Annual Physical

Annual Physical is Important – What is Measured is Equally Important

From the New York Times op-ed, available here, we have a public health expert declaring that the annual physical is a waste of time. Don’t follow this advice. Instead, change what is measured and how it is interpreted.dasd

The op-ed piece develops the idea that the annual physical, as currently done, is worthless. We sort of agree. However, the correct solution is not to dispense with this rite, but to replace it with genuinely useful measurements and diagnoses.

In the Times, mention is made of over-treated diseases, prostate cancer being the poster boy in this category. The reality is this: Prostate cancer is the tortoise of cancers. It usually takes a lifetime to develop, but it typically will. The probability that a man has prostate cancer is approximately equal to his age.  Most men will die with prostate cancer, but not because of it.

However, a major medical industry has developed treating this slow-motion cancer. Men discover they have prostate cancer and essentially panic and rush to treatment. These treatments all have serious side effects, and for many, perhaps most, the treatments are unnecessary. OK, so it’s over treated, does that mean the diagnosis should stop? Well, that’s what the high priests of medicine seem to have decided. Prostate cancer screening does not appear to be covered by Medicare anymore, nor is it recommended for men over 70, etc.

dfasdfLikewise, in the absence of any obvious problems (which shouldn’t have waited anyway), the annual physical largely consists of a blood pressure measurement, which is inaccurate in the office setting, and interpretation of the usual blood tests. And here lies the major problem.  Most M.D.’s 1) do not measure the right things, 2) Do not know how to interpret what they do measure, and 3) Do not believe patients will alter their lifestyles in any case. So typically the patient is given the ritualistic incantation to ‘eat better and exercise more’  and then put on pills.

In Quantitative Medicine practice, I have seen time and time again that people will change, change dramatically, if they understand why they have to, why the change will work, what effect the change will have, and how long it will take.

For instance, consider this: Insulin resistance, a precursor to Adult Onset Diabetes, can effectively be determined by measuring four things: Glucose, triglycerides, Hemoglobin A1c, and insulin.

These are important measurements, and every person – and I mean everybody – should know what theirs are, what these numbers mean, where they should be, what happens if they are not where they should be, and how to change them. Do you know all this? If not, read on, you are about to learn.

Unfortunately, most physicians don’t understand how these numbers interact and, consequently,  they cannot explain this to their patients. So indeed an annual physical can be a waste of time and money.

In fact, triglycerides are circulating fat. The physician may assume, incorrectly, that this is due to excess fat consumption, and recommend a low fat, or low saturated fat diet. This is a recommendation that is guaranteed to make the situation worse.

However, if these numbers (and about half a dozen others) are correctly interpreted, and lifestyle changes undertaken, the effects can be dramatic. Specifically, with all the numbers ‘right’ your risk for developing degenerate diseases, such as heart disease, cancer, adult onset diabetes, etc. , will plummet. You will age slowly as well.

Glucose, Triglyceride, Hemoglobin A1c, Insulin

Here’s the short version. There will be lots more about these and other crucial numbers in future posts.

Hemoglobin A1c, sometimes simply called A1c, is a measure of average sugar in your blood over a 3 to 4 month period.

Glucose, is the level of sugar after a 12 hour fast, a normal requirement for a blood draw. Insulin and triglycerides are also fasting levels.dfds

Here is how these interrelate. Sugar gets into your blood from the stuff you eat. The sugar you ate does of course, but importantly, all starch you ate is converted to sugar as well.

High sugar levels aren’t healthy, but after a meal, especially one with a lot of starches or sugars, these levels will spike.

The body secretes insulin, which acts as an escort service to drive the excess sugar into muscle or fat cells.

If all is well, this will go on for about 2 hours after a meal, and then the body will start burning fat, those triglycerides we just measured.

Now if these are all in good shape, you likely are too. Your risk of heart disease and Adult Onset Diabetes will be very low. What is ‘good shape?’ Ideally, fasting glucose around 80 mg/dl, an A1c below 5.2%, triglycerides under 100 mg/dl an insulin under 8 µu/ml. Actually, even lower is better but these are good and reasonable goals.

Now suppose the following happens: Suppose the ‘patient’ eats several hundred grams of starches a day. This is all converted into glucose, whole grain or not. This is more than the body can use; the cells simply won’t take any more. So the following chain reaction happens:

  • The glucose level goes up and stays up. (Dangerous)
  • The insulin level goes up, but to no avail, it can’t reduce the glucose. So it stays high. (Dangerous)
  • With insulin high, the cells won’t use any circulating fat, so triglycerides go up. (Dangerous)
  • With triglycerides high, very small LDL particles develop, and it is these that get stuck in arteries and cause heart disease. (Dangerous)

So a simple dietary starch overload is causing a rapid progression toward Adult Onset Diabetes (chronically high glucose) and heart disease (very small LDL particles). It’s a vicious circle. And it is also an extremely common one.

Most M.D.’s don’t see all this as a process. They just see numbers that are high or not, and rattle off something like ‘eat right and exercise’. This fails miserably to convey both the ‘what’ and the ‘why’ of the situation.

The cure is possible. Step one: cut sugar and starches till the numbers fall in line. Three important takeaways here:

  • This will make an enormous contribution, even in extreme cases.
  • Cutting starchs and sugars will cause a craving that will subside in 2-6 weeks.
  • You should measure again in three month’s time. Both to check your progress, and to see if you need to cut more, or additionally address alcohol, or change your response to stress which can also make these numbers worse, or change or decrease or increase the role of exercise. Remember: measure, change, remeasure, change, remeasure…

Get a handle on these numbers and get into the measure – modify – measure – modify loop and anyone can improve their health enormously.

This is the potential value of an annual physical.  An annual physical where the proper things are measured and properly interpreted can be the opening bell to the beginning of true health.

Don’t forego your annual physical. Change how it is done. If necessary, educate your doctor.

  4 comments for “Annual Physical

  1. Sri
    February 5, 2015 at 8:05 pm

    Thanks Doc,
    apart from the blood work, are there any other tests you recommend for annual Physical

  2. February 6, 2015 at 8:26 am

    Yes, and we will get into this in more detail in coming posts. At least initially an accurate non-invasive imaging of your coronary and carotid arteries should be included. The truth remains that for all of medicine’s advances too little is known about any individual’s risk for vascular disease. So don’t risk it; find out. An accurate old saw goes like this: over 80% of those who will never have heart disease have cholesterol numbers exactly like those who do have heart disease. The take away is statistical models may be good enough for populations but they are not good enough for individuals. Dig deeper. Dr. Mike

  3. Sri
    February 9, 2015 at 8:05 pm

    Thanks Doc

  4. Tony Hallam
    June 26, 2015 at 10:10 am

    I am impressed by the philosophy of QM. I am persuaded that engaging with a doctor to maintain health rather than treat illness is wise. Two questions: How would you go about identifying a practitioner sympathetic to this approach? ( I live in Spain, so general principles may be more helpful!) Also, when can we expect the remaining parts of the book to be published?

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