs in bread and pasta can cause elevated triglycerides.  The TGs should be less than 150 mg/dl.  A level over 200 mg/dl greatly increases one's chance of developing diabetes.  At very high levels, such as 800-1000 mg/dl, pancreatitis can even be triggered.  

With a basic understanding of the cholesterol components, I can now start answering the questions I received above.  Stay tuned next week for some answers!

Occupational Challenges

Last week I wrote about what I enjoy most as a physician.  This week, I'll share some of the challenges that I face.  Let me just say upfront that the good outweigh the bad.  I hope it will forever be the case.  My daughter once asked me what the hardest part of my job was.  She had an occupational survey to do for a school assignment.  My mind went immediately to the part of the physical exam which is most distasteful to both me and my male patients.  Upon further reflection, though, I decided that delivering bad news was probably the hardest.  As I said last week, the end process can be very satisfying, but that initial conversation when I need to tell someone that they have cancer, or another serious illness, is very difficult.  It is gut wrenching.  About the only thing that comes close is when I was in a movie theater many years ago watching the "Lion King" with my daughter.  Simba's father falls to his death in the canyon stampede.  With tears in her eyes, she looks into my face and asks, "Is he going to be all right, Daddy?"  You want to respond that all is going to be fine.  It is important to give hope when there is hope and to be positive so that the patient remains positive.  However, it is also important to be truthful so that they understand what to expect and how to plan.  Some are not ready to hear the bad news and it may have to be explained several times.  Patience is the key.

Sometimes I wish I could be perfect.  There are many stresses that come with our job as physicians.  We have the stress of trying to stay on time, of writing complete notes, of being too busy, of not being busy enough.  We have phone calls and tasks and emails, faxes and letters all pulling us in a hundred different directions.  Now we have the stress of the electronic health record.  We have to make sure we have clicked every box and entered every requirement or we are told that medicare will void out the entire visit.  It is stressful to respond to a patient who is requesting a medication that we feel would do them more harm than good.  By nature we want to please.  Some patients can become very upset if they are not given an antibiotic for their cold or pain pills for their headaches.  Above all else, my greatest stress, though, is the stress of missing a diagnosis or of making the wrong treatment decision.  There have been times when I have made a subtle diagnosis that has likely saved a patient's life.  One in particular was that of picking up prostate cancer in a 38 year old man.  I did an exam and it felt abnormal so I sent him for a biopsy.  He now lives 2000 miles a way but just last year, while visiting St. Louis, he came to say hello and thank me once again.  He is doing fine.  Instead of feeling good about this, it frightens me.  When I saw him, I thought he was over forty.  I did the exam by mistake.  It was pure luck that allowed for his early diagnosis.  Another example is that of an older woman with a fatty mass in her thigh.  I have felt many of these, "lipomas" in patients and sent them on their way, telling them it was nothing to worry about. In her case, it felt just a bit different than the others.  It was a little more firm and more fixed to the leg.  I can still recall the back and forth of my thoughts considering course of action to take.  I was so close to letting it go that her words of gratitude terrify me.  I know how close it was.  She had an aggressive tumor that is usually fatal.  Another month or two may have made the difference between life and death.  It terrifies me that there will be someone else who I may decide to go the other way.  I know I cannot always be right, but I want to be.  I want to do the best for my patients.  That is my greatest stress.

This may be more truth than what you want to hear from a physician but I felt like it would be good to share.    Let me know what your concerns are as you come to the doctor's office.  What worries you the most?  What are your expectations?

What a Great Job!

Let me start by saying that I love my job.  I feel very fortunate to work in area that is stimulating, rewarding financially and most of all where I can make a difference in the lives with whom I work.  I thought it might be interesting to others to know why I do what I do and what I enjoy the most.

Being a doctor is a wonderful profession.  Being a primary care doctor is even better.  It is a great feeling to be able to have someone come in to the office, diagnose their problems, and work together on solutions.  Just being able to tell someone what their problem is often all they need.  I can see the worry in their eyes when I come in to the room.  They have been on the internet.  They are quite sure they have MS (multiple sclerosis) or perhaps a stroke.  Maybe it is celiac disease or possibly autoimmune relapsing polychondritis?  (No, not even spell check knows what that one is!)  It is easy to get frightened by the possibilities.  More often than not it is something more common, less dangerous.  It is a good feeling to be able to reassure and educate them.

As good as it is to fix problems, I get much more enjoyment in preventing them.  Health is so much more than the absence of disease.  Health is determined by all the choices we make in a day.  It is a feeling of well being when all parts of our life are in harmony.  Last week I saw a young woman for a routine physical examination who truly had no medical problems.  Yes, she could exercise more.  Junk food is pretty rare.  Though not perfect, she does a good job with nutrition.  She doesn't smoke, she does not drink alcohol.  It seemed that all was well.  After a busy morning of seeing people with lots of problems, I thought to myself, "this is great, to see someone so healthy."  Literally on the way out of the door, she asked "is there anything good you can give me for anxiety?"  It turns out her husband is an alcoholic.  I need not outline any details but her mental health has taken a beating for awhile.  I could not solve her problems in those few minutes together, but being able to discuss them with her is a step in the right direction for her well being, for being truly healthy.

One of the hardest parts of my job, but one that I take a lot of satisfaction in, is helping others understand and deal with bad news.  I understand that we are all mortal.  All of my patients will eventually succumb to some sort of illness.  It is my job to tell them and their families what process is occurring, what their options are and what they might be able to expect in the future.  Sometimes it is better to stop treating all of their problems and focus on a patient's level of comfort.  It may no longer be important how long someone lives but that they be surrounded by the ones they love at the end.  End of life discussions are gut wrenching, emotional but are so very important.  My warmest hugs, my most heart felt compliments and expressions of gratitude have not been received from those who finally started to exercise and eat right, it has come from the family members of my dear friends who have passed on from this life.

Do you know what is the most fun?  I love the look in someone's eye when I walk in the room and they have lost seven or eight pounds from their last visit.  They have been trying so hard to eat right.  It has been a struggle to get up and exercise, but they have been determined and are really doing their best.  Their blood pressure is down, their blood sugar numbers are down and they are excited.  They are quietly waiting for me to notice on my own.  I love saying, "good job, keep it up."  This is especially true with smokers.  Sometimes I need to be stern and "lay it on the line."  Sometimes I am more of a cheer leader.  Sometimes I just need to listen.  That is the art of medicine.  I know I don't always get it right.  There is nothing better than having someone come in who has finally quit smoking.  It may take years and years of trying but when they do, I know that I have helped them achieve health in a more significant way than any surgeon or specialist ever could with their expensive surgeries or their fancy procedures.  My greatest reward is to see my patients be simply healthy.

The Individual Mandate

This has been a hot topic of late in regards to healthcare with the Supreme Court deliberating as to if this portion of the law is constitutional or not.  I thought I would share my thoughts on the matter.  As a disclaimer, I do not consider myself neither a Republican or Democrat, more aptly a Republocrat.  My expressed opinions are just that, opinion.  I may even change them next week as I consider new possibilities and ideas.

I find it interesting that we can have a law requiring anyone who drives a car to carry automobile insurance and have very little complain about it.  In fact, in an accident, he "who doesn't have insurance" is looked upon in quite a derogatory manner, someone who is a drag on society.  Those same people who support the driver's insurance mandate look at the health insurance mandate as being one of the craziest ideas ever put forth.  I understand the reluctance.  Who wants to be told by the government that we "have to" do something?  As Americans we are fiercely independent.  Freedom has been ingrained in our very being from the start.  In my mind, the bigger question is not whether there should be an individual mandate but it is whether our society has an obligation to provide basic health care to its citizens.

There are two rather charged words that delineate this conundrum, "socialized" and "rationed."  Many of my patients fear that if the government gets too involved in healthcare we will end up like Canada or England having a healthcare system where there may be long wait lists for not only elective surgeries but even just imaging tests.  We want the best and we want it now.  We don't want to see our care "rationed." The truth of the matter is that we already exist in a system that rations healthcare.  Do I treat patients differently when I volunteer at an indigent spanish speaking clinic once a month?  Sure I do.  I see patients in my office without insurance from time to time.  Do I treat them differently?  Absolutely.  We don't even consider sending one of them for joint replacements no matter how bad their arthritis may be.  Sending one of them for a screening colonoscopy is out of the question.  I recently saw a patient in my office who is becoming demented.  As part of his evaluation I sent him for an MRI of the brain.  This looks for evidence of stroke or other conditions that can be contributing to his memory loss.  It is a recommended part of the evaluation but frankly has a very low chance of affecting how he is treated.  I was able to see the patient and have the test done all in the same day.  If he had no insurance, I likely wouldn't have even offered the test to the patient or the family.  Taking care of diabetics who have no insurance is like playing darts in a dark room.  They cannot afford the strips to check their blood sugar levels.  If they are on insulin, I try and choose a dose that won't harm them, knowing that tight control is not going to be possible.

The American Health Care system is widely regarded as the best in the world.  The health of our society, however, is not the best.  Other countries do far better than we do in many areas.  I firmly believe the reason is because we don't think of the dark side of our system, those without insurance who are on the outside looking in.  We have two systems, a very good one and a lousy one.  The flip side to freedom is equality.  If we decide that equal access to basic health care is not important in our society, then so be it.  We will continue to exist in this two headed monstrous state of medical feudalism.  Are we that far away from "The Hunger Games"?

I feel that if we are going to provide basic services to all of our citizens, we must have an individual mandate.  Guess what happens to the uninsured patients I described above who have a truly life threatening emergency?  They get taken to an emergency and are taken care of.  If they need heart surgery, they get it.  If they are in a serious care accident, they get fixed up.  The hospital rights off the charges but it doesn't end there.  The hospital cannot afford to sustain such losses so those costs get consumed by the revenue that comes in from all the other patients who have insurance.  The cost gets shifted to you and to me.  This is one of the many reasons why our cost of healthcare is so high.  I would much rather see us ask all citizens and non citizens to pay for insurance than to see my own costs go up and up and up.  Thanks for reading my thoughts.  I would love to hear yours and respond to them.  Let me know what you think.

Laughter is the Best Medicine :)

The following is a post from my colleague, Dr. Benjamin Voss.  Great information-enjoy!

Is Laughter really the Best Medicine?                                                                

 

This talk was originally presented on July 29, 2010 at Washington University School of Medicine Grand Rounds. This is backed by real research. Smile, it’s true.

 

I have always been told the laughter is the best medicine and when I finished residency, I was determined to investigate if this is indeed true. The story of the The Roseto Effect peaked my interest. In the 1950s, a visiting professor named Dr. Stewart Wolf noted that he rarely found anyone from Roseto, Pennsylvania under the age of 65 with heart disease. Their diet was high in fat consisting of lard, pizza, and biscotti, they smoked heavily, and the majority of them were overweight. After years of research, he concluded that their unique Community where they recreated their Italian heritage was health protective. They had three-generation family meals, talked to each other in the street, respected elders, enjoyed the calming effect of church, and had many civic organizations. The protective social structure insulated them from the pressures of the modern world.

 

Depression is obviously bad. However, its severity is traditionally underappreciated. Depression is an independent risk factor for developing heart disease and dying regardless of one’s other medial problems. Answering yes to “During the last month have you felt so sad, discouraged, hopeless, or had so many problems that you wondered if anything was worthwhile?" more than doubled one’s risk of developing heart disease. People with a Type A personality have a 2-fold increase risk of having a heart attack. Depression after a heart attack predicts the likelihood of death as much as developing heart failure after the heart attack. There are many physiological theories and explanations for this, but the key is that one’s body has “chronic sympathetic activation,” or a stressed body and mind all the time.

 

Positive affect, defined as “the experience of pleasurable emotions such as joy, happiness, excitement, enthusiasm, and contentment,” has the opposite effect on people. Comedian Bill Cosby once said “Immortality is a long shot, I admit. But somebody has to be first.” While humor is his occupation, the research actually supports his idea. Studies have shown people with a positive affect have better immune function and a greater resistance to upper respiratory infections. People who have hope and curiosity have lower blood pressure. Agreeing with one of the following four statements:“I felt that I was just as good as other people,” “I felt hopeful about the future,” “I was happy,” and “I enjoyed life,” showed a lower risk of stroke. While depression increases the risk of death in diabetics, positive affect lowers that risk. Hospitalized patients who answered yes to “I still enjoy things I used to enjoy” lived longer than patients who disagreed. Positive affect lowers the risk of death after a heart attack and in patients with AIDS. The physiological explanation here is enhanced parasympathetic activation, meaning lower heart rate, lower blood pressure, and increased glucose tolerance.

 

“Behavioral activation interventions” have been studied and these include increasing the frequency of enjoyable hobbies and activities. Exercise has been shown to reduce depression. Nutritional counseling in order to avoid overeating when stressed is important. Stress management options include yoga, vacations, and music. Social support is critical and walking groups are a great way to exercise and build community. So while it is critically important to take your medication and listen to your doctor, try adding a laugh or two to your daily routine.

 

Thank you Dr. Fuller for this opportunity to be a guest blogger. I do my best to get him to laugh everyday. 

The Statin Scare

Many of you may have heard the recent news in regards to the FDA updating the risk profile for the common cholesterol lowering medications referred to as "statins."  As portrayed by the media, if you take this medication you are sure to end up with dementia and crippling diabetes.  Let me share my perspective on this situation.

First of all, it must be reemphasized that statin medications have unequivocally resulted in lower rates of death due to heart disease.  Even in the short time that I have been in practice I have seen far fewer patients develop heart disease, suffer heart attacks or had the need for procedures and surgery.  This certainly is not due to the population eating better and getting more exercise since obesity rates have steadily climbed higher and higher over that same time period. It is due to driving down cholesterol levels, largely from statin medications.  This has been quantified to about a 25% decrease chance of death in those who take the medication.  That is very substantial.

Now to the cautions.  I'll be the first one to say that I do not want to take one of these medications.  I put a lot of time and effort into exercising regularly and eating right so that I do not have to.  I have grandparents who had heart disease and stroke.  My father was recently put on a statin medication.  I may have to take one some day but I will do all in my power to lower my risk through non pharmaceutical means first.  If my levels raise despite my best efforts I'll have no second thoughts about trying a statin medication.

The FDA highlighted two main concerns.  The first is the "reports of memory loss."  This sounds like the medicine can cause dementia.  That is as scary a thought as having cancer.  I have dementia in my family as well and have no desire to head down that path.  What has been reported is not dementia but more of a "brain fog." Patients describe this as muddled thinking, not being as sharp.  The good news is that this is totally reversible.  It goes away when the medications is stopped.  It happens quite infrequently but I have seen it in my practice on occasion.

The second concern is for elevated blood sugar readings.  As a prescribing physician I have not seen diabetic patients have problems with their blood sugars after taking the statin medications.  I wonder if this is related to the population becoming more obese.  That would be a reason both for having elevated cholesterol levels requiring medication as well as being predisposed to developing diabetes.  It is important to understand that the lower cardiovascular risk seen in studies using statin are the most robust in the subset of patients who have diabetes.  It is currently considered to be bad practice to avoid statin drugs in diabetics whose LDL cholesterol values are over 100 mg/dl.  Dr. Amy Egan, the deputy director of safety for the FDA's metabolism and endocrinology division summed it by saying, “Clearly we think that the heart benefit of statins outweighs this small increased risk, But what this means for patients taking statins and the health care professionals prescribing them is that blood-sugar levels may need to be assessed after instituting statin therapy” (link here).


If you have concerns, by all means share those with your physician but don't stop taking your medication till you do.  These are life saving medications.  They need to be treated with care, yes.  The risks of not taking them may well be higher than the risk of stopping them.  

The Wicked Whoop

One of medicine's achievements is the near eradication of  of whooping cough.  Or so we thought.  This potentially devastating illness often attacks the very young resulting in spasm after spasm of violent coughing.  It is now also making a resurgence in adults.  The force of air through the throat results in a "whooping" noise, thus the name.  The cough is not only severe it is doggedly persistent, lasting for months in many patients.  There are antibiotics which treat the infection but even if started early, the cough may linger for months.  The disease is caused by the bacteria Bordetella Purtussis.  It is the "P" in the childhood vaccine DPT.  As children have been vaccinated, the incidence of whooping cough has dropped significantly in our society.  Given the aging population of those who have received the vaccine, there is now a sizeable number of adults who have never had whooping cough.  It was felt that the vaccine provided life long immunity until a few years ago when groups of cases started popping up.  We have now learned that adults need a booster.  A new form of the tetanus vaccine is available called the Tdap, which accomplishes just that.  It is recommended to be given immediately to anyone who has close contact with infants.  The rest of us should receive it ten years after our last tetanus shot.  It is a completely killed vaccine, not a partially live one. It is quite safe.  The most common effects are a sore arm or a headache.  Many people are not familiar with how bad whooping cough can be.  Let me assure you, it is worth having the pain of the vaccine.  Don't let the wicked whoop snatch you.  Ask your doctor about getting your vaccine.