Tuesday, February 16, 2010

My Year in Review

The past twelve months have not been amongst my favorites. In fact, to use the scientific term, they have pretty much sucked. That, however, was the past twelve. Like someone who missed New Years because of a coma and has now awakened, I presently feel free to resolve to have a better year this time around.

On February 17th of 2009, they discovered I had severe high blood pressure, and the fun began. A good percentage of my blood pressure problem was real, but an equal percentage was what’s called “white coat hypertension,” which is an exaggerated blood pressure response to being in a doctor’s office. At least 20 percent of the population suffers from white coat syndrome, which means that, despite all the ranting by public health officials about the dangers of undiagnosed hypertension, literally tens of millions of people are taking blood pressure medications they don’t need.

It’s been quite a ride, and everything that I’ve discovered along the way has made me wary of the medical system. I’m a member of Kaiser Permanente, a large HMO, which has some benefits; they have a wide-ranging system, and also keep all their records electronically so that anyone anywhere can pull them up with the touch of a button. But Kaiser also makes system-wide policy decisions that are based on research that, although it has been adopted by government panels as best practice, is around twenty years out of date and considered ridiculous or even dangerous by scientists engaged in current research.

The systems first response was to put me on medication. (As the doctor in Urgent Care told me as she wrote the prescription, “You should count on taking these for the rest of your life. People always say they’ll make diet and lifestyle changes, but I’ve never seen anyone do it.” Good attitude, huh?)

When I complained to my primary physician about side effects from the first drug (an ACE inhibitor), he responded by adding two more—a beta-blocker and a thiazide diuretic. He also—without asking how much salt I ate—ordered me to cut down on salt.

Now, I was losing weight at a good clip, and also exercising. In particular, I was doing a lot of Bikram Yoga, which is a strenuous practice done in a room heated to 104 F. So if there was anyone in the world who didn’t need a diuretic, and who needed higher salt intake, it ws me. But the doctor paid no attention to this, with the result that I passed out after one class, and had a mild seizure at home on another occasion (because of natropenia, or lack of sodium).

Now, many people take beta-blockers, and get nothing but benefits. But beta-blockers work by suppressing the sympathetic nervous system—and they actually prevent your heart rate from rising much. It’s a godawful feeling, exercising and having your heart refuse to respond. And I’m one of those people who responds to beta-blockers by becoming severely depressed. After only two weeks on them, I was starting my day by getting out of bed and sitting down on the floor and sobbing. Every day I felt worse, and, quite frankly, suicide began to seem like an attractive option compared to going on like that.

And why didn’t I contact my doctor? Because I no longer trusted him in any degree. So I stopped taking the beta-blocker, even though the label warns you that discontinuing the drug abruptly can be dangerous or fatal. To tell the truth, dying from stopping the damn drug seemed more attractive than continuing to take it.

I felt better immediately. Not great, mind you, but as if I might want to live. And I went through the tedious process of changing primary-care physicians, which at Kaiser is sort of like rolling dice. But I got lucky; my new doctor was far more reasonable. When I told him I had stopped the beta-blocker, instead of lecturing me, he remarked that I should have never been on it in the first place, and he promptly took me off the diuretic as well. In addition, he told me that new research showed that only a small percentage of people had their blood pressure increased by salt intake, and that an equal percentage of people had their blood pressure increase when they limited their sodium intake, and that he thought that in most cases the “authorities” were a decade behind the times.

Of course, Kaiser policy is to counsel severely limiting salt. And beta-blockers and diuretics are both considered by Kaiser to be first-line treatments for all cases of high blood pressure.

As it turns out, recent research shows that long-term use of both beta-blockers and diuretics are diabetogenic—that is, in many people (and perhaps everyone, if administered long enough), they cause adult-onset (Type II) diabetes. We are constantly hearing about the epidemic of Type II diabetes, and hear about the need for diet and exercise, but no one seems to want to discuss the fact that the many cases of diabetes are probably the result of years of taking these safe, proven blood-pressure drugs.

Kaiser is so behind the times that they are still focused on cholesterol and LDL cholesterol. It isn’t surprising when Joe Public believes that cholesterol causes heart disease; he’s had that message hammered at him since the 1970s. But Kaiser ought to know better. A recent editorial in Cardiovascular Drugs and Therapy (told you I’d learned a lot in the last year) says that the link between cholesterol and heart disease “…continues in popular folklore and government dietary policies but it seems to have been quietly dropped by most cholesterol-heart researchers.”

Indeed. Part of the confusion is because of the bestselling statin drugs, which lower cholesterol. These drugs have been shown to have some cardiovascular benefits, but it has been conclusively demonstrated that they do create these benefits by lowering cholesterol! (When a non-statin cholesterol-lowering drug, ezetimbe, was recently tested, it dramatically lowered cholesterol…and displayed no cardiovascular benefits whatsoever.) Statins do something beneficial (and also have a huge number of terrible side effects), but these appear to have nothing to do with cholesterol. Some people think that they have a useful anti-inflammatory effect; other researchers have shown that they increase circulating levels of Vitamin D. (The drug companies aren’t enthusiastic about the latter possibility, since it would mean their expensive drugs could be replaced by a cheap, safe vitamin.) But, of course, Kaiser pushes hard for anyone with blood pressure issues to get started on statins, despite the risk of liver damage and memory loss.

So, I'm pretty much in the position of having to ignore my HMO; they seem to know roughly as much about health research as your average TV news anchor. I concentrate on the things I can control. I’ve lost about 60 pounds, and actually gained some muscle; my body fat percentage is now below 12 percent. My blood pressure is generally around normal--unless I have to go to the doctor.

But although I’m healthier, it’s been a drag getting here. Working, or writing, have been nigh unto impossible. I have to get myself into something of a hyper state to do either, and—surprise, surprise!—doing so pushes my blood pressure up.

In the earlier months, an hour or two of working or writing took my blood pressure up into the danger zone. As I’ve gotten healthier, the increases are more moderate, but a good session at the keyboard still takes my blood pressure up to sketchy levels. The solution, I’ve found, is to do the work, but then blow it out of my system by following it with intense exercise. My blood pressure plummets after yoga or a run, often dropping down to 95/60.

It’s been kind of a wasted year, especially from a writing point of view. But that all changes tomorrow. It’s New Years, right?


Neil said...

Happy New Year, David.

Aliya Whiteley said...

Yes, happy new year to you. Good golly to all of last year's sucky stuff, and yay! for all the good things awaiting this year. Including salt. Phew.

Actually, I missed you at the the MNW gathering - please come to the UK again!

Alis said...

Yes, you were kind of the empty seat at the table, David. Any plans to come to the UK soon? And Happy - healthy - New Year!

David Isaak said...

Thanks, Neil. Auld Lang Syne and all that.

David Isaak said...

Hi, Aliya.

I once heard someone define salt and fat as "those things that make food taste bad when they aren't in it."

The UK...well, it all depends on my consulting jobs.

David Isaak said...

Thanks, Alis.

Even though I wasn't at The Gathering of the Tribes this time, I'm happy to hear that MNWers are still a clique.

I can't possibly come to the UK until I'm happy with my current WIP. (I can't face Will until then!)

Aliya Whiteley said...

Coincidentally, I came across this today: http://www.prescriber.org.uk/2010/02/statins-and-diabetes-risk/

David Isaak said...

Well, well. Thanks, Aliya. Now I can add that to the list of problems with statins.

Tim Stretton said...

I love a happy ending...

You were definitely much missed at the MNWorama. You have to get a London (or Lake District...) gig!

Eliza Graham said...

I missed you too!

Nodding my head about your problems. I have white coat sympton too and keep a record of my blood pressure at home so that I can take it into the doctor/nurse and persuade them not to take my bp.

Writing makes me feel 'stressy' as my children put it, too. But not writing is even worse...

Deborah Swift said...

Gadzooks! That was some year. Here's to a better one.
Have to say, I have completely ignored the medical professions view that I need statins (i'm not ill - yet, but on statins I might be!)and as the other MNW'ers will vouch, I tucked into Steak pie probably full of salt and fat, and a pudding with cream, bursting with sugar and fat. But the mind is a powerful thing I think, so as long as my body thinks this is a healthy thing to do, I hope it might behave like it is.

I found your post really interesting because it shows that once you start treating side-effects, then the side-effects of the drug you used to counter the side-effects of that etc etc, you are on a slippery path to becoming severely over-medicated, but not necessarily healthier.

Do you think round your writing when you run? I used to run a fair bit and found the rhythm a great way to let your mind wander round the plot.Haven't done much recently - too much snow and wet.

David Isaak said...

London gig may be in the works, but timing is unclear.

I can't imagine any work arrangement that would take me to the Lake District--though I'd love to find one!

David Isaak said...

Hi, Eliza!

At last, someone who understands in detail what I'm talking about.

Alas, my HMO won't take my home BP records into account--it's against their "policy," even though the American Heart Association recently issued a statement that home records are the most accurate was to assess hypertension--and that doctor's-office measurements are misleading.

I think I'll adopt your word "stressy" for how writing makes me feel. And I agree--not writing is worse, and in manifold ways.

David Isaak said...

Hi, Deborah--

I think statins are terrifically dangerous. I have a colleague who has been on them for several years, and has started to get statin-induced amnesia--he simply has blackout periods where he remembers nothing of the proceding few hours. (He once found himself on a plane headed to Korea with no memory of how he got there or why he was going to Korea.) It tuns out that cholesterol is one of the most important constituents of the brain...

As to thinking through writing while running--Nope. Wish I could. Joyce Carol Oates is famous for thinking through stories while sprinting along. Concentrating on not falling over is about as far as my mental capacity extends when running.

Walking, however, or better yet, hiking--that's when my writing brain gets spinning along. When I get stuck, I go for a walk.

Tim Stretton said...

Walking is the thing for me too. Nothing like it for seeing a story unfold. (A nice long bath is a close second)

Alis said...

Yes, never could think while running (apart from 'breathe in, breathe out' and 'God this hurts') but walking seems to do wonderful things to my brain. All thanks to brain-derived neurotrophic factor according to a book I read on what we need to do to make our brains work optimally. (Brain Rules by John Medina - excellent popular science)

Frances Garrood said...

An interesting post, David, and I'm sorry you've had such a bad year.

Re the cholesterol argument - I was talking to son and duaghter -in-law yesterday (she's a GP, he a consultant physician) and they both say there's irrefutable evidence that raised cholesterol can be harmful to the heart, especailly the LDL. They say the HDL/LDL ratio is crucial. I'm not taking sides on this, but I think there are at least two (sides, that is).
And talking of cholesterol, the bread and butter pudding at our lunch was divine...you simply have to come next time!

Matt Curran said...

Bloody hell.  I knew things were tough with you last year, but not that tough.  Glad to see you’ve come through it with your enthusiasm and sense of humour intact though, David.  As a writing addict, I find getting immersed in written worlds are a much-needed shot in the arm, blood pressure-riser or not.  I hope this new regime, finely balanced, means you can get through the WIP without any problems (been looking forward to the next book since Shock and Awe). 

On the blogging side of things, perhaps you should keep posts to a minimum for the next couple of months – which might feel kind of selfish, but you were posting every other day before the blood-pressure thing kicked off and easing yourself back into that writing regime might be the right course regardless of the temptation to squeeze out another post on writing.  Or better still… why not have other bloggers post something on Tomorrowville about a writing topic – kinda like guest blogging - just until you get back on your feet physically?

And of course, until you have a good excuse to come over to the UK!

David Isaak said...

Hi, Tim--

Baths relax me too much. They stimulate my imagination, but in a very aimless fashion.

I'm jealous that they work for you!

David Isaak said...

Hi, Alis--

That book sounds interesting--I'll go look it up. No doubt I could use some neurotrophic factors.

Tim Stretton said...

David, this may be too much information but -

I can structure my imagination in the bath because of the tiles. I can touch the tiles and 'put' an idea in them.

The twin narrative structure for The Dog of the North arose using bath tiles - the Arren strand on one row, the Beauceron on the one below. Until that point the book was conceived as a sequential narrative. Strange but true.

David Isaak said...

Hi, Frances--

Most, though not all, doctors are sort of lagging behind the curve on this topic. I've spent a lot of time with recent medical journals--a luxury most MDs can't afford.

As to the irrefutable link between LDL and heart disease, a lot of experts think it already was refuted by the Vytorin/Zetia study published in 2008. As one doctor commented at the time:

"It appears that the combination of a statin and Zetia, despite lowering cholesterol levels by 40 percent more than a statin, was no more effective than the statin alone in preventing problems. Which would lead anyone with critical thinking skills to wonder about the hypothesis that LDL-cholesterol is really a problem."

For a nice popular review of the state of statins, see this article in, appropriately, >Business Week (statins are a roughly $30 billion business).

Research in the last two decades shows that "LDL" itself is an oversimplification. There are at least two kinds--large, "fluffy" LDL (good) and small, dense, oxidized LDL (the kind that gets deposited in your arteries).

Back in the 70s and early 80s, they used to look only at total cholesterol, which they told us was bad. Then the profession was gradually converted to the understanding that there was "good" cholesterol (HDL)--which was something they were actively trying to reduce in the previous decades, much to the harm of their patients.

Since few labs can test for LDL density and few doctors know anything about it, I suspect that we'll have another 20 years of trying to lower total LDL, until someone manages the job of telling the public (and the physicians) that not only is there "good cholesterol" and "bad cholesterol," but there is also "bad bad cholesterol" and "good bad cholesterol."

But I digress. And I must confess I've never heard of bread and butter pudding. I'll go Google it!

David Isaak said...

Hi, Matt--

My posts have indeed already become less frequent--and, as in your own case, may become less frequent still as I get buried deeper in the WIP. (Or perhaps WNIP, Work Not In Progress, would be more accurate in my case.)

Watch out--I might take you up on that guest blogging option!

David Isaak said...

Hi, Tim--

Now that is truly odd and marvelous. I've know people who used index cards on corkboards for similar strategies, but bath tiles are genuinely original!

Frances Garrood said...
This comment has been removed by the author.
David Isaak said...

Hi, Frances--

You've obviously got a better class of doctor over there.

Physicians over here claim to spend an average of four hours a week keeping up with the literature. There are claims from researchers that even this is an exaggeration; and that when our lot do read, most read only editorials.

To give a simple example, the American Heart Association and the National Institutes of Health have established standards for how blood pressure is taken. There are five basic elements to obtaining a valid reading. Three separate studies showed that no physicians observed followed the full five-part protocol, and than in many cases none of the five parts was followed. Moreover, one study showed that most physicians couldn't even remember what the protocol was!

Maybe it's because our health system over here is exclusively profit-based?

In any case, hooray for bread-and-butter pudding!

Janet Ursel said...

Sorry I'm late again. I've been struggling with my own issues. I do share your skepticism toward the knee-jerk prescribing that goes on. Glad to hear you're getting things under control and here's to a better writing year.

I'm whittling away at my weight too, but in fits and starts. Deliberately. But I'll get there in a year or two.

Jake Jesson said...

Hey David,

Interesting post. I'm sorry to hear that your year sucked, though hopefully this will change in coming times.

In defense of your pessimistic doctor, I recall that the statistical figure for who will actually change if faced with a you-will-die-if-you-don't-make-this-life-change dilemma is about 9 or 10 percent. So, when people are faced with the choice between 'change' or 'die', odds are they'll pick 'die'. Funnily enough I learned this in a management class.

Happy new year, I think! Hope it's working out.

Now, I'm off to a writing group, from which you are sorely missed! :)

David Isaak said...

Hi, Janet--

Well, slow and steady is supposed to be better. I'm not a slow and steady kind of guy, though, so listen to what I say rather than what I do...

Janet Ursel said...

I'm not good at the steady part either, so I'm aiming for slow and sporadic. ;o) I only try to actually lose for three weeks at a time. The rest of the time my goal is just to hold the line. So far, it's working, but it will take a while like this. But it fits both my personality, and the limits that the chronic fatigue places on me. I've lost enough to drop a clothing size though, which has been quite a thrill.

David Isaak said...

Hi, Jake--

It's perfectly permissible for the doctor to be pessimistic, but sharing that pessimism with the patient, no matter how well supported by statistics, verges on malpractice. I think she's a jerk.

If I was a kid from an inner-city neighborhood hoping to go to college, the last thing in the world I would want is some teacher or school counselor confronting me with the fact that most people in my situation don't make it. Statisitics apply well to masses, but they are lousy guides to individual outcomes.

So, her outlook might be realistic. But that doesn't mean it's healthy.

Did you see that research a while back that shows that depressed people tend to have more realistic views of life and of their own capabilities and talents? That doesn't mean that being depressed is smart--or does it?

David Isaak said...

Hi, Janet--

You may be doing something more in keeping with the body's natural rhythm anyhow. There seems to be a common pattern of losing weight and then hitting plateaus and then losing again, and that pattern often asserts itself in spite of any caloric or exercise manipulations. The body seems to like to find equilibrium again before changing size.

So what you're doing might actually be more natural and normal. Those of us who pull the wieght off rapidly have to deal with plateaus despite our efforts--so counting on them might be a sensible thing to do!

Jake Jesson said...

Oh, I agree. She sounds like an asshole. I'm sorry that you got stuck with her. (Perhaps I should've said that in my original comment! What an unsympathetic jerk I am.)

I totally agree with your example; homeless kids from abusive broken families - that's me! - don't usually go to Berkeley, even with the grades I had. And I did have people shooting me down. Screw 'em.

I also saw that research. The brutal flip side, though, is that people can't be very creative (particularly relevant for problem solving) unless they're happy, so depressed people's "realism" doesn't help them much. So... nope, being depressed isn't smart. You're depressed because you can't solve your problems and you can't solve your problems because you're depressed.

This research - a fun experiment with putting rats on either depressants or endorphins and having them solve a maze - hit particularly home because I've struggled with depression for years. Fat lot of good it's done me!

David Isaak said...

Hi, Jake--

As Twain wrote (though he never claimed it was original with him), there are three kinds of lies: lies, damned lies, and statistics.

From a practical point of view, in terms of useful creative output, the manic-depressives seem to have everyone else beat cold.

Which I suppose suggests that realism has its uses, but only when counterbalanced by a huge dose of unwarranted enthusiasm...

Janet Ursel said...

David, it was precisely those kind of rhythms that I'm looking to exploit. The standard method of beating the plateaus is increasing exercise, to force the body to maintain a higher metabolism. That option isn't open to me because of the chronic fatigue. Pushing past my endurance will just land me in bed for days on end. So I figured that instead of fighting it, I'd work with it. So far, so good.