‘Can you sigh for once,’ says Remko Kuipers at the Dijklander Hospital in Enkhuizen. A blonde, 58-year-old woman sits in her bra on the examination bed. Kuipers, cardiologist, listens to her heart.
She has already had chest pains a few times, the woman says when she has put her outerwear back on. The pain radiates to her jaws. And sometimes her heart skips a beat.
“It does sound typical,” says Kuipers, “for the heart. You have a heartbeat with what we call dynamics. That could fit with oxygen deficiency.”
Kuipers continues reading her medical file.
“Your cholesterol was better in 2014, which means that part of it is in your lifestyle. Then losing weight is one thing, eating the good fats. Sugars, also reduce carbohydrates. High-fiber vegetables are best. The risk of a heart attack can be influenced by lifestyle.”
“Yes,” says the woman. “Because how much should my weight be, on average?”
“An easy mnemonic is: as tall as you are, minus the first number. For you, 69 kilos is ideal, roughly ten off. The most important thing is to lose fat, because that is unhealthy. It is eating and moving.”
The woman will receive extra tests, and a cholesterol lowering and blood thinner to reduce the risk of a heart attack until the results are available.
Remko Kuipers (42) talks about lifestyle in his consulting room. As much as possible. He’s not your average doctor. He lived with East African tribes for over a year to research their lifestyle. He learned how to stay healthy with a varied diet, eating unprocessed products, enough exercise, taking rest. With that look he returned to Western healthcare, a world of expensive pills and lifestyle diseases. A world in which people sometimes eat themselves sick.
He thinks cardiologists – and other medical specialists – talk too little about lifestyle. Cardiovascular diseases, he says, are related in more than 80 percent of cases to an unhealthy living environment. The role of genetic predisposition is overestimated. “We benefit much more from stimulating a healthy lifestyle than from yet another new drug that reduces the risk of a heart attack by a few percent.”
Kuipers is by no means the only doctor who advocates that prevention should be given more attention in healthcare. The highest boss also thinks so: Minister of Health Ernst Kuipers (who wants to focus “much more” on prevention), just like his predecessor Hugo de Jonge. Hospitals, insurers, regulators think so. However, prevention in the sector is not getting off the ground. According to the Scientific Council for Government Policy (WRR), this is because too little is being invested in it. “Despite repeated calls” for more prevention, “the share of spending on this has been falling steadily since the turn of the millennium.”
Advocates of prevention believe that now that healthcare providers are threatening to succumb to the great pressure, prevention is more necessary than ever. Many chronic diseases are related to obesity and can be prevented by living a healthy life from an early age.
Lottery you don’t want to win
“Yes, with Kuipers, the cardiologist. I’m not calling unexpectedly, am I?”
One of Kuipers’ patients gave birth a few weeks ago, she came into treatment because she suffered from a rapid heartbeat during pregnancy. She had a heart ultrasound. Kuipers calls about the result.
“Everything looks neat, only the left atrium is a bit large. We see this more often in people who are slightly overweight, that there is more pressure on the left atrium. And then pregnancy also gives some extra pressure. The only tip I can give you: try to get the weight down, then the bust will also improve. If it remains dilated for a long time, the risk of a heart rhythm disorder increases. The chances are small that you will get it at this age. But if you stay overweight all your life, there is a chance that you will get it at fifty, sixty – that is a shame.”
The woman says that she does indeed intend to exercise.
“Very good. Every little thing helps. Try to find a line down. At what speed that is … as long as it goes down, then it is beautiful.”
“It’s double,” he says after hanging up. “I do make people a little sick with what I say, while they don’t feel it. The chance that she really has a heart rhythm disorder is maybe 30 percent, not 100. So I’m wrong more often than I am. But I do have an impact on a population level. Out of a thousand people I see, I can protect hundreds against a cardiac arrhythmia – if they manage to lose weight.”
Lifestyle is a sensitive subject. Don’t blame the patient for his illness. A patient is unlucky, not a perpetrator. Kuipers does not want to blame anyone, he says, but warns. Everyone is at risk of heart problems. “It’s like a lottery, one you don’t want to win. Everyone has a chance, but you can influence how big that chance is.”
Most people respond well, he says, when he brings up the subject. “Some say: that lifestyle has an impact on the heart, no one has ever told me that.”
Still, not everyone is waiting for it. “Some say literally: I don’t feel like it. One person said: give me pills, then I can just eat a steak every day.”
But more often, he says, people admit to finding it difficult. “Or they say: we do eat healthy at home. But then I keep asking, and it turns out that someone drinks a carton of orange juice a day.”
A good conversation about nutrition takes at least half an hour, says Kuipers. That is not good in the fifteen minutes he gets for a consultation. “To be allowed to register an official consultation, I always have to go through the medication and ask about complaints that the patient experiences.”
The Cardiology department where Kuipers works is considering setting up a lifestyle clinic with specialized nurses who can have extensive discussions with patients about this. However, no reimbursement has been arranged for this in the national system of healthcare products (so-called ‘dbc’s’). For example, no reimbursement has been arranged for a slightly longer consultation to talk about lifestyle with the patient, says Kuipers. “That would be very nice, then I can justify in the hospital that I take half an hour for someone.”
The patient can often achieve much more with lifestyle than with pills, says Kuipers. Pills do help, but some of the pills he prescribes only reduce the risk of heart problems by a few percent in absolute terms, says Kuipers. “The risk of a heart attack increases exponentially with multiple risk factors, such as diabetes in addition to high cholesterol, and smoking.”
During lunch, Kuipers walks down the green stairs of the hospital ward in Enkhuizen. Outside he crosses the street to the Albert Heijn on the other side. He bends his knees in the seafood section to grab a packet of smoked mackerel. He opens it in the cafeteria of the hospital ward. It’s his lunch. “More than usual.”
We Dutch eat, he says, too much and too often. “In Tanzania they only ate when there was food. Fasting occasionally is actually good for your body.”
Despite the fact that he didn’t learn anything about nutrition at his training (“completely zero”), he was already fascinated by it at the time. After his studies, he wanted to research health in the place where humans come from: East Africa. Kuipers lived with the Hadzabe, a thousands of years old tribe of hunter-gatherers. In order to talk to them, he learned Swahili. He empathized with them, slept in a cabin, and later a land cruiser with solar panels on the roof, in which he had set up his own lab. He examined their BMI (Body Mass Index), nutrition, took blood, stool and breast milk samples.
Despite the fact that there is hardly any health care for this tribe, the Hadzabe are slim and fit, and hardly have cardiovascular disease and cancer. They have a varied diet and exercise a lot.
The transition to a Western hospital could not have been greater for the young doctor. The abundance was especially striking. “People die in Africa because there are no antibiotics at that time. Here there are people who receive chemotherapy for millions of euros, but who continue to smoke.”
As a cardiologist, he is surprised that he hears little at conferences about the effects of lifestyle and diet on the heart. Much more often it is about pills and medical devices, and the meetings are sponsored by the pharmaceutical industry. “Sometimes I hear: there is not enough evidence for the effects of lifestyle. No, because few large studies are done: it is not subsidized by anyone. There are tig small studies that show that a better lifestyle helps very well. Let’s not pump a billion into a study into yet another cholesterol-lowering agent, but into a major lifestyle study.”
Heart as the engine
The WRR advocates a ‘structurally greater commitment to health’ and broad prevention, not only within the health care sector. What Kuipers finds “frustrating” is the little stimulus from politics. “There is no sugar tax, supermarkets are still allowed to levy more margins on vegetables than on sweets. Everyone knows that lifestyle is important. But why is that can of soda only 29 cents?”
The heart is one of the (many) organs that suffer from an unhealthy life. Think of it as an engine, says Kuipers. “If you are too heavy, the engine cannot cope with the daily ‘work’ and it will wear out faster. If you are under a lot of stress, the engine is always in fifth gear. If you smoke, or if you have high cholesterol, the supply hoses [de bloedvaten] silting up for fuel to the engine.”
Doctors can learn more about the lifestyle of patients based on their blood values than they often do now, says Kuipers, pointing to a file on his computer. “Look, this woman, she is 65, has recently had a heart attack. Her BMI was good, as was her blood pressure. This value here in the blood – the triglycerides – many doctors do not use. I myself was never trained to explain what a triglyceride is until I started my PhD. While the value can actually make a link with how unhealthy someone eats. The higher your triglycerides, the higher the amount of fat that passes from your liver into your blood. To this woman I said: how is it possible that you are slim, but this value is high? ‘I do have a lot of sweets’, said the woman, she was now going to do something about it.”
A healthy lifestyle is not just about nutrition and exercise. Stress can also lead to heart problems. In the afternoon, Kuipers calls a woman who has had a heart attack at the age of 46. A refugee: she was under a lot of stress. Another woman comes in with heart problems after a rough few years with her foster children. “Stress is a huge risk factor. Just look at how many cardiovascular [hart- en vaat] prevent disorders in psychiatric patients.”
The best is a combination of relaxation and exercise, says Kuipers, and then again the best is a combination of power sports and endurance sports. But we should also build more peace into our daily lives. “We live in such a stressed society. Now I have a full clinic day, but if I could schedule half an hour after lunch for a walk, I would be sharper afterwards. Better for the patients afterwards.”
A version of this article also appeared in the December 10, 2022 newspaper