For 35 years I’ve been involved in healthcare and healthcare IT.  And for 35 years I have been clinically obese as measured by BMI.  Over the past 18 months I’ve made two concerted efforts to change that.  At first I used diet alone and managed to drop from 242lbs to 207lbs, just in time for my daughter’s wedding.

I loved what I achieved and had every intention of continuing, but life and stress at work got in the way and I slipped back over a period of 5 months gaining back 22lbs of that 35lb loss.  Ugh!

So beginning this year I restarted the diet efforts and in February had a physical to make sure I had a baseline of how my body was dealing.  Good news all around with no abnormal results for cholesterol, diabetes markers and a blood pressure that was reasonable for my age.  In April I decided to kick it up and engage in working out with a personal trainer to gain strength and stamina as well as reinforce the dietary weight loss.

I am delighted with the outcome and the trajectory of improvements, and finally am seeing muscle gains and definition that I have never seen before.  That’s because for the first time ever I am using weight based High Intensity Interval training and for the first time ever using a rowing machine (works 85% of your bodies muscles!).  Previous exercise regimes had been limited to walking primarily on a treadmill, great aerobic exercise and walking is great, but I was after a bigger change. I made a repeat visit to the doctors office at the 90 day mark to repeat the bloodwork and left delighted that my BP had improved.

Alarm bells sound

Three days later I got an alarming message through the patient portal that they wanted me to have an ultrasound of my liver due to elevated liver enzyme results and had already tested my blood for Viral hepatitis (thankfully negative!) and therefore were worried that I had a condition known as Autoimune Hepatitis. 

Now, as a nurse I was perplexed as I had no signs or symptoms that would indicate active disease (no jaundice, no gastric pain, weight gain – quite the opposite!) but I agreed to have the ultrasound.  Great news they didn’t find anything bad other than it indicated I had Non Alcoholic Fatty Liver Disease (NAFLD).  I was not surprised as someone whose been obese for more than 30 years that that was there and when I researched further the results of the ultrasound it was clear that the results were typical (and present in 75% of obese people).  The standard protocol that is recommended for managing NFLD is lifestyle change, lose weight and exercise more…..exactly what I was already successfully doing!

The doctor was still not satisfied he wanted me to have a Fibroscan and potentially a Liver biopsy.  At that point I drew the line and started my own research and lo and behold found some studies that confirmed what I had suspected….strenuous muscular exercise is shown to elevate liver enzymes! Learn more here!

Breaking down muscle to build it up

Basically when you build muscle through strenuous exercise you effectively stress and “tear up” the muscle fibers and the debris from that activity ends up in your liver, which is your bodies cleaning and filtration system.  Accordingly your liver has to work harder and produces more of the chemicals it needs to do that.

I provided the research literature to my doctor and told him I was happy to repeat the blood work in another 90 days and if I had any signs or symptoms I would immediately come and see him as there was nothing he could do for my NFLD that I wasn’t already doing!

Lesson for doctors and the EMR

There are a couple of key lesson to this that relate to the use of clinical decision support (CDS) and alerting tools in electronic medical records.

1. CDS is great but it has to be thoughtfully designed and tested to ensure that it targets appropriately.  Alert fatigue from EMR’s and other clinical systems is real and contributing to increased stress and burnout.Alerts also shouldn’t remove the clinician’s ability to look at the patient in the round.  In my case the physician forgot, or ignored, my immediate history (‘Hey doc I am exercising hard and enjoying the gym!’) and wanted to start a cascade of diagnostics ($$$) on an asymptomatic healthy male due to slightly elevated AST/ALT levels but with a ominous and conservative warning from the lab system.  My doc is a decent guy and defensive medicine has honorable intentions, but it shouldn’t be a carte blanche to run up the bill/revenue of the medical providers.  Major issue here in the US healthcare system.
2. Every cohort of patients has outliers. I am sure the doc sees plenty of patients through his door with pathological liver disease.  I just wasn’t one of those!  Exceptions are there all the time, so look for the individual story.

Conclusion

I am going to continue my good work, I am enjoying it and now have overcome all that regained 22lbs.  I am back to 207lbs and continuing the trajectory downwards.  My waist has gone from a 42” pant size to now 36” feeling relaxed.  I have a ways to go to get my BMI score below 30 from obese to just overweight (at 5’6” that would be 184lbs).  I’m also not sure I will ever hit a BMI score of 25 as that would require an ideal weight of just 142lbs.  That seems a long way from here, but I suspect if I can lose another 30lbs and get to between 170-180lbs with the increased muscle gain from the workouts I will be in a very good place!