Friday, February 8, 2008

Longevity, Reece, Personal Musings - Ponce de Leon and The Quest for Normality

We doctors are conquistadors. We seek to conquer disease. We strive to restore our patients as close to youth as possible. We do this by keeping or returning patients to “normal” values of youth, for weight, blood pressure, lipids, and glucose by any means we have at our disposal – drugs, diets, and advice to exercise.

I applaud us for pursuing these noble normality goals for our patients. But is this quest for youthful normality realistic given changes associated with aging? You no doubt have observed that specialty societies have recommended patients should maintain,

• a normal body mass index

• a systolic blood pressure of 110 or less

• a serum cholesterol of 200 or less

• a calculated LDL of 100 or less

• a blood glucose of 110 or less

• a glycosylated hemoglobin of 6.0 or less.

We advise patients to strive for normality. We prescribe drugs if they can’t achieve normal values on their own. I‘ve been part of this quest for normalcy. In the 1980s, I came up with something called the HQ (Health Quotient). The HQ, like the IQ, had a normal range of 80 to 120. Anything below was “subnormal.” Anything above was “remarkable good health.” The HQ was based on a collective deviation from normal for blood pressure, blood lipids, glucose, and body mass index. We tested the HQ
on thousands of patients. In retrospect, it was an idealistic quest for good health based on normal values found in the young. Subjects with HQs of over 150 were invariably young women or young males.

But as I age, my hair grays, my middle thickens, my sight dims, my memory fades, my blood pressure rises ever so slightly, my friends drop off, my movie idols disappear, and as more people take more drugs to achieve normality, the realism of aging has begun to replace the idealism of my younger years.

Let me share with you two reasons why.

• I have a friend, a 105 pound, 5’ 2”, 81 year old widow, with a blood pressure of 120/70, a cholesterol of 205 with a calculated LDL of 104 and a blood glucose of 110. She has no history of chronic disease.

Her doctor has suggested she be treated with blood pressure drugs, statins, and a low sugar, low fat diet lest her weight, blood sugar, blood pressure, and lipids spin out of control. My friend has asked me for advice, and I have recommended she do nothing for now.Despite my reassurances, she remains terrified of exceeding normality and paying the mortal consequences.

• A New York Times article crossed my desk on February 8 bearing this title, ”Diabetes Study Partially Halted After Deaths.”It told this story, “ A major federal study of more than 10,000 middle-aged and older people with Type 2 diabetes has found that lowering blood sugar actually increased their risk of death.”

How could this be?

I called Stanley Feld, MD, a Dallas endocrinologist widely known for commanding and persuading his patients to maintain stringent near-normal blood glucose levels. He went so far as to issue T-shirts to patients bearing the words, “In Control.”

I asked Stanley , “What’s going on?” He gently pointed out the study was done on older diabetics, many with heart disease. They were monitored with glycosylated hemoglobin levels. These levels reflect average blood glucoses over the past three months. This average doesn’t account for day to day variations. When their “average glucose” of these high-risk patients was driven to normal, many patients may have had hypoglycemic episodes, with release of epinephrine, and sudden death.

At about the same time, February 7 to be precise, the NEJM released a study “Effect of a Multifactorial Intervention on Mortality in Type 2 Diabetes. “ The study showed intensive intervention with multiple drug combinations and behavior modification reduced vascular complications and deaths from any cause and from cardiovascular causes. It restored my belief in maintaining normal or near normal glucose levels.

Still, I wonder: is it worthwhile or even desirable to drive blood chemistries and body weights to normal in aging individuals? My elderly friend is terrified lest her daily habits and failure to follow physician advice precipitate some terrible illness.

I fear we’re creating a nation of hypochondriacs. As we age, we’re not going to have the same blood chemistries, blood pressures, or body mass indices we had at 20 to 30 years of age. Furthermore, is it worth the enormous drug costs required to maintain or reach this state of normality?

I told my elderly friend: Relax. You’re OK for your age. Your measurements go with the territory.

Is my advice wrong?

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