Beyond Ecstatic!

I read something this morning that validates the value of prevention in a profound manner and reinforced my convictions and sense of mission. It started with some bad news, but it got much better.

The bad news was that a recent pilot study,  led by Sabyasachi Sen, MD, from Baystate Medical Center in Springfield, Mass., and colleagues, showed that prediabetics have similar micro-vascular dysfunction as diabetics. Prediabetes is generally defined as fasting blood sugar between 100 and 125. Vascular dysfunction refers to the changes to the flexibility of arteries that contributes toward stroke, heart disease, and death. The less flexible your arteries, due to factors such as hardening of the arteries, the greater the vascular dysfunction.  It's long been known that diabetics have vascular problems, but this study showed that so do prediabetics. This is bad news because it is estimated that  nearly 80 million Americans are already prediabetic and that number is expected to steadily grow as the obesity rate grows.

The good news was that unlike with diabetics, aerobic exercise can have a profound effect. It's not to say that exercise doesn't help diabetics; rather, exercise has a dramatic impact on prediabetics. The researchers found that "exercise improves vessel function almost back to normal status, which is not the case with diabetes. It's been shown that exercise only improves the vascular reactivity of diabetics by half of what was achieved during the study."

The implications of the study is that there is a therapeutic window (an ideal period to treat) for prediabetics to return their vascular function to normal with a non-pharmacologic (no drugs) intervention. Aerobic exercise can "reduce the cardiovascular risk in a patient population that is at risk of developing diabetes."

The patients involved in the study did not have high blood pressure and were fairly active but not undergoing any type of formal exercise program. The exercise consisted of 150 minutes per week at 70% of the maximum heart rate, which is considered moderate exercise by American Diabetes Association criteria. This leads me to believe that those who are hypertensive and live sedentary lives will garner even greater benefit from increasing their exercise.

The implication of this study is further support of the Ben Franklin adage, "an ounce of prevention is worth a pound of cure."  Don't wait until you are diagnosed with diabetes. Don't wait until you add the next few pounds and become further overweight and obese. Don't wait until you find out you have heart disease or suffer a heart attack or stroke. Get more exercise today when your efforts will yield far greater results. You only have one life to live and one body to live it in. Get up now and start exercising! You must do it and you can.

Prevention May Be The Best Path

Did you hear the good news? Yesterday, researchers at Duke University using a new model, predicted that by 2030, only 42% of Americans will be obese. Today that number is 36%, but the apparent good news is that a previous model predicted it would be 51%.  At the same time, the researchers predict that severe obesity would rise to 11% instead of the previously predicted 9%. 

The reasons for the discrepancy were described as the researchers taking into account factors such as unemployment rates; prices for alcohol, gas, and fast food; prices of healthy versus unhealthy foods; access to the Internet; and the number of fast-food and full-service restaurants per 10,000 people.

So is this really good news? Should we break out the champagne or the tissues? I find it hard to imagine that nearly half of all Americans will be considered obese in less than twenty years. But what is even more difficult to absorb is that our government is not obsessing about this problem.

This year, the Centers for Medicare and Medicaid Services (CMS) took a big step forward and initiated coverage of Intensive Behavioral Therapy for Obesity. They define obesity as a body mass index (BMI) of 30, which is about a 5 foot 4 inch woman weighing about 170 pounds or a 5 foot 9 man weighing about 200 pounds.  The problem is that if your BMI is 29.9, you are out of luck. At that number, you are entitled to no therapy whatsoever.

I can appreciate that there needs to be a threshold at some level, but I believe it should be several BMI points lower. Why wait until someone is already obese to intervene? Studies show that many things change including our gut bacteria, metabolism, and hormonal balances as we gain weight. Basically, it gets harder to lose weight the more you gain AND it gets harder to keep it off after we gain it and try to lose it again.

The other problem with CMS's obesity initiative is that the reimbursement is approximately $27 for 15 minutes up to 16 times spread across 6 months (6 more spread across the next 6 months if you lose 6.6 pounds after the first 6 months). That extrapolates to about $108 per hour, far below what the average primary care physician, which is the only type of physician that can offer the service, earns before overhead, staff, malpractice insurance, billing costs, etc.

Multiple google searches have failed to identify a single doctor or practice in the U.S. offering this service. I can find no practice marketing it. I also asked dozens of primary care providers and they have said they do not as well.

Is it the low reimbursement? Maybe. Is it the lack of knowledge necessary to provide intensive behavioral therapy? Maybe? Is it the reluctance of doctors to tackle their patients' obesity?  I can only say maybe again because I don't really know any of these answers as to why other doctors choose as they do. But I do know we have a problem and it's not just doctor engagement.

I think the real problem is the patients.  Tackling obesity with just primary care practitioner led therapy, instead of pills and surgery, requires real commitment on the part of patients. Obese patients know they have a health problem and that their long term health prospects are at play. Most also know that obesity is not particularly attractive. Yet, whether you believe it is a disease or a choice, these same people find it difficult to tackle their issue. Few prefer to be so overweight and need help to break out of their weight captivity.

So what do we do about this problem? Some may say financial incentives. I don't think that is a long term solution and I have previously explained why. While short-term incentives may work, weight is often easily regained unless fundamental changes to lifestyle are made and such changes can most of the time only be brought about by a concerted effort.

So how do we do that? I propose an integrated and interdisciplinary approach. In other words, I think it will take a team effort of motivated, committed, and trained practitioners to support, guide and educate patients to bring about real change. About 4 months ago, MDPrevent proposed such a model to CMS. MDPrevent asked for funds, to which I and others would contribute additional funds, to tackle not only the rising epidemic of obesity, but also heart disease, diabetes, dementia, and cancer.

MDPrevent's program, which we titled, Intensive and Integrated Behavioral Therapy for Lifestyle Modification would combine the talents of a primary care provider, a registered dietitian, a health psychologist, a fitness instructor, and a health educator to work with patients on both an individual and group (group success can be contagious) basis and help them tap into their own motivation to make change.

We anticipated that it would take a full year to bring about meaningful success and expected to be able to do so at a cost of slightly above $600 per patient. For this meager amount, we believe that we can change the course of someone's health and life trajectory.

Can anyone argue that it isn't worth the effort given the obesity and other chronic disease projectories? There is no profit for MDPrevent in the amounts requested because we believe that we must first prove the success of such a program before profits can even be considered.

The goal of the program is to identify and tackle pre-obesity, pre-diabetes, pre-stroke, pre-heart attack, and pre-cancer situations and implement a series of lifestyle changes to prevent, delay or even mitigate the development of these life threatening conditions.

The decision from CMS regarding funding this initiative was originally due March 30. We are in overtime. I am told it will come shortly. This program could be a game-changer for the country at large. Wish us luck!

Longevity and Weight: What's the connection?

For the past year, I have been meeting with, treating, and lecturing to over a thousand seniors. Although this is not a scientific conclusion, I notice that people in their late 80s and above are never markedly overweight and those who are markedly overweight often look older than they are. This is consistent with a study of Jews of Eastern European descent that are believed to have a longevity gene that confers the potential to live into their 90s and above. The study showed that despite sometimes living unhealthy lifestyles, none of those living into their 90s were overweight.

A study reported today further supports this conclusion.

First, let's review what is the Body Mass Index (BMI).  BMI is a measurement of weight classification calculated by factoring in your weight and height. It is an imperfect measurement because it doesn't differentiate between high body fat and muscle content. BMI has been used by the World Health Organization as the standard for recording obesity statistics since the early 1980s. (The formula is pasted at the end of the blog.) Here in the U.S., it is also the most commonly used measurement to determine underweight, normal weight, overweight, and obesity.

Generally a BMI below 18.5 is considered underweight, 18.5-25 is considered normal, above 25 to 30 is overweight, 30 to 35 moderately obese, 35 to 40 severely obese, and above 40 very severely or morbidly obese.  (It is used differently for children but I won't discuss that here. Write me for more information.)

In a new study,  Nicholas J. Timpson, PhD, of the University of Bristol, in England, and colleagues found that for every .8 (point eight)  increase in BMI, ischemic heart disease risk rose 52%.

 "These data add evidence to support a causal link between increased BMI and ischemic heart disease risk, though the mechanism may ultimately be through intermediate factors like hypertension, dyslipidemia, and type 2 diabetes," the group wrote in the May issue of PLoS Medicine."

Furthermore, they explained that "Observational studies, both prospective and retrospective, consistently link higher BMI to heart risks across different populations, but haven't convincingly demonstrated causality because of the possibility of confounding, reverse causation, and bias."


Everyone knows that being overweight is often associated with developing chronic diseases like heart disease, diabetes, stroke, cancer and dementia. However, this study is a big deal because it shows a direct correlation between weight and heart disease risks.

So it turns out that what I have been noting empirically, is in fact, scientifically grounded. The heavier you are over a BMI of 25 the more likely you are to die prematurely from ischemic heart disease, and I suspect, from other diseases as well.

At a health fair on Monday, I greeted passersbys with "How would you like to add more healthy years to your life?"  I thought this question will receive a resounding yes every time asked and it would allow me to engage the person in a meaningful conversation regarding the benefits of taking advantage of Medicare's smorgasbord of wellness and preventive services. I was wrong.

At least a quarter of the people said they were not interested. Perhaps it was my delivery or they were wary of what I was offering as too good to be true.  I really don't know the reason, but it amazed me anyway that anyone could answer that question negatively. I shouldn't be surprised.  Since the introduction of new wellness and preventive benefits in January 2011, less than 94% of eligible seniors nationwide have taken advantage of over $1,000 worth of these life-enhancing benefits. These services were implemented by Medicare to help seniors avoid chronic disease, prevent heart attacks, lose weight, and allow for early disease detection. Yet, few doctors are providing the service and few seniors are receiving them. What gives? Do they not know of the benefits or are they simply not interested?

I can't profess to know exactly what goes through seniors minds (even though in my past work experience I led an organization that cared for 5 million seniors), as I am a generation younger, but it still breaks my heart that they are not all willing to do whatever they can to live longer, healthier lives.

I can only imagine the fears they have of doing so-fears of developing dementia, fears of running out of money, fears of being institutionalized, or being left alone with the passage of friends and family. These can be legitimate fears as they can and do happen, but early planning can make a difference and I know plenty of seniors who continue to enjoy life into their 90s and beyond. I recently presented to three centenarians, the oldest 103. They all peppered me with questions.

Many seniors don't realize that the longer they live, the more good years they have enjoyed. A researcher at Albert Einstein College of Medicine also concluded that the longer you live, the less you spend on medical care. That may not make sense at first pass, but when you think about it, it begins to resonate. Living longer typically means you have less sick days and that means less visits to doctors, etc. Medical costs are a huge drain as we age and avoiding such expenses preserves our capital.

The bottom line is whether you do it for yourself, for some member of your family, or for any reason that motivates you, take care of your health (and weight) so that you can enjoy a long, healthy life.

BMI formula:

To Drink Or Not To Drink? A Tale of Two Studies

This morning, I read about two new studies about the health effects related to alcohol consumption. In one study, women who drank more alcohol had fewer strokes. In another study, mean and women who drank more alcohol had higher rates of cancer.  That's the problem with studies that only look at only one factor of health. You get a one-sided perspective.

Did people who drank alcohol develop more cancer because they had fewer strokes, or are people who escape cancer more likely to die from a stroke? There are no easy answers to these questions and clearly these studies don't provide them.

So what's a person to do?  I follow my own basic rule in regards to drugs, food, and anything else that has known positive and negative benefits. The rule is to answer the following question: Can I get the positive benefits elsewhere? If the answer is yes, then I avoid the item to avoid the negative consequences.

As to avoiding strokes, there are many known dietary and lifestyle strategies that markedly reduce the risk of stroke. Simply put, what's good for the heart is good for the head. Avoid unhealthy fats, exercise regularly, manage stress, etc. The usual list of suspects.

So when people ask me is it healthy to drink alcohol,  knowing the cardiovascular benefits versus the cancer risks, I answer that I wouldn't recommend drinking much (more than a glass) or often (more than once in a while). While alcohol does provide some calming effects and helps manage stress, it's not on the same level as exercise or finding purposeful engagement, etc. and so even for that reason, I don't tilt the scale in favor of much consumption. 

So staying healthy may require you to say "bottom's down."