Dietary Modification
Most people go on a diet when they want to lose weight. Since most remain overweight, sounds like life is one long continuous or intermittent diet. This is clearly the wrong way to think about it as you have likely seen in this column before. Get the word “diet” out of your vocabulary. Stop focusing on weight loss. Think about how to make your life healthy (not just healthier than it is now as that may still be very unhealthy. You know it requires regular exercise and healthy eating. Let’s concentrate on the eating or nutrition aspect at this time.
Start by making a list of what you typically eat writing down not only the main ingredients, but all the ingredients. Ex. Hamburger on a bun. What did you put on the bun? Did you put cheese on the burger? If so, how much? Did you have chips or fries with it? Anything else? Did you make it at home or eat it at a restaurant or fast fat place?
If you are eating out a lot, you will not likely ever eat healthy. You will also be spending far more money on food than if you prepared your own meals. I personally avoid eating meat, but if I did, I’d buy the leanest hamburger meat I could find, grill it in a Teflon pan or on an outdoor grill with virtually no oil or butter, put it on a whole grain bun or bread with mustard or ketchup, and avoid the cheese. I would munch some low fat baked chips with it. You are still getting your hamburger, but you’ve reduced the bad stuff (saturated fat) by 0%. If you want to reduce it by 90%, substitute ground turkey for the ground beef and you’d be eating like I do.
If I’ve had a lunch like the burger, I’ll go for a lighter supper. I’ll make an eggbeater (no yolk) omelet and put some sautéed onions and low fat chicken sausage in it which I cook out with a little Pam spray before starting the eggs. A half bagel with jam or low fat cheese with it suits my taste.
What I have done is modified foods I like to make them healthy. You can do that with most any foods today. A ham sandwich with some of the newer hams has ½ gram of fat per one ounce slice. That’s less than 1/10 what regular ham has. Limiting fat, particularly saturated fat, is what it is all about.
Gerald L. Evans, M.D.
Recent travel to Japan
Sorry for lack of recent updates. I was traveling in Japan and many health related impressions are worthy of comment. First and foremost, food is healthier than in the U.S. The main ingredient in the Japanese diet is still rice. The major protein source is fish. My wife and I visited the famous Tokyo fish market where all fish is processed and sold to restaurants and markets. It is huge and there are many hundreds of types of fish from tiny (1”long) to giant tuna. Most, I must confess, I’ve never seen nor heard of before. Most meals consist of several small courses, literally one or two bites each. Servings are small. A multitude of mushrooms accompany almost all dishes. A fish course might offer 1-2 ounces of a white fish. A piece of sushi might be a serving (90%rice with a thin slice of salmon or tuna; all wrapped in seaweed). Miso soup is commonly served as a course. Their diet is obviously low on saturated fat. It is however high on sodium content. Japanese smoking clearly seems down from prior years, but still many Japanese smoke cigarettes. Obesity appears far less than in the U.S. both in the major cities and in the countryside. You see lots of bicycles everywhere; especially for such an industrialized nation. Business workers dress more formally than in the U.S.
The most striking difference between Japanese and Americans was evident in all aspects of their behavior. The country is immaculate – everywhere. There are no rubbish receptacles seen on the streets; nor is there any rubbish strewn about. Cars are clean as is the air. Service wherever you go is beyond anything I have ever seen anywhere. If I asked someone on the street for help finding an address, whether they spoke English or not, they took me to the place. I f I walked into a shop and told someone I was having trouble finding a certain restaurant, they left their shop and took me there. In restaurants, servers were solicitous and very attentive. There is no tipping anywhere in Japan to motivate that behavior. Most workers put in a fair amount of overtime to finish their work. There is no overtime pay; it is basic work ethic to stay and do your job with excellence. I had woken early one morning and went to the desk in the hotel to use a computer. The fellow who was there was also there at 4 o’clock that afternoon. When I asked him what type of schedule he worked, he indicated that they alternate 8 and 16 hours shifts. Two people cover the 24 hours. The people at the desk have multiple responsibilities. They register you, take you to your room and serve as concierge as well. You can imagine how refreshing it was to interact with the Japanese people. The subways are quiet, fast, and smooth. The bullet train is fabulous. We could take a few lessons from them.
Gerald L. Evans, M.D.
Is there any adult NOT on pills today? And the vast majority are on cholesterol and blood pressure pills with the number on blood sugar pills is increasing exponentially as obesity explodes? The sad reality is that the benefit of all these medications is far less than those taking them believe. Type II diabetes is a killer.
A recent compilation of more than 70 research studies that included greater than a million patients (by Mark Eisenberg, M.D.) showed that those with the “metabolic syndrome” were 2.5 times more likely to die of heart-related causes and to have heart disease, a heart attack or stroke, compared to people without the syndrome,” as well as having a 50% greater risk of death in the follow-up period after the study.
If you are overweight, address it before it is overt obesity. Start TODAY. If you are already obese, get some of that weight off, get your sugar levels into the normal range and get off those diabetic medications if at all possible. YOU can do it and the benefit exceeds that of the pills.
Remember – exercise and nutrition are the keys to a healthy life.
Gerald L. Evans, M.D.
WAKE UP!
Everyone has repeatedly heard that being physically inactive and eating a high fat diet leads to weight gain which sooner or later leads to Type II Diabetes (plus heart disease). But YOU know there are pills you can take for the high sugar and if that does not do the trick, you can take Insulin injections. So, what the heck? Right?
Several recent studies should serve as a WAKE UP call for you.
Avandia-wonder diabetes pill causes a 40% increase in heart attack rates
Actos- wonder diabetes pill causes a 40% increase in heart attack rates
Insulin- wonder injectable causes a 50% increase in cancer risk – mostly G-I, Pancreas or Liver
What will it take for you to take control of your own life and start changing your personal behaviors to achieve a healthy lifestyle?
Guidance is available from a myriad of sources including my book Why Health Insurance does not ensure Health.
Gerald L. Evans, M.D.
Changes in Health Care over time
An article in Saturday’s Boston Globe (8/21/10) recalling the 200th anniversary of two physicians starting the first hospital in the United States evoked many memories of the way changes in health care innovation have evolved since then; many wonderful and some not so wonderful. Great contributions like the development of penicillin by Dr. Fleming in the late 1920s and cardiac catheterization by Dr. Lewis Dexter at the Brigham in the 1960s led to great advances.
Physicians in the 60s and 70s recognized the need for specialized technology to further advance their ideas which led to collaboration with bright engineers like Herb Karsh at MIT’s Lincoln labs which led to the development of an early computer to facilitate physiologic study of the heart.
Paralleling these medical innovations were health insurance programs. Initially there were indemnity programs which set “reasonable” (less than charged) fees. In the 80s HMOs made their appearance with moderately discounted fees which physicians, hospitals and other medical personnel either accepted or were unable to care for patients who joined those HMOs. That was probably the beginning of the end of the strong bond of the physician/patient relationship. Patients from one community could not continue to see specialists from another as they were not in the same circle or network. Significant reductions in reimbursement led physicians to reduce their time spent with patients further eroding that relationship. Independently, technology exploded with bright engineers developing solutions to medical problems before physicians recognized their potential usefulness. Health care costs exploded. HMOs discounted more. Medicare, facing depletion of its trust funds, encouraged patients to shift to HMO Medicare plans which costs the government less than traditional Medicare.
Cost containment became more important than how medical care was delivered. All those payers – government, insurance companies, and HMOs focused all their attention on that goal. Hospitals became more concerned with garnering your insurance information to ensure payment then to addressing your care. Rising care costs have been attributed to variations in care, too great a use of technology, excessive pharmaceutical costs, defensive medicine etc. Each attempt to rein in costs has, not surprisingly, led to rapid escalation in costs. The “system” has not yet figured out then when two parties ( doctor and patient) decide on what is done for a patient AND someone else pays for it (insurance company), there will be excessive spending. Every patient will tell you to spare no expense. “I’ve got insurance”. Go to a cocktail party where there is an open bar and see how much liquor is consumed in comparison to a similar party with a cash bar.
So now we have health care reform which will add 30 – 40 million people to the insured pool and we are told it will save money. How are they going to do it? Standards of care are being developed which stipulate what care is appropriate for a given diagnosis and equally important, what care is inappropriate (unnecessary or redundant). Interestingly, there are few if any physicians in clinical practice developing these standards. The newly enacted Health Care Reform Act has hundreds of parts. Another one of these is mandatory computerized medical records for physicians and hospitals. Using the standards of care and the medical record will make it easy for any insurance company to control the practice of medicine. Just print out the guidelines and pay for those things that are recommended and debit the provider for those not recommended.
We’ve come a long way from those two physicians who started a hospital 200 years ago. Unfortunately it may not be such a good direction.
Gerald L. Evans, M.D.
Health Care Reform’s “Medical Home”
Editor’s Corner
Raymond Carter, Editor, Medical Home News Volume 2, Number 8 August, 2010
I have invited members of the Medical Home News Advisory Board to submit short op ed pieces for inclusion in this space. Other Medical Home News readers are welcome to do so as well. This month, in fact, we feature a piece from a Medical Home News subscriber, Dr. Gerald Evans.
Medical Home Circa 1975 – Bring It Back!
By Gerald L. Evans, MD
The Medical Home Concept is trying to define itself. Is it care coordination? Is it proactive reaching out to patients instead of waiting for them to come to you? Is it physician run, nurse practitioner run, or team run? Could it be specialist run or multidisciplinary? It would appear all options are evolving as examples of the so- called medical home. I have my own bias as to what it should be, but you will figure that out below.
We have certainly seen a very definite trend in the last 20 years away from the private physician supported by a cadre of others (RNs, LPNs, Techs) to teams of health care professionals working as a team without a designated leader. Indeed, medical schools shy away from applicants known for their leadership skills in college as they preferentially want team players. Thus, in this new concept of medical home, it can be run by a physician, a nurse practitioner, or by a coordinator who is responsible for the overall patient interaction to make the parts flow amongst the providers in the group. However, before describing the medical home itself, it would be wise to define the purpose of the medical home. I find very limited descriptions of what it should actually do. Maybe it is not as implicit as the articles on the topic appear to presume. I think this will have great bearing on the structure of the successful medical home of the future.
What are the primary functions of the medical home?
#1. In my practice, I told my patients my primary responsibility was to make sure they took the best care of themselves they possibly could in order to remain free of the need for medical services and to minimize those medical needs when they did develop illnesses. Part of my initial assessment was a focus on personal behaviors, emphasizing daily aerobic exercise (all ages) and healthy low fat nutrition. Smokers were told my practice was smoke free and they had to commit to stopping smoking. I gave them 3 months to achieve that goal and told them I would bust my chops to help them. The success rate was greater than 90% and most of them quit that day. Everything I told them to do was spelled out in detail with reasons supporting its importance. Their behavioral changes were an integral part of their ongoing medical care and revisited at all visits. Laboratory work was done for baseline and to show them how effective their personal efforts were in reducing their disease risks. Avoidance of medications to treat numbers was always a goal. More detailed testing was done as clinically indicated by symptoms or risk stratification in high risk individuals — always with the thought that abnormalities were powerful reinforcement of their need to work hard in their own behalf.
The vast majority of people responded very favorably. (In addition to individual patients, I have done this with corporate, municipal, and union workers in groups at worksites with similar success and much more cost-effectively). I would add that effectiveness in this approach is enhanced by the authority of the physician. In our worksite programs, nurses, exercise physiologists, and nutritionists supported the effort, but the physician impact and leadership was a powerful motivating factor.
continued on page 9
Medical Home Circa 1975 – Bring It Back!…continued
#2. The second part of the medical home is patient care when needed. Preventive care is part and parcel of the above, but patients do get sick and need care. Recognition of when a patient has a significant illness is based on many factors, not the least of which is prior knowledge of the patient. The more experienced practitioner will likely be the better diagnostician. That individual can evaluate the patient quite well without involving specialists early on.
In current practice, the patient who tells his primary care physician that he has a burning discomfort deep in his anterior chest when he walks about after dinner will usually be sent promptly to a cardiologist without initial treatment or further assessment by the primary physician (risk of heart attack more concerning than acid indigestion). That will lead to a major workup starting with a stress test (likely abnormal if a typical 48 year old male with risk factors), which will lead to a cardiac catheterization and an angioplasty. In the medical home concept, that physician would have given the patient an Rx for sublingual nitroglycerin with specific instructions how to take it. The patient would also be told after testing that he should take some Tums for the next episode and then call you. The results would dictate any additional steps that may or may not be indicated.
With Steps #1 and #2 you are well on your way to a medical home concept as I see it. Obviously scheduling next steps in the computerized calendar to make sure you call the patient (smokers in particular) or the patient calls you back (results of nitroglycerin/antacid trial) should be part of any good practice. Personally, I always found email extremely useful, especially with patients who traveled a great deal. (Monitoring pro-times all over the world for Coumadin patients was easy via email.) The more medically experienced the practitioner, the less likely the patient will need referral to a specialist and the more likely they will respond to behavioral changes; i.e. the more successful the medical home.
Gerald L. Evans, M.D. is the former chief of cardiology at MetroWest Medical Center in Framingham, MA and the Founder and Director of HeartVentures, LLC in Framingham. He may be reached at evans@heartventures.com. He also maintains a blog at http://blog.heartventures.com.
Published by Health Policy Publishing, LLC ● 209-577-4888 ● www.MedicalHomeNews.com
Potato gets a bad “wrap”
For many good reasons, “white” foods have gotten a bad “rap”. Like white flour, and white rice, they have suffered by being primarily sugar with little or no fiber. Whole grains provide less sugar spikes in your blood stream which have a negative effect on appetite thereby contributing to obesity.
I would like to come to the aid of the poor potato. If you “wrap” it up in a foil jacket and bake it and then eat it with its skin, you are getting plenty of fiber from the skin and it becomes a healthy potato; undeserving of a bad “rap”.
However, if you un-wrap that potato and add butter, sour cream, bacon bits etc, you have converted that healthy high fiber sugar into an unhealthy, high FAT food. Same problem if you mash it with butter, milk, and salt creating a similar high fat, and also, high salt food which predisposes to high blood pressure.
Now, if you find the plain backed potato blah, you could “flavor” it with something healthy like a small amount of a healthy margarine like Benecol® which is made from plants or add a little salsa or whatever healthy low fat condiment you like. Personally, I like the clean taste of a pure baked potato. (You can quickly bake one un-wrapped in the microwave in 4-5 minutes on high.) Bon appétit!
Gerald L. Evans, M.D.
Weight versus Risk
There is a major concern regarding the increase in weight which is becoming pervasive in our society. We now categorize these as Overweight, Obesity, and Morbid Obesity. Millions are on diets – Atkins, South Beach, low carb, high carb, low fat, no sugar and many self designed “starvation” approaches. Programs like weight watchers are having a major resurgence. Several medications are available and more are in the pipeline. Several have been taken off the market for dangerous side effects. Three are in the FDA pipeline; the first of which received a negative recommendation from the review panel.
The problem is, all of these “diets” result in short term weight loss, but none result in long term weight loss. The very reason for that seems obvious when you stop and think about it. Most people diet for a specific short term goal such as looking good at an upcoming special event. Almost by definition, a diet is a short term undertaking to lose a certain number of pounds. When you get to your goal, you end the diet and return to your old eating habits. Guess what? You gain the weight back. No surprise.
Several points need to be made.
#1 You should not make weight loss your goal. Excess weight causes you problems by raising your blood sugar, blood pressure, and cholesterol. These lead to “vascular” disease which affects the arteries in your body producing heart attacks, strokes and other crippling diseases. Diabetes also prevails. Prevention of these diseases by controlling your risk factors should be your primary goal. That is an important focus because:
a. It does take a lot of weight loss to reduce risk factors
b. It is extremely difficult to lose a lot of weight
The way in which you achieve risk factor reduction/normalization is straight forward. It involves TWO things – modification of your current eating habits to make them “heart healthy” AND DAILY aerobic exercise.
For this article, let’s talk about modifying your eating habits. The real culprits are SATURATED and TRANS fat in terms of risk factors. The secondary factors are other types of fat – the many unsaturated or healthy fats. I advise reducing all fats initially because all fats are very calorie dense (9 calories/gram) versus carbohydrates and proteins (4 calories/gram). The combination of these two nutritional changes along with daily exercise will produce dramatic results. When you reach your weight goal, you can liberalize your healthy fats and maintain your new way of eating FOREVER. Why does this work? Because YOU are going to modify YOUR current eating habits to make them heart healthy by removing or substituting the high fat items. And since your modified eating pattern will be similar to how you now eat, it is easy to sustain as opposed to a DIET.
This is described in great detail in the Nutrition chapters of my book.
Gerald L. Evans, M.D.
Is BIG Better?
I’m not convinced that BIG MEDICINE is better than small medicine. I grew up in a family that owned a paint and wallpaper store. Customer service was a large part of what they sold. Over the years, we have seen “mom and pop” operations bought out and replaced by chains who offered somewhat lower prices. The remaining “mom and pops” could not compete and went out of business. The chain prices rose, but the service component was lost forever.
Big Medicine is heading that way. Physicians who were solo practitioners have had so many external requirements placed on them by government, insurers, HMOs and other entities, that they would have no time to see patients unless they formed groups and hired management to deal with the bureaucracies, Many or most computerized the business side of the office, but now the government has mandated that medical records be computerized. This is not to improve the care of patients, but rather provide data to those external groups who pay for health care and want to find ways to pay less.
Other creative ways to control costs are included in the Health Care Reform bill. Accountable Care Organizations (ACOs) will be created. These are large entities made up of many thousands of patients who will get their entire care from the ACO. The payers, especially Medicare to start, will pay so many dollars per year for your care. The ACO will have to decide how much each member gets paid from that money – a monumental challenge. Is the cardiac surgeon worth more than the chief financial officer? Is the emergency room nurse worth more than the nurse practitioner on the cardiac floor? Is a gastroenterologist who does hundreds of endoscopies worth more than a hematologist who does few procedures? In fact, the gastroenterologist may argue that his/her services generate a lot of charges, so is therefore worth more. The hospital may counter that the income is now fixed in the ACO and all you are doing is spending the profits!
Part of the theory of ACOs is good. Spend more time at the primary care level talking to patients and sorting out the issues rather than sending them quickly for a lot of tests and procedures. That presupposes that the primary care physician is well suited to that task. Certainly the senior ones who trained in the 60’s and 70’s are, but I’m not so confident that the younger primary care physicians have that breadth of clinical knowledge. The medical profession has been pushing for standards of care for the past 20 years. Guidelines, generated from “Evidence Based” clinical research studies have medicine much more cookbook in nature. They do not translate to direct patient care in a clinical setting very easily. Physicians are currently, at least in part, paid on the basis of measurable performance standards like asthma Rx, or ordering certain blood tests to follow a diabetic patient. These are computer measurements, easily extracted from a computerized medical record. Hence, we see the logic of the government’s approach. These measures do not translate to the quality of care the physician is really giving the patient.
We’ll talk more about what quality of care really means in an upcoming blog.
Gerald L. Evans, M.D.
Exercise is Crucial!
In my book, “Why Health Insurance Does Not Ensure Health”, there is a lengthy chapter on the critical need for exercise. A summary of the specifics of what you need to do are outlined here:
FREQUENCY: Plan to exercise every day. The goal is to exercise six or seven days per week. There will be days, often unanticipated, in which something comes up and you just do not have a chance to exercise. Do not plan a day off; rather let it occur naturally. You need to schedule your exercise time into your daily schedule. Do not leave it unplanned with the thought of fitting it in. It will not work. Exercise has to be as important to you as your other activities, both work and leisure.
DURATION: You need to do a minimum of 30 minutes, NON-STOP, aerobic exercise at a pace that makes you “comfortably” short of breath. The 30-minute non-stop requirement is critical to achieving what is called the “training effect”. It relates to the blood pressure and cardio-protective aspects of exercise. Two 15 minute periods do not make 30 minutes NON-STOP!
If you stop and think about it, when you exercise, you are not training your heart. Your heart exercises all the time. In fact, you exercise to reduce the amount of work your heart does. Your heart beats all the time. It beats slower when you rest or sleep and faster when you exercise. The fitter you are, the slower it beats – not just with exercise, but at rest as well. Are you aware that fit individuals have very slow resting heart rates? Marathoners and fit tennis players run resting heart rates in the 30s and 40s. They develop those slowed rates by intense aerobic training, virtually always by running. Playing tennis is a stop and go sport. Running, jogging, and walking are aerobic activities. A sustained aerobic activity (age and health appropriate), is what you want to do.
When you engage in sustained aerobic exercise (30+ minutes non-stop), you are training the arm and leg muscles to be more efficient. You might think of it as your muscles getting better gas mileage. The fuel your muscles use is oxygen which is carried in your blood. Your heart is pumping that blood to your muscles. If you make those muscles more fuel efficient, they will need less oxygen-containing blood to nourish them and thus the heart will not have to work as hard pumping that blood to them. This efficiency is called the training effect. It reduces the workload on the heart both at rest and at exercise. It takes sustained aerobic exercise to achieve it and thus the 30 minutes non-stop exercise prescription. The training effect reduces both resting heart rate and resting blood pressure which also reduces the body’s oxygen needs at rest and exercise. This is one of the ways that fitness reduces the work of the heart at rest and exercise. Since for most of us, the majority of our day is spent fairly sedentary, this is very important. Similarly, the rise in blood pressure and heart rate with exercise will be attenuated which is also of major importance. So that is why you are going to exercise every day and why you are going to exercise at least 30 minutes non-stop each time.
Please go to the full text for much additional detail.
Gerald L. Evans, M.D.
