Is Fat in Food Fun Again?

An editorial recently published in the British Journal of Sports Medicine is getting a lot of press. http://www.cnn.com/2017/04/25/health/saturated-fat-arteries-study/index.html Why? It’s throwing conventional wisdom about heart disease up in the air. The main point of the writers is this: Our focus on saturated fat (red meat, butter, full fat dairy) is misguided. We shouldn’t worry as much about the saturated fat, we should focus instead on a different set of proven strategies to reduce the impact of coronary artery disease on public health.

There are many that might raise an eyebrow that this editorial was published in the relatively obscure British Journal of Sports Medicine. It wasn’t published in prestigious journals such as the New England Journal of Medicine, the Journal of the American Medical Association, or Circulation, the journal for the American Heart Association. Keep in mind, sometimes major journals, and the people that run them, aren't ready for a shake-up.

I will say as I write this that I am not a cardiologist. However, I do try and keep up with the literature on preventive health, and in my practice I implement innovative strategies to combat the risk of heart disease in my patients. All of us, as primary care doctors, are on the front lines of keeping people out of the hospital and away from the cardiologists.

Here are my initial thoughts on the editorial:

1. The editorial writers may be cherry-picking data to prove their point. This is an important criticism, but shouldn’t completely invalidate their premise.

2. The editorialists’ key point isn't a bad one, and one we have been hearing about for a while: sugar/refined carbohydrates are really bad for us. It IS the bun, fries and sweetened beverage that are significantly contributing to worsening public health outcomes.

3. The editorialists and the critics may both be right. Think of it this way: coronary artery disease has two outcomes. A. Blockage of the heart artery that can lead to chest pain (angina) when we exercise and B. Acute clots that suddenly emerge in a heart artery that directly lead to what we call a heart attack. We need to think of them as two different issues, with potentially two different treatment approaches. This editorial may prompt this conversation.

Look, no one wants chest pain. Angina is uncomfortable and unpleasant. But a heart attack? This is different. Heart attacks kill people. So, it’s an important question as to what drives the heart attack, the widow(er) maker? Evidence seems to be pointing toward inflammation, an idea that goes back as far as  a 2005 review article in the New England Journal of Medicine, an article that has been referenced by other authors over 7000 times. High levels of inflammation inside the arteries = higher risk of death.

I believe the editorial authors' focus on inflammation is NOT unfounded. I also believe the criticism of the authors' analysis is NOT completely unfounded. Can they both be correct? I say yes, particularly if you think of coronary artery disease as these two different processes.

What are the authors’ recommendations, then?

1. Eat healthy: Consume fewer processed foods. We can't argue there (unless you're "Big Food").  The closer we are to the food that we eat, the better off we are likely to be. Here in Chicago, for example, there is a company that grows great tasting tomatoes all year around. Let’s do more of this.

2. Exercise: Can't argue there. We sit too much and don't exercise enough. We all know that. And the data suggests that all we need is a brisk walk a few times a week.

3. Manage stress: Can't argue with this, either. There is a lot of emerging data on the value of meditation/mindfulness/relaxation. It doesn't mean we can't have stress; we all have stress. It just means we need to have an active strategy to manage it.

So, my take on this editorial is that we should listen. Listen to the outliers who are finding fault with conventional wisdom. If people are still dropping dead of heart attacks while on cholesterol medication, do we have the right treatment plan? Also, let’s not underestimate the influence that Big Pharma plays in this whole conversation. In the three recommendations the authors make, we don’t see a drug, do we?

Another way of saying this is to put the challenge to you and me. You and I can’t outsource our health to the maker of a pill. We need to take accountability for what we’re putting into our mouths, how we move our bodies, and how we calm our minds. The power to control the future of our health is in our control. How will we respond?

William Harper MD is the founder of Harper Health Streeterville, a membership-based primary care practice based in Chicago.

Photo by eelnosiva/iStock / Getty Images
Photo by eelnosiva/iStock / Getty Images

Changes in the ACA Need to Put Patients First

 The call came at 430 a.m. I answered when she called the second time, as I was too late to answer the first. “Dr. Harper. I think I need to go to the hospital. I just feel so weak.” It was Bessie, a patient I have known for over 15 years. She’s been struggling for a few week, and while we are working through this struggle we are clearly not doing it fast enough.

Standing in our way is the health care system, serving as a barrier to her getting well. In our efforts to meet outcomes, lower costs, improve satisfaction (whatever that means), we’re losing sight of our mission: to truly care for each patient as the unique individual they are.

So back to Bessie: I stopped by her home the following morning, and when I looked in her eyes I saw sadness, fear, and despair. This is not the Bessie I know. She is a retired pediatric intensive care charge nurse. It takes a strong person to be a nurse in a unit caring for the sickest children. Every day these women and men go to work and look into the fearful eyes of both parents and patients. Nurses are the anchors in these units, offering counsel, hope, and strength when times are at their worst.

I have seen both this strength and grace in Bessie through a lot of challenges over our fifteen years: heart surgery, blood clots, kidney disease progressing to dialysis, diabetes, dialysis access challenges, and now cancer. Strong through it all, the warm glow from her heart and smile on her face bring us all joy when we see her. And while the compassion, gentleness, and grace were in her eyes when I arrived that morning, the strength and courage were waning. Why?

Three weeks prior she had successful surgery to remove an early stage tumor from her stomach. The cancer was completely excised, no lymph nodes were involved, and her surgical recovery has been uneventful. She said, “My surgeon is happy with me.”

Yet while in the operating room, the hospital lost her dentures leaving her toothless for the week-to-months-long process it will take for her to get new ones. Having a now-smaller stomach doesn’t help either, as Bessie needs to eat smaller portions with added frequency. She has been stuck eating softened foods and liquid supplements. Even in the best of situations, consuming food from a blender or drinking calories out of a can is frightfully unappetizing. Not surprisingly she has lost her appetite and has not been able to keep up her calorie intake.

Five days prior to her early-morning call, she called me to talk about her weight loss and resulting weakness. We recognized that as part of the surgical protocol for her operation the surgeon had put a feeding tube through the skin of her abdomen. It was meant to be temporary, to be taken out when she demonstrated no further need for it. “Perfect,” I told my team. “We can just use the J-tube to supplement her calories until she’s able to support nutrition on her own.” Well, that’s when the gears of patient-centered care ground to a halt.

“Where’s the note from the dietitian?” Apparently Medicare needs a note from a dietitian in order to process the order; my prescription wasn’t good enough. So we called her dialysis center: “Our dietitian is off and won’t be back for five days. Our social worker is off, too. [Holiday week] There’s nothing we can do.” We were also told, “Even with the dietitian note, Medicare likely won’t approve this.” Why? Medicare only pays for permanent tube feeds, not tube feeding that is temporary.

This is where the system is terribly broken. I know there are forms to fill out and checklists to complete. I understand that Medicare and health plans have coverage limitations and “screening criteria.” Yet I’m more frustrated by the attitude. Instead of, “How can we get this done?” we’re stuck with “It’s not going to work out” so you shouldn’t even try.

How could you not want to go to bat for Bessie? Here is a woman who spent her career giving so much to patients, families, and colleagues in the healthcare system. We should do all we can to return the gifts she has given? Regardless of who the patient is, though, supporting any patient through this challenge would just be the right thing to do.

“The right thing to do.” Where has that gone? We are so caught up in pre-authorizations, red tape, and non-clinical third party administrators that we have lost sight of our mission. Why are we here? What is the healthcare system for? To help those who need it.

So, after five days of frustrating red tape and obstruction, our team did the right thing. We called back the home health agency and asked how much it would cost to go outside of insurance to get her the necessary supplies for her tube feeds. Fifteen dollars per day for the pump and $12 for the Nepro tube feeds, we were told. So little. She was one step away from the emergency room when she called me. The moment she steps in the door of the emergency room the costs of the tube feeds are dwarfed.

Fortunately, my practice is membership-based, where for a fixed fee all primary care is provided. We do high-tech, leading-edge preventive screening, and involve allied health professionals such as health coaches, personal trainers, and dietitians to help patients reach their health goals. It’s not inexpensive to be a member, and Bessie is one of a couple dozen patients from my prior practice that I welcomed to remain with me, paying little to be a member.

In this model I have budgeted a certain amount for each patient for health-related tools: FitBit, Bluetooth scale, blood pressure cuff, etc. I want to make it as easy as possible for people to build their health. No excuses. So, from this bucket I pull the necessary funds to supply Bessie with her tube feeds for a couple of weeks. She is surprised, humbled, and grateful. I am humbled and grateful to have this brave and resilient woman in my life.

Her first day of tube feeds went well. Yet we have a long way to go to get her physical and emotional strength back. I am confident we will be successful. I am not as confident about the state of healthcare. What’s next? There are talks of repeal of Obamacare and changes to Medicare and Medicaid. Who knows how it will all play out? I strongly suspect that whatever happens next won’t lead to a more patient-centered system. It won’t leave patients feeling supported, cared-for, and valued. We who do put patients first will just have to do it ourselves, one patient at a time.

Do you always need a parachute?

On July 31, after 21 years at an academic institution as an internist and educator I hung my shingle and started my own solo practice, Harper Health Streeterville. Many considered this decision a bit unusual in today’s healthcare marketplace where more often we are seeing consolidation. As I reflect on why I chose to do this, it comes down to four main reasons...

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