The “Fat but Fit” Paradox

The Reznick family has always struggled with weight issues. We enjoy eating large portions, snacking and having our wine and spirits in moderation.

I remember accompanying my dad to his checkup in my teenage years. His internist was a highly respected chief of the internal medicine department at a large NY academic teaching facility as well as a long-time family friend. I remember the conversation well. Dr. Cohen would say, “Lou you are too heavy and I don’t want you to get sick from it!” Dad would respond with,” Ted I am not too fat I am just too short.! I am really fit working on the loading docks at my business and running around on my feet all day.”

Here we are 60 years later and the “fat but fit“ paradox has been examined in the journal Preventive Cardiology where researchers looked at 527,662 adults aged 18-64 years. This was performed by reviewing insurance information of patients who underwent regular health checkups through an occupational risk- prevention company.

They divided the group into normal weight, overweight and obese. They then separated them by activity levels with some being inactive (64%), insufficiently active (12%) and regularly active (24%). Of the study group, 30% had elevated cholesterol, 15% had high blood pressure and 3% had diabetes.

The study showed that those who were physically active reduced their cardiovascular risk. The overweight and obese individuals who were active were never ever able to reduce their cardiovascular risk to the level of a normal weight active individual of similar age. Overweight individuals are still more likely to develop hypertension, high cholesterol and diabetes due to insulin resistance in lipid rich cells.

The goal for physicians is to help you to live longer with a high-quality life. To accomplish this, we still need to emphasize achieving a normal body mass index or weight, maintaining a healthy active lifestyle and controlling those health issues that still develop in fit active adults.

Weight control and regular check-ups with your physician remain extremely important!

The Importance of the Physical Examination

Medical Schools and residency training programs are beginning to realize that they must devote more attention to training young physicians in the skills of physical examination. In recent years the tendency has been to concentrate on the technology rather than taking a thorough history and performing a comprehensive examination. Abraham Verghese M.D., a chairperson at Stanford’s medical program has been instrumental in creating the Stanford Medicine 25 program which emphasizes 25 physical exam skills that all students must learn, demonstrate and then teach. Prior to the program Verghese felt that ,” If you come to our hospital missing a finger, no one will believe you until we get a CT scan, an MRI and an orthopedic consult.” Steven McGee M.D., of the University Of Washington School Of Medicine is author of a book on evidence based diagnosis based on physical examination. He believes a physical exam can be as accurate as technology citing instances where evaluating patients’ eye movements are as accurate as an MRI scan in differentiating vertigo due to an inner ear problem as compared to dizziness from a stroke. W. Reid Thompson M.D. of the John Hopkins Pediatric Cardiology Division launched Murmurlab, a website containing the heart sounds of 1300 people to train his students how to distinguish which cardiac findings require further evaluation and an echocardiogram and which do not.

These physicians believe tests lead to tests and more tests and may obscure the diagnosis when a simple physical exam might provide the answer. They cite examples such as the 40 year old woman in a Northern California hospital who was being evaluated for a blood clot to her lungs with a CT scan because she had extremely high blood pressure and was confused. A simple examination of her breasts which had not previously been performed revealed bilateral hard non moveable malignant masses which were in fact the source of her problems.

Not all leaders in medical education feel the need to teach physical examination more effectively. Robert Wachter MD, the father of hospitalist medicine and former head of the American Board of Internal Medicine disagrees and feels more time should be spent on developing critical thinking skills than on physical diagnosis. Dr Wachter is part of a movement to shorten medical school education and shorten residency training. He believes in educating new physicians in a much narrower specialty oriented manner. Under his influence and leadership the Internal Medicine Board Examination is now a separate exam for doctors practicing in hospitals and those practicing outside hospitals.

I have been a faculty member teaching medical history taking and physical diagnosis to medical students for over a decade at the University Of Miami Miller School Of Medicine and the Charles E Schmidt College of Medicine at Florida Atlantic University. These two institutions have managed to teach both critical thinking skills and excellence in physical diagnosis without shortchanging either skill. There is no reason to narrowly train doctors when the fund of knowledge and technology is dramatically increasing. The goal to shorten medical school and residency seems to be an economic goal designed to reduce the costs of education and training a doctor and produce a class of physicians who can be compensated at a lower level. If anything today our future physicians need a broader more comprehensive training to improve understanding and communication regarding the increasingly complex and aging patient population they care for.

Do Routine Physical Examinations Save Lives?

Lasse T. Krogboll, of the Cochrane Nordic Center in Copenhagen, Denmark and coauthors published an article in the online edition of the Database of Systematic Reviews that suggests that routine examinations do not save lives.  The material was reviewed in the University of Pennsylvania Medical Center online periodical Medpage Today and was critiqued by a physician at the Harvard Medical School.

The study was a systematic review of 16 clinical trials involving 183,000 patients followed for a median of 9 years. The review concluded the risk of mortality in individuals who had regular checkups, compared to those who did not, was not statistically different.  “General health checkups did not reduce morbidity or mortality, neither overall nor for cardiovascular or cancer causes, although the number of new diagnoses was increased.”  “With the large number of participants and deaths included, the long follow-up periods used and, considering that cardiovascular and cancer mortality was not reduced, general health checkups are unlikely to be beneficial.”

In commenting upon the study, Doris F. Zaleznik, MD, Associate Clinical Professor of Medicine at Harvard Medical School and Dorothy Caputo, MA BSN RN admitted that “most of the trials were old, which makes the results less applicable to today’s settings because the treatments used for conditions and risk factors have changed.”  They additionally noted that one reason for the lack of efficacy of routine general checkups might be that “primary care physicians already identify and intervene when they suspect a patient to be at high risk of developing disease when they see them for other reasons.” They additionally suspect that “those at high risk of developing disease may not attend general and health checks when invited.”

The release of this online study was dramatically promoted. One must embrace evidence based data but keep in mind that there is a strong push in the USA to reduce health care spending overall as a percentage of the gross national product.  Anything that seems to say, “Do not seek evaluation “seems to garner more attention than it is due these days.

The study did not clearly define what a general health checkup includes.  I still believe that finding a good doctor and seeing that doctor annually for a benchmarking session to review your health wellness and habits by performing a thorough history and physical examination and, comparing your habits and findings to current recommended guidelines and treatments, is a worthwhile endeavor.  The general health exam does not need to include numerous and expensive laboratory and imaging studies unless the history and examination suggest the need to pursue those options.

As medical science identifies genetic and molecular mechanisms of disease, I am sure the next long-term Cochrane Review will show the efficacy of these annual general physical examination sessions in limiting disease and extending life.

 

Flu Shot Campaign Begins

As school bells ring out announcing a new school year and pigskins fly through the air announcing the arrival of a new football season, the Center for Disease Control and Prevention (“CDC”) begins its annual influenza vaccine campaign.  “Flu” or influenza is a viral illness associated with fever, severe muscle aches, general malaise and respiratory symptoms.  Most healthy children and adults can run a fever for 5 – 7 days and fight off the infection over a 10 day to three week period.  There is clearly a long period of malaise and debilitation in many that lasts for weeks after the acute febrile illness resolves.

The illness is especially severe and often lethal in the elderly, in infants, in patients with asthma and chronic lung disease and in those patients who have a weakened immune system due to disease or cancer treatments. Diabetics and heart patients are particularly vulnerable to the lethal effects of unchecked influenza.

The CDC recommends vaccinating all Americans over six years old against influenza.  Adults can receive an injection, or a nasal application.  The 2012 – 2013 vaccine has been updated from the 2011 – 2012 version based on samplings of current influenza viruses spreading around the world.   It takes about two weeks to develop antibodies and immunity to influenza after you receive the vaccination.  If you received the vaccine last season or had the flu last season you are still advised to receive the 2012 – 2013 vaccine this year because immunity fades with time.  Flu vaccine should have arrived in most physician offices and community health centers and pharmacies by mid- August.  The CDC advises taking the shot as soon as it is available.

The vaccines used are not live viruses so one cannot catch the flu from the vaccine. Side effects usually include warmth and tenderness at the injection site and rarely general malaise and low grade fever a day or so later.  The benefits of receiving the vaccine far outweigh these minor and rare ill effects which can be treated with an ice pack to the injection site and some acetaminophen.  Please call your doctor to set up an appointment for a flu vaccine.

For those individuals who catch the flu we still have several antiviral agents available to treat the illness. These agents should decrease the intensity or severity and duration of the flu. We try to use these medicines as infrequently as possible because the flu can develop resistance to them over time.

Prevention of disease is an ever increasing component of our everyday language. Vaccination against an infectious disease such as flu or influenza is clearly one of the more effective preventive strategies physicians have available to offer patients.  While you are making arrangements to receive your flu shot inquire about several other effective adult vaccines including Pneumovax to prevent bacterial pneumonia, Zostavax to prevent shingles and post herpetic neuralgia and Tdap to prevent whooping cough or pertussis and tetanus.

Strolling After Dinner Wards Off Peripheral Arterial Vascular Disease Risk

Healthy lifestyles with excellent food choices and regular physical activity have been encouraged as the secret to a long and healthy life for years.  The U.S Department of Health and Human Services has promoted and encouraged every adult to get up to 90 minutes of exercise per day to stay healthy.  This type of time commitment is difficult for many active working adults to achieve.

In an article published recently in the Journal of Vascular Surgery, Stanford researchers point out that you just might be able to protect yourself against peripheral arterial vascular disease with a much more modest evening stroll. They noted that “a lifetime of even light exercise not only protects the heart but also the legs, reducing the risk of peripheral arterial disease (PAD).”

According to John P. Cooke, M.D., PhD of Stanford University Medical Center, a sedentary lifestyle predicted a 46% higher risk of peripheral arterial disease compared with a lifetime of recreational activity of any intensity. The biggest gains in PAD protection came in people who went from virtually no physical activity to minimal activity. “Even light activity, such as strolling, is enough to protect against PAD.” According to Dr. Cooke “ Get up off the couch, go for a walk, and you will be less likely to have problems in the future.”

Cooke and his group at Stanford looked at 1,381 patients and noted that inactive patients were nearly twice as likely to have PAD as those who had active lives. While inactivity is a risk factor in developing PAD other controllable risk factors exist and should be modified. These would include tobacco use, elevated blood sugars and elevated triglyceride levels. Once individuals develop narrowing of the peripheral arteries producing pain on exertion called claudication, their activity becomes limited by the pain.

The message is clear.  Stop smoking and start walking – even if the walk is a slow relaxing stroll.

Cervical Cancer Screening Guidelines – Role of HPV Testing

The American Cancer Society says women over 30 years old who have had three normal Pap smear test results in a row can get screened every 2-3 years rather than annually. They can be screened with a conventional Pap smear test or a liquid based Pap test or the HPV (Human Papilloma Virus) test.

A recent study at Kaiser Permanente Northern California from 2003 through 2005 suggested that HPV (Human Papilloma Virus) testing may be more accurate than Pap smears. Their analysis showed that:

>  For all women with a normal Pap smear test there were 7.5 cervical cancers detected per 100,000 woman/ years.

>  For all women who were HPV-negative the rate was 3.8 cervical cancers per woman/years.

>  For women who were both HPV-negative with normal Pap smears the rate was 3.2 cervical cancers per 100,000 woman /years.

Hormuzd Katki, PhD, of the National Cancer Institute in Bethesda, Maryland recognized the increased accuracy of HPV testing over Pap testing but encouraged co-testing.

“ Most women still undergo annual screening out of habit” according to Brent DuBeshter, M.D. of the University of Rochester Medical Center in Rochester NY. Even stranger is the case of women post hysterectomy with no cervix continuing to see their gynecologists on an annual basis for pap testing?

The recommendation for annual pap smears had been present for so many years that many doctors and patients aren’t “comfortable with the new guidelines that call for screening every three years in those at low risk for cervical cancer” according to DuBeshter.  “Many providers have a hard time changing habitual practice and adopting new evidence and practice guidelines,” says Ranit Mishori, M.D. of Georgetown University School of Medicine.

What is clear is that screening every three years in low risk patients works. What will need to be determined is the evidence based role of HPV testing in conjunction with, or as a replacement for, Pap smears.

Dutch Diet Drink Reduces Hunger

Obesity is an epidemic negatively impacting our health in America and around the world.  According to the National Center for Health Statistics, over 68% of American adults are overweight or obese.  As we move away from a hard working agrarian society to a society which consumes fast food while getting less activity due, in part, to our technological advances, we are always looking for aids to keep our weight down.

In recent years the pharmacological approach has fallen on hard times due to the many significant side effects associated with diet medications.  Expensive surgery to reduce the stomach size and re-route the intestines has met with mixed success, high costs and adverse effects as well.

Last month, Harry Peters, a research manager of Unilever Research and Development in the Netherlands announced preliminary successful results of a prototype diet beverage. He and his staff concocted a chocolate flavored brew that stayed liquid and palatable when you drank it but firmed up into a thick gel when exposed to the acidic and digestive juices in the stomach.  The gel distended the stomach and produced a sense of satiety and fullness with a resultant decrease in appetite in the vast majority of the study participants. The research is quite preliminary but again presents hope to those of us fighting the battle of the bulge.

“Although the self-reported decreases in hunger are robustly reported in this study, further studies are needed to establish its implications for food intake, compliance to weight loss programs and long-term effects on weight loss or weight maintenance,” Peters and colleagues concluded.

The Importance of an Annual Physical Exam

I have listened to health economists debate the value of an annual physical exam.  Is it cost effective?  Does it prevent disease?  It doesn’t matter.  It is an essential part of the development and continuation of the doctor patient relationship.

The annual physical exam is a form of benchmarking. It allows the doctor and patient to review all the pertinent aspects of your health history and physical exam and use the data to coordinate a care plan for you which is personalized.

The history of present illness illustrates any immediate and current concerns. The past history reviews previous illness and how those problems may affect your current and future health. A family history presents genetic data which may affect you and your loved ones in the future. It updates your physician on what changes have occurred in your family’s’ health that may affect you. The social history looks at your school and employment history as well as lifestyle choices. Are you working with industrial toxins or in a field prone to certain predictable and preventable disease?  Are you smoking?  How much alcohol is in your diet? Are you partaking in physical exercise?  Are you in a stable relationship?  All these factors influence your health and choices.  Do you have a living will?  Who is your health care surrogate and who are your emergency contacts?  It is a great time to review your allergies and medications both prescription and over the counter vitamins, minerals, herbs and supplements.  Last but not least we look at checkups, vaccinations and immunizations.  Are you current on tetanus shots?  Do you know about pneumonia vaccine and zostavax for shingles?  Have you had your eyes checked for glaucoma?  When did you last see a dentist?  What about skin checks, colonoscopies, mammograms, pap smears and bone densitometry?   The history session ends with a complete review of all your body systems. By asking a laundry list of questions we hope to jog your memory to discuss all those little items you meant to ask about but may have forgotten to bring up.

The physical exam is used to support the hypothesis and answer the questions raised during the history taking session. It should be thorough looking at you from the top of your head to the bottom of your feet without skipping any orifices in between. The findings of the exam, coupled with the history session, will determine which laboratory tests, if any, your doctor will choose to order.  In thirty years of practice, I am rarely surprised by the results of a blood test if I have done a thorough and complete history and exam. Patients seem to feel something magical about lab tests but the truth is that a thorough and experienced clinician usually knows what the findings will be before he orders the test.

The complete exam should be followed by a consultative review session during which the doctor explains the findings of the history, exam and lab and makes suggestions. A care plan should be established at that session and a defined follow-up plan suggested and scheduled.

During your physical exam the doctor is learning a great deal about you. From the way you dress, to the way you carry yourself to your speech pattern; the physician is seeing you while you are healthy. It is much easier to diagnose a problem if you have had the opportunity to see the patient when everything is normal.  This knowledge of your normal appearance is what allows your doctor to find a problem in its initial stages rather than a crisis requiring a visit to a hospital emergency department. It is all part of the concept of longitudinal long term care and relationship.

Find a doctor. Schedule your yearly checkups.  If you find a physician you trust and respect stick with them. It may save your life.