Lifestyle changes, cycling and normal…

Tonight, let’s talk a little about ‘normal.’

Nearly every weekend in the fall, during cyclocross season, I line up with a cadre of other men who look as though they desperately need to “eat a sandwich.” You look around for calm and all you see are ribs and hip bones poking through spandex. Seriously, these guys are ridiculously skinny. One of them tells me he drinks protein shakes to keep his weight above 135 pounds.

This is the weekend scene. It’s much different from what I see Monday through Friday at work.

Which is normal?

To explain where I’m going, let’s go under the tape for a spell. It’s a little circuitous, so allow me some leeway. I’ll get back to cycling and ‘normal’ at the end.

You well know that I am hell-bent on promoting the value of stacking together small lifestyle choices. If you followed me in the office for a day, you would might think…this is one scratched-up disc. “He says the same stuff over and over and over again.”

It’s true. The message is repetitive. In fact, my yearly follow-up patients often say I told them the same thing years ago. That’s the thing about recommending lifestyle changes: it’s time-tested.

To bolster my message, I’m always on the alert for studies that support the view that wellness sprouts from simple choices—not pills or procedures. Take this one from today: The British Medical Journal reports an analysis that says folks who eat real fish, not fish pills, have better outcomes. See what I mean? Simple stuff, not pills.

The problem with relying on evidence-based reasoning comes when studies don’t (seem to) support your view. Here, there is a choice: ignore the negative study or face the results head on.

The Look Ahead study:

Last week, as reported by theHeart.org, the Look Ahead trial was stopped because of futility. After analyzing five-year data, researchers concluded that a program of intensive lifestyle interventions in adult onset diabetics would not ever be able to reduce adverse cardiovascular outcomes, like heart attacks, strokes or death.

The study randomized overweight middle-aged diabetic patients to either an intensive lifestyle intervention program or standard education. Those on the intensive program had a lot of advantages: pre-packaged healthy meals, sessions with nutritionists and personal trainers and other ancillary health classes. Let’s just say this group was seriously encouraged to help themselves.

The results:

Yes, intensively prodding unhealthy patients resulted in statistically significant improvements in weight, fitness, levels of hemoglobin A1c (a measure of blood sugar control) and blood pressure.

But, no, these improvements did not result in fewer heart attacks, strokes or hospitalizations.

The spin:

The exerciser naysayers rejoiced. So did the establishment of ‘treaters’, who basically said…see…we told you all: lifestyle changes are not enough. Patients with lifestyle-acquired diabetes will need medicine and perhaps even stomach-stapling surgery.

My take:

This health blogger says not so fast establishment. Let’s take a closer look at what really happened in the study. How could significant improvements in fitness, weight and blood pressure fail to reduce outcomes?

Now I’m getting back to normal—and cycling.

The problem with the study was one of absolutes. Statistically significant–but tiny–improvements in weight loss left subjects still way overweight. Likewise, fitness improved but subjects were hardly fit; and blood pressure was reduced but the changes were paltry. In other words, the intensive intervention program barely changed these people. Though better, they were still a long way from toeing the line in a bike race or 10K.

My cardiology colleague and fellow blogger on theHeart.org, Dr. Melissa Walton-Shirley, captured the much-ado-about-doing-nothing study with panache: (emphasis mine)

At the beginning of the trial, “Rhonda” weighs 185 pounds. At the end of four years of “dieting and exercising,” she still weighs 175 pounds. Who in their right mind would think that’s really going to make much difference? She’s still overweight. She’s still diabetic….She looks nothing like the gaunt Paleolithic-appearing Dean Ornish, who hasn’t had a gram of fat in 40 years, and she doesn’t look like someone who drank the sugar-free Kool-Aid offered by Atkins…

…Let’s face it, 95% of type 2 diabetics could be cured if they achieved a weight that made their neighbors question if they were dying of something. In America, we are not socialized to accept a really healthy weight. Instead, we’ve been raised on the Hansel-and-Gretel diet, made to clean our plates or our drive-through wrappers until our fat little fingers are just plump enough to appease our penchant for a sedentary lifestyle and distaste for denying ourselves anything. The unpleasant fact is that the typical American smorgasbord has been far more effective than (terrorism) will ever be in destroying our population. Until we change our trial designs on diabetes and lifestyle and dietary changes, our country will continue to spiral downward into a sinkhole of debt and death. Healthcare reform will mean nothing and healthcare reform will do nothing until we “get it.”

You may think these words are harsh. I don’t. Blindness, amputations, dialysis, heart failure and impotence–from diabetes—that’s harsh.

So yes, cycling friends, your neighbors might think you are dying of something.

But to cure chronic diseases, like diabetes and heart disease, normal people are going to have to look a lot more like you. Indeed, you are the normal ones.

Dang it.

I’m still hungry. I want a sandwich.

JMM