The Physical

“I don’t have time for this. I have other patients to see.” Said my doctor, clearly indicating that I had used up all my allocated time for my yearly physical – or had finally pushed enough of his buttons. One or the other. It was awfully late and I thought I was his last patient. Perhaps it was true that he had other patients to see, or maybe it would have been more truthful for him to say: “I’ve had enough of arguing with you. I’m hungry and tired and want to go home and see my wife and kids.”

Either way I wasn’t offended. I am an exasperating patient. I am exasperating human in general, always questioning the obvious, asking questions that generate cow-stares or mild shock from those within earshot, or saying what I believe to be the unvarnished truth when it might be more prudent to just shut the fuck up.

In this particular instance of exasperating another human being, it was because my doctor, assessing my spectacular weight gain of 40 pounds since my last visit and a crappy total cholesterol count in the 260s, wanted to put me on statins – cholesterol-lowering drugs.

He showed me a worksheet from the American Heart Association that, when my crappy blood work numbers were plugged in, said I had a 14% chance of a heart attack in the next 5 years. He had done his homework probably because he knew I was a hard sell. We had the ‘statin talk’ last year when I was about 207 pounds and my total cholesterol was only a little elevated. I told him ‘no’ then.

And 40 pounds heavier and with really shitty blood work – the worst ever, I told him ‘no’ again.

I told him: “I have to be honest with you: I’m not a big fan of statins. They have not been shown to reduce all-cause mortality in patients like me and they also have a curious side effect, little discussed, of increasing the risk of violent death and suicide.”

My doc is a chill guy. I like him, though we don’t agree on a lot of things. I’ve mentioned this to people and they say: “Why don’t you change doctors?”

“Why? I’m not looking for somebody to always agree with me.” He’s smart and has a good 15 years of experience as a clinician. I also think he cares. He took the time to prep for me coming in by running that American Heart Association risk assessment. I think that counts as ‘going the extra mile’. He genuinely thought that he had the evidence to convince me – a seemingly rational and  medically knowledgeable layperson – to comply with his recommendation.

And I exasperated him by still saying ‘no’.

So I suppose I like him because, with nearly every relationship I have, there is a certain aspect to it where the other person has to put up with me.

People in their professional roles sometime turn into caricatures – and I suppose doctors are probably more guilty of this than most professions. In a line of business where on any given day your job might be to tell a seemingly young and healthy parent who came in with what they thought to be some minor ill that they need to ‘get their affairs in order’ because they are going to die soon, I can’t judge them harshly for perhaps putting up a wall of sorts between their patients and themselves.

But I am fascinated with these walls we put up as part of our daily interactions – and I love to break through them. Being exasperating frequently causes people’s walls to unexpectedly crumble – and what’s behind them is usually interesting.

So when I mentioned the statin research showing no benefit in all-cause mortality for patients without active cardiac vascular disease – and the crack about the increased risk of suicide and violent death, my doc’s usual chill turned less chill. He seemed slightly taken aback by the all-cause mortality, violent death and suicide bit and said with reserved force: “I challenge you to produce the evidence on these.”

I could easily find these mentioned in respected journals like the Oxford University Press, Pubmed, and the Lancet sitting in my car on my smart phone before leaving the parking lot of his office. I’ll be printing out whatever isn’t paywalled before my next visit.

Here’s one link: http://www.thennt.com/nnt/statins-for-heart-disease-prevention-without-prior-heart-disease/

It says – and backs it up with a boatload of legitimate citations – that after 5 years of statin use in patients without known cardiac vascular disease:

  • None were helped (life saved)
  • 1 in 104 were helped (preventing heart attack)
  • 1 in 154 were helped (preventing stroke)
  • 1 in 50 were harmed (develop diabetes)
  • 1 in 10 were harmed (muscle damage)

Here’s another: http://qjmed.oxfordjournals.org/content/97/4/229 – you might have heard of Oxford, it is the world’s second oldest university, having been around since 1167. 16 Nobel prizes in medicine were awarded to alumni. It’s not a citation from some jackass with a blog and an axe to grind.

The study was small and warrants further investigation, surely, but a few people put on statins got really grumpy afterward. The link notes:

Manifestations of severe irritability included homicidal impulses, threats to others, road rage, generation of fear in family members, and damage to property.

Now – don’t get me wrong – statins have their place. In people with CVD it is a lifesaver (http://www.thennt.com/nnt/statins-for-heart-disease-prevention-with-known-heart-disease/). However, I come from a family with no predisposition toward heart disease even though my father’s side of my family ate and drank with abandon and all had potbellies and ruddy faces from all the beer they drank. A good part of my heredity ate whatever the hell they wanted and lived well past 80 – with 80 being the point where the dodginess from the family predisposition toward Alzheimer’s began to take full effect.

I don’t have known heart disease, nor do I have diabetes though my brother, sister, father, and mother all had it – with my siblings getting it way before the age I currently am. I don’t have a family history of CVD. I see nothing in my medical history nor my heredity that makes me a good candidate for statins and have to put up with the potential to develop diabetes, the potential for muscle damage, or the potential for negative psychological effects.

Before the ‘statin talk’ I had already parried with him on diet. As I sat in my underwear, an unpleasant sight except perhaps to a clinician who has trained themselves to be detached and doesn’t really give a shit as a protection mechanism from going insane, he mentioned in what in retrospect was carefully chosen language that “I was a much larger patient” than when he last saw me – and he hoped I had a plan.

“Yeah. My plan is to go on a low carb diet.” I said.

“Do you mean below 100 grams of carbs or below 50 grams?” He asked.

“Oh, I want to do a ketogenic diet. I’ve been on one on and off for a decade and I find it works quite well for me. It even seems to make me calmer.”

“What is recommended is a calorie-restricted diets with legumes, whole grains, and lean meat, along with vigorous exercise most days of the week.”

“Well, a ketogenic diet has worked for me in the past.”

His tone changed. He was going into his ‘learned clinician schtick’. It became more patronizing. “Well you know, a ketogenic diet puts your body into a mode similar to starving. You body can’t live without glucose. What is most important is that a diet be sustainable – and a low carb diet isn’t sustainable.”

OK – a decade of sustained weight loss shows it isn’t ‘sustainable’ – he’s right – I gained weight after a decade. Got it.

I did counter on the glucose thing, though: “Um…but your body can create the glucose it needs from a moderate protein diet and converts the protein into glucose through gluconeogenesis – right?”

He didn’t say anything for a bit – frankly, I don’t recall a direct response at all. Perhaps he had busied himself with the next part of the examination – the part that included the snap of a latex glove and ‘bend over’.

Given the asymmetry of the situation – he fully clothed and I in my skivvies – I wasn’t about to tell him that my lack of exercise is almost a badge of honor for me. I follow the advice of a quote I once read: ‘Whenever I get the urge to exercise, I lie down until the feeling passes.’ I have a sneaking suspicion that the relentless advocation of ‘exercise for everyone’ is not so much for the health of individuals but rather the health of the economy: every gym membership, every Thighmaster, every pair of running shoes raises the GDP – and so do the attendant sports injuries: muscle pulls and torn ligaments provide physical therapists gainful employment; injections of steroids provide income to doctors as well as relief to the patients who have exercised their way to worn out joints, and finally the people who thrive on a steady stream of former exercise enthusiasts who, instead of choosing the next pair of running shoes to buy, now have a choice between a hip replacement or a walker and constant pain.

I also feel that above a given weight, it is smart to start losing weight without the exercise (it can be done – I did it) – and with an increasingly lighter body comes more energy and the freedom of movement that can make you *want* to exercise.

And I haven’t even begun with my feelings about what constitutes ‘healthy eating’. If my differences with the standard accepted notions on exercise were a flaming match head, my differences on nutrition from most people were a nuclear bomb.

As I left I mentioned he should check out the book ‘The Big Fat Suprise‘ – a masterfully written work that clearly explains just how we ended up vilifying fat as a nutrient because of bad science, big egos, and politics. He just snorted. It was only a:

  • A New York Times bestseller
  • Named one of The Economist’s Books of the Year 2014
  • Named one of The Wall Street Journal’s Top Ten Best Nonfiction Books of 2014
  • Kirkus Reviews Best Nonfiction Books of 2014
  • Forbes’s Most Memorable Healthcare Book of 2014
  • Named a Best Food Book of 2014 by Mother Jones
  • Named one of Library Journal’s Best Books of 2014

Kinda what I expected. 

For those of you unfamiliar with my backstory, in 2003 I lost 80 pounds on a low carb diet. Unlike most people who would have reveled in their success, bought new clothes and left it at that, I needed to know why. How could I eat like I did and lose weight? I had only read the Atkins book, and learned about ketosis: a chemical transformation to your body that allows you to run your body on ketones – the product of burning fat – instead of glucose – which comes from sugars and starches and is what the vast majority of human beings run on these days. In fact, running your body on ketones is so rare that one way of measuring your ketones to track your progress – urine strips – are actually manufactured for people with severe diabetes to manage a severe side effect called ‘ketoacidosis’.

Being slightly obsessive – or maybe a tad more than ‘slight’ – I spent the next 10 years reading books, research, blogs, and articles and all aspects of diet nutrition, the history of diets and dieting, how diet has changed over the centuries, the psychology and sociology of food and eating, as well as a myriad of odd little detours into admittedly wacky material produced by people with dubious credibility as well as my own hare-brained ideas.

All that obsession spilled out into a blog on low carb which I started on a whim and then wrote and published over 500 articles over 7 years. I sort of abandoned writing on low carb and shuttered the blog at the end of 2014 for reasons not entirely clear to me. Perhaps I had grown tired of it all. Perhaps I had said all that I had to say on the subject.

Perhaps I was just paying lip-service to my low carb lifestyle and writing about it – as I gained weight – seemed disingenuous.

Perhaps I needed to regain enough weight to give a shit again.