Gettysburg Medical News
 The Clinical View
 by P.E. Hoffsten, MD
 11 May 2005

“DOCTOR, YOU HAVE REAL PROBLEM !” – PART 2

            Last week’s column described a lady 52 years old, 5 feet 6 inches tall, weighing 174 pounds.  She was seen to establish a new physician relationship in the setting of a high blood cholesterol, substantial overweight, hypertension and diabetes.  She qualified for having the “metabolic syndrome”.  This syndrome is associated with a very substantial increased risk for development of strokes and heart attacks.  But for the most part, the metabolic syndrome is a genetically permitted condition which is then unmasked by the person’s lifestyle.  In order to reverse the metabolic syndrome and prevent the risks heart attack or stroke, lifestyle change is the critical step in care.

            This lady had the initial impression that her problem really belonged to the healthcare providers.  She did not accept any ownership or responsibility for the lifestyle that unmasked her metabolic syndrome.  She had thus said “Doctor, you have a real problem!”

            She had the additional delusion that medications were bad because “they weren’t natural”.  Over several months time, steps were taken as outlined in last week’s column, one at a time to first correct her cholesterol, and secondly deal with her diabetic condition.  The first steps in care involved getting her to accept responsibility for her lifestyle, accepting the medication to change her cholesterol, and accepting a medication to better control her diabetic condition.

            There still remained the high blood pressure which she continued to believe would self correct when she lost weight.  The problem here is that only 2% of an overweight population will achieve meaningful effective weight loss and maintain it over 10 years.  The obesity problem in America has thus far been resistant to all efforts except gastric bypass.

            Thus, the next step in her care was to convince her that a medication to control hypertension was definitely an indicated step.

            In the 1990’s, a study was done called a UKPDS.  The question raised was whether control of diabetes really made a difference in preventing heart attack and stroke that is so common in diabetics.  The study did demonstrate that control of the blood sugars was helpful.  But even more helpful was the control of the high blood pressure.  A person can have blood sugars out of control but did not deteriorate or have as many vascular events as those diabetics who blood pressure remained high.  Thus, the most critical step in care for a diabetic is control of high blood pressure.

            High blood pressure doesn’t kill or cause heart attacks and strokes quickly.  Instead, it takes 10-20 years of persistent high blood pressure before the stroke or the heart attack comes.  Thus, the type II diabetic whose condition can be treated with pills instead of insulin, really begins in those individuals 30-50 years old.  It then becomes a big problem with heart attacks/strokes occurring in the 50 and 60 year old age group.  Considering that the average lifespan of the United States at this time is 77 years, those dying in the 50’s and 60’s, are way below the average.

            Trying to convince this lady that it was a futile idea to believe that she could control her weight and thereby control her blood pressure took some effort.  The first step was to get a blood pressure cuff of her own and measure her blood pressure in her own world.  Initially, she was convinced that her blood pressure was only high in the doctor’s office but when she got a blood pressure cuff of her own and measured her blood pressure in her home and other places where she might be, she did demonstrate to herself that her blood pressure was persistently in the 160/90-100 range.  The survival curves for this level of blood pressure are distinctly different than for the normal blood pressure of 120/80 that is strived for at this time.  Using a home blood pressure cuff, she was able to demonstrate to herself that her pressure really was high.

            Following this, it became an effort to convince her that blood pressure pills would not have more complications than benefits.  In the past, certain blood pressure medications have had problems.  With modern day medications, it is clear that the fringe benefits of anti-hypertensive medications far outweigh any side effects that might occur.  Side effects can be often be worked around and drug combinations developed that do not cause side effects or symptoms and instead very well control the blood pressure.  In a diabetic, the average number of blood pressure medications required is 3.  Trying to convince her that the use of three medications to control her blood pressure was a likely necessity took a lot of convincing.  Eventually, as each new medication was added, her blood pressure finally did become controlled.

            The last problem to address was her excessive weight.  It is a remarkable achievement to control high blood cholesterol, diabetes, and high blood pressure.  Trying to have a person predictably reach ideal body weight has only been achieved in 2% of those that make the attempt.  Patients sometimes yoyo with substantial weight losses that are then regained.  But developing a whole new eating habit that results in long term effective weight control has not been achieved in the clinical practice of medicine to this time.  Thus, this lady was encouraged to control her diet if she could, to exercise if she could but setting goals that were unrealistic often results in such frustration that other efforts are lost.

            This lady is now six months into the above program.  Her weight hasn’t changed one iota but her blood pressure is controlled, her diabetes is controlled, and her cholesterol is normal.  In order to encourage increased activity, she was advised to obtain a pedometer that will measure how many steps that she walks each day and to set a goal of getting 6,000 steps per day.  This amounts to three miles of walking per day.  While this is not an easy goal to achieve, it is within her reach and has become a welcome challenge for her to achieve this on a daily basis.

            Thus, the “real problem” is partially solved.  For cosmetic reasons of her own, she would like to lose weight and now has more self esteem in having controlled the blood pressure, cholesterol and diabetic problems that she had previously.  It is now approximately six months into her problem and “so far, so good”.  The healthcare providers at your local clinics deal with this as the most common problem we see every day.  Patients often want one day quick and easy solutions which are simply not available.  Problems of this sort are like trying to eat an elephant; it can only be done one bit at a time.