Gettysburg Medical News
Clinical View
  By Phillip E. Hoffsten
 May 5, 2005

“Doctor, you have a real problem!”

The lady was 52 years old and wanted to be seen because she had been told she had problems with her heart.  She had been going to another physician “for years” but didn’t feel that he was helping her with her heart problem.  Six months previously, she had had a heart attack, which fortunately was treated with clot melting medicine and then a stent placement to correct the obstructed coronary artery.  She had been told, at that time, that there were other arteries that were blocked and might require address in the future unless she could “change her lifestyle.”

She brought clinical records with her from her previous medical history showing that her cholesterol was 326mg% (normal value less than 200mg%) and an LDL or bad cholesterol of 180mg% (normal value less than 100mg%, ideal LDL less than 70mg%).  These were terribly dangerous values and highly associated with heart attacks.  In addition, it was seen that her blood pressure was 150/90mmHg.  Normal values for blood pressure are now well known to be less than 130/80, ideally 120/70mmHg.  Her blood sugars were seen to be consistently high, although she had been told she had hidden diabetes.  In fact, she was blatantly diabetic.  She was 5’6” tall and weighed 174 pounds.  She had two children that were grown and out of the home and worked as a loan officer at a local financial institution.

I reviewed the records that had accompanied her and saw that her former physician had made all of the appropriate suggestions on how to deal with her heart disease, high blood pressure, high blood cholesterol, and diabetes.  She found fault with the medications, feeling that they “were not natural.”  She insisted on controlling her diabetic condition with diet and was in no way successful to this point.  She felt that if she could just lose some weight, her blood pressure would come down and everything would be okay.  She agreed to a “statin” drug to bring her cholesterol down in the past, but felt that it caused muscle aching and she stopped the medication.

After reviewing all of her history and doing a physical exam, she volunteered, “If I am going to be your patient, Doctor, you have a real problem!”  This poor lady had so many misconceptions and so much misinformation I really didn’t even know where to begin.  She was accepting no part of the responsibility for her illness.

At a discussion one time, I heard the question “How does a person eat an elephant?”  After pondering the question for several seconds, the questioner volunteered “One bite at a time.”  That was certainly the approach that was needed for a  lady with this type of problem.

The first step was to inform her very clearly that I was not the one with the problem.  It was pointed out in no uncertain terms that she was the one with the problem and unless she was willing to change, the problem would not be solved.  As a physician helping her, I could provide advice and medications, but only she could change the lifestyle that was killing her.

Step two in her care was to provide some ray of hope.  Inquiry was made about the statin drug to lower her cholesterol and why she had stopped it.  She said the muscle aching wasn’t so unbearable, rather she was concerned about what it represented as a greater complication over long term usage.  I pointed out that the muscle aching she was having was more likely coming from her diabetic condition, her inactivity, and deconditioning.  It was clearly pointed out that muscle aching as a result of the statin drug was remarkably unusual and that the drug probably wasn’t responsible for whatever muscle aching she had.  Her statin drug was restarted and she returned in six weeks with cholesterol values now at 192mg% with an LDL of 86mg%.  She was very sensitive to the statin drug.  Fortunately, she did not find the fault with the drug on this occasion that she had in the past and at least her cholesterol was now corrected.

The third step in her care was to address the weight problem.  She acknowledged enjoying sweets, pastries, and ice cream.  At that point, about an hour was spent playing the game “What would you rather have?”  With this game, a person expresses choices between two objects.  The choices start off with simple alternatives such as an apple or a candy bar.  The questions get progressively harder for the person being asked to make a choice between having candy bars with associated diabetic complications and heart disease or watching their grandchildren grow up and go to college.  There is a lot of technique and preparation that goes into these alternative choices, but eventually it is made clear to the person that they are making a choice between a mouthful of sweet with an early heart attack or getting rid of the sweets in their diet and watching their grandchildren grow up.  These sessions are often tearful and emotional sessions.  It is hard to accept that your personal practices that seem so dear are in fact contributing to a fatal disease process.

By the time these sessions were finished, she was willing to accept a diabetic medication called Metformin.  This medication creates a loss of appetite and helps correct the high blood sugars.

In the course of two months’ time, her blood sugars came down into the normal range, her cholesterol was now corrected, and the next step in her care (bite of the elephant) was ready to be addressed.  This will be done in next week’s column.  To this point in her course, it was established that:

1.                          her problems belong to her.  They do not belong to her healthcare provider.  The healthcare provider can give advice and medications to help correct cholesterol and diabetes, but only the patient can change her lifestyle.

2.                          statin drugs rarely are responsible for the muscle aching that people feel and have a huge benefit to risk ratio with multiple fringe benefits that exceed simply lowering the blood cholesterol.

3.                          diabetes requires a change in eating pattern to delete concentrated sweets from the diet.  Medications can help curb the sweet tooth appetite.