You don’t have to take a pill



APRIL 2008


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

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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 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 socalled 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

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.

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Dr.D. Every additional gram of soluble fiber per day—the sort of fiber found in D. Stephen E. the results in people with early.D.harvard.S.D.. “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%.. M.M. and almonds).D. and even full-fledged. Harvard Health Letter P. 2nd Floor. a drop comparable to that seen when people take antidepressant medications or receive cognitive behavioral therapy. But there are questions about the quality of a lot of the research showing positive results. www. low-fat. Donald T.Medication alternatives continued from page 1 Cholesterol WHo WE ARE Editor in Chief Anthony L. by and large. Evidence for the mental benefits of physical exercise may be stronger and more consistent than the evidence for mental gymnastics.. Jo Shapiro. Moreover. Dr. and fruit—may reduce LDL levels by about 2 mg/dL. Manson. Kenneth Arndt. Editor Peter Wehrwein peter_ wehrwein@hms. Letters Harvard Health Letter 10 Shattuck St.harvard.D. The particulars of the program seem less important than sticking with it. Kenneth L.D. MA 02115 Permissions Copyright Clearance Center.copyright. Physical activity may affect the brain directly by boosting neurogenesis: brain cells grow a bit and make more connections where it counts. ON N8X 1Z1 E-mail: ddewitt@swchp. a division of Harvard Medical School Editor in Chief Anthony L. Moderate alcohol consumption (one or two drinks a day) is another HDL booster.. M.. TX 75755-9308 Subscriptions $32 per year (U. 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. M. Finding the motivation to exercise may be a huge.D. R. soluble fiber.D.D. MA 02115 PUBLICATIONS MAIL AGREEMENT NO. Excess weight.D. Miller. Pauker. And in others.D. M. Cardiology Dental Medicine Dermatology Emergency Medicine Gastroenterology Genetics Gerontology Internal Medicine Neurology Nutrition Oncology Ophthalmology Orthopedics Otolaryngology Preventive Medicine Psychiatry Surgery Urology Women’s Health Thomas H. Alzheimer’s have been positive. You can adjust your diet in several ways to lower levels of “bad” LDL cholesterol. Soheyla Gharib. the bar for success is set pretty low: a positive finding is often a slowing of the rate of cognitive decline. Minaker. Willett. Robert J. M.harvard. Dennis Selkoe. M. Your LDL level may drop by 5% or so if you keep foods high in saturated fat (namely. Writer Christine Junge Art Director Heather Derocher Illustrator Alex Gonzalez Production Coordinator Charmian Lessis Copy Editor Robin Netherton • Editorial Board Board members are associated with Harvard Medical School and affiliated institutions.D. 2nd Floor Boston..P. M. A study published last year is typical.D. nuts.D.P.H. Ph. M. Reilly. CT 06901 jmitchell@staywell. not reversing it. M. Bruce Bistrian. It showed that even a simple. soy protein. M. hourlong exercise program twice a week had a positive effect on the ability of Alzheimer’s patients in nursing homes to perform daily activities. even insurmountable. It may not be just the physical activity alone that improves mood. Komaroff. meat and full-fat dairy products) off the menu. 1415 JANETTE AVE. Corporate Sales/Licensing StayWell Consumer Health Publishing One Atlantic St. Depression Many studies have found that regular physical activity seems to have an antidepressant effect. Lee. Publishing Director Edward Coburn © 2008 Harvard University (ISSN 1052-1577) Proceeds support research efforts of Harvard Medical School. M. B. Jerome P. hurdle for some. Several studies have shown that structured “cognitive stimulation” programs administered by caregivers at home may help Alzheimer’s patients.. Box 9308 Big Sandy. They review all published Published monthly by Harvard Health Publications. Call E-mail Online Letters Cognitive decline Memory training and other “brain exercises” seem to help healthy older people stay 2 | Harvard Health Letter April 2008 . head-to-head studies. JoAnn E. Consider everything that can come with it: camaraderie if you exercise with others.harvard. the relief of focusing on something besides your problems. Boston. Ph. Stamford. so changes in those areas can give your HDL a lift. www. Bruce Donoff.D. M. 40906010 RETURN UNDELIVERABLE CANADIAN ADDRESSES TO: CIRCULATION DEPT. Edward Wolpow. although there’s been some question how well the gains translate to real. John Tobias Nagurney. Richie. • HoW To REACH us Customer service 877-649-9457 (toll-free) harvardHL@strategicfulfillment. Komaroff. Richard Hodin. beans. Inactive people who start to exercise regularly have seen their HDL levels increase by as much as 20%. Some research has shown that a fairly strenuous exercise program results in a 50% decrease in depressive Walter C. The exerciseas-antidepressant formula does have a major problem: one common feature of depression is that nothing seems enjoyable or worthwhile.) Bulk Subscriptions StayWell Consumer Health Publishing One Atlantic St. Mayer.. The exception may be a diet that includes a veritable dream team of LDL-lowering foods (plant sterols. WINDSOR. Stamford. everyday activities.D. CT 06901 888-456-1222 x106 (toll-free) 203-975-8854 x106 ddewitt@swchp. Scores of studies have been done and. M. Online Editorial Correspondence E-mail health _ letter@hms. Michael C. Thomas Hutchinson. It has managed to match effects of statins in several short. 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.H.D. And HDL? Exercise is probably the best way to boost levels of the “good” cholesterol. M.D.. Nancy Keating.D.O. M.P. M. M.D. Harvard Health Publications 10 Shattuck St. M. M. M. M. the psychologic boost from adhering to a challenging routine. Susan P.D. and diets heavy in easy-to-digest carbohydrates depress HDL levels.H.

and climbing stairs as well as the actual lifting of weights. we know—translates into a 1 mm Hg drop in systolic (the top number) and diastolic (the bottom number) blood pressure. exercise builds up bone. But weight loss.8 grams of sodium) from your diet each day may drop your systolic reading by 5 points and the diastolic by 3. but they aren’t terribly optimistic about the control part. Current guidelines recommend lifestyle changes for prevention and control of high blood pressure. When it comes to developing diabetes. that may be if someone has other health problems (diabetes. nuts. Take your pick: lose some weight. High blood pressure If there’s one condition that you can change without a pill. Regular exercise can even lower your blood pressure if you don’t lose weight. change your diet. If you’re heavy.Diabetes Although a recent study cast some doubt about how low blood sugar levels should go. If you’ve got the discipline to follow DASH and keep your salt intake low. It’s more potent than any medicine yet invented. but haven’t yet reached diabetic levels. and for women. running. Now the ADA says people should start taking metformin right away. April 2008 Harvard Health Letter | 3 . Even at lower readings. it might be worth a short trial. poultry. 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. and fish. and by what means. Many studies have shown that people whose blood sugar levels have crept up. and sweets to a minimum. and bone tissue reacts by getting stronger and denser. and perhaps especially older women. and perhaps better balance. red meat.000 IU daily) and calcium (600 to 1. eat less sodium. taking a drug like alendronate (Fosamax) would probably have more of an effect. as doctors call it. Extra vitamin D (800 to 1. both of which are quickly turned into blood sugar. can avoid full-fledged diabetes with a combination of exercise and diet — without any medication. each two pounds of weight loss—easier said than done. Any of these lifestyle strategies will also make blood pressure–lowering medication more effective. Nearly twice as many people in the metformin group wound up with diabetes compared with those in the lifestyle group. for example). most doctors will prescribe blood pressure pills. the effect of weight-bearing exercise on bone may be quite small. Whether exercise and diet alone can control blood sugar levels once people are diabetic is harder to answer. the sudden drop-off of estrogen at menopause accelerates the decline. although for most people. not appreciably denser bones. Whether they can replace the pills depends on how high your blood pressure is. Some experts believe any decrease in the fracture risk from exercise is probably the result of stronger muscles. They all work. But in older people. which includes walking. The difference was even greater in people older than 60. Overall. predicting that most people with high blood pressure (defined as 140/90 and above) will need to take one or two medications. 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). Weight-bearing exercise. and diet can make lower dosages possible and even eliminate the need for medication altogether.harvard. the decrease in blood pressure is comparable to that seen with high blood pressure medications. hypertension. get more exercise. but the ADA also encourages doctors to tailor their treatment to the individual patient. it’s high blood pressure or. 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. lowering systolic blood pressure as much as 12 points and diastolic pressure by 5.000 mg) top the list of dietary recommendations for osteoporosis. it’s not just that exercise is good for you. At the very least. Studies have shown pretty consistently that intense exercise can increase the bone mineral density of the lumbar spine. The American Diabetes Association (ADA) used to recommend that people newly diagnosed with diabetes try exercise and diet first before moving to medication. puts stress on bones. Pills may be the best and easiest way to get the vitamin and mineral in those amounts. all while keeping saturated fat. www. Trials of vegetarian diets have shown they can reduce systolic blood pressure by 5 mm Hg. plus whole grains. People with diabetes who want to try to control the disease with exercise and diet alone should talk to their doctor. The Dietary Approaches to Stop Hypertension (DASH) diet is even better. Eating fewer sweets and easy-to-digest Osteoporosis Our bones start to weaken at about age 40. 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. When we’re young. exercise. also helps keep the lid on blood sugar levels. Eliminating about three-quarters of a teaspoon of salt (1. it’s still important to keep them under control.