You Don't Have to Take The Pill

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INSIDE

Rendered scentless

Causes and treatments

or the loss o our

most neglected sense,

smell. 4 – 5

Paws and effects

The risks and benefts

o having a pet. 6 –7

By the way, doctor

Vitamin D: How much is too

much? Why does my mitral

valve leak? 8

In future issues

Masculinity and men’s health

Herb-drug interactions

Peripheral neuropathy

We’ve gotten used to taking pills ormuch that ails us, but these days,the medicine cabinet is looking like

a rogues’ gallery. Tere’s been bad news aboutthe painkiller roecoxib (Vioxx), the diabetesdrug rosiglitazone (Avandia), and, most re-cently, the cholesterol-lowering combination

o ezetimibe and simvastatin (Vytorin). Prob-lems with hormone therapy and antidepres-sants have also been bannered in headlines.

We don’t lack or alternatives. Plenty o research shows that exercise, diet, and otherliestyle changes are eective weapons againstmany chronic diseases. But there are morendings about preventing diseases with so-called liestyle changes than there are abouttreating them. And you won’t ind many head-to-head comparisons between the con-ventional drug treatments and the nondrug

ones. Ofen it seems like the nonpharmaco-logical approach doesn’t quite get its due. Te

long review papers on treatment choices typi-cally squirrel it away in a small section, almostas an aferthought.

Inertia, reimbursement incentives, pharma-ceutical companiesyou can wag an accus-ing nger at all these. But let’s be honest:there’s also the wonderul convenience o tak-

ing a pill. It’s just so much easier than chang-ing what we eat, mustering up the time andwillpower to exercise, or ghting the uphillbattle o weight loss. Doctors see this and,understandably, gure medication is a moredependable, and responsible, way o treatinga disease. And the health care system, as cur-rently confgured, doesn’t do much to supporta nondrug approach.

But or those wary o taking medicationswho want to take the road less traveled, here’sa brie overview o seven common conditions

and approaches to managing them withoutmedication or supplements.

You don’t have to take a pillMedications have their dark side. Exercise, diet, and other changescan be alternatives, but could feel like a whole lot of hard work.

VOLUME 33 • NUMBER 6

APRIL 20

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I you’re heavy and the problem is arthritic

knees, losing weight won’t make the arthritis

go away, but there’s a good chance it will

make it less painuland that’s what most

people care about. Research results published

several years ago showed that combining

some weight loss (5.7% o body weight)

with moderate exercise will result in less pain

and improved mobility or heavy people with

arthritic knees. The same research group re-

ported results in 2006 showing that a more

intensive weight-loss program (8.7% o body

weight) results in pain and unction

improvements in obese people

(a body mass index o 30 or more).

Even or those who aren’t heavy, ex-

ercise that doesn’t put “load” on the

jointsswimming and bicycling are

good examplesworks to reduce pain. For

walking, the right shoes can make a huge

dierence or people with arthritic knees. Re-

searchers have shown that a padded heel can

cut in hal the orce with which your oot hits

the ground with each stride. A knee brace is

another thing to try. It can realign the knee,

taking pressure o the “compartment” o the

joint that’s the most arthritic. Knee braces can

be bulky and inconvenient, so getting people

to wear them is a problem. Activity that tar-

gets certain muscle groups is a proven pain

reliever; beleaguered knees respond well

to stronger quadriceps, or example.

Some rain on the exercise parade:

exercise may be more benefcial

and practicalor people with rela-

tively mild cases o arthritis.

Arthritis



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Harvard Health Letter April 2008

www.health.harvard.edu

Cognitive decline

Memory training and other “brain exer-cises” seem to help healthy older peoplestay sharp, although there’s been somequestion how well the gains translateto real, everyday activities. Scores o

studies have been done and, by andlarge, the results in people with early,and even ull-fedged, Alzheimer’shave been positive. Several studieshave shown that structured “cognitivestimulation” programs administered bycaregivers at home may help Alzheim-er’s patients. But there are questionsabout the quality o a lot o the researchshowing positive results. Moreover, thebar or success is set pretty low: a posi-tive nding is oten a slowing o therate o cognitive decline, not revers-ing it. Evidence or the mental benetso physical exercise may bestronger and more consistentthan the evidence or mentalgymnastics. A study publishedlast year is typical. It showedthat even a simple, hour-long exercise program twicea week had a positive eecton the ability o Alzheimer’spatients in nursing homesto perorm daily activities.

Medication alternatives continued rom page 1

WHo WE ARE

Editor in Chief Anthony L. Komaro, M.D.

Editor Peter [email protected]

Writer Christine Junge

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Board members are associated with Harvard Medical Schooland afliated institutions. They review all published articles.

Cardiology Thomas H. Lee, M.D.

Dental Medicine R. Bruce Dono, D.M.D., M.D.

Dermatology Kenneth Arndt, M.D.

Emergency Medicine John Tobias Nagurney, M.D.

Gastroenterology Stephen E. Goldfnger, M.D.

Genetics Susan P. Pauker, M.D.

Gerontology Kenneth L. Minaker, M.D.

Internal Medicine Nancy Keating, M.D ., M.P.H.

Neurology Dennis Selkoe, M.D.Edward Wolpow, M.D.

Nutrition Bruce Bistrian, M.D., Ph.D.Walter C. Willett, M.D., Dr.P.H.

Oncology Robert J. Mayer, M.D.

Ophthalmology B. Thomas Hutchinson, M.D. Orthopedics Donald T. Reilly, M.D., Ph.D.

Otolaryngology Jo Shapiro, M.D.

Preventive Medicine JoAnn E. Manson, M.D., Dr.P.H.

Psychiatry Michael C. Miller, M.D.

Surgery Richard Hodin, M.D.

Urology Jerome P. Richie, M.D.

Women’s Health Soheyla Gharib, M.D.

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Cholesterol

You can adjust your diet in several ways to lower levelso “bad” LDL cholesterol. Your LDL level may drop by 5%or so i you keep oods high in saturated at (namely, meatand ull-at dairy products) o the menu. Every additionalgram o soluble ber per daythe sort o ber ound in oatmeal, beans,nuts, and ruitmay reduce LDL levels by about 2 mg/dL. Diets that have

included margarines ortied with sterolscompounds that block cholesterolabsorptionhave brought about LDL drops o 10% to 20% in some studies.And in others, low-at, “plant-based” diets that are very heavy on the vegeta-bles (10 servings a day) and legumes and nuts (4 servings a day) have dialeddown LDL levels by almost 10%.

Te problem is that all o these approaches all short o what the statindrugs can accomplish: a drop o 25% to 35% in LDL. Te exception may be adiet that includes a veritable dream team o LDL-lowering oods (plant sterols,soy protein, soluble ber, and almonds). It has managed to match eects o statins in several short, head-to-head studies.

And HDL? Exercise is probably the best way to boost levels o the “good”cholesterol. Inactive people who start to exercise regularly have seen their HDL

levels increase by as much as 20%. Moderate alcohol consumption (one or twodrinks a day) is another HDL booster. Excess weight, smoking, and diets heavy in easy-to-digest carbohydrates depress HDL levels, so changes in those areascan give your HDL a lif.

Depression

Many studies have ound that regularphysical activity seems to have an anti-depressant eect. Some research hasshown that a airly strenuous exerciseprogram results in a 50% decrease in

depressive symptoms, a drop compa-rable to that seen when people takeantidepressant medications or receivecognitive behavioral therapy. The par-ticulars o the program seem less impor-tant than sticking with it. Physical activitymay aect the brain directly by boostingneurogenesis: brain cells grow a bit andmake more connections where it counts.It may not be just the physical activityalone that improves mood. Considereverything that can come with it: cama-raderie i you exercise with others, thepsychologic boost rom adhering to a

challenging routine, the relie oocusing on something besidesyour problems. The exercise-as-antidepressant ormula doeshave a major problem: onecommon eature o depressionis that nothing seems enjoy-able or worthwhile. Finding themotivation to exercise may bea huge, even insurmountable,hurdle or some.



www.health.harvard.edu April 2008 Harvard Health Letter |

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Although a recent study cast some doubt about how low bloodsugar levels should go, and by what means, it’s still important tokeep them under control. Regular physical activity is a powerfulbrake on blood sugar levels because well-exercised muscle becomesmore receptive to the insulin that helps it pull sugar in from thebloodstreamsugar that the muscle tissue needs as “fuel” to func-tion properly. Eating fewer sweets and easy-to-digest carbohydrates,both of which are quickly turned into blood sugar, also helps keepthe lid on blood sugar levels. Many studies have shown that peoplewhose blood sugar levels have crept up, but haven’t yet reacheddiabetic levels, can avoid full-fl edged diabetes with a combinationof exercise and dietwithout any medication. One of the largestof those studies randomly assigned people to take metformin(Glucophage) or to make lifestyle changes that included a goal of weight loss (7% of body weight) and two and a half hours of exer-cise a week. Nearly twice as many people in the metformin groupwound up with diabetes compared with those in the lifestyle group.The difference was even greater in people older than 60. When it

comes to developing diabetes, it’s not just that exercise is good foryou. It’s more potent than any medicine yet invented.

Whether exercise and diet alone can control blood sugar levelsonce people are diabetic is harder to answer. The American DiabetesAssociation (ADA) used to recommend that people newly diagnosedwith diabetes try exercise and diet fi rst before moving to medica-tion. Now the ADA says people should start taking metformin rightaway. The reasoning is that few people were able to keep theirblood sugar levels in line with exercise and diet and that failurewinds up making the underlying diabetesharder to manage. Overall, that may betrue, but the ADA also encourages doctorsto tailor their treatment to the individualpatient. People with diabetes who wantto try to control the disease with exerciseand diet alone should talk to their doc-tor. At the very least, it might be wortha short trial.

High blood pressure

I there’s one condition that you can change without a pill, it’s high bloodpressure or, as doctors call it, hypertension. ake your pick: lose some weight,get more exercise, eat less sodium, change your diet. T ey all work.

I you’re heavy, each two pounds o weight losseasier said than done, weknowtranslates into a 1 mm Hg drop in systolic (the top number) and dia-stolic (the bottom number) blood pressure. Regular exercise can even lower

your blood pressure i you don’t lose weight.Eliminating about three-quarters o

a teaspoon o salt (1.8 grams o sodium)rom your diet each day may drop your

systolic reading by 5 points and thediastolic by 3. rials o vegetarian diets

have shown they can reduce systolicblood pressure by 5 mm Hg. T e Dietary

Approaches to Stop Hypertension (DASH) dietis even better, lowering systolic blood pressure as much as 12 points and dia-stolic pressure by 5. DASH dieting does involve eating a lot o ruits and veg-etables (seven to nine servings a day) and low-at dairy products (two to threeservings a day), plus whole grains, nuts, poultry, and f sh, all while keepingsaturated at, red meat, and sweets to a minimum. I you’ve got the disciplineto ollow DASH and keep your salt intake low, the decrease in blood pressureis comparable to that seen with high blood pressure medications.

Any o these liestyle strategies will also make blood pressure–loweringmedication more e ective. Whether they can replace the pills depends on howhigh your blood pressure is. Current guidelines recommend liestyle changesor prevention and control o high blood pressure, but they aren’t terribly optimistic about the control part, predicting that most people with high bloodpressure (def ned as 140/90 and above) will need to take one or two medica-tions. Even at lower readings, i someone has other health problems (diabetes,or example), most doctors will prescribe blood pressure pills. But weight loss,exercise, and diet can make lower dosages possible and even eliminate theneed or medication altogether.

Osteoporosis

Our bones start to weaken at aboutage 40, and for women, the sud-den drop-off of estrogen at meno-pause accelerates the decline.Weight-bearing exercise, which in-cludes walking, running, and climb-ing stairs as well as the actual liftingof weights, puts stress on bones,and bone tissue reacts by gettingstronger and denser. When we’re

young, exercise builds up bone.But in older people, and perhapsespecially older women, the effectof weight-bearing exercise on bonemay be quite small. Studies haveshown pretty consistently thatintense exercise can increase thebone mineral density of the lumbarspine, although for most people,taking a drug like alendronate(Fosamax) would probably havemore of an effect. Some expertsbelieve any decrease in the fracture

risk from exercise is probably theresult of stronger muscles, and per-haps better balance, not apprecia-bly denser bones. Extra vitamin D(800 to 1,000 IU daily) and calcium(600 to 1,000 mg) top the list ofdietary recommendations for osteo-porosis. Pills may be the best andeasiest way to get the vitamin andmineral in those amounts.

Diabetes

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