I went to see a cardiologist recently.
If you’re the kind of person who can’t read all the way to the end without knowing, don’t worry: I’m fine.
But here’s the story.
When you walk into an urgent care facility and say that you have been have chest pain and shortness of breath all weekend, everybody who works there stops what they’re doing and looks up in alarm. “Urgent care” is pretty much the opposite of what it sounds like — they’re mostly set up for things like colds and sprained ankles; i.e., things that are basically going to get better on their own. They don’t really want you bringing your five-day-old heart attack through the door.
But the PA at the urgent care did her best, giving me a thorough examination, an EKG, and a chest X-ray. Everything looked okay (really — check out the pics after this paragraph), so she told me to be sure to visit my doctor right away. Which assumed that I had some sort of primary care doctor, but I told her not to worry, I would go back for a second visit to the guy I saw once to get some migraine medication.
My, um, primary care physician looked at the EKG and the X-ray and asked me some questions and then said it could be any number of things, probably nothing serious, but he wanted me to see a cardiologist (or, as we shall later see, “cardiologist”), and he had the front desk set up a referral. Under most insurance plans, you have to get a referral from a primary care physician to see a specialist, because obviously his half-assed guess that you probably don’t have heart disease but maybe ought to see someone just to be safe is much better than your half-assed guess of same.
At this point in the story, I want to point out that my wife had already been suggesting for a while that it might be acid reflux, which also causes chest pain and tightness of breath and, as an explanatory hypothesis, has the added benefit of being something other than vanishingly unlikely in a healthy 37-year-old man. PCP was also willing to consider reflux and recommended Prilosec. More on this later.
The first thing you see when you open the door to the cardiologist’s office is this cabinet full of dietary supplements for sale:
I didn’t realize that’s what it was, at first, because that’s such an unexpected thing to see in a doctor’s office that I think my brain just filtered it out. Instead of thinking about that, I checked in, sat down, and started flipping through a magazine.
It was early in the morning, so the TV was off. But a member of the staff soon rectified that, and after a few minutes I could no longer concentrate on my magazine over the insistent trumpeting of an ad for some kind of weight loss scheme called “Ideal Protein.” (It claims to “give your pancreas a rest.” And everybody likes rest!) I was mildly irritated by this, but I assumed that the video was some sort of freebie given out by a rep and thoughtlessly put on a loop by a staff member who wrongly assumed that any TV must be better than no TV.
But after I was called back to the exam room I began to notice that ads for “Ideal Protein” were everywhere. Of course, almost all doctors’ offices these days have those “Lower Back Inflammation? Find Out More” pamphlet-holders that always end up being sponsored by the makers of Lumbaleve, an anti-inflammatory for lower backs. But this wasn’t just that. This was… well… straight-up advertising. Weirdest of all, to my mind, was the “Certificate of Excellence” next to the check-in desk proclaiming her virtues as an Ideal Protein “Consultant.” Huh.
A nurse took my blood pressure. It was a little high (130s/80s), but after consulting with the doctor she took it again. I concentrated on relaxing (playing this Sheila Chandra song in my head), and my BP came back down to a perfectly normal 120/80. Satisfied, she left me alone with the Ideal Protein posters.
When the doctor finally came in for the exam, you may be unsurprised to learn, she seemed relatively uninterested in my symptoms, but was terrifically interested in my weight. She literally came into the room convinced I was overweight and demanded to know my “ideal weight,” and when I said I had no idea what that would mean, she clarified, “What did you weigh when you graduated high school?”
I’m not going to catalog the ways that’s a stupid, stupid standard.
Anyway, after deciding I was a big fat fatty, she turned me over to a technician for a “stress test,” aka power-walking while a guy tries to take your blood pressure. I did the stress test with no trouble, but the tech noted that while my diastolic BP held rock-steady at around 80, my systolic did rise to 170 by the end of the test. He felt this was a little high, but said cheerfully, “That’s minor. That’s not a big deal at all.”
I was then ushered into the doctor’s private office, where, after a while, she came to talk to me about my results. The good news, she told me, was that my heart was fine. The bad news? My blood pressure was too high during the stress test. Probably because (well, you’re a smart reader, I think you know where this is going) I was horribly, hideously fat. “There are two ways we can handle this,” she said. “One is that I can give you anti-hypertensive drugs. The other is very difficult, and not everybody can do it. You’ll have to lose about thirty pounds, at least twenty, and restrict your salt to less than 2,000 mg per day, stop smoking, cut back on alcohol, start an exercise program. Okay?”
So, uh… what was causing my chest pain? “I don’t know,” she said, sounding like that was the least interesting thing anyone could choose to discuss right now.
“Well,” I said, feeling my blood pressure rise for fat-unrelated reasons, “I’m not taking drugs. Come on. And to be honest, I have a hard time taking you seriously about losing weight when you sell weight-loss products out of your office.” I pointed at another small poster on her desk.
“Oh,” she said, “but that’s just one of the products we sell. You know, I was just talking to another patient about detoxifying his body using nothing but green plants….”
“Okay,” I said. “Anything else?”
“No,” she said, but she sort of looked like I had farted. I got up to leave. She followed me down the hall to the desk. “Do you want to do any kind of follow-up?” she asked.
“No,” I said. Because my mother raised me better than to say “You have to be fucking kidding.”
Was she right? Do I have high blood pressure? Do I need to stop eating salt and stop drinking the booze and most of all stop being such a huge fatwad?
I don’t know. But I’m sure as shit not taking her word for it.
This is the thing: being a doctor is probably the closest thing we have anymore to an actual sacred profession. Medical expertise vests you with perhaps the greatest personal authority one person can reasonably expect to have over another in a secular society. If anyone can explain the mysteries of being human and assuage our deepest fears — about life and death, about the validity of our personal choices, about whether our children are going to grow up okay — it’s doctors. Or at least medical scientists, on whose behalf doctors are presumably speaking to the layperson. A doctor is a kind of priest for science — he reads the arcane texts (JAMA, BMJ, Heart) and interprets them for the masses.
Any whiff of corruption that attaches itself to a doctor’s credibility, therefore, is extremely disturbing to the patient. When a person comes into a cardiologist’s office, he’s already frightened and bracing for the worst. He needs an honest diagnosis, one uninflected by either the doctor’s personal hangups (about fat, for instance) or any commercial interest in the cure.
This is why the AMA’s Code of Ethics strongly recommends that doctors minimize even the appearance of a conflict of interest:
In-office sale of health-related products by physicians presents a financial conflict of interest, risks placing undue pressure on the patient, and threatens to erode patient trust and undermine the primary obligation of physicians to serve the interests of their patients before their own….
Because of the risk of patient exploitation and the potential to demean the profession of medicine, physicians who choose to sell health-related products from their offices must take steps to minimize their financial conflicts of interest….
Physicians should not participate in exclusive distributorships of health-related products which are available only through physicians’ offices.
Maybe the cardiologist was 100% right about everything she said. But how can I trust her judgement? Why should I take her advice? The problem with conducting your practice the way she does is that you send patients scrambling back to their own meager resources in trying to separate science from bullshit.
Here, then, are the answers my meager resources have been able to uncover about my medical situation. No help from my cardiologist, sadly.
Do I Have Hypertension?
Maybe. We still have a blood pressure cuff from when Elana was recovering from eclampsia. I’ve been monitoring my BP in a kind of haphazard way since seeing the cardiologist. Systolic fluctuates between the high 110s and the 130s; diastolic between 75 and 85. That’s not great. It’s ranging between normal and what’s known as “pre-hypertensive” — actual hypertension being defined as greater than 140/90. It’s something I’m keeping an eye on.
But what about the specific claim that my 170/80 max during exercise was excessive and indicative of a hypertension problem so severe I needed to either go on medication or give up my Caligulan excesses? This looks like bullshit to me. I’ve googled and PubMeded any number of combinations of “blood pressure” and “exercise” and “stress test” and “hypertension” and “treadmill” over the past several weeks, and every source I can find that actually addresses the subject seems to think that a BP of 170/80 during moderately strenuous exercise is actually right about smack in the middle of the normal range. Reasonably non-crackpot-ish lay sources are here, here, and here. For those who would like something toothier, here’s a chart I pulled from a study in Stroke about the correlation between high BP during an exercise stress test and risk of stroke. The center line shows the mean response for a sample of “1026 men without clinical coronary heart disease, antihypertensive medication, or prior stroke at baseline.” (The X-axis is number of minutes exercising — on a bicycle rather than a treadmill, it should be noted, though I doubt that’s significant here.)
Or consider Figure 1 (page 4) in this study of BP during exercise (PDF) from the journal Hypertension. The 50th percentile BP at 50% Heart Rate Reserve in this sample of 1033 men “free from cardiovascular disease and with normal ECG results” was, in fact… 170/80. (Heart Rate Reserve is defined as Maximum Heart Rate minus Resting Heart Rate; I calculated mine to be right around 100 BPM, a number I greatly exceeded during the stress test.)
I call bullshit on this one. I’m actually apparently healthier when exercising than when sitting still.
Do I Need To Cut Salt?
I’m going to skip alcohol and tobacco, because I don’t drink or smoke. The fact that the cardiologist told me to cut alcohol without bothering to ask whether I drink, or how much, was one of the things that made me feel she wasn’t really paying much attention to me as an individual patient, though.
So, salt — ARE IT DANGEROUS????!!!!1!!??
This turns out to be a complicated question. Some things seem certain: in studies, lower salt intake is statistically associated with reduced risk of hypertension, and conversely, people with hypertension seem to eat more salt than normotensive people. (At least in Canada.) And in this admittedly very small study, patients with “resistant hypertension,” i.e., hypertension not ameliorated by up to three anti-hypertensive medications at a time, reduced their BP by an impressive 22.7/9.1 mmHg by drastically reducing salt. (If you had a BP of, say, 150/95, that would be enough to bring you down from “hypertension” to “pre-hypertension” or “high normal.”)
On the other hand, it’s possible to overstate the value of salt reduction. This 2004 meta-analysis of 28 studies found that
“In individuals with elevated blood pressure the median reduction in 24-h urinary sodium excretion was 78 mmol (4.6 g/day of salt), the mean reduction in systolic blood pressure was -4.97 mmHg (95%CI:-5.76 to -4.18), and the mean reduction in diastolic blood pressure was -2.74 mmHg (95% CI:-3.22 to -2.26).”
The authors of the study describe this finding (well, meta-finding) as “significant,” which in a statistical, population-wide sense is probably true. But note that that effect is for people who already have elevated blood pressure. For people with normal blood pressure, the effect of a similar drop in sodium reduction is only -2.03/0.99 mmHg.
What explains the difference? It turns out there is a population of people who are described as “salt-sensitive,” meaning their blood pressure rises by 10 mmHg or more after a load of sodium, while some other people are “salt-resistant,” meaning that ingesting a bunch of salt hardly moves the needle for them. Studies have found that as many as 50% of people with hypertension (73% for African-Americans), and 26% of normotensive people, are salt-sensitive. So if you have hypertension, you’re more likely to be salt-sensitive, and the Scammy Cardiologist’s advice is relatively sound — reducing salt has at least a 50/50 chance of having a positive effect on your blood pressure.
But that advice should come with some caveats. First, there are dissenters from the public health recommendations suggesting that everyone reduce sodium. In May Belgian researchers claimed to have found an inverse relationship between salt consumption and deaths from cardiovascular disease in a study of 2,856 patients followed over 7 years. They also found that sodium consumption was not correlated with new incidence of hypertension and with only a very mild rise in systolic BP (1.71 mm Hg) and no rise in diastolic at all. Based on these findings, the authors felt they could not support the common public health line that almost everyone should reduce sodium intake to below 1500 mg/day.
The primary author of the study, Jan Staessen, said in an interview with JAMA that one reason a low-sodium diet might be associated with negative outcomes is that it could trigger sodium-conserving mechanisms in the body, which, he says, are “known to have a negative influence on cardiovascular outcomes.”
It’s important not to read too much into a single study, and this study has been criticized for studying a relatively young population (average age was about 39) with a low risk of cardiovascular events to begin with. But Dr. Staessen has a point — there is certainly a level below which you’ve lowered people’s sodium levels too much, and that level could easily be higher in salt-resistant people than in salt-sensitive people.
Unfortunately, much of the practice of medicine is about playing the numbers rather than understanding the individual patient. So if a patient presents with hypertension (or pre-hypertension), a doctor will recommend many of the things Scammy Cardiologist recommended: stop smoking, cut drinking, lose weight, cut salt, get more exercise. Each of those recommendations has been shown, at a population level, to be likely to result in lowered blood pressure. So why not have the patient try them all? The problem with this, of course, is that if the patient actually does them all, you have no way of knowing which recommendation did the trick, and which ones were superfluous. And meanwhile there are, potentially, poorly-understood risks to each of these interventions for at least some patients. Moreover, lifestyle modifications are hard for most people to maintain over the long haul, and the more modifications, the harder the regimen will be to sustain.
Where does this leave us with sodium? Well, after seeing Scammy Cardiologist, I began keeping a food diary and tracking my blood pressure to see if I could find evidence of salt sensitivity in myself. Unfortunately, as I quickly realized, attempting to implement the other advice at the same time (dieting, increasing exercise) added potential confounding factors. Ideally after a doctor sees a patient with less-than-emergency-level high blood pressure for the first time, she should have that person change nothing about their routine except salt intake for a month or two, and see if that lowers blood pressure by itself. If it does, that would form a solid basis for concluding that the patient is salt-sensitive. If they’re not, then the doctor could move on to other tests, figuring out the source of this particular patient’s hypertension.
Of course, this is a time-consuming method that requires a lot of ongoing care and monitoring, which is expensive and hard to do. But it would be the approach of a scientist.
The other caveat about sodium is that salt-sensitivity doesn’t happen in a vacuum — the body’s response to salt is dependent on other factors in the body. One is insulin resistance, which we’ll talk more about in part 3 of this series, but which we should for now note is highly diet-dependent, meaning that the foods you eat can, themselves, have an effect on how salt-sensitive you are. Another may be exercise, which at least one study found can reduce salt-sensitivity.
So have I reduced my salt intake? Some days. When we cook from scratch at home, it’s often not hard to do. But sometimes we end up eating out, and sometimes I really want to eat sausage and bacon and feta cheese. All dusted with kosher salt and topped with sea-salt caramels. What can I say? I’d like to eat less salt… but you’re kind of fighting evolution there. Salt is delicious!
Ahem. Back to the science.
Should I Exercise More?
Sure! Why not? Exercise makes you feel good, and it makes your body stronger and more able to do hard work. I give Scammy Cardiologist a pass on this one. As a guy with an officially-okay ticker, I’ve embarked on a plan of running longer distances more often. Plus I’ve been skimming this hilarious blog, Fat Chicks Running, written by ladies who run half-marathons. Since I’d like to run a half-marathon myself someday, I find this girl’s wall of medals very inspiring.
Oh, but will it fix hypertension? The Mayo Clinic seems to think so, for mild cases:
Becoming more active can lower your systolic blood pressure — the top number in a blood pressure reading — by an average of 5 to 10 millimeters of mercury (mm Hg). That’s as good as some blood pressure medications.
Between you and me, that makes “some blood pressure medications” sound like bullshit. 5mm Hg? That’s a measurement error. But, to be serious, the journal Nature cautions that
Even though it is well established that moderate exercise lowers blood pressure in most hypertensives, about a quarter do not respond to exercise training. In particular, patients with ‘nondipping’ hypertension (ie, hypertensive patients with <10% reduction in average nighttime blood pressure compared to average daytime blood pressure — thought to reflect a greater blood pressure 'load') have been suggested to be nonresponders to exercise training.
But they also note that
The beneficial effect of regular exercise in hypertension is not limited to reduction of blood pressure only. It has also been shown to reduce left ventricular hypertrophy, improve exercise capacity and quality of life. When combined with dietary alterations, regular exercise causes reduction of oxidative stress, increases nitric oxide availability and improves the overall metabolic profile.
So, fuck it. Exercise! Final question:
Am I A Big Fat Fatty Who Needs To Lose Weight Right Away?
I’m 75″ and about 220 lbs, and if you saw me “overweight” would not be the word that leapt to mind. “Overweight” is a medical category based on BMI, or “body mass index,” which is notoriously difficult to correlate with actual health, or even build, on an individual basis. I could cite you some studies, but instead, here is a hilarious Flickr user group called “Illustrated BMI Categories”. It’s full of pictures of people whose appearance is often comically out-of-sync with their supposed BMI category. E.g.,
There’s also been substantial research in recent years suggesting that, for example, merely being in the “overweight” category results in no higher rate of death than being “normal”, while being “underweight” does carry a higher risk of death. Or that when economic and behavioral risk factors are controlled for,
Compared to those in the “normal” weight category, neither overweight nor obesity was significantly associated with the risk of mortality. Among adults age 55 and older at baseline, the risk of mortality was actually reduced for those were overweight (hazard rate ratio = 0.83) and those who were obese (hazard rate ratio = 0.68), controlling for other health risk behaviors and health status.
That’s right old people — pack on the pounds! It’s good for you!
(The same study also found that “Having a low level of physical activity was a significant risk factor for mortality (hazard rate ratio = 1.58).” Tick up another notch for exercise.)
But we keep getting off track — what about hypertension? Well, other studies, including this one from 1999, seem to find that exercise and diet modification work to reduce blood pressure independently of weight loss. And liposuction, for example, does not appear to reduce blood pressure in the absence of lifestyle changes.
This may be because, even to the extent that fat is associated with disease, the arrow of causality may point in the other direction — i.e., disease causes people to gain weight. Paul Campos of the University of Colorado writes that when public health officials claim that fat causes disease, they’re treading uncertain ground:
With the exception of osteoarthritis, where increased body mass contributes to wear on joints, and a few cancers where oestrogen originating in adipose tissue may contribute, causal links between body fat and disease remain hypothetical. It is quite possible, and even likely, that higher than average body fat is merely an expression of underlying metabolic processes that themselves may be the sources of the pathologies in question. For example, much evidence suggests that insulin resistance is a product of an underlying metabolic syndrome that also predisposes persons to higher adiposity because compensatory insulin secretion promotes fat storage. Modern molecular genetics confirms the thrifty gene hypothesis that mutations favouring fat storage and survival of famine also confer risk of diabetes. Thus, obesity may be an early symptom of diabetes rather than its underlying cause.
I hope to get into this a little more in part 3 of “Science Gone Wrong,” but for now let’s say this — weight loss is not necessarily a good in itself, and if dieting causes “weight cycling” or “yo-yoing,” it may actually do substantially more harm than just remaining a little tubby. (More reading on the subject here.)
– My blood pressure is probably somewhat too high at rest, but there’s really nothing all that alarming about my blood pressure during exercise.
– There’s a good chance reducing salt would help, but it would take some fairly careful testing to figure out if that’s true. Also, cheese is delicious, so good luck, salt-reduction proponents!
– Exercise — it’s fun and reduces mortality and morbidity. Does it help with hypertension? A bit. And particularly if your hypertension is at all stress-related. As My Sister The Doctor explains,
All the adrenaline and steroids that your body releases when you’re under stress are designed to help you fight sabre-toothed tigers. If you only do battle by typing on your laptop, those hormones will just bounce around in your body and drive up your BP. You need to simulate fighting off (or outrunning) a sabre-toothed tiger several times a week, to manage the physical effects of your stress.
– Finally, don’t stress about being fat too much. Instead, ask yourself if there are underlying health concerns (like diabetes) that might be causing you to get fat. If there aren’t, go for a short jog and don’t worry about it.
If you are very attentive, you may be asking, “But wait — weren’t you sick at the beginning of this?” Yes. I was. Pretty sure it was reflux — store-brand Prilosec really seems to have helped. I’ll be going to a doctor this week to check in, but really, score one for my wife, who sussed it early on.