I introduced Henry in an earlier article; here is his story in more detail. Henry is a 69-year-old widower living alone in a small town about 60 miles from the nearest metropolitan area. He has a small pension and healthcare coverage via Medicare, a Medigap policy, and a Medicare Part D drug policy. He was recently hospitalized in the ICU with a serious urinary tract infection that spread to his kidneys [pyelonephritis] and to his bloodstream [septicemia], and then his lungs [acute respiratory distress syndrome.] This was a recipe for rapid demise, but the needed intensive acute care is where American medicine excels. It was the full court press to save his life, and it was successful.

A week later, he called me and asked for some advice. He was discharged from the hospital to take his former medications plus a few more. He was now to take twenty-three — yes, 23 — different prescription drugs, some once, some twice, and some three times per day, along with one by shot monthly. He was not sure why many of them had been prescribed and asked if I thought he needed them all.

I responded that, at 400 miles distant, I could not be his doctor, but I would review the list and offer some questions he might ask his physician. He sent me the list, and I reordered it by category: two for heart failure (he did not know that he had heart failure!,) two for diabetes, three for high blood pressure, one to lower his cholesterol, a monthly shot of testosterone for impotence, one to shrink his prostate (it was felt in the hospital that an enlarged prostate had been a predisposition to his urinary tract infection), one for depression, an antibiotic to finish up the treatment of his kidney infection and a few others.

I asked him who his primary care physician was and learned he did not have one but went to four different doctors, each of whom treated different issues, and none of whom shared all of his information with each other. Whenever one of them checked his blood pressure, it would be elevated, so that doctor would either add a drug or increase the dosage of one or more.

He told me that it was always normal when he went to the local drug store and checked his blood pressure. I told him it might well be that he had “white coat hypertension,” meaning it was only high in the doctor’s office. Perhaps if he took these regular readings to his doctor, the physician would get him off one or more of the blood pressure meds. Besides, two of the three had a known side effect of impotence. Finally, I noted that he was on one drug to shrink his prostate, yet the testosterone might well be causing some of his prostate enlargement.

Henry’s story represents much of what is not working in the delivery of medical care today. He has four complex, chronic illnesses – heart failure, diabetes, hypertension, and depression. These all require careful attention and care coordination, preferably by a single primary care physician who knows the patient’s home and social setting as well as his direct medical issues.

The blood pressure medication story is representative. He was getting many too many drugs that he did not need and had become impotent as a result. Rather than looking for the cause, he was given another drug [testosterone] that probably had no value but was likely enlarging his prostate. As a result, he developed an infection that almost killed him. The hospital doctors had added a drug to shrink his prostate but left the testosterone in place. And all these drugs were expensive for him and his Medicare Part D insurance plan.

Heart failure and diabetes together consume more than 50% of our healthcare dollars. Here is a person whose care is not being adequately monitored; instead, he is getting one drug after another without attention to what else is happening. This lack of care coordination is a prime reason why the costs are so high yet the quality so low. The problem is less that drug companies charge too much for many drugs (they do) but rather that too many drugs are prescribed unnecessarily or inappropriately.

It is also instructive that Medicare pays without question for intensive hospital care – tens of thousands of dollars in Henry’s case, yet pays primary care physicians minimally – even though with time to listen, think and consider, a PCP could have, with limited costs, prevented the hospitalization.

My first suggestion was that Henry needed a primary care physician, one to call his own. He learned that a young doctor he had met at a nearby hospital would be setting up private practice near his town, so he became one of the first patients. Since the PCP did not have many patients yet, he gave Henry the time needed. A few months later, he called and told me that he was now taking just seven medicines, felt better, and was saving a lot of money.

But during our initial discussion, I also asked him what he weighed. I have known him for over forty years but had not seen him for more than twenty. I recalled a stocky, muscular man with perhaps a bit of a beer belly, so I was surprised when he said he weighed 285 pounds. His wife of more than 50 years had died a few years before and he found himself lonely and isolated. He rarely went out and told me he did not exercise; it was just too difficult. He fixed his own meals, mainly from prepared foods.

I asked him what he planned for lunch and was told soup and a sandwich. The soup was a canned one, so I asked him to read the sodium content to me. It was 320mg, or 35% of the daily recommended amount. The can had “two servings,” but he planned to eat the whole thing or 70% of his daily salt requirement (assuming he was not on a restricted salt intake because of his high blood pressure and heart failure) in the soup alone! The sandwich was salami on white bread with some lettuce and mayonnaise.

That sounded great for his high cholesterol problem. Together we figured out that he ate about 2000 calories per day, which he thought was about right based on the soup can label. I suggested that 2000 calories was about right when he was 22 and in the Army, but now, since he did not exercise and needed to lose weight, this was way too much.

My next suggestion was that he needed to get out, interact with people again, carefully consider his diet and begin a modest exercise program, perhaps just a short walk each day. When he called later, he told me that a friend had gotten him to start going with him to the local senior center, where he had made some new friends. Eventually, he agreed to go to evening dances, where he met a widow whose company he enjoyed. His depression seemed to have lifted; he was exercising and enjoying dancing again. I could hear the smile in his voice.

Henry still has four serious chronic conditions. But with a single physician serving as his primary care physician who was aware of all of his medical, emotional, family, and financial issues, his care became much more effective. And when he did need a specialist, which was now rare, the primary care physician became the orchestrator, not just the referrer. As a result, Henry now has better quality medical care, he has a much higher quality of life, he is spending less of his money and much less of Medicare, Medigap, and Medicare Part D’s money. In short, it is a win-win for all concerned.

The key to improving Henry’s care was to find a PCP who would and could spend the time with Henry necessary to offer such comprehensive care. Today, because of high overhead costs and low insurance payments per visit, most PCPs need to see about three patients per hour. They just do not have the amount of time a person like Henry requires. But those that do provide such time offer much better care. Yes, more time per patient means fewer patient visits per day, so someone has to pay for the difference. Insurance rarely does, which is unfortunate. The patient will have to pay the PCP directly, “Direct Primary Care” or DPC. But as we will see in later articles, the total cost of care comes way down, quality goes up, and patient and doctor become less frustrated. Henry is a great example of how totally dysfunctional care can, quite simply and a very low cost, be converted to excellent, cost-effective care.

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 Only 6.8% of the group in 2017-2018 had what would be considered optimal cardiometabolic health. And the trend is down, substantially. (See the article text for the graphic presentation.)

Let that sink in for a moment. We Americans stack up health wise very poorly.

African Americans and Mexican Americans fared somewhat worse than whites as did men compared to women, less educated vs more educated, and less affluent than more so participants.

But for you well-educated, affluent whites, be aware, you still did poorly.

Equally important, the trend is down in every category over the almost twenty years of this survey.

It is notable that the survey criteria used here did not include measurements of exercise (most Americans are deficient,) diet (most Americans eat an unhealthy diet,) stress (most are chronically stressed,) or sleep (most are sleep deprived.) Add these in along with tobacco usage (fortunately now down below 15%) and excessive alcohol consumption and we are a woeful group wondering why we develop diabetes, angina, a heart attack or a stroke, cancer, kidney disease or Alzheimer’s.

The authors of the study made the obvious conclusion that “the findings inform the need for nationwide clinical and public health interventions to improve cardiometabolic health and health equity.”

In an accompanying editorial, Failing Cardiovascular Health: A Population Code Blue^∗ in the Journal of Cardiology, the authors observe, “The reported findings of secular trends of stalling and worsening cardiometabolic profile should not be a surprise as the obesogenic lifestyle—unhealthy dietary patterns that feature foods and beverages high in saturated fat, sugar, salt, and calories; little or no physical activity; alcohol; too much or too little sleep; and hours of screen time—seems to be the norm for many Americans and other populations. These obesogenic behaviors are promoted by increasing opportunities for screen time, a snack food industry [the link will bring you to an interesting short article] that uses science to craft products that are tasty and addictive yet neither satisfying nor filling, and community designs that favor travel by automobile and discourage walking and bicycling. We are particularly concerned about the potential for the developing metaverse to decrease physical activity and increase obesity.

“Regaining the momentum toward positive cardiovascular health will not occur spontaneously. It will require the engagement of every physician and every public health policy with action at 3 levels—personal, clinical, and community.”

My last article in this series on our dysfunctional healthcare delivery system was titled “Follow the Money in Healthcare – It Will Lead You to Chronic Diseases.”

In a reader’s comment, with only the first two paragraphs copied here, Jo Lis wrote, “Prevention of chronic disease is as a practical matter, for most people; eat sensibly, exercise, don’t smoke, don’t drink excessively, get enough sleep, time outdoors, etc. We all know this, and yet only some of us check a few of those boxes regularly. Food is the key to all of this, and it is the most misunderstood ingredient in preventative care. The big #1 one principle is to eat sensibly. Most of us don’t even know what that means anymore. Consuming whole foods is the point. But that is not profitable for the big food companies, so we get told lies to make us buy processed foods that end up causing preventable chronic disease. You see the vicious circle there? … Follow the money, as usual.”

Since industry and government probably will not help much, it is incumbent upon us to take the first steps. In this regard, the American Heart Association (AHA) has set out a set of metrics designed to assist us in determining our health status and watching it into the future. Called “Life’s Essential 8,” it is an update in June 2022 of their earlier “Life’s Simple 7” published in 2010. That was a “a novel construct of cardiovascular health to promote a paradigm shift from a focus solely on disease treatment to one inclusive of positive health promotion and preservation across the life course.” This is an important paradigm shift as the vast majority of the dollars expended today for are for diagnosis and treatment of chronic disease; hardly any goes to disease prevention, wellness maintenance and health preservation.

“Life’s Essential 8,” by the American Heart Association. Each of the four health behaviors and four health factors are graded on a scale of 1-10. Those summarize as a composite score shown on the Overall scale at the top which, in this example, gives a score of 68. See text for details.

The new AHA metrics recognize that social determinants and psychological health are important determinants of cardiovascular (and all) health. The Life’s Essential 8 include health behaviors of diet, physical activity, tobacco (including vaping and chews), sleep, and health factors of BMI (body mass index), blood lipids (non-high density lipoprotein cholesterol), blood glucose (sugar, as also measured by hemoglobin A1c), and blood pressure.

As the authors point out, “numerous studies have shown strong, stepwise, inverse associations between the number of ideal CVH [cardiovascular health] metrics or overall CVH score and total cardiovascular disease (CVD) and CVD mortality” but also “all-cause mortality and a wide variety of non-CVD outcomes.”

In other words, measuring cardiovascular health status is an excellent guide toward health in general. This suggests that using the Life’s Essential 8 methodology can be an excellent guide to developing effective wellness preservation and chronic disease prevention approaches.

The Life’s Essential 8 emphasizes the importance of social and economic conditions that impact ultimate CVH. Community resources such as education, agriculture, employment, water and sanitation, housing, etc. are foundational to good health overall and CVH in particular. So too are a person’s psychological health where anxiety, depression and pessimism detract from health whereas psychological well-being, gratitude, optimism and a sense of life’s purpose all benefit good health. These factors have consistently been shown to improve longevity and “healthspan,” i.e., life lived without disease.

Obviously, the community resources group are dependent on government actions whereas the psychosocial are closely related to community status and issues but still are largely in the preview of the individual and his or her family and counsellors.

Sleep has been ignored until recently but new science has shown its importance to overall health and to cardiovascular health. Sleep is important to manage stress and inflammation, two interconnected conditions that are extremely important in the development of most all chronic diseases including coronary artery damage and plaque buildup.

Unfortunately, with just food alone, the cards are stacked against us in many ways. Nevertheless, we each need to assume responsibility for our health status. We also need help from the industrial agriculture and manufacturers of food industries, the food purveyors, insurers and governments at all levels. So far, except for tobacco, efforts have been minimal. And it is unlikely to change. There is just too much money being reaped that any attempts to push back is always met with strong resistance. Lobbyists keep Congress under control and marketing encourages us to eat more and more unhealthy processed foods.

So, it is up to you and you alone. If you would like to augment your and your loved one’s lives toward better health and a longer health lifespan, I encourage you to focus on at least some of the elements of healthy living. Read the AHA’s article in full. In later articles I will review the key concepts as outlined in the books noted below in my bio sketch.

Veal, squash, broccoli, salad, iced tea. Author’s image.

The authors of the newly released study from the CDC referred to at the top of this article also note that the prevalence of an ideal diet among all age groups of Americans is “negligible (<1%).” So, for now, focus on what you eat. That will be a great place to start. You don’t have to be perfect, just a bit better than yesterday. Each day you can make added headway.

Cut way down on sugar (soda, candies, ice cream) and white flour products (white bread, pastries, muffins, most cereals, even pizza.) Those are the “Nos.” Instead focus on fresh fruits and vegetables, whole grains, seeds and nuts, olives and olive oil, fatty fin fish like salmon, mackerel, or sardines, plus some dairy, poultry (preferably free range), and a limited amount of red meat, again preferably free range, grass fed. Look at the image above; do not think of this as unpleasant. Instead, make it a tasty, enjoyable meal preferably shared with a friend or two.

This will be an excellent start. You will feel better and then you can address some of the other key steps including exercise, stress management, and enhanced sleep. Follow the money; you will save dollars, not only now but big dollars in a future of lessened chronic illnesses. Your health will stack up way better than most.

Stephen C Schimpff, MD, MACP, is a quasi-retired internist, professor of medicine, former CEO of the University of Maryland Medical Center and author of Longevity Decoded – The 7 Keys to Healthy Aging and his co-authored book with Dr Harry Oken BOOM — Boost Our Own Metabolism

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