Thursday, June 23, 2011

How to interpret your cholesterol test: The Basics

Despite the fact that nearly every adult American has these tests done at some point, it never ceases to surprise me when I’m asked what the tests mean. I order this test fairly regularly, but additionally, I have patients ask me to explain what the tests mean when their MD has ordered them. It’s an unfortunate fact that doctors often don’t fully explain the tests they are ordering, what the results mean, and what to do about it. I’m going to avoid speaking to the question of what to do about it, except in general terms, in order to provide a brief explanation of what’s being tested and what it means.

Total Cholesterol
Cholesterol is a small molecule found almost everywhere in the body, and which serves a wide variety number of functions, most of them beneficial. However, the reason doctors test for it is because excessively high levels of cholesterol in the blood have been linked to increased risk for heart disease. The basic mechanism is this – overly high levels of cholesterol in the blood mean increased amounts of cholesterol being deposited in artery walls, causing the walls to become stiff and inflexible. This damage leads to other disease further on down the road.

As medicine has learned more, cholesterol isn’t tested alone, but is parsed out into HDL and LDL. One important thing to understand is that cholesterol includes molecules aside from HDL and LDL (such as IDL and VLDL), so when you add your HDL and LDL counts together, it may not add up to your total cholesterol. While an ideal cholesterol count is below 200 mg/dL, patients with counts between 200 and 230 don’t necessarily need medication, especially if modifiable factors are identified that could be contributing to high cholesterol – these include lack of exercise and poor diet.

First, ‘good cholesterol’. The reason HDL is referred to as ‘good cholesterol’ is because higher counts of HDL are actually protective against heart disease. HDL is a molecule that travels throughout the bloodstream taking cholesterol out of blood vessel walls, thus reducing damage. Ideal HDL counts are between 45 and 60 mg/dL, though higher levels (above 60) may confer additional protection. Among the things found to increase HDL in the blood are exercise and fish oil.

LDL has earned the term ‘bad cholesterol’, because LDL travels the blood depositing cholesterol into blood vessel walls, opposite to HDL. Ideal numbers most people are 100 to 129 mg/dL, though many people, especially those with a family history of heart disease, will need to aim for levels lower than 100. When a high LDL is seen in conjunction with a low HDL, this is often an indication that dietary and lifestyle factors are at fault. LDL can be lowered by exercise and dietary fiber.

Triglycerides (TAGs) are more complicated than simple cholesterol, but provide a great piece of information. Though TAGs are tested along with fat molecules, they are actually made from sugars, and thus reflect dietary intake of carbohydrates, especially simple carbohydrates and sugar. While elevations in triglycerides don’t indicate diabetes, people with type II diabetes (adult onset diabetes) often have elevated triglycerides. Ideal levels of TAGs are below 150 mg/dL, and these tend to decrease fairly quickly in response to dietary changes.

While not specifically part of cholesterol testing, these are often ordered at the same time, because diabetes is a major contributor to cardiovascular disease. Type II diabetes is very controllable with diet and lifestyle changes, and can actually be reversed in some cases. Ideal levels are below 100 mg/dL after an overnight fast. Many doctors are now also testing hemoglobin A1c (HbA1c) to assess for long-term exposure to high blood sugar levels, so you may start seeing that appearing on your lab tests in the future, if you haven’t already.

CRP or hsCRP
Many of you will have seen this on lab tests as well. These molecules are generally interpreted as indicators of inflammation in the body. There have been efforts to link them to heart disease, because they are elevated as a result of artery wall damage, but unfortunately they are not very specific, as they can become elevated due to a variety of factors including acute illnesses. While the search for a reliable marker for vessel wall damage is important, and it’s laudable that people are looking, this test isn’t as reliable as we’d like it to be.

Conclusion: Metabolic Syndrome
This disease has gone through a number of names, including Syndrome X and Metabolic Syndrome X. It’s important to be aware of Metabolic Syndrome because it’s a major health problem in the US, especially among men, and it’s largely a result of diet and lifestyle. While the tests discussed can be affected by a variety of diseases, when they add up to Metabolic Syndrome, diet and lifestyle changes can have a major impact. Metabolic Syndrome is defined as the presence of three of the following five criteria: abdominal obesity, high triglycerides, low HDL, high blood pressure, and high fasting blood glucose. The guideline numbers can be found here.

A basic prescription for Metabolic Syndrome is this: moderate fat consumption (with a focus on healthy fats), low sugar consumption, and an exercise regimen.  Because Metabolic Syndrome is induced by lifestyle, lifestyle is the way out, and it requires work – my advice is to find a qualified naturopathic doctor or primary care medical doctor to work with you on this, to help you set and reach goals. In the age of the internet, it’s increasingly possible for consumers to become educated about their healthcare, and I encourage you to do so. While it’s important to be knowledgeable about health, don’t forget that being healthy is hard work, and you’ll need help along the way – find a good doctor who you work well with. Form a therapeutic alliance and use that person as a trusted advisor. Not every disease is caused by diet or lifestyle, but many are, and it’s important to have someone in your corner working for you.

Friday, June 17, 2011

On the Importance of Pronunciation, or, The Benefits of a Classical Education

It has been pointed out that Modern American English is not Ancient Greek. It has also been pointed out that Classical Latin and Modern American English are distinct and separate languages. Thirdly, for all of the cultural poaching that the Romans did from the Greeks, Latin and Greek are nonetheless not one in the same. However, despite differences in alphabet, grammar and literary tradition, these three languages come crashing together in one area – medicine.

For most, a classical education merely provides the ability to guess the end to every movie ever made, as they are invariably based upon plots which have been recycled again and again since the days of Aristophanes. However, for the physician, a basic understanding of Greek and Latin provides many benefits, beginning of course with anatomy – foramen magnum or thyroid, anyone? Greek and Latin have historically provided the basis for naming in medicine, though as we’ve entered the era of genetics, and what once may have been given a tripartite, multisyllabic, heroically dense name is now referred to as BrCA1. Alas, how far we have fallen.

While the American educational system is well-equipped to make sure that most who make it all the way to medical school are able to differentiate between “there”, “their”, and “they’re”, it’s become deplorably commonplace that Latin and Ancient Greek are no longer required core classes, depriving millions of their Zeus-given right to a classical education, not to mention the joys of being forced to sing Gaudeamus igitur. Nowhere is this failing more evident than in pronunciation. As a first year medical student, my ears were put through agony by the attempts that my classmates would make at the new words we would encounter – for the most part, they did fairly well, but I’ve identified two specific instances in which the average medical student (naturopathic, anyway) could use a little advice.

1. The Latin pronunciation of the letter C

Latin is a man’s language. Most of what was written by the Romans describes thousands of people being killed, either in real life, as in the conquest of the Mediterranean, or in the mythological past, where we mere mortals were being killed left and right. As a result, there are few soft consonants in Latin. This is especially true of the letter c, which is almost always pronounced as a k and never as an s.

Sure, we may slip sometimes and say “extensor pollisis longus”, instead of the firmly masculine “extensor pollikis longus”, but when discussing the Seven Principles of Naturopathic Medicine, it’s important to get your pronunciation right. Remember, you’re a doctor, not a dostor, so don’t forget to emphasize the hard c when you talk about Docere to your patients. Similarly, Primum non nocere takes on a special ring when pronounced correctly, a ring that reverberates with the sound of harm not being done. These may seem like minor points in the greater scheme of things, but know that generations of Latin teachers will smile upon you for your good work.

Adding some complication to this is the fact that Medieval Latin, and by extension Church Latin, replaced many of the c sounds of Classical Latin with the softer ch. “Primum non nokere” gave way to “Primum non nochere”, and thus began the Dark Ages. Believe me, all it took was a few lazy students ignoring their teachers’ stern warnings about pronunciation, and soon half of Europe was dying from plague. It’s really that simple. Let’s not have to go through that again.

2. Greek Consonant Clusters

Greek consonant clusters, while not technically diphthongs, are best explained as really complicated diphthongs that the Greeks created to express their deep appreciation of the challenging, laborious nature of the universe. In the same way that there is something deeply rewarding about listening to an old blind man ramble for days about some guy who gets lost on his way home, just to hear the part where he kills everyone who’s been trying to sleep with his wife, so too is there something gratifying about having to pronounce p and n in direct succession every time you want to refer to the lungs.

Three of the most commonly used examples in medicine involve the letter ngn, pn, and mn. People run into trouble with them because they’re involved in three words that sound very similar, and while no one would nor diamnose someone with gneumonia, when you throw mnemonic, pneumonic and pathognomonic at someone, you run into trouble. Trust me – looks these words up on Wikipedia and you’ll see mention of the difficulties people encounter when dealing with these words. Modern English speakers simply ignore those first consonants and focus on the n, but that’s no way to behave.

People also run into problems with the even more challenging pt. Once relegated to the nightmares of young students trying to translate passages from the works of Ptolemy, this linguistic stumbling block has now been thrust back into the spotlight by oncologists, who insist on constantly referring to apoptosis. Medical necessity, combined with the decline of American educational standards, means that every day, medical students and professionals speak of “ay-pop-toe-sis”, causing thousands of Greek warriors, long dead and buried on the shores of Ilion, to scream from the depth of Hades, “It’s aah-puh-pto-sis, you idiots!”

Here’s what it comes down to: the mountain crags and rocky soil of Attica are no place for frivolity. Food, water, money, and above all letters were conserved, and nothing was wasted. If the Greeks put a letter there, they did it for a damn good reason, so show some respect and pronounce it. Not only will you appease the spirits of red-haired Menelaus and the mighty Ajax, but it builds character too.

In Conclusion

A classical education isn’t all fun and games. Sometimes there were fun and games, for example on Exelauno Day, when we were treated to the delight of several hours of Greek and Latin declamations. But we also learned something: the past isn’t dead, it’s all around us. It’s in the language we speak (even everyday English), it’s in our government and society, it’s even in the food on our tables and herbs in our gardens. The fathers of modern medicine used the languages of the past to describe the world around them, because they knew that new discoveries were made because of old knowledge. As it says in the great seal of the Oldest School in Continuous Existence in North America, The One True School: Mortui vivos docent, The Dead teach the Living. We understand our world because they lead the way, and we who have inherited their legacy are in their debt.

Remember that the next time you bungle your way through pheochromocytoma. I mean, it’s just a growth of dusky-colored cells.

Friday, June 10, 2011

Is orthorexia worth talking about?

In 1997, Dr. Steven Bratman published an article in Yoga Journal about what he felt was a side effect of nutritional medicine, 'orthorexia nervosa', an unhealthy obsession with ‘healthy’ diets, which he felt could lead to malnutrition and other problems. While not an officially recognized illness, orthorexia has been the subject of some discussion in the popular media and the medical literature.

Of all the criticisms leveled at alternative medicine, this one will perhaps prove the most difficult to shake. Statements about poor education standards and lack of evidence are rapidly disappearing as naturopathic doctors now receive physician-level education, and clinical and laboratory trials of vitamins and herbs are increasing. However, ‘orthorexia’ has proven to be a bit of a blind spot for alternative medicine, and solving the problem will probably take a bit of soul-searching.

The issue at stake is one that’s fairly common in alternative medicine. Dietary medicine, and specifically the restriction of certain foods, is a fairly common practice among naturopaths, acupuncturists, chiropractors, and other professionals, be it avoid sugary foods during a cold, cut out dairy for chronic ear infections, or cut out wheat for just about everything from eczema to IgA nephropathy. It’s commonly taught at schools, positive results are regularly seen in clinical practice, and research into the practice is beginning to appear. As effective as it is, it’s not always an easy practice – as clinicians can tell you, most patients resist dietary changes vehemently. In the vast majority of cases, the possibility of developing an eating disorder are negligible.

However, some clinicians can also tell you about at least one or two patients they have seen whose diets are too restricted. In his initial article, Dr. Bratman discusses a patient who had gone from four asthma medications to none through elimination of dietary allergens, but in the process had also gone from eating a full range of foods to a very narrow spectrum. I myself once worked with a patient who had started with mild digestive symptoms, and through a process of strict dietary elimination (he was on a list of about 10 ‘acceptable’ foods when I saw him), had achieved some improvement of his initial symptoms, but was now suffering an increasing number of vague constitutional symptoms (fatigue, memory loss, weakness, joint pain), and was on his way to developing something like pancytopenia (a lack of red blood cells and immune cells), largely due to malnutrition.

The atmosphere is murky around orthorexia, in part due to another theme common in alternative medicine: Dr Bratman claims that he also had a brush with the disease in the late 1970’s while living on a commune and experimenting with a variety of esoteric diets. The story of the practitioner who diagnoses and/or then cures him- or herself and then goes about spreading the word is a common one in alternative medicine, and while it doesn’t completely disqualify his points (new diseases do emerge from clinical observations of a few individuals), it makes one examine the situation a little harder while trying to become informed.

In an effort to classify orthorexia as a true disorder, a questionnaire to identify orthorexia has been developed, the ORTO-15, and a limited number of studies have been done to verify accuracy of the questionnaire to detect disordered eating. Broad research into the topic is lacking, but the small amount available indicates that orthorexia is fairly uncommon in the general populace, but that incidence is higher in certain groups – medical students, doctors, nutrition students, and members of professional art performance groups (ballet, opera, and orchestra). Should orthorexia become recognized as an ‘official’ disorder, more research will likely be done resulting in better description of its prevalence and manifestations. As as been pointed out, there is significant overlap of orthorexia with other disorders, such as obsessive compulsive disorder and anorexia, but even so, doctors shouldn’t ignore the role that they can play in exacerbating symptoms, or even setting up a unique manifestation of disordered eating.

My take-home message is this. People practicing dietary medicine should screen for any history of disordered eating before making recommendations, especially as regards elimination of foods or food groups. Regardless of whether orthorexia should be classified as a distinct illness, practitioner recommendations about diet may play into pre-existing eating disorders, and for all the talk of being natural and free of side effects, may cause harm to the patient. And after all, those of us who have become involved in natural medicine did so for a reason, because we believe in the principle of primum non nocere – let’s not forget that this principle is sometimes more complicated in practice than simply avoiding the harshest of pharmaceuticals.

Friday, June 3, 2011

The battle over cutting Medicare costs

A few months ago, I wrote a blog entry on new trends to provide cost-effective healthcare in the US. These trends are largely aimed at consumers, with the goal of allowing individuals to purchase high-quality services on a budget. However, the economic crisis around healthcare isn’t simply limited to individuals– with growing concern over the national debt, healthcare costs have become a political debate, with both parties agreeing that Medicare costs must be cut. Despite bipartisan agreement that the problem must be dealt with, arguments over how to cut Medicare are explosive – when Obama proposed cuts in 2009, he was branded as proposing ‘death panels’, and when Republicans proposed cuts to Medicare this year, they were treated to a similar backlash.

Emotions run high in the debate, and what makes sense on a global scale is hard to accept on a personal one. The majority of the proposed cuts are around medically unnecessary treatments, and most of those treatments occur in the last year of life as a person is dying. While it may be easy to acknowledge from a distance that prolonging life for a few weeks, weeks that will be spent in intensive care units, is unnecessary and in some ways only prolongs suffering, many people would hardly make such a judgment in the heat of the moment.

This discussion intersects somewhat with the issues posed by the Death With Dignity movement, which has raised questions about end-of-life care. For many imminently terminal patients, prolonging life at this phase is merely drawing out the agony, and in addition, it is remarkably expensive. Though Death With Dignity remains a small movement at this point, many of its beliefs intersect with those of the much larger hospice care movement. Hospice care provides nursing and medical care to the terminally ill and dying in a comforting, quiet, relaxed atmosphere – for many, it’s a welcome departure from the chaos of the hospital. An emphasis is placed on comfort, palliation of symptoms, and minimal medical treatments, rather than high force efforts to postpone death.

In addition to the amount of money spent on prolonging the lives of the dying, there are questions about money spent on medically unnecessary treatments and screenings for the elderly. The New York Times recently ran an op-ed article in their ‘Room for Debate’ series, which solicited opinions from doctors, economists, and other professionals on their opinion of what ought to be cut. The various authors point to a wide number of costly but unnecessary procedures that are performed largely with profit in mind. Examples include hip replacements for Alzheimer’s patients who would be unable to perform physical therapy after the replacement, and prostate cancer screenings for elderly men against the recommendations of the AMA.

The final missing piece of the puzzle, in my mind, is the crucial role to be played by primary care providers. Primary care is less expensive than specialty medicine, and keeps patients in their homes, rather than in hospitals. Additionally, the oversight provided by primary care physicians would prevent some of the unnecessary medical procedures performed. For example, a few months ago I saw in my practice a woman who had recently gone to the hospital complaining of chest pain. Given her age and family history, it was important to rule out a heart attack, and so a barrage of basic tests were run, all of which came back normal.  Up to now, everything had gone well – an elderly woman complaining of chest pain was assessed for a heart attack, which was ruled out. Unfortunately, as this woman lacked a primary care provider, no one was on board to let the hospital staff know that she suffered from anxiety attacks characterized by chest pain, and that, so long as it wasn’t a heart attack, she was fine and could go home. As a result, increasingly expensive and invasive imaging studies were perfomed, each indicating no abnormalities. Several thousand dollars later, I can conclusively say that this woman wasn’t having a heart attack, wasn’t having angina, and will probably live out the rest of her days happily free from cardiovascular disease of any sort.

This is, of course, just a story, and it doesn’t factually prove anything. But it does illustrate some of the broader problems in Medicare. Abuses are possible in part because of lack of oversight by primary care physicians, but also, as the New York Times points out, because the definition of ‘medically necessary’ is vague. Tightening the budget too much is likely to cause problems, but even so, significant amounts of money can be saved by eliminating medically unnecessary expenses.

I hope you enjoy the Times’ Room for Debate. A few months ago, the Times published an excellent interactive feature entitled You Fix the Budget. I recommend taking a look at it, not only to gain a sense of what programs contribute to our national debt, but also the proportion of the national debt that Medicare contributes. In our national effort to improve health, profiteering and irresponsible spending not only don’t improve health at the moment, but will probably have long-term negative health effects, as they may saddle our country with massive debt, which in turn may lower living standards.