Monday, October 28, 2019

What is "pre-illness" and what can you do about it?

OK, so you have been told you have “pre-diabetes” or “pre-hypertension.” What does that really mean? What should you do about it?
“Pre-disease” is a relatively new concept, unheard of when I started practice, but being applied more and more. It simply means that you have some measurement that is abnormal but does not meet the established criteria for a diagnosis. A friend of mine once observed that “there are no healthy people, simply those who have not had enough tests,” and this concept of our fragility seems to be applied more and more. Commonly used labels I have come across, in addition to pre-diabetes and pre-hypertension (now more commonly described as “Stage 1 hypertension”), include dyslipidemia, osteopenia and pre-cancer. The rationale for applying these labels is that catching a disease early, in its “pre-“ stage, and treating it, will somehow help avoid serious problems down the road. The evidence that this is true is very limited.
The CDC recently claimed that 84 million Americans had pre-diabetes – an enormous number, and an enormous potential group of customers for the pharmaceutical industry. An article in the journal Diabetes Care in 2016, however, found that only about 2% of pre-diabetics went on annually to have overt diabetes. At least a third in whom no intervention was carried out reverted to completely normal blood sugars, and the rest remained with mildly elevated sugar values. A more recent study in the same journal looked at 3313 black adults and defined pre-diabetes as a fasting sugar between 100 and 125 (below 100 being normal). They found no increased risk of cardiovascular disease in those with mildly elevated sugars.
Hypertension was previously defined as a BP persistently over 140/90, but values of 130-139/80-89 are now called “Stage 1 hypertension,” and it is estimated that one third of American adults have this “condition.” There are many problems with this labelling. One is that there is increasing evidence that office or clinic BP measurements are not truly representative of our usual BP and are frequently not even measured accurately. Another is that there is to date no evidence that treating this with medication does more good than harm.
Another common “pre-condition” is osteopenia, a bone density below normal but not severe enough to be osteoporosis. Some estimates claim osteopenia affects about 43 million U.S. adults, mostly women. How important is this? A study of 5000 older women with osteopenia found that after 10 years, only 5% had gone on to develop osteoporosis. If you want to estimate your risk of fracture, and you know your actual bone density numbers, you can go to and run the numbers. (If you are a U.S. Caucasian, go to
What should you do if you have been told you have one of these “pre-diseases.” What I would NOT do is begin medication. You may want to take this as a kick in the rear to motivate you to make some healthy lifestyle changes. Losing a few pounds or beginning a regular exercise program will usually reduce your sugar. Exercise, a more vegetarian diet and cutting down on alcohol will drop your blood pressure. Weight-bearing exercise and a diet rich in Vitamin D and calcium (but not supplements) and stopping smoking will strengthen your bones. Note the common thread in all of these?
Equivocal cancers are a whole other subject, which I will get to in another post.
Happy exercising!

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Thursday, October 17, 2019

Should you get a flu shot?

Let’s get one thing out there up front: flu shots are not guaranteed to prevent you getting influenza. Neither are seat belts a guarantee you won’t die in a car crash or bicycle helmets that you will survive getting thrown off your bike, but we still strongly recommend that you wear your seat belt when in a car and a helmet when on your bike. Why? Because they both greatly increase your odds of surviving an accident. It is the same with a flu shot: getting the shot cuts your odds of being hospitalized or dying of influenza by about a half.
A few facts: during the 2018-19 flu season, about 50,000 Americans and 3500 Canadians died of influenza. When the CDC looked patients hospitalized with influenza, those who had received the vaccine had a 36% lower risk of dying and 34% less risk of needing to be on a ventilator than those who had not.
Even if you do catch influenza despite getting the shot, you are going to be less sick and have a much lower risk of passing the disease on to others, which is one reason health care facilities make such a push to get all of their staff immunized.
Let’s clear up some common myths. First, influenza is not just a bad cold. If someone says they missed a couple of days of work because of the flu, they did not have influenza. With influenza you are sick for a good week or more with high fever, terrible cough and ache all over.
Second, you cannot catch anything from the shot. I used to hear “I had a flu shot once and got sick, so now I don’t get one.” The influenza vaccine is a “killed vaccine.” There is no live virus in the shot, just ground up particles from killed viruses. What may happen is that after getting a flu shot you get the same cold you were going to get anyway, and blame it on the shot. While you may get minor soreness at the site of the injection, serious side effects are very rare.
“I’m not around people that much, so I don’t need it.” True if you are a hermit, but not if you are a normal person, even an at-home worker. It is clearly true that school teachers, bus drivers and others who are around lots of people are at higher risk, but in an epidemic year we are all at risk.
Finally, “they never get it right.” We are all aware that some years the vaccine seems more protective than others, because the public health authorities who tell the manufacturers what strains of influenza to include in each year’s vaccine are making “educated guesses,” based on which strains were common in the southern hemisphere during their season. Some years they get it spot on and others they do not, but even a less-than-perfect vaccine is better than none.
So… role up your sleeve and do it before the flu season is in full swing.

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Monday, October 7, 2019

Getting the most from a doctor visit

For most of us, going to the doctor is not at the top of our favorite things to do list, but it may be one of the most important. Whether the visit is for a scheduled check-up or to deal with a new problem, there are ways you can make the visit less stressful and more useful.
You must remember that things have changed. In the “good old days,” when I started in practice, the visit involved just the patient and the doctor. Nowadays, there are many other players, who may not be physically present but are influencing the visit, including insurers, lawyers and the ubiquitous electronic medical record (EMR). I recently saw an article headlined “Don’t let patient care interfere with documentation,” not-so-subtly making the point that doctors are overwhelmed with demands for data to satisfy the demands of multiple third parties; it has been estimated that for every hour directly interacting with patients, doctors spend two hours on administrative tasks. Despite this, most doctors really do want to do what is best for their patients, and you can help them achieve this.
Arrive on time for your visit, but be prepared to wait. Doctors run late for many reasons. It may be the fault of the office, scheduling patients to maximize the doctor’s time at the expense of patient convenience, and if you ALWAYS wait a long time, you may want to change doctors. More common reasons are that earlier patients arrived late but were seen anyway or that patients had more complicated problems than anticipated, turning a 15-minute visit into 30 minutes or more.
Silence or turn off your cell phone! It is hard enough to have a good conversation about an illness without the distraction of a phone going off. If you actually answer the phone, my reaction would be that since you are clearly not very worried about your health problem, I will not be either.
Do your homework and arrive prepared. While the doctor may be the expert on medicine, you are the expert on your own body, and you are the one to note that while a symptom may not be dramatic, it is new. Before the visit, put things down in chronologic order – what happened first, what happened next, and over roughly what time frame. It is OK to check your symptoms “on-line,” but please use a legitimate web site such as,, or and do not “google” your symptoms. Whatever you do, do not say “I read on Facebook…” or your doctor will mentally tune out everything else you say.
Bring notes and take notes. It is easy to get side-tracked and forget things you thought were important. Have a summary of prior surgery, current medications, medication allergies and major medical problems printed and on your phone. Since it has been shown that 80%+ of what a doctor says is forgotten by the time you leave the building, either bring a friend or family member to act as a scribe and second pair of ears or make some written notes. Ask the doctor if it is OK to record the visit so you can listen to the conversation and advice given when you are less stressed.
It is OK to question the doctor. While doctors know a lot more about medicine than you do, we are not infallible. If the doctor dismisses a complaint when you “know” something is wrong, it is reasonable to ask for a second opinion. Misdiagnosis is increasingly recognized as a serious problem. You should be prepared to ask the doctor why they have made a diagnosis and what else it could be. You should also have a timetable for when you should feel better and what the plan is if you do not respond to the suggested treatment.
Remember: it is not your job to please the doctor; it is the doctor’s job to help you feel better. If you have a doctor with whom you cannot communicate, look for another.

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Thursday, October 3, 2019

Where's the beef?

A study published by the Annals of Internal Medicine on October 1 titled “Unprocessed Red Meat and Processed Meat Consumption: Dietary Guideline Recommendations from the NutriRECS Consortium” has unleashed a firestorm of controversy. This publication and the reaction to it reveal so much about medical studies and recommendations that I was tempted to write a book about it, but will try to be briefer.

The conclusion of the paper was that adults continue their current consumption of both red meat and processed meat, noting that the recommendation was a weak one based on low-quality evidence. The reaction from such groups as the Harvard School of Public Health, the American Cancer Society and the American College of Cardiology was vehement opposition to this statement, implying that the authors were irresponsible and would contribute to more heart attacks and cancer.

Why the controversy? First, we must note that the ideal way medical recommendations are reached is through randomized controlled clinical trials: a group of people are given treatment A or Treatment B, selected randomly, and neither the subjects nor the researchers know which they get. The groups are followed for an appropriate time and at the end, the researchers look for a difference in the outcome between those given A and those given B. If there is a substantial difference between the groups, and if the people given A and those given B are shown to be pretty much the same except for the treatment, it is assumed that the difference in outcome was due to the treatment. I must note that small differences in outcome may be “statistically significant” if the groups are large enough even though the magnitude of the effect may be so small that it is not “clinically significant.”

While randomized trials work well when comparing two medicines, they are impossible to do when studying diet. Most of us can tell the difference between a steak and a roasted cauliflower. Dietary studies are thus mostly done by looking at what people do, generally based on self-reporting, and comparing the outcomes between those who claim to eat one way or another. These observational studies are fraught with difficulty. We learned long ago that when you compare people who do one thing differently, it is highly likely they do other things differently. Studies comparing vegetarians with omnivores cannot assume that their diets are the only thing different between them. Vegetarians may smoke less, may drink less (or more), may exercise more, may be leaner – all factors that impact health.

The NutriRECS group took this into account when they looked at all the published studies on diet and health. They concluded that the evidence base for recommending people cut down on their consumption of red and processed meat was weak. They also noted that the absolute benefit, in terms of number of heart attacks or cancers prevented, was relatively small. One example was an estimated 7 fewer cancers per 1000 people over their lifetime, a risk that omnivores might be willing to take when weighed against quality of life.

So, who is right? Both sides! If you are a vegetarian, you can be satisfied that you are slightly reducing your risk of cancer and heart attack (though slightly increasing your risk of stroke per another recent study in the British Medical Journal!) If you like to eat meat, you can be content that the absolute risk of your preference is relatively small and you do not need to make yourself miserable – and you can always balance your love of steak by walking more and dropping a few pounds.

Prescription for Bankruptcy. Buy the book on Amazon