"Corpulence is not only a disease itself, but the harbinger of others," wrote Hippocrates, the father of medicine and famous author of oaths.  I really can’t imagine that obesity was a preeminent malady in Greece of 400 BC—those fortunate enough to be spared the Spartan swords spent their lives scrambling to come up with enough calories to sustain them from day to day.  Still, there must have been a few portly people around for Hippocrates to examine and they must have lived long enough to develop the typical obesity-related health problems we see today, most notably diabetes, sleep apnea, heart disease and cancer.

Up until a century ago obesity was really only a phenomenon of the wealthy upper class, those who could afford a rich diet and avoid manual labor.  The painter Peter Paul Rubens gained fame by illustrating overfed and well-paying patrons in all their fleshy glory, thereby earning his own adjective: “Rubenesque.”

Obesity on the general stage didn’t make its entrance until the industrial age allowed people to spend less time in hard labor and in search of sustenance and more time in leisurely pursuits.  We invented autos to solve the need for walking and remote controls to keep us from climbing out of our Lay-Z-Boys.  Agrarian ingenuity, particularly in the United States, has managed to secure a practically limitless supply of energy-rich, nutritious food.

Then, of course, we took our bounty one step further: we deep-fried it and served it with blue cheese and mayo with a giant order of curly fries and a 64 oz Coke.

The New Yorker magazine recently reviewed several new books on obesity and thereby provided some frightening figures (pun only somewhat intended). 

• The weight of the average American rose steadily, but only slightly, for decades up until the 1980s.  In the last 30 years there’s been a rise in obesity by almost 25% per year.
• Men are now on average seventeen pounds heavier than they were in the late seventies, and for women that figure is higher: nineteen pounds.
• The proportion of overweight children has more than doubled, while the proportion of overweight adolescents has more than tripled.
• Presently, 40% of young women and 25% of young men are too obese to enter the US military, based on current standards.
• It has been estimated that Americans’ extra bulk costs the airlines a quarter of a billion dollars’ worth of jet fuel annually.
• Over the last ten years Americans have collectively gained more than a billion pounds.

There is no easy societal fix for this problem, only an individual one.  Each person has to take responsibility for their own health and improve exercise and eating habits. It has to be done in baby steps rather than loping strides. It’s one more apple and one less funnel cake; stepping outside for a walk instead of spending another evening on the couch; choosing the grilled chicken sandwich with no mayo instead of the McBlubber burger.

Patients aren’t the only ones who wrangle with this.  The New York Times published a short article last week written by an overweight pediatric doctor who not only struggles with her own obesity but also with the perception that she’s being ingenuous when she lectures others on weight loss.

“How on earth, I was thinking, am I supposed to give sound nutritional advice when all they have to do is look at me to see that I don’t follow it very well myself?  How am I supposed to help stem the so-called epidemic of childhood obesity when not a week goes by that I don’t break my own resolutions? What price the not-skinny doctor?”

We live in a society composed of the dangerous mix of bounteous calorie-rich food and technology that has effectively created a cure for exercise. These days, for most people corpulence, along with its associated ailments, is avoidable only with real effort and determination. But, take it from Hippocrates, it’s worth it.

Hippocrates would have been proud of our 6 BetterU participants (the ancient Greeks would have also been prolific bloggers, I’m sure).  Log on to the BetterU website to follow our 6 local challengers as they start the first weeks of their 12-week journey to gain fitness and avoid corpulence. Meanwhile, you can encourage the women in your life to take another look at their own cardiovascular health. 

I was recently invited to participate in what I think is a rather exceptional program sponsored by the American Heart Association, Alegent Health, and WOWT.  BetterU is a program designed to help women achieve their goals of healthier hearts through medical screening, better fitness, tighter diets, education, and positive feedback.  The ultimate goal is to cut the risk of heart disease and stroke in women and to highlight these diseases in a population where heart problems are often neglected.

The Better U program has selected 6 young ladies ("challengers" as they call them) who will participate in the 12-week program and blog on their personal efforts.  The profiles of each of these individuals are posted on the site.  Last weekend they met with a panel of diet and fitness experts to evaluate their baseline health and help them design their best fitness strategy.

Each of our subjects has a unique set of health and lifestyle challenges but they all seem to share the common trait of eager motivation and I look forward to tracking their progress.  For those women out their who'd like to follow our participants' inspiration and launch your own health challenge feel free to enroll yourself into the same 12-week program at http://www.goredforwomen.org/BetterU/program_overview.aspx.

Good luck to Pat, Laurie, Lynette, Paige, Jennie, and Colleen. We'll be following you closely.

In 1982 the National Heart, Lung and Blood Institute (NHLBI) launched the Cardiac Arrhythmia Suppression Trial (CAST) which was completed in 1986 and published in the New England Journal of Medicine in 1989.  I learned about it the year it came out from my medical school professors since it caused quite a stir in the cardiology community.  While I don’t think medical students hear about it anymore (it is 20 years out of date, after all) I think they could still glean a valuable lesson from it.

Let’s go back in time.  If you had a heart attack in 1982 there really wasn’t much that could be done.  Angioplasty, developed in 1977, hadn’t made its way to mainstream hospitals until the mid-80s, and streptokinase, the first thrombolytic, wasn’t in common use until the GISSI trial was published in 1986.  Mostly, you would come into the hospital and receive morphine and nitroglycerin until the affected heart tissue expired and the pain subsided.  Long ago doctors noticed that people who exhibited ventricular electrical irritability in the form of frequent premature ventricular complexes (PVCs) and ventricular tachycardia were at much higher risk of dying from ventricular fibrillation (VF) in the early period after a heart attack.

Several rhythm control drugs were available at that time and appeared to do a good job of decreasing the frequency of PVCs.  It became common practice to empirically start patients on medications such as lidocaine in an effort to decrease the risk of death from ventricular arrhythmia. 

It was during that time that several other antiarrhythmic drugs became available.  Encainide, flecainide, and moricizine were considerably more effective than lidocaine at extinguishing PVCs and became popular among cardiologists.  If lidocaine is good—so the thinking went—these others must be better.

So the logic went like this:

1. More PVCs equals more death from VF
2. Lidocaine decreases the rate of PVCs
3. Ergo, using medications even better than lidocaine will prevent death from VF

Here’s where the lesson comes in.  In medicine we are taught to implement a hypothesized therapy into general use only after it has been rigorously validated.  This last part was bypassed, as lidocaine, encainide, flecainide and moricizine were all used in thousands of patients before any significant research was done to validate the line of logic.

Enter the CAST trial.  When the NHLBI proposed the design of this study (prospective, placebo controlled) some prominent members of the cardiology community were aghast at the possibility of withholding an established therapy from the patients who were randomized to the placebo arm.  They claimed that it was medical malpractice to not give antiarrhythmics to patients with heart attacks and frequent PVCs.

Skip forward to 1989.  The results of the CAST trial settled the debate and retired the routine use of antiarrhythmics in the setting of heart attacks.  It turns out that the empiric use of these medications actually led to a higher rate of death among these patients than the placebo pills.  Apparently this class of medications actually stimulates a more lethal type of ventricular arrhythmia in patients with recently-injured heart muscle.

In the ensuing years encainide and moricizine were pulled from the market, and flecainide is now used only cautiously in younger patients with atrial fibrillation.  We no longer attempt to suppress asymptomatic ventricular activity in people with recent heart attacks and instead focus on restoring blood flow.

The lesson can’t be forgotten.  Even if a course of therapy seems logical we can’t deploy it into general use until the hypothesis is thoroughly tested.  Assumptions and anecdotal evidence are not enough.

If you were to spend the next twenty years smoking two packs of cigarettes a day you would be entering into a habit that 45 million other Americans (roughly 20% of the adult population) engage in.  During the course of the next two decades you would spend somewhere around $55,000 (based on the average price of cigarettes today and not accounting for inflation or rise in taxes) and have nothing more to show for it than yellow teeth, a smoker’s cough, and a dramatically increased risk of stroke, heart attack, cancer, and emphysema.  The 55 grand that you will have spent represents only the direct, out-of-pocket cost, and doesn’t take into account the indirect financial burden your habit will have on the healthcare system.  You will be paying higher premiums to your insurance company, and they would in turn be paying higher bills to your doctors, hospitals and pharmacies.  It costs a lot of money to treat chronic heart and lung disease.

Of course, you could prevent all this by not taking up the habit at all.  If you already smoke, you could save yourself a lot of money and misery by quitting today.  It would take determination, fortitude, and persistence.  Given the high financial toll affixed to a lifetime of cigarette use you’d think that your insurance company would jump at the chance to nip the smoking habit in the bud with a therapy that costs only a few hundred dollars.      

Chantix (varenicline) is a relatively new medication (available since August 2006) that has done more for smoking cessation that any previously developed drug.  While there’s no such thing as a magic bullet to help people kick the habit, Chantix is about as close as we’ve ever had.  In the largest study of tobacco cessation, the use of Chantix increased the participants’ chance of remaining smoke-free by three-fold when compared to other conventional methods.

The drug isn’t cheap, though.  A month’s worth of therapy runs about $120 and most patients are encouraged to stay on the drug for 90 days.  Still, $360 seems like a bargain if you compare it to the sums of money I described above.  You’d think insurance companies would fall over themselves trying to provide this for their patients, wouldn’t you?  Think again.

My experience is that the insurance providers here in Omaha almost universally deny coverage for Chantix and require that patients pay out of pocket if they want to fill the prescription.  This sort of shortsightedness bothered me for a while, but after I put some thought to it I’ve come to the conclusion that I’m glad insurance companies don’t cover it and I hope they never do.

Right now most smokers I speak to have heard of Chantix and are under the impression that it is effective.  There is a certain amount of spontaneous word-of-mouth advertising among smokers that leads them to assume a better efficacy than is perhaps realistic. As I offer them a prescription for the medication I find that each patient reacts in one of two fairly predictable ways. 

1. “Insurance doesn’t cover it?  I can’t afford $120 a month for a pill.  Forget it.”
   
   
2. “Insurance doesn’t cover it?  No problem.  I’m already spending $120 a month on cigarettes anyway, and if I can quit I’ll save all kinds of money down the road.  Sure I’ll take the prescription.”

My belief is that the requirement for out-of-pocket payment screens out those patients who are not really serious about quitting smoking, leaving only those who will make an honest effort.  This biases the population who receives the drug and selects for people who are more likely to be successful at giving up tobacco.  In turn, the “word on the street” is that the drug is highly effective with few failures.

I’d like to keep it this way.  I’d like people to continue to believe that Chantix is going to work for them if they are serious enough about quitting that they are willing to part with their own cash.  I don’t want the public perception of Chantix watered down by a lot of treatment failures among patients who are ambivalent about quitting, but who take the drug because it is free to them.

A couple of other issues about Chantix to keep in mind:

1. On July 2 the New York Times reported that experts at the FDA are raising concerns about Chantix.  Federal drug regulators warned that patients taking Chantix “should be watched closely for signs of serious mental illness, as reports mount of suicides among the drugs’ users.”  I don’t really know what to make of this but I plan to continue to offer Chantix to willing patients.  I’ll probably ask patients with a history of depression to clear this therapy with their primary doctors prior to initiation.
   
   
2. A moderate number of patients on Chantix report gastrointestinal side effects.  Most of the symptoms are tolerable and worth the effort if the patient can stick with the medication.  Here’s a good resource to read up on the use of Chantix and its potential side effects.

On an unrelated note, I’d like to make you aware of a service our clever web experts offer with our cardiology blog.  Click here and you’ll be able to sign up to have this blog sent to you via email whenever a new article is posted.  As always, I encourage you to submit comments and questions about any post you find interesting (if you find nothing I say interesting you can comment on that, too).

“When I go to the hospital I don’t want to see a nurse practitioner.  I want to see a doctor!”

I heard this a few weeks ago from one of my neighbors.  He was complaining about a recent visit to the ER at an area hospital.  As far as I can tell he survived the encounter with all but his civility intact.

My group employs 7 physician assistants (PA) and nurse practitioners (NP).  To reward them for being faithful readers of my blog (or maybe to punish them for being frequent critics) I’ve decided to devote this segment to them.

Collectively, these health-care professionals are known by the terms “mid-level providers” (MLP) or physician extenders.  The concept of an MLP really began to blossom in the 1960s when the demand for rural health care outstripped the supply of medical doctors.  These days this profession is seen as a good one—well paid, highly respected, in huge demand—so good, in fact, that in 2006 Money magazine ranked physician assistants as having the 5th best job in the country (my guess is they would rank at least a notch or two higher with the economic collapse of this last year, since the number 3 and 4 spots were occupied by financial analysts and human resource directors).

What PAs and NPs are allowed to do really depends on the state laws that govern the independent activity of these health-care providers.  Nebraska is a primarily rural and often underserved environment and the state provides wide latitude in the types of settings where MLPs can operate.  Many MLPs in the primary care arena see patients independently with only loose oversight from a medical doctor.  A number of the primary care groups we interact with have such an arrangement, where the PA or NP is really the only face the patient ever sees and provides all the routine care.

In my practice the MLPs serve a somewhat different role.  Their main purpose with us is to make us more thorough and efficient.  In both the hospital and clinic the MLP collects information, examines and interacts with the patient, creates an opinion of the patient’s medical condition, and devises and implements a treatment approach.  Since our MLPs are all very experienced and competent, each of them is perfectly capable of executing every step of this process without the input of the doctor, but they rarely do.  In nearly all cases my physician colleagues and I have a direct hand in the process of patient care, even if it is to simply confirm what the MLP has already deduced.

So, do you get inferior care when you are seen by an MLP alone?  I used to think about this type of question when I was in training.  I spent part of my residency at a private hospital where many of the more affluent members of the community sought care.  It wasn’t uncommon for some of them to begin their hospitalization with the demand that only attending physicians have access to their cases.  I remember thinking how wrong their perceptions of quality care were.  Sure, you may have to put up with some additional poking and prodding if you allow yourself to be admitted to the “teaching service” but look what you get in return.  Throughout the course of a single day you and your chart will be examined by a medical student (or two), an intern, a resident, perhaps a fellow, and then finally by the attending physician.  With that type of scrutiny I can guarantee there will be no lab anomaly unaccounted for and no possible diagnosis unimagined.  If you limit yourself to your solitary attending physician you’ll be lucky to see him for 2 minutes a day.

Now I’m years out of training and I still stand by the belief that a patient should never turn down the opportunity to be seen by trainees.  I feel the same way about MLPs, too.  Several studies have clearly shown that care by MLPs is not only as good as care by physicians, but that MLPs spend more time with patients, dispense more information, provide more preventive care and receive higher patient satisfaction scores—all this while saving health care dollars.  In my group our MLPs also serve as an automatic second opinion—a second set of eyes on your case.  For better or worse, our MLPs don’t seem to have any compunction about calling into question any decision I make about which they have concerns.  Our debates and disagreements result in more reasoned decisions on behalf of our patients.

So, feel lucky if you get to see a nurse practitioner or physician assistant.  They provide great care and, according to Money magazine, they love their jobs.  And if they don’t, I heard there are some openings in financial consulting and human resources.