VOLUME 33 • N UMBER 6
You don’t have to take a pill
Medications have their dark side. Exercise, diet, and other changes
can be alternatives, but could feel like a whole lot of hard work.
W
e’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 re-
cently, the cholesterol-lowering combination
of ezetimibe and simvastatin (Vytorin). Prob-
lems with hormone therapy and antidepres-
sants 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 con-
ventional drug treatments and the nondrug
ones. Often it seems like the nonpharmaco-
logical approach doesn’t quite get its due. The
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 re-
ported 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, ex-
ercise that doesn’t put “load” on the
joints — swimming and bicycling are
APRIL 2008
INSIDE
Rendered scentless
long review papers on treatment choices typi- Causes and treatments
cally squirrel it away in a small section, almost for the loss of our
most neglected sense,
as an afterthought. smell.. . . . . . . . . . . . . . . 4 – 5
Inertia, reimbursement incentives, pharma­
ceutical companies—you can wag an accus­ Paws and effects
ing finger at all these. But let’s be honest: The risks and benefits
there’s also the wonderful convenience of tak- of having a pet.. . . . . . . 6 –7
ing a pill. It’s just so much easier than chang- By the way, doctor
ing what we eat, mustering up the time and Vitamin D: How much is too
willpower to exercise, or fighting the uphill much? Why does my mitral
battle of weight loss. Doctors see this and, valve leak? . . . . . . . . . . . . . . 8
understandably, figure medication is a more
dependable, and responsible, way of treating In future issues
a disease. And the health care system, as cur- Masculinity and men’s health
rently configured, doesn’t do much to support Herb-drug interactions
a nondrug approach.
Peripheral neuropathy
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.
Newly Revised
good examples — works to reduce pain. For Special Health Reports
walking, the right shoes can make a huge from Harvard Medical School
difference for people with arthritic knees. Re-
Prostate Disease
searchers have shown that a padded heel can
cut in half the force with which your foot hits Osteoporosis: A guide to
prevention and treatment
the ground with each stride. A knee brace is
another thing to try. It can realign the knee, To order, call 877-649-9457
(toll free) or visit www.health.
taking pressure off the “compartment” of the
harvard.edu.
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 Write to us at
health _letter@hms.harvard.edu
to stronger quadriceps, for example.
Some rain on the exercise parade: Visit us online at
exercise may be more beneficial — www.health.harvard.edu
and practical — for people with rela- For customer service, write us at
tively mild cases of arthritis. harvardHL@strategicfulfillment.com
 Medication alternatives continued from page 1

Cholesterol
Who WE ARE
Editor in Chief Anthony L. Komaroff, M.D. You can adjust your diet in several ways to lower levels
Editor Peter Wehrwein of “bad” LDL cholesterol. Your LDL level may drop by 5%
peter_ wehrwein@hms.harvard.edu
Writer Christine Junge or so if you keep foods high in saturated fat (namely, meat
Art Director Heather Derocher and full-fat dairy products) off the menu. Every additional
Illustrator Alex Gonzalez
Production Coordinator Charmian Lessis gram of soluble fiber per day—the sort of fiber found in oatmeal, beans,
Copy Editor Robin Netherton nuts, and fruit—may reduce LDL levels by about 2 mg/dL. Diets that have
• included margarines fortified with sterols—compounds that block cholesterol
Editorial Board absorption—have brought about LDL drops of 10% to 20% in some studies.
Board members are associated with Harvard Medical School
and affiliated institutions. They review all published articles. And in others, low-fat, “plant-based” diets that are very heavy on the vegeta­
Cardiology Thomas H. Lee, M.D. bles (10 servings a day) and legumes and nuts (4 servings a day) have dialed
Dental Medicine R. Bruce Donoff, D.M.D., M.D.
Dermatology Kenneth Arndt, M.D. down LDL levels by almost 10%.
Emergency Medicine John Tobias Nagurney, M.D. The problem is that all of these approaches fall short of what the statin
Gastroenterology

Genetics
Stephen E. Goldfinger, M.D.
Susan P. Pauker, M.D.
drugs can accomplish: a drop of 25% to 35% in LDL. The exception may be a
Gerontology Kenneth L. Minaker, M.D. diet that includes a veritable dream team of LDL-lowering foods (plant sterols,
Internal Medicine Nancy Keating, M.D., M.P.H. soy protein, soluble fiber, and almonds). It has managed to match effects of
Neurology Dennis Selkoe, M.D.
Edward Wolpow, M.D. statins in several short, head-to-head studies.


Nutrition Bruce Bistrian, M.D., Ph.D.
Walter C. Willett, M.D., Dr.P.H.
And HDL? Exercise is probably the best way to boost levels of the “good”
Oncology Robert J. Mayer, M.D. cholesterol. Inactive people who start to exercise regularly have seen their HDL


Ophthalmology
Orthopedics
B. Thomas Hutchinson, M.D.
Donald T. Reilly, M.D., Ph.D.
levels increase by as much as 20%. Moderate alcohol consumption (one or two
Otolaryngology Jo Shapiro, M.D. drinks a day) is another HDL booster. Excess weight, smoking, and diets heavy
Preventive Medicine JoAnn E. Manson, M.D., Dr.P.H. in easy-to-digest carbohydrates depress HDL levels, so changes in those areas
Psychiatry Michael C. Miller, M.D.
Surgery Richard Hodin, M.D. can give your HDL a lift.
Urology Jerome P. Richie, M.D.
Women’s Health Soheyla Gharib, M.D.

• Cognitive decline Depression

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Memory training and other “brain exer-
cises” 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 Alzheim-
er’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 posi-
tive finding is often a slowing of the
rate of cognitive decline, not revers-
ing it. Evidence for the mental benefits
of physical exercise may be
stronger and more consistent
than the evidence for mental
gymnastics. A study published
last year 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.
Many studies have found that regular
physical activity seems to have an anti­
depressant effect. Some research has
shown that a fairly strenuous exercise
program results in a 50% decrease in
depressive symptoms, a drop compa-
rable to that seen when people take
anti­depressant medications or receive
cognitive behavioral therapy. The par-
ticulars of the program seem less impor-
tant 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: cama-
raderie 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 enjoy-
able or worthwhile. Finding the
motivation to exercise may be
a huge, even insurmount­able,
hurdle for some.

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

Diabetes
Although a recent 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 func-
tion 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 exer-
cise 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 medica-
tion. 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 doc-
tor. 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 Osteoporosis
pressure or, as doctors call it, hypertension. Take your pick: lose some weight, Our bones start to weaken at about
get more exercise, eat less sodium, change your diet. They all work. age 40, and for women, the sud-
If you’re heavy, each two pounds of weight loss—easier said than done, we den drop-off of estrogen at meno-
know—translates into a 1 mm Hg drop in systolic (the top number) and dia- pause accelerates the decline.
Weight-bearing exercise, which in-
stolic (the bottom number) blood pressure. Regular exercise can even lower
cludes walking, running, and climb-
your blood pressure if you don’t lose weight. ing stairs as well as the actual lifting
Eliminating about three-quarters of of weights, puts stress on bones,
a teaspoon of salt (1.8 grams of sodium) and bone tissue reacts by getting
from your diet each day may drop your stronger and denser. When we’re
systolic reading by 5 points and the young, exercise builds up bone.
diastolic by 3. Trials of vegetarian diets But in older people, and perhaps
have shown they can reduce systolic especially older women, the effect
blood pressure by 5 mm Hg. The Dietary of weight-bearing exercise on bone
Approaches to Stop Hypertension (DASH) diet may be quite small. Studies have
shown pretty consistently that
is even better, lowering systolic blood pressure as much as 12 points and dia-
intense exercise can increase the
stolic pressure by 5. DASH dieting does involve eating a lot of fruits and veg- bone mineral density of the lumbar
etables (seven to nine servings a day) and low-fat dairy products (two to three spine, although for most people,
servings a day), plus whole grains, nuts, poultry, and fish, all while keeping taking a drug like alendronate
saturated fat, red meat, and sweets to a minimum. If you’ve got the discipline (Fosamax) would probably have
to follow DASH and keep your salt intake low, the decrease in blood pressure more of an effect. Some experts
is comparable to that seen with high blood pressure medications. believe any decrease in the fracture
Any of these lifestyle strategies will also make blood pressure–lowering risk from exercise is probably the
medication more effective. Whether they can replace the pills depends on how result of stronger muscles, and per-
high your blood pressure is. Current guidelines recommend lifestyle changes haps better balance, not apprecia-
bly denser bones. Extra vitamin D
for prevention and control of high blood pressure, but they aren’t terribly
(800 to 1,000 IU daily) and calcium
optimistic about the control part, predicting that most people with high blood (600 to 1,000 mg) top the list of
pressure (defined as 140/90 and above) will need to take one or two medica- dietary recommendations for osteo-
tions. Even at lower readings, if someone has other health problems (diabetes, porosis. Pills may be the best and
for example), most doctors will prescribe blood pressure pills. But weight loss, easiest way to get the vitamin and
exercise, and diet can make lower dosages possible and even eliminate the mineral in those amounts.
need for medication altogether.

www.health.harvard.edu April 2008 Harvard Health Letter | 3