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You don't have to take a pill

APR 2008

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Medications have their dark side. Exercise, diet, and other changes can be alternatives, but could feel like a whole lot of hard work.

We've gotten used to taking pills for much that ails us, but these days, the medicine cabinet is looking like a rogues' gallery. There's been bad news about the painkiller rofecoxib (Vioxx), the diabetes drug rosiglitazone (Avandia), and, most recently, the cholesterol-lowering combination of ezetimibe and simvastatin (Vytorin). Problems with hormone therapy and antidepressants have also been bannered in headlines.

We don't lack for alternatives. Plenty of research shows that exercise, diet, and other lifestyle changes are effective weapons against many chronic diseases. But there are more findings about preventing diseases with so-called lifestyle changes than there are about treating them. And you won't find many head-to-head comparisons between the conventional drug treatments and the nondrug ones. Often it seems like the nonpharmacological approach doesn't quite get its due. The long review papers on treatment choices typically squirrel it away in a small section, almost as an afterthought.

Inertia, reimbursement incentives, pharmaceutical companies — you can wag an accusing finger at all these. But let's be honest: there's also the wonderful convenience of taking a pill. It's just so much easier than changing what we eat, mustering up the time and willpower to exercise, or fighting the uphill battle of weight loss. Doctors see this and, understandably, figure medication is a more dependable, and responsible, way of treating a disease. And the health care system, as currently configured, doesn't do much to support a nondrug approach.

But for those wary of taking medications who want to take the road less traveled, here's a brief overview of seven common conditions and approaches to managing them without medication or supplements.

 

Arthritis

If 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 painful — and that's what most people care about. Research results published several years ago showed that combining some weight loss (5.7% of body weight) with moderate exercise will result in less pain and improved mobility for heavy people with arthritic knees. The same research group reported results in 2006 showing that a more intensive weight-loss program (8.7% of body weight) results in pain and function improvements in obese people (a body mass index of 30 or more). Even for those who aren't heavy, exercise that doesn't put "load" on the joints — swimming and bicycling are good examples — works to reduce pain. For walking, the right shoes can make a huge difference for people with arthritic knees. Researchers have shown that a padded heel can cut in half the force with which your foot hits the ground with each stride. A knee brace is another thing to try. It can realign the knee, taking pressure off the "compartment" of 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 targets certain muscle groups is a proven pain reliever; beleaguered knees respond well to stronger quadriceps, for example. Some rain on the exercise parade: exercise may be more beneficial — and practical — for people with relatively mild cases of arthritis.

 

Cholesterol

You can adjust your diet in several ways to lower levels of "bad" LDL cholesterol. Your LDL level may drop by 5% or so if you keep foods high in saturated fat (namely, meat and full-fat dairy products) off the menu. Every additional gram of soluble fiber per day — the sort of fiber found in oatmeal, beans, nuts, and fruit — may reduce LDL levels by about 2 mg/dL. Diets that have included margarines fortified with sterols — compounds that block cholesterol absorption — have brought about LDL drops of 10% to 20% in some studies. And in others, low-fat, "plant-based" diets that are very heavy on the vegetables (10 servings a day) and legumes and nuts (4 servings a day) have dialed down LDL levels by almost 10%.

The problem is that all of these approaches fall short of what the statin drugs can accomplish: a drop of 25% to 35% in LDL. The exception may be a diet that includes a veritable dream team of LDL-lowering foods (plant sterols, soy protein, soluble fiber, and almonds). It has managed to match effects of statins in several short, head-to-head studies.

And HDL? Exercise is probably the best way to boost levels of 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 two drinks a day) is another HDL booster. Excess weight, smoking, and diets heavy in easy-to-digest carbohydrates depress HDL levels, so changes in those areas can give your HDL a lift.

 

Cognitive decline

Memory training and other "brain exercises" seem to help healthy older people stay sharp, although there's been some question how well the gains translate to real, everyday activities. Scores of studies have been done and, by and large, the results in people with early, and even full-fledged, Alzheimer's have been positive. Several studies have shown that structured "cognitive stimulation" programs administered by caregivers at home may help Alzheimer's patients. But there are questions about the quality of a lot of the research showing positive results. Moreover, the bar for success is set pretty low: a positive finding is often a slowing of the rate of cognitive decline, not reversing it. Evidence for the mental benefits of physical exercise may be stronger and more consistent than the evidence for mental gymnastics. A study published in 2007 is typical. It showed that even a simple, hour-long exercise program twice a week had a positive effect on the ability of Alzheimer's patients in nursing homes to perform daily activities.

 

Depression

Many studies have found that regular physical activity seems to have an antidepressant effect. Some research has shown that a fairly strenuous exercise program results in a 50% decrease in depressive symptoms, a drop comparable to that seen when people take antidepressant medications or receive cognitive behavioral therapy. The particulars of the program seem less important than sticking with it. Physical activity may affect the brain directly by boosting neurogenesis: brain cells grow a bit and make more connections where it counts. It may not be just the physical activity alone that improves mood. Consider everything that can come with it: camaraderie if you exercise with others, the psychologic boost from adhering to a challenging routine, the relief of focusing on something besides your problems. The exercise-as-antidepressant formula does have a major problem: one common feature of depression is that nothing seems enjoyable or worthwhile. Finding the motivation to exercise may be a huge, even insurmountable, hurdle for some.

 

Diabetes

Although a study cast some doubt about how low blood sugar levels should go, and by what means, it's still important to keep them under control. Regular physical activity is a powerful brake on blood sugar levels because well-exercised muscle becomes more receptive to the insulin that helps it pull sugar in from the bloodstream — sugar that the muscle tissue needs as "fuel" to function properly. Eating fewer sweets and easy-to-digest carbohydrates, both of which are quickly turned into blood sugar, also helps keep the lid on blood sugar levels. Many studies have shown that people whose blood sugar levels have crept up, but haven't yet reached diabetic levels, can avoid full-fledged diabetes with a combination of exercise and diet — without any medication. One of the largest of 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 exercise a week. Nearly twice as many people in the metformin group wound 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 for you. It's more potent than any medicine yet invented.

Whether exercise and diet alone can control blood sugar levels once people are diabetic is harder to answer. The American Diabetes Association (ADA) used to recommend that people newly diagnosed with diabetes try exercise and diet first before moving to medication. Now the ADA says people should start taking metformin right away. The reasoning is that few people were able to keep their blood sugar levels in line with exercise and diet and that failure winds up making the underlying diabetes harder to manage. Overall, that may be true, but the ADA also encourages doctors to tailor their treatment to the individual patient. People with diabetes who want to try to control the disease with exercise and diet alone should talk to their doctor. At the very least, it might be worth a short trial.

 

High blood pressure

If there's one condition that you can change without a pill, it's high blood pressure or, as doctors call it, hypertension. Take your pick: lose some weight, get more exercise, eat less sodium, change your diet. They all work.

If you're heavy, each two pounds of weight loss — easier said than done, we know — translates into a 1 mm Hg drop in systolic (the top number) and diastolic (the bottom number) blood pressure. Regular exercise can even lower your blood pressure if you don't lose weight.

Eliminating about three-quarters of a teaspoon of salt (1.8 grams of sodium) from your diet each day may drop your systolic reading by 5 points and the diastolic by 3. Trials of vegetarian diets have shown they can reduce systolic blood pressure by 5 mm Hg. The Dietary Approaches to Stop Hypertension (DASH) diet is even better, lowering systolic blood pressure as much as 12 points and diastolic pressure by 5. DASH dieting does involve eating a lot of fruits and vegetables (seven to nine servings a day) and low-fat dairy products (two to three servings a day), plus whole grains, nuts, poultry, and fish, all while keeping saturated fat, red meat, and sweets to a minimum. If you've got the discipline to follow DASH and keep your salt intake low, the decrease in blood pressure is comparable to that seen with high blood pressure medications.

Any of these lifestyle strategies will also make blood pressure–lowering medication more effective. Whether they can replace the pills depends on how high your blood pressure is. Current guidelines recommend lifestyle changes for prevention and control of high blood pressure, but they aren't terribly optimistic about the control part, predicting that most people with high blood pressure (defined as 140/90 and above) will need to take one or two medications. Even at lower readings, if someone has other health problems (diabetes, for example), most doctors will prescribe blood pressure pills. But weight loss, exercise, and diet can make lower dosages possible and even eliminate the need for medication altogether.

 

Osteoporosis

Our bones start to weaken at about age 40, and for women, the sudden drop-off of estrogen at menopause accelerates the decline. Weight-bearing exercise, which includes walking, running, and climbing stairs as well as the actual lifting of weights, puts stress on bones, and bone tissue reacts by getting stronger and denser. When we're young, exercise builds up bone. But in older people, and perhaps especially older women, the effect of weight-bearing exercise on bone may be quite small. Studies have shown pretty consistently that intense exercise can increase the bone mineral density of the lumbar spine, although for most people, taking a drug like alendronate (Fosamax) would probably have more of an effect. Some experts believe any decrease in the fracture risk from exercise is probably the result of stronger muscles, and perhaps better balance, not appreciably denser bones. Extra vitamin D (800 to 1,000 IU daily) and calcium (600 to 1,000 mg) top the list of dietary recommendations for osteoporosis. Pills may be the best and easiest way to get the vitamin and mineral in those amounts.