How to stem the incipient epidemic of hypertension

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On November 13, 2017, an epidemic of hypertension broke out and could rapidly affect tens of millions of Americans.  The epicenter of the outbreak was traced back to the halls of the Anaheim, CA, convention center where the annual meeting of the American Heart Association was taking place.

The pathogen was released in a special 488-page document labeled “Hypertension Guidelines.”  The document’s suspicious content was apparently noted by meeting personnel, but initial attempts to contain it with an embargo failed and the virus was leaked to the press.  Within minutes, the entire healthcare ecosystem was contaminated.

At this point, strong measures are necessary to stem the epidemic.  Everyone is advised not to click on any document or any link connected to this virus.  Instead, we are offering the following code that will serve both as a decoy and as an antidote for the virulent trojan horse.

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You eat as you are

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Here’s the typical story we come across every day:

Jack was overweight and had a terrible cardio-metabolic profile.  Jack changed his diet: he eliminated X, Y, Z and added more A, B, and C.  He’s now lost 30 pounds and he feels fantastic.  His numbers are also perfect: his HDL is through the roof, his LDL is undetectable, and his A1c is smack in the normal range.

Todd was overweight and had a terrible metabolic profile.  Todd changed his diet but he did not eliminate X, Y, or Z.  In fact, he did the opposite.  He increased his intake of X, Y, and Z but eliminated A, B, and C.  He’s now lost 30 pounds and he feels fantastic.  His numbers are also perfect: his HDL is through the roof, his LDL is undetectable, and his A1c is smack in the normal range. 

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I refuse to tell you what to eat

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Note: I first published this on the website of Athletic Heart SF, my cardiology practice.

A recent tweet from JAMA, the journal of the American Medical Association, urged me and other doctors to “include nutrition counseling into the flow of [our] daily practice.”

Along with the tweet came a link to an article that outlines “relatively small” dietary changes, based on the latest Dietary Guidelines for Americans, that can “significantly improve health.”

My response to the tweet was swift and knee-jerk.  I will not do it.  I simply will not.  I refuse to follow dietary guidelines or recommend them to my patients.

“What are you saying?!” “Are you the kind of self-interested doctor who only treats disease and cares nothing about prevention?!”  I imagine my outraged critics erupting in a chorus of disapproval.

Is my reaction unwarranted?  After all, the recommendations themselves seem sensible enough:  Eat fast food less often; drink fewer sugary sodas; consume more fruits and vegetables.  What’s not to like?

Unhealthy guidelines

I don’t know.  Perhaps it’s dietary guideline fatigue.

For more than 40 years, the nutrition experts have instructed us with guideline after guideline, food pyramid after food pyramid.  But what have they got to show for?  The obesity epidemic followed the introduction of dietary recommendations, and some doctors even blame those recommendations for causing the epidemic!

The blame may be far-fetched, but there’s something un-natural and perhaps even unhealthy about dietary guidelines.

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Health insurance is not insurance

A message for conservatives

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Is health insurance a plan to help healthy people mitigate against an unexpected illness, or an income subsidy to help the sick pay for medical care?

Conservatives ought to have a clear answer to that question.  Congressman Morris Brooks from Alabama did not and found himself on the receiving end of liberal ridicule.

By suggesting that those who take better care of themselves should pay lower health insurance premiums, Brooks implied that health insurance is indeed a type of insurance arrangement.  After all, the risk adjustment of premiums is a practice proper to all other kinds of insurance services: A prudent driver pays less for auto insurance than one with a pre-existing driving record.  A home owner pays more for home insurance if the property is on muddy terrain rather than on sturdy ground.  A smoker pays more for life insurance than a non-smoker, as does anyone whose risk of dying prematurely is high, even if that predisposition is inherited genetically.

Brooks’ conception of health insurance, however, intuitive as it may be, is wrong.

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Good health care news from America

My dispatch to Switzerland

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I was kindly asked to provide an article for Courrier du Medecin Vaudois, the French language journal of the medical society of the canton of Vaud.  The article was published as part of an issue on the theme of ‘America First against Obamacare.’ Below is an English version of the piece.

Health care in the United States: The surprising good news

On the surface, the news from America about health care seems rather grim: cost and dissatisfaction keep rising, reforms are stalling, and, for some, even life expectancy may be declining.  If that wasn’t bad enough, President Trump issued a tweet on March 25 predicting that “Obamacare will explode.”

For a small but growing number of doctors and patients, however, the future is surprisingly hopeful. 

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Does Bergen, Norway, hold the key to the mystery of hypertension?

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At the beginning of my new book, Socrates engages Geoffrey Rose to discuss one of the most fascinating conceptual questions regarding hypertension.

The question is the following:  Compared to normal subjects, do hypertensive patients constitute a distinct population of patients?  In other words, if we go out and measure the resting blood pressure of a large swath of the population and plot the numbers as a distribution curve, do we get two separate bell-shaped curves or just one?

 

A “2-peak” distribution of systolic BP

The answer to that question was the subject of an intense debate that began in the mid 1950s and lasted a couple of decades until it died down in the 1970s without any settled conclusion.  Yet, an answer to that question is of critical importance not just for our understanding of hypertension, but for medical science in general and, by implication, for the direction of our healthcare system.

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A health insurance CEO daydreams

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Jim was at his desk, looking weary.

The last few weeks had been brutal.  Despite working twelve-hour days, he felt that he had little to show for.  His annual board meeting was to take place the next day, and he expected it to be tense.

With a replacement bill for the ACA about to be voted on, and with Trump in the White House, the situation seemed particularly precarious.  The board members had asked him to present a contingency plan, in case things in DC didn’t go well.

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Should we blame technology for increased healthcare spending?

Healthcare economists mistake cause and effect

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Should we blame technology for the growth in healthcare spending?  Austin Frakt, a healthcare economist who writes for the New York Times, thinks so.  Citing several studies conducted over the last several years, he claims that technology could account for up to two-thirds of per capita healthcare spending growth.

In this piece, Frakt contrasts the contribution of technology to that of the ageing of the population.  Frakt notes that age per se is a poor marker of costs associated with healthcare utilization.  What’s important is the amount of money spent near death.  If you’re 80 years old and healthy, your usage of healthcare services won’t be much more than that of a 40-year-old person.

So far, so good.  But should we accept the proposition that technology is the culprit for healthcare spending growth?

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The body language of assisted suicide

What the verbal request fails to reveal

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Laws that allow assisted suicide restrict the provision of “aid-in-dying” drugs to patients whose mental status is not impaired and who are capable of sound judgment.

Medscape recently featured a video interview of Timothy Quill, the palliative care specialist and long-term assisted suicide activist.  He is interviewed by the ethicist Arthur Caplan, and the two discuss the psychological evaluation of terminally ill patients who request physician-assisted suicide (PAS).

Several points made by Quill caught my attention.

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Evidence that women are better cooks than men

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I must admit that my initial reaction to the now famous study by Ashish Jha and colleagues—showing that female internists achieve slightly better 30-day inpatient mortality rates than male internists—was one of annoyance.  “Here we go again,” I thought.  “Data mining at the service of political correctness.”  And I was pleased to read David Shaywitz reply to the study with a piece in Forbes aptly titled “When Science Confirms Your Cherished Beliefs—Worry.”

That said, I must give credit to the study authors for generating a lot of interesting discussion and for stimulating Saurabh Jha to write his magnificent commentary “Homme Fatale.”

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