I tend to think of doctors as mechanics. Often when something breaks on my car, the explanation is "it's an old car, that happens eventually." And when they talk about it after fixing it, it's usually "Toyota's a good brand. Take care of it and you'll get another 100k miles from that engine." If I took my car to my mechanic with nothing wrong and asked what I should be doing to make sure the transmission lasts as long as possible, they will give me some generic intuitive advice, but they have no real insight because they are not in the business of maximizing the lifetime of healthy cars.
Doctors are kind of the same way. They see patients who have problems and need them fixed. If you walk into a doctor's office and say your family has a history of heart disease and you're concerned, they'll run a standard diagnostic to see if there is a problem. If there isn't, they'll give you generic advice. Outside of that, they are not really likely to have much insight into how to prevent heart disease in your specific case. Maybe you'll get lucky and the doctor will have recently read a relevant paper.
This seems to me like a problem that you're better off having answered by a medical researcher rather than a physician in the trenches. Researchers are the ones who are taking the long view on outcomes in patients. Keeping with the same analogy, you're probably better off talking to a mechanical engineer at a car company about maximizing the life of your currently healthy transmission.
Also, I generally see this as a problem that will be best addressed by machine learning researchers collaborating with medical researchers. Then again, I'm an ML PhD student working on health applications, so I'm biased. :)
Even the front side of your analogy is broken. Mechanics are great sources of information on how to drive so you can maximize the life of your engine. It's like you haven't had a conversation with a mechanic before.
Likewise with doctors. I have had 4 doctors in my family (3 still alive), and I've spent many the family meal talking with them about health, longevity, and the mechanical/biology/chemistry behind how your body works and when it works best.
Your interactions with mechanics and doctors imply a closer relationship than perhaps that of the OP. My typical experience with is closer to the OP's--that is they have a lot of vehicles/patients to see and don't go in to too much detail on each visit.
Many of them don't go into detail because 99% of customers don't give the slightest fuck. Show genuine interest, strike up conversation, and you can sometimes get a lot out of them.
In any case, service life in cars is usually determined by a couple key things: The design of the system, driving conditions, and service. You may feel like you're being blown off when the mechanic says "obey the service intervals and avoid short trips", but that's 99.9% of what you can do to make the car last.
(Special corner cases are widely-understood and well-documented, such as the impact of very high operating temperatures in automatic transmissions during towing)
my mom(who was a primary school teacher) had been a diabetic for about 10 years.The doctors who treated her told her to eat more wheat based meals instead of rice based ones and told her to increase the dosage of tablets when sugar level crossed 200 .No doctor ever told her about carb counting which IMO, was the first thing she should have been told.I came upon carb counting from some articles on the internet.She is trying this for the last couple of years and now her ppbs is 107.
It seems that reducing dietary carbohydrates should be the primary treatment of most diabetics. Eating too many carbohydrates seems to be the cause for most people.
The conversation with the doctor/nurse should go something like:
You have diabetes.
Your body has become insulin resistant because you ate too much sugary/starchy stuff.
Eat less of it and you will get better.
My fiancée is a psychiatric nurse practitioner. Recently, we were having dinner with a few of her colleagues, and they were complaining about the overwhelming number of new medications coming to market, and how they could never remember all the interactions, what to use for what, which ones were new, which had been retired, etc, etc.
As a CS person, I piped up and suggested, tongue in cheek, that the computers were going to take their jobs. This led to a healthy discussion about the human practitioners role in a time when the amount of information they're expected to know is rapidly expanding.
What's your take in the future role of the human in diagnosing and prescribing in a situation like this?
I love your analogy, but I think you drew the wrong conclusion. Doctors don't have an incentive to prevent you from getting sicker any more than your mechanic has an incentive for keeping your car out of the shop. Why would your doctor read the latest research on preventing disease when he can make a tidy profit from treating your disease?
Now this isn't to say that doctors are bad people who want to make you sick... on the contrary, most of the doctors I know are more passionate about helping people than making money. They are, however, subject to whims of the hospital they work for, which I can almost guarantee is more interested in making a buck than keeping you healthy. This is true of all large companies though, and as Clayton Christensen has taught us, this sort of marginal thinking usually leads to disruptive innovation by a start-up.
<shameless_plug> Want to disrupt health care? Omada Health is hiring! http://omadahealth.com/jobs </shameless_plug>
I once mentioned that to a family friend who was a doctor. He said that if he wanted to make money off of people's suffering, he'd have become a lawyer. Its way easier.
Do realize that doctors are required to do continuing medical education (CME [1]) to maintain their license? Not to say that the system is perfect, but it is false that doctors do not do some sort of continued study in their field (mandated or not.)
Doctors most certainly have an incentive to keep their patients from getting sicker. One of the ways we evaluate quality of care is incidence of morbidity. How often does this patient continue to return to the hospital? This is a huge risk to physicians, in the form of a lawsuit.
It isn't like there is any shortage of patients who require care. There are so many ways that hospitals encourage doctors to do bad things to make a buck, but preventing preventative care would not be the first thing I'd target.
I think another big problem is the generic advice (eat better, exercise more, don't smoke, etc.) is incredibly effective, but doctors routinely see huge numbers of their patients not doing it at all, so why would they bother researching for more specialized advice?
> Why would your doctor read the latest research on preventing disease when he can make a tidy profit from treating your disease?
Woah woah woah there. Are you really saying doctors don't read the latest research so that they can make a greater profit? Really?
You could have at least picked a more realistic example of misaligned incentives in medicine... e.g. using a more expensive drill bit during a surgery because you know that the surgical rep will take you out to a nice dinner every time he's in town.
There's a huge population of doctors. Some ethical. Some unethical. But I believe the profession does a pretty admirable job of stamping out immoral behavior when it finds it.
The OP phrased it badly, but the point is sound. Suppose a doctor has a choice of two activities:
1. Read research, unpaid
2. Treat patient, paid
The doctor clearly has an incentive to focus on treating disease. They do read research, but they would surely read even more if they were paid directly to do so.
There's nothing nefarious in this, it happens in any industry. We do more of the things we're paid to do, and less of the things we're not.
Doctors, especially at academic institutions, are required not only to be up to date in the latest research, but contribute to it. If a doctor treats a patient in a way not up to par with current practices in research, he will be sued and lose his licensure.
The education tries to ingrain "do no harm" but then again, human nature is human nature.
The folks who go into primary care - i.e. GP's, pediatricians, etc, tend to be more altruistic, and think along the lines of preventative medicine. (They certainly aren't in it for the money...). It's really the subspecialties you hear about some random doc who is pushing tests or surgeries somewhere.
There is a push behind the new "Accountable Care Model" that tries to incentivize better performance on overall health metrics that tries to address this, but too soon to tell how well it works.
I don't think there will be a shortage of sick people anytime soon.
Also, the problem is that such papers don't exist, or at least not in the accuracy or certainty you'd like to have.
It's much easier to gather data from sick people and which treatments worked for them, than gathering decades worth of data from healthy people and correlate causes to which diseases they eventually may have developed.
Agreed. In my experience doctors are fixated on symptoms and seem to be saying "if you have no symtoms you're wasting my time". I would say they're right. There are enough sick people to keep them busy, why would they spend time with healthy people?
If you're healthy (as in, no symptoms) then managing your lifestyle should be your business, not your doctor's, and most advice is obvious anyway (don't eat or drink too much, avoid processed food and all manners of sodas whenever possible, sleep well, exercise).
Regarding lifestyle choices, I also think doctors have seen many people getting sick that seemed to be doing everything right, they're not sure what's best. It's very possible stress is a main contributor to poor health, and just worrying too much about it is bad in itself.
The issue is that you're an individual, whereas the "standard of care" that your doctor is duty-bound to provide is based on population studies. Your doctor may be able to adapt this care to your specific case if you have obvious specific secondary conditions.
Ideally, your doctor would be able to tailor your care to your genetics, your lifestyle as well as to your medical history. That is the goal of "personalized medicine". This will likely become more and more common-place over the next decade or two, in particular with respect to the genetic aspect. But for now it remains too expensive and uncertain to be rolled-out by HMOs and national healthcare systems. So you end up with "generic" advice, which is in fact in most cases the best they can do.
The big professional associates generally put out a set of consensus guidelines that are aimed at giving "physicians in the trenches" a (relatively) easy interface as to "best practices" in terms of preventative medicine and risk reduction.
That being said, this is a matter of separating the noise from the signal in the population which is quite hard. AFAIK, and I am probably missing a few, but the only real long term modifiers are aspirin, low blood pressure, and high fiber/low cholesterol/low glycemic index foods. Everything else - there isn't enough data to separate noise from signal except for a few specific cases (someone found a gene polymorphism or mutation to something specific, i.e. the risk of blue converse sneakers or something like that)
To some extent that's unavoidable past a certain point. Your doctor can give you lots of advice on living past 40 or 60. If you want to live past 90-100, there are far too few examples to go by, and you start seeing the kind of "what worked for me" random advice that you see from the ones who managed it. And if you want to live past ~120, you'll hit some of the species-wide hard limits we don't know how to solve yet. At that point the answer for most doctors really is "that happens", unless you're one of the folks trying to solve the fundamental problems of longevity, which past that point have very little overlap with the problems doctors solve on a regular basis.
(0) Be female. Don't be born with heart defects. Don't be old. Don't have Marfan or Loeys-Dietz syndromes. (All of the unfair/can't modify factors will get lumped into recommendation #0.)
(1) Don't use tobacco or cocaine, and don't drink too much alcohol.
(2) Don't get exposed to radiation or chemotherapy.
(3) Don't have diabetes.
(4) Don't have high blood pressure.
(5) Have low levels of LDL and triglycerides.
(6) Don't eat too much. This is tightly related to #3 and #4, and reasonably related to #5.
(7) Have extremely low levels of LDL and triglycerides throughout your entire life. Having low LDL throughout your entire life reduces your risk of heart disease, even moreso than you would expect based on the LDL value alone. It seems that lifelong exposure to low LDL is more valuable than just late-life exposure to low LDL. [a]
Most of the genetic variants that we can currently interpret when accounting for risk (as opposed to the innumerable ones which we cannot yet interpret) fall into lipoprotein-related pathways. It will be interesting to learn about ones that do not, yet still confer meaningful cardiovascular risk. I don't think that we have a mechanistic explanation yet for the risk conferred by variants in the 9p21 locus, for example. [b]
I'm reasonably certain that your HDL is not particularly important (except as a poor proxy for your socioeconomic status, perhaps).[c] And omega-3 fatty acids have no visible effect when examined in the rigorous way in which we examine any other new drug. [d]
Grandfather was in decent shape at 40 when pretty much all his arteries clogged. He is now 87 with half a single artery left in his heart. He is not what I would call "living" as much as existing.
On the other side, my mother, grandmother, and great grandmother have intense high blood pressure with no understandable reason.
Well, I figure I may have till I'm 50. Though I hope doing biking marathons would train my heart even a bit to help.
To the extent that it is important to you, you can work with your doctor to modify the risk factors that you can and would like to modify. Interestingly, 90% of Americans over 55 will develop high blood pressure; it is the norm [1]. (Not saying you are an American, as I don't know; just saying that I also don't know if this applies to the rest of the world.)
Soviet Union represent! Moved to America bout 22 years ago. And of course after all these diseases hit the family. For the record only my father is overweight, and he's the healthiest of them all (not true but at least his heart is alright for now)
a) G.grandmother is 2 years older than grandfather (young mothers in my family)
b) 15-20 years of being completely and utterly crippled, unable to walk (over a few minutes at a time), eat salt at all, lay down, stand, etc... not sure if this is much of a life.
FYI: if you have clogged arteries, your heart is unable to move the water in your blood, thus if you lay down all that water gathers near the lungs and you can't inhale.
Do not follow quack recommendations like this. pw is not a medical doctor and is not licenced to practice medecine. That makes pw a quack.
Instead, seek out professionals who don't just say everything is OK, but who tell you what specific things to do and tell you why you should do those things backed up by research. A competent MD will not be afraid to refer you to the research that they are using to make their recommendations. A real MD does not say (I'm and expert, trust me) but they are willing to point to the studies and the opinions of other experts. Experts will not all agree but usually, when something really works, there will be a majority who do prescribe that course of action.
Sorry, no, that does not logically follow. You do not need to be a professional to recommend that you use professional advice. It would only be hypocritical if memracon had subsequently made specific recommendations.
There's a tremendous body of evidence showing improved cardiovascular outcomes -- ie, reduced heart attacks and strokes; even, in some studies, improved survival -- with statin use. Aside from lowering LDL, they appear to have direct anti-inflammatory effects within the vessels. I've heard anecdotal mention of memory problems with statin use, but have never been convinced I've seen it in any of my patients.
And then there is non-alcoholic fatty liver disease (NAFLD).
I am not fat, I've always been thin and my cholesterol is bang on perfect, my blood pressure 120/80 or better. Although I've slacked off the gym for about four years I'm pretty active at work.
Anyway out of the blue I am diagnosed with fatty liver: it hurts, I can feel it. Know how people with fatty liver die? Heart attack or stroke, fatty liver significantly increases the chances of either or both.
My grandfather died at age 52 of a heart attack, his daughter my aunt died of a stroke after multiple heart attacks age 70-ish and her brother my uncle also died of a heart attack at age 52 same as his father. Their brother my uncle had a quadruple bypass in his late 50s.
I'm beginning to wonder if people with a family history of heart disease really have NAFLD.
NAFLD is usually caused by obesity. However, it is also a common finding in those with ApoB defects. People with these defects have a curious phenotype: normal or even fantastic lipid levels but with NAFLD/NASH. Essentially, the defective ApoB doesn't get secreted from the liver so serum cholesterol levels look good, but the liver becomes fatty as it cannot export TG and cholesterol.
Certainly not trying to diagnose your familial disorder over the Internet, but taking a trip to a good lipid clinic might be something worth considering if you wanted to be aggressive in the pursuit of a diagnosis. (Which, again, might not be what I'm talking about above.)
At work a nurse comes in and we can get tested for high cholesterol, high blood pressure, diabetes. I go and each time even up until my NAFLD my numbers practically perfect.
Maybe I do have some ApoB protein trouble. Although I doubt there is a lipid clinic anywhere in Canada for me to go to.
Actually Canada has fantastic lipid clinics. (Disclosure: lipoproteins were the focus of my research and I collaborated with these folks.) Rob Hegele is a big name in lipids and his clinic is in Southwest Ontario, I believe.
I have a dull ache in my right side, back under shoulder blade and lower right abdomen. It's not painful just an annoying constant ache. Sometimes pins and needles on my back over my shoulder blade.
From what I understand most people with NAFLD feel nothing, some people who develop scarring (cirrhosis) and even cancer don't feel anything. The liver is weird, at least it can regenerate from a lot of abuse.
5 and 7 could be achieved by taking a statin (or a PCSK9 inhibitor) lifelong. This has not been clinically trialed–it is only my (and others') extrapolation from the genetic data.
3 and 4 can often be achieved by succeeding at #6, but certainly this is not true for type I diabetics nor for people with MODY or other non-metabolic-syndrome-type diabetes. Dietary discretion is difficult for almost all of us, it is true.
Well, if it is the male hormones causing trouble for part of (0), technically you could get a sex change after you have children...that would remove the male hormones and give you female hormone supplements.
> Generic advice to eat well and exercise is not as effective as having a specific number you're trying to improve on e.g. lowering your ApoB count.
I'm not so sure this is a wise approach.
I won't say that numbers aren't important, but it's worth noting that in many cases, doctors still don't know what particular measurements actually mean in practical terms because cause versus correlation is so hard to figure out in complex systems like the human body.
As an example: the general consensus has been that "good" cholesterol (HDL) has a protective effect and that those with lower HDL levels are at risk. You can have an LDL of under 150, low triglycerides and your cholesterol ratios can be stellar, but if your absolute HDL number is low, there's a good chance your doctor will talk to you and, at a minimum, recommend ways that you might be able to bring your HDL level up.
One common approach of doing this has been to use niacin, yet a 2011 clinical trial involving the use of niacin in an attempt to increase HDL levels in a high-risk population failed to produce the hoped-for risk reduction despite the fact that the niacin did increase HDL levels[1]. A larger, more recent study had a very similar outcome[2].
One logical possibility is that the HDL level reflects some other underlying factor which controls for risk and doesn't itself have the ability to influence risk. If this is the case, a higher HDL number may confer little to no protection unless it is the product of some other natural process.
I think the OP is referring to the fact it's much easier to focus and improve on specific items than it is to follow some nebulous generic advice. "Lose weight" is much less effective than "Exercise 30 minutes per day and eat 2200 calories per day".
What seems to be likely regarding cholesterol in general is that it has been greatly over focused on to the detriment of more likely culprits like sugar and refined foods. Of course, the cynic might say you can't take a pill made by Pfizer to lower your sugar and refined foods like you can to lower your cholesterol.
I think the parent comment's argument is that improvement on specific items isn't well correlated with "better health". Even interventions aimed at specific metrics have shown to have no or negative consequences. For example, niacin in the AIM-HIGH trial.
My father is in the hospital about to have a quadruple bypass. He has been a vegan for 15 years and is on his 2nd heart attack. The "animal fats cause heart disease" stuff has brainwashed him into thinking that his carb rich vegan diet is good for him. It's not (which isn't to say that if he did a GOOD vegan diet he wouldn't be much healthier).
I think this article is very insightful. One very good indicator (although not as good as the details the author got tested) is a person's HDL to triglyceride ratio. High levels of HDL are good, and low triglycerides are good, since its currently thought that higher triglyceride levels are linked to the small, dense LDL particles that work their way into artery walls.
> Am I missing other major downsides to taking a more proactive approach to managing my own health? Are there other things I should consider looking at to get a complete picture of my health?
A potential downside is the tendency is to shift from being proactive about your health to diagnosing (or worse -- treating) yourself based on independent research. I get that it's tempting to fire up google scholar, pubmed, uptodate etc to get a better understanding of what's going on -- just don't go the next step and start diagnosing and treating yourself.
See a specialist. See a domain specialist if you can. Get another opinion. Ask questions and air your concerns. If your doctor doesn't adequately answer your questions and concerns, see another doctor. Your greatest asset -- and the one you should be focused on-- is the ability to get multiple opinions from people who have trained for decades on a topic.
It seems like you need to see a new doctor -- not order your own tests.
There's also a risk of becoming hyper-aware of stuff that just doesn't matter.
Your heart tends to just do it's thing. But if you concentrate on it you might start noticing weirdnesses. These probably aren't your heart, but now you're anxious, so you think about seeing a doctor. But you don't want to waste the doctor's time, so you look around on the Internet to see what it is. And now you're really worried even though you know you don't have any of those things. So you go and see a doctor, and sure enough you don't have anything wrong.
Except now you caught some cold / flu bug from someone in the waiting room.
This happened to me with cars & funny noises. I noticed a noise in my first car that, two years later, turned into a spun bearing & rod knock. Ever since I pay super close attention to every noise my vehicles make! Problem is, vehicles make a lot of noises, even when they are operating correctly. Drives me crazy
The issue is that doctors give you muddled advice too. I had my blood test done last year and I was told that I should cut down on eating any meat and switch to a plant based diet. He also vaguely told me to do more exercise. Yet, I eat incredibly lean food, albeit high protein mainly because I weight lift. I also run 4.5 miles every other day. He couldn't go into more detail apart from this general warning. I could switch to a more plant, low fat diet. However, would that mean that I would be overall healthy considering that any resistance training would essentially be diminished because I am not getting enough protein in my diet? Should I run more than 15 miles a week and potentially screw my knees. He wasn't sure.
The claim that you can't get sufficient protein for pretty much any level of exercise from a plant-based diet is utterly specious. For example, quinoa is 14% complete protein, and chia is almost 17% — also complete protein — with an Ω3-to-Ω6 ratio of around 3:1, almost exactly the inverse of beef.
Source: I'm a vegetarian, and I pay scrupulous attention to this stuff.
> Quinoa is 14% complete protein, and chia is almost 17%
Quinoa provides 3.8 grams of protein per 100kcal of energy [1]. Boneless skinless chicken breast provides 18.8 grams of protein per 100kcal of energy [2].
A weightlifter who wished to consume 100 grams of protein per day would have to eat 2632 kcal of quinoa, vs. 532 kcal of chicken breast.
Just as a quick look to see details as to what would be required. Quinoa is hardly the only source of non-meat protein.
Now, yes that does include a lot of protein shake stuff, that's not that unusual for most weightlifting diets. That's also a vegan diet, so you might be able to add eggs, cheese and milk to that diet and cut back on the powder in the meals if you just wanted to be vegetarian.
The powder is of course to solve the issue you pointed out already.
The biggest problem I see with that meal plan is that it is planned for someone with a ridiculous activity level - it reaches "only" 207g protein for 3387kcal.
For comparison, I'm a powerlifter. I'm 238lbs currently. My maintenance calorie intake is roughly 2450kcal on average. I aim for about 2800kcal on training days, and equivalently lower on rest days to roughly meet that average. Fitting 220g or so of protein in that is not that hard: I can eat 400g lean chicken and get 100g protein for <900kcal. I can tack on 100g beef jerky and get another 50g protein for less than <300kcal; which leaves it almost hard not to meet the protein target within my calorie goals.
If I were to eat 3387kcal to meet 207g protein, I'd be adding 1-2kg a week.
That's well in excess of the protein synthesis a typical human male body is capable of. In other words: A substantial percentage would be fat. Quite possibly I might end up adding 1.5kg of fat a week on a diet like that, which would get me quite a lot less protein than what I do on my current diet.
For a body builder exercising heavily 2-3 hours a day, on steroids (otherwise lifting heavily for that long every day would just be a total waste of time), that calorie intake might be reasonable. Or for someone who combines the exercise with a highly active job, like say, construction.
It'd be interesting to see that diet brought down to 2400kcal or below with the same protein levels. I suspect it would look a whole lot less pleasant (and that diet looks awful to me in the first place, but I love my meat).
(Now, protein amounts this high are in the "might as well, just in case" level - the possible incremental benefits hinted at in the literature are as far as I know quite marginal - so a lower protein intake would not necessarily be bad, and then it'd quickly become a lot easier to meet it with a reasonable calorie intake)
Most of the protein shake stuff would not solve the issue for a vegan diet. Most of the protein shake stuff is made from Whey or Casein or egg whites which IIRC are not vegan. There is pea protein or hemp protein but my quick googling tells me is high carb and low protein and can easily throw you off your calorie limits.
Both pea protein and soy protein products with comparable protein to kcal ratios are available from the company I buy my protein from.
I'm not vegan, so I've never bothered trying them, but it doesn't seem like it'd be a big problem.
My concern (see my other comment) would be that the diet shown certainly is extremely high calorie, and it looks like it'd be pretty much all nasty shakes to get it down to a more normal level with the same amount of protein.
(EDIT: Note, this would only really be an issue if you do heavy resistance training, as the protein level in that diet is very high for someone who isn't doing weight lifting)
Sure. I am not denying that. It is just inefficient. Let us do some math. I try to hit 150 gms of protein per day while also staying within my calorie limit. I can do that right now while staying under a 1800 calorie limit.
From Google, 1 ounce of Chia seeds is 4.7 gms of protein, 138 calories. I would have to eat 31 ounces of Chia seeds to get 150 gms of protein. That is 4030 calories per day. Guess what happens then? I gain weight.
You're not going to get much protein from vegetables without a lot of carbs unless you eat protein powder. The two foods you cite are good examples. Quinoa is 71% carb, 14% fat, and 15% protein by calorie. Chia is 36% carbs, 53% fat and 11% protein. If you eat protein powder than it works out fine. (I'm vegan and weightlift).
Human bodies are really complicated. Doctors can always be better informed, but in the end they're still playing the statistics game, and we have pretty poor statistics on this stuff (especially with diet, which is almost always self-reported in any large study). For most people, beyond smoking, weight management, and maybe exercise and sleep, we've found basically nothing that will move your risk factors more than a handful of percentage points in either direction. You can easily negate those benefits by having a stressful few months in your job or in your marriage, and meanwhile you very well might die of cancer in the few years you bought yourself.
We're not going to "solve" the problem until we have a ton more data (maybe sensors in everyone along with the understanding of the markers to look for) so we can fit you to an optimal path based on a lot of observed variables. But even then we're just going to be playing percentages off each other, and contrary to the life-extender crowd out there, it may turn out that there is no 110-year optimal path for most of us, at least until we start reengineering the body at a more fundamental level.
Sure, I understand no one has the answers yet. The good thing about being able to understand some stats is that I can read these medical papers that doctors also read. It just surprised me to hear this coming from this specific doctor who is well respected sports doctor who also works with the Giants.
So what if your GP is not a leading expert on nutrition? He is a GP. Not a nutrionist. Would you expect on-point LAMP design recommendations from an IT worker?
Of course it's important care about your health and do what you can, but given the large error bars on our knowledge and the randomness of life in general, I think that it's worth thinking about how much time and effort should be spent on it. There is a correct amount of effort, I'm just not sure that monitoring these additional numbers is worth it; it may be adding more noise than signal to the problem of living a fulfilled, healthy, and happy life.
What's scary is that we really don't know much about it. I heard Randell Schwartz (of Perl fame) talk about how the modern carb diet is killing people. He lost 60 pounds by monitoring his carb intake.
The thing about diets is that everybody has got one that worked for them.
It seems to me that the one thing all of these different diets have in common is that they require the person to monitor what they eat. Whatever the specifics of the diet, the dieter ends up paying more attention to their meals in general and that extra digilgence translates into reduced caloric intake.
I'm not making a judgment on the nutritional value of any particular diet, just the underlying mechanism for why different diets all have somebody claiming that they work.
Anyone can lose weight simply reducing calories, but that weight loss isn't permanent or sustainable, and it may not be healthy. If you run the numbers, the Twinkie Diet guy was actually eating fewer carbs than the average American simply because of calorie restriction, and his low protein intake would almost certainly result in the loss of muscle mass.
The age old advice of "eat less, move more" ignores the body's natural mechanism for fat regulation, which is primarily the hormone insulin. The higher your blood glucose, the more insulin your body produces, the more fat your body will store, and the less reluctant it will be to release its stored energy.
It's obvious that if you're eating fewer calories, then less energy is available for fat storage -- it's simple thermodynamics -- but basic endocrinology tells us that to lose weight all we need is the negative stimulus of insulin, which is primarily achieved through reducing carbohydrate intake.
Yes, that is generally true throughout the developed world. On the other hand, heart disease death rates have been declining at all relevant ages across several decades throughout the developed world.[1]
Our understanding of what causes heart disease is very partial indeed. On the other hand, our understanding of how to treat heart disease has increased enormously in my lifetime. My mom, still alive and well at age eighty-one, was a surgical nurse who was described by my late dad as "one of a dozen people in the world who could disassemble and reassemble a heart-lung machine" early in her career. She has seen enormous progress in surgical treatment of heart conditions that used to be sure death sentences, and medical treatment for heart disease has improved greatly too. A CDC report on declining heart disease in the United States[2] suggests what more can be done.
We may not know much about it, but the doctor who invented bypass surgery and a partner did a study where they reversed everyone who changed their diets heart disease.
These were very sick heart disease patients who were told by their cardiologists they had a year to live, and Dr. Esselstyn (recommended in OPs blog post comments) and Dr. Farvalaro (the guy who invented bypass surgery) cured them all, then took photographic proof with an angioplasty.
Diet is the problem, and a proper diet can fix heart disease.
Catalyst, an excellent science program on the ABC [1], Australia's national broadcaster, has just had a two-part episode called "The Heart of the Matter", about the science (or lack of it) behind the cholesterol theory.
The researcher Dr Maryanne Demasi[2], herself a research pathologist, has spent three years gathering data, interviewing researchers, scientists and doctors on both sides of the argument, and the show has caused major ripples throughout the medical profession in Australia [3].
The two episodes are on YouTube in full [4] [5] and the transcripts are on the ABC website [6] [7].
For anyone interested in this topic, these shows are HIGHLY recommended.
Don't bother with the first episode. It is full of nonsense, including a naturopath as an "expert". The second episode regarding statins is far more evidence-based.
I'm not sure Catalyst is excellent anymore - it's certainly not as good as when it was called Quantum. That particular episode has been extremely divisive and for me personally I'm not sure what to take from it at all.
I agree it's tough trying to glean facts from the media now. Everyone seems to have a vested interest.
However, when you consider that pharmaceutical companies in the US pay doctors (not always directly for prescribing their drugs, but close enough), and also fund most of the research in the US, Australia and probably most other countries, that seems a much stronger candidate for bias than a science researcher who is trying to tell a story on a not-for-profit TV network.
There are plenty of medical "breakthroughs" throughout history that have come from people who were initially branded as heretics/crazies but who eventually were proved correct. Germ theory, antibiotics, anaesthesia etc.
Fact is, eat well and exercise is better advice than checking a bunch of numbers of unproven value for preventing heart disease.
Doctor's don't know how to prevent heart disease, but at least one knows how to reverse heart disease. His advice is a little more extensive: eat well (mostly vegetarian), exercise, meditate, have social support and don't smoke. But it does not involve, in any way, tracking your blood test results. http://en.wikipedia.org/wiki/Dean_Ornish
It’s great to see other tech people educate themselves about health and help break the stereotypes of the ramen eating, soda drinking nerd. This story reads almost like what happened to my dad last year. He complained of shortness of breath and went to see a cardiologist. He got an angioplasty done, which showed severe calcification of the arteries. The doctor advised him to have a quadruple bypass the very next day. I flew in from San Francisco to be with my dad in the hospital.
After my dad’s surgery, I decided to get more involved in his health. As someone who’s been following a Paleo lifestyle for over 4 years now, I stayed in NJ for 3 months and nursed my dad back to health. I cooked every one his meals for those 3 months. His fasting blood sugar fell from a borderline diabetic value of 121 to a more normal 92. He lost considerable visceral fat around his waist and was looking better than he has in maybe 20 years. All of his blood markers improved.
Good health is both easy and hard. The easy approach is to understand that modern industrialized food is harmful and try to emulate a diet from yesteryear, like Paleo, or your ancestral cultural diet. The flip side of the coin is to dig into science, as you have done, and understand the intriciacies of various blood markers like cholesterol, the difference between small and large particle size, Ha1bc, the various types of short chain fatty acids, figuring out that fat is not a villain, learning the dangerous of low fat foods, etc. I’ve been studying this stuff independently for 4 years, including learning enough biochemistry to get through medical research papers. Everything I have read so far points to a Paleo-type diet being optimal. As an engineer I’m taking the latter approach as I need to prove things to myself before taking it for face value. But for the layman, it’s not really that hard.
Something is wrong in this world when Tom Hanks, with access to the best doctors in the world, announces that he has type 2 diabetes, when I was able to reverse it in my dad in 3 months through diet alone.
I use DirectLabs for my blood work. Crappy site, but very happy with the turnaround time.
> Something is wrong in this world when Tom Hanks, with access to the best doctors in the world, announces that he has type 2 diabetes
I would imagine that the client relationship in medicine in similar to other industries. Failure is often not a result of the service you provide, but from the fact that the client doesn't listen to the advice they are paying for.
When I was 28 years old, found I had high blood pressure. Over next 7 years I took BP meds but also lost weight and worked out. Doctors ran tests but never found a root cause - it was just high for no assignable reason and I was told to take meds. At 34 years old, was in best shape of my life, except still taking BP meds. That year, I stopped taking the meds, but monitored BP every few months. It was borderline high but not crazy.
So this year, I turned 38, off the BP meds more than 3 years now. Then, last month while in China with my family, I had a full blown stroke. Result was lost 2cm of my left brain directly in the region that controls speech and right arm & hand motor skills. Spent 8 days in a Chinese hospital.
For about one week, I talked like a stone cold drunk and my right arm was useless. I thought I might be that way forever. Luckily, after two months, I'm basically fully functionally recovered. Bottom line is the path from a risk indicator like high blood pressure to a stroke or heart attack can be fairly short. Now, at 38 I know I must make some radical change if I'm going to live to 70, no less not be a paralyzed half brain dead invalid.
I'm certainly interested in quantified self tech now. The problem is everyone that needs a doctor to take an intense personal interest in their long term health cannot possibly find a doctor to do so, for any number of reasons. Opportunity is to empower the individual non-medial experts to easily monitor their own health and risk factors over time. Will likely be moving into product development in this space myself.
His doctor is correct. Even the lab work obtained - ApoB and CRP - was just a picture in a moment in time. You are not going to be checking these levels on a daily basis, or monthly, at least not until there's an easier way to measure things without having to get stuck with a needle all the time.
Stress is considered a risk factor, but how do you plan on measuring stress? And maybe not with respect to heart disease specifically, but today a study was released suggesting loneliness was as much a health risk as drinking and smoking 15 cigs a day - but how does one measure the extent of loneliness?
A good diet is important, and there's enough information out there to determine what a good diet is. I believe weighing yourself daily is real helpful. And regular exercise - a combination or aerobic and anaerobic. There's enough data to indicate that these interventions, combined, are effective in reducing risk.
And, on a less preventive note, truth be told, if someone in their mid 50's is complaining of SOB and has a family history heart disease, most doctors, in the US at least, are going to do more extensive testing.
"Numbers are constantly fluctuating, monitor them too frequently and you'll get stressed. This is actually a direct quote from my doctor. In my opinion it's still not a reason to ignore the numbers."
I'm firmly on the camp that one should measure more - not less - if numbers are fluctuating to reduce worry and stress. Frequent samples, but examining weekly/monthly aggregate trends is the way to go. We just need great tools for visualization.
I am pretty late to this but i wanted to raise an important point.
Dont overanalyze yourself. Since passing out about a year ago because of an infection and not drinking/eating anything that morning i have some serious anxiety issues that affect my life in a bad way. I started to monitor my heart, my blood pressure, my pulse and freaked out whenever something was slightly off. I went to numerous doctors and cardiologists, nobody could find anything of relevance, no risk factors at all. I still worry.
With time it got better but there is a reason we dont usually think about bad things to happen or us or even death, because it affects our psychology in a bad way.
I am not saying do not care for this, but also trust the doctors. The advice of eating healthy, exercising regularly and stop overanalyzing yourself is the right approach and will lower your general risk considerably. Of course go and check your blood once a year but overall there is only so much you can do.
In the end theres many,many risks in life that you cant really pre proactive about because we also dont really know the human body yet. If you get into this you will find hundreds of people suggesting different things, you will learn about all kinds of diseases you shouldnt really worry about in the back of your head because it will bring your quality of life down in the end.
I myself am not very good at what i suggest here, but i wish i was.
I have a theory that rather than heart disease being genetic, it is environmental that is passed down through family.
Lets say your family eats a certain way when you are young, and your family members die of heart disease. And you continue that pattern into adulthood, eating the same way you were brought up, and you get heart disease.
I have heart disease. if I hadn't followed the advice of Dr. Joel Fuhrman (drfuhrman.com) I'd already be dead. I don't have time to get into it here, but conventional cardiology is essentially malpractice in my opinion. if you have heart disease, or you know someone who does, please check out Dr. Fuhrman's work.
Joel Fuhrman http://www.drfuhrman.com/ is one of a number of medical doctors who promote a coordinated attack on the causes of bad health like heart disease, rather than relying on reducing one or two indicators. Neal Barnard is another such doctor http://www.nealbarnard.org/
In North America, both of these doctors have shows on PBS a couple of times a year, in the weekday evenings and they generally run as part of a series of similar shows by other medical doctors.
The two named above have done a significant amount of research into the programs that they suggest, and they publish widely and openly and tell you what research they are looking at and why they recommend certain actions.
I can really empathize with Harj. I have a paternal history of high cholesterol, my grandfather recently having bypass surgery. Using WellnessFX I discovered that I have an extremely high Apo B level, nearly twice the upper limit of the low-risk range. Thinking my first test was an anomaly, I was retested over the course of several months with consistent results of less than 3% variation.
Using this data, I've modified my diet and am seeking medical advice to reduce to a normal range. My cholesterol levels are all normal. I eat healthy (a seemingly subjective measure) and exercise regularly. My doctor said I am in perfect health at my recent annual physical.
I'm privileged to be able to afford private blood testing. Apo B data is within everyone's grasp, yet it seems so under-utilized.
That's a fascinating story. My company makes biosensors for people to track blood sugar, and our tech has applications to cardiac markers. We've always wanted to sell a kit for home testing, but the market size of willing testers doesn't justify the investment. If a story like yours led some researcher to conduct a study it could lead to a cascade that ultimately puts tools into your hands. Thanks for sharing.
Planning to manage one's own health is probably best.
I would love to be a customer of a competent company that managed body scans and the process of looking for deltas using humans assisted by software every N years.
Why?
Common medical wisdom now is that doing proactive body scans (usually just the trunk), even just MRI (so no radiation) is bad because it drives the expense and uncertainty of investigating every bump and shadow. And many of the tests will come back inconclusive. I understand that argument but it seems the way to deal with that is to focus not as much on scan #1 but scan deltas.
My anecodtal (IANAD) evidence is that in more than 5 cases of cancer in friends and families, a cancer diagnosis was delayed for many months from onset of symptoms and a few Oncologists have told me that they agree that for most of those cancers, that latency could have been improved if a baseline scan had been available of the organs/bones/nodes in question.
Not every patient would be a good candidate for such a service but the same is true for 23andme.
Surprised that there is just one mention in this entire thread of Dr. Esselstyn[1] and Dr. Dean Ornish[2] - two doctors who deserve more attention in any discussion on the topic of preventing heart disease. They have published research and studies showing that it is possible to prevent and actually reverse heart disease - even in advanced cases of artery blockage - by strict diet and lifestyle changes. President Clinton has adopted their recommended diet after his coronary bypass surgery. Highly recommend reading their research studies and books on the subject.
>The advice to "eat well and exercise" didn't seem particularly insightful
...but it actually makes a world of a difference. I think this is the most important advice and people tend to discard it as generic and useless - the truth is that it's very hard. Being active isn't a big deal, but for a week? For a full month? Full year? Full decade? Being consistent in eating well and exercising is challenging.
The doctor won't set goals for yourself, but if need a number, give yourself one and try improving on it constantly. There are tons of tools, apps, websites to help you. I've always been very active since I was a kid and still am now (~500 minutes of sports/week) and I can already see a big difference with my friends who aren't. And I'm not old at all.
If you decide to start exercising cause you have symptoms, it's probably too late.
The problem is that most people don't know what "eating well" and "exercising" really means. I will take myself as an example. When I graduated from grad. school in December of 2011, I was 270 lbs which at 5'10" is fucking fat. I had some idea that I needed to eat less. I remember going to a nutritionist and a doctor back in school. She gave me some vague ideas that were taken from the pyramid scale about how I should be having 3 full meals a day and should incorporate "some exercise" every day. It took me two years to understand that no diet actually works as well as a life style change. It took me that long to understand everything from macros, to body fat percentage and to be able to accurately predict my weekly weight based on my intake. This was all stuff that I had to learn on my own. For example, common wisdom is to exercise more, jog say 30 minutes a week. Last week, I ran 4.5 miles at 8 minutes a mile. My heart rate monitor told me I burnt 200 calories. That is one tablespoon of peanut butter. There are loads of people who spend 3 hours in the gym and then go "re-energize" with a frappucino which completely destroys the time in the gym. This shit is not easy to understand and comprehend. However, yes it is doable. I lost about 110 lbs over the past two years and have consistently kept it off but I know this will be a struggle forever to reshape myself. However, when I look back into notes I made, I realize how hard the process really is.
> (genetic,
Oh sure. I can't control genetics but I can definitely try to work hard to control what is within my hands. E.g. I am of Indian cultural heritage. Both my parents are first generation and the cuisine is incredibly high fat, high carb and low protein. This simply sets the stage for obesity very easily (yes, ironical in a country of crippling poverty and starvation). That coupled with sedentary lifestyles has shown (at least in studies) that Indian Americans are [1] more prone to heart diseases than other sectors. This means unlearning the habits of an entire childhood and learning how to eat more carefully. It is not easy and it is definitely not simply a matter of "eating more healthy" and "exercising more".
iirc High end athletes (not sure if ~500 minutes /wk counts) die younger due to accumulated byproducts of metabolism and accumulated damage/wear across the body.
I read this treat protocol from a dr. on a heart forum :
"I use EBT calcium imaging to identify who needs treatment and serial EBT calcium measurements to document adequacy of treatment. I use low dose statin or bile salt sequestrate plus ASA, high dose fish oil derived omega-3 plus frequently add nicotinic acid. In addition I screen for sub clinical insulin resistance, sleep apnea and encourage daily flossing and dental hygiene, regular mild exercise, and lots of fruit and veggies. The calcium score helps motivate compliance and the result is the near elimination of heart attacks and ischemic strokes."
http://www.theheart.org/article/1269619.do
> I've been wondering though why didn't I have this level of discussion with my doctor?
1. For starters doctors are good but not super people. The amount of time you can allocate yourself can mean you win via quantity over quality.
2. Tragedy of the commons. Tests that might help you don't necessarily help society. Tying up a machine that helps people with cancer hurts society but might have a benefit to yourself. What you want is different to what your doctor wants.
3. Doctors are not specialists. I read a quote(Unknown how truth) doctors only have 24 hours of dietary training and should not be giving out dietary advice. But given they often see people incapable of helping themselves or going to a specialist they give out advice anyway.
1. Doctors are people like any other. But they've spent years specializing in evidence based medicine. They aren't perfect. No. But they are the best we have.
2. The far bigger problem is doctors order tests that wouldn't change treatment but rather help avoid malpractice.
3. The quote -- every time I read it -- makes me laugh because it's so disingenuous. My wife had a week of dietary training in med school. You know what else she had a week of? Renal. Cardiology. etc. If you think diet and exercise are the only--or even the most effective--means of lowering morbidity for chd (which is what OP is worried about) you'd also be wrong. So I'm not really sure why OP should be looking for a dietary specialist vs a cardiologist.
First of all, if your wife graduated from med school, she should have taken the Hippocratic oath. An oath written by the guy considered the father of western medicine.
You know what he had to say about diet?
“Let food be thy medicine and medicine be thy food”
He also said something along the lines of "if you don't know diet you can't call yourself a doctor" but I can't find the exact quote.
>If you think diet and exercise are the only--or even the most effective--means of lowering morbidity for chd (which is what OP is worried about) you'd also be wrong.
Actually, you'd be wrong. Consider a clinical study carried out by the inventor of bypass surgery and another doctor, in the best heart hospital in the world considered by US News & World Report.
The study had very sick heart disease patients, who were told they had a year to live by their cardiologists, change their diet. 23 opted in for the study but only 18 chose to continue with the diet after a couple months. Those 18 patients are still alive today 20 years later, and several had an angioplasty done giving photographic proof their plaque buildup had cleared out. The ones who dropped out died shorty after.
The 18 never had a heart attack after they changed their diets, while before they did they had a combined 49 coronary events (that's ~3 heart related emergencies per person average).
Actually, you'd be wrong. Consider a clinical study carried out by the inventor of bypass surgery and another doctor, in the best heart hospital in the world considered by US News & World Report.
It would be so much easier if you could provide some names, or better - the title of the study. I'd like to read it, but can't find it easily. The inventor of the bypass surgery appears to be Michael E. DeBakey, but which of his publications should I read? Thank you.
My #3 point was not that dietary health isn't important. It IS important. It's as important as cardiology, renal, etc in the curriculum. That it's "only" one week is shouldn't be taken (and is repeatedly put forth as, as the OP did) proof of how physicians don't care/ aren't trained in diet.
What does your rant about saying the hippocratic oath have to do with anything? What does that have to do with the amount of emphasis the modern medical education puts on health through diet? Of course food should be your medicine. Natural plants are also the base for some ~70% of our drugs. It's just not the only tool in the toolbox.
Then you accidentally support my earlier point that the average joe is godawful self-treating/diagnosing based on their own research. Thanks.
> Doctors are people like any other. But they've spent years specializing in evidence based medicine.
Evidence-based medicine [1] as a norm is actually a surprisingly new thing. Assuming that because someone is a doctor they've "spent years specializing" in it is probably optimistic.
Most here are engineers with a BS/BA. Maybe a MA. And fewer still with a PhD. Not that education is everything, but it's certainly "years specializing."
Compare that to the track of a typical specialist md:
After your undergrad degree you've got.... 4 years in med school. 4-6 years in residency. Plus a 1-3 year fellowship.
Long story short, what's the credible alternative to relying on multiple expert opinions? Are educated (engineers/lawyers/etc) ordering tests based on research they really don't understand on themselves a better? By what evidence?
One thing I have recently become aware of, after my doctor ordered a test, is checking for mutations in the MTHFR gene. It's an enzyme which deals with how we process folate into its active form and is important in many pathways
Supposedly the C677T mutation increases your risk for heart disease. There is also another one, A1298C that is very common but no consensus on how it may effect health. I also matters whether you you have one or two copies of the mutations.
Some recommend supplementing with methylated B vitamins to offset the any negative health effects, but I'm still soaking this in and am not sure what the consensus is it yet.
I worked for WellnessFX (mentioned in the article) in the past and definitely recommend their service. The stuff they test for is not a part of standard (e.g yearly physical) blood work and you'd have to convince your doctor to give you the tests (intimidating, expensive). Granted, this is because the larger medical establishment either doesn't think they're necessary, or has yet to come to a consensus on their interpretation.
Personally, given the recent wave of news debunking low-fat/high-carb diets, I'm inclined to take the health research from the past couple of decades with a grain of salt.
It seems to me, as a curious non-medic, that at the root of heart disease is a state of persistent arousal, which is similar to stress -- high blood pressure, high blood sugars and fats, tachycardia, low immune, high inflammation, poor digestion, etc. All arguably useful if you are hunting prey or raiding the next village. But bad for the body in the long run. So I think we ought to ask why in this day and age do we seem to find this biological state desirable -- for example, does it paradoxically enable us, while still alive, to be more productive?
Interesting writeup - I've been thinking a lot about this recently, as a member of my family is dealing with an ongoing illness which is poorly understood.
I would love for them to be able to monitor their own vital signs more closely (via wearable tech), but even that when done in isolation is not necessarily going to help - for me the real breakthrough will come when we aggregate this data. Imagine being able to use machine learning to detect patterns across groups of people that can help pinpoint specific triggers for disease and illness.
For those interested in getting a much more comprehensive look at their blood, along with a consultation from a doctor to help you better understand the connections, check out http://www.wellnessfx.com/
(I haven't tried it out myself yet, but I'm planning to next year - I'm in no way affiliated with them, but definitely seems like a great idea)
> [3] I looked into how I'd get these tests ordered myself and found these options: [...] Directlabs: A dated looking website but offering the option of a la carte tests. Total cost for these three tests: $205
I'll vouch for directlabs. I was very happy with their "Comprehensive Wellness Profile". Their website looks slightly sketchy, but their service is fast and cheap.
http://www.bumrungrad.com/ is the place I use. It's a bit more than $200 for MR, etc., but I'm doing the exec screening w/ stress test and ultrasound (http://www.bumrungrad.com/en/health-check-up-bangkok-thailan...) and x-ray, and may do MR and would potentially get a CT (obviously avoid CT if you don't need it due to the radiation dose, but with modern equipment I'm personally not super worried).
I got my LASIK done about 8y ago at TRSC (www.lasikthai.com) which means free checkups and touchups for life, too, also down the street. Eye exams are one case where I usually use a hotel car vs. a taxi to get around, as dealing with obnoxious taxi drivers while sort of blind sucks.
My feeling is that the state of scientific knowledge is pretty weak on how to prevent a heart attack that's still 20 years away. Doctors should not overstate what is known scientifically, otherwise they are probably telling you things that are not true.
Tim Ferris has an excellent write up on 4 hour body. Part of it is to do extensive bloodwork & other tests that go far beyond what most doctors do - with them you can get a clearer picture. Talking to doctor with those in hand might give a clearer picture to you and your doctor.
Not sure if those are available in India, but my cousin did follow through those tests(in estonia) and has lost 50lbs - now healthier than ever. Has something to do with kinds of blood indicated what kind of diet you suppose to be on, vegeterian, paleo or whatever.
my 2c.
Doctors are kind of the same way. They see patients who have problems and need them fixed. If you walk into a doctor's office and say your family has a history of heart disease and you're concerned, they'll run a standard diagnostic to see if there is a problem. If there isn't, they'll give you generic advice. Outside of that, they are not really likely to have much insight into how to prevent heart disease in your specific case. Maybe you'll get lucky and the doctor will have recently read a relevant paper.
This seems to me like a problem that you're better off having answered by a medical researcher rather than a physician in the trenches. Researchers are the ones who are taking the long view on outcomes in patients. Keeping with the same analogy, you're probably better off talking to a mechanical engineer at a car company about maximizing the life of your currently healthy transmission.
Also, I generally see this as a problem that will be best addressed by machine learning researchers collaborating with medical researchers. Then again, I'm an ML PhD student working on health applications, so I'm biased. :)