Should You Get an Annual Physical Exam?

What are the risks and benefits of getting a comprehensive annual physical exam and routine blood testing?

The model of getting an annual physical exam dates back nearly a century in American medicine, but recently, many health authorities “have all agreed that routine annual checkups for healthy adults should be abandoned”—yet, the majority of the public still expects not only a comprehensive annual physical exam, but also extensive routine blood testing. “Given the gap between patients’ enthusiasm for and [the new] guidelines’ skepticism about annual head-to-toe examinations, what are physicians to do?” As I discuss in my video Is It Worth Getting an Annual Physical Exam?, “first, we must educate patients about preventive practices of proven and unproven benefit.” For example, the only routine blood test currently recommended by the USPSTF, the official preventive medicine guidelines setting body, is cholesterol.

The reason “why many physicians continue to perform annual examinations of patients’ hearts, lungs, abdomens and even reflexes and continue to order some of the tests that have been proven ineffectual or even harmful” is because, otherwise, the patient might leave unsatisfied with the visit. “Evidence suggests that the more thorough physicians are (that is, the more physical and laboratory examinations they perform), the better patients feel about their health and their physicians.” So, they are like “placebo clinical manoeuvers…But rather than performing unnecessary (and sometimes contraindicated) physical exams and laboratory tests during an annual visit, perhaps physicians should spend some of the time saved by telling their patients why they are not examining their abdomens, hearts and lungs”—that is, why are aren’t just going to go through the motions like some witch doctor. 

“Most important, we need to educate ourselves about the dangers of overdiagnosis….There will always remain a small possibility that our examination might detect some silent, potentially deadly cancer or aneurysm. Unfortunately for our patients, these serendipitous, life-saving events are much less common than the false-positive findings that lead to invasive and potentially life-threatening tests,” wrote a doctor from the Cleveland Clinic. He went on to share a story about his own father who went in for a checkup. Can’t hurt, right? His dad’s physician thought he felt what might have been an aortic aneurism, so he ordered an abdominal ultrasound. Can’t hurt, right? His aorta was fine, but something looked suspicious on his pancreas, so a CT scan was ordered. Well, that can hurt—it’s a lot of radiation—but thankfully, his pancreas looked fine. But…what’s that on his liver? It looked like cancer, which made a certain amount of sense since his dad had worked in the chemical industry. Realizing how ineffective the treatments were for liver cancer, he realized he was going to die.

His daughter was not ready to give up on him, though, and convinced him to see a specialist. Maybe if they cut it out, he could live a few more years. But first, they had to do a biopsy. The good news was he didn’t have cancer. The bad news, though, was that it was a benign mass of blood vessels, so when they stuck a needle in it to biopsy, he almost bled to death. He required ten units of blood—and ten units is about all you have! This resulted in pain, thus morphine, thus urinary retention, and thus a catheter, yet, thankfully, no infection. Just a bill for $50,000. 

The frustrating thing is that there wasn’t any malpractice or anything in the whole horrible sequence. Every step logically led to the next. “The only way to have prevented this [life-threatening] outcome would have been to dispense with the initial physical examination”—the “checkup” that couldn’t hurt, right?

“Why, then, do we continue to examine healthy patients? First of all, we get paid to do it.” His dad’s initial doctor only received a hundred bucks or so, but just think about all that “downstream revenue” for the hospital and all the specialists. Overdiagnosis is big business.

“Too many patients bear the costs and harms of unneeded tests and procedures,” but without annual check-ups, we doctors would miss out on all those opportunities for “open communication and interpersonal continuity…” Is that so? In that case, replied one physician, if you want communication, why not just take your patients out to lunch? 

“Of course, such lunches should fairly and ethically be preceded by an informed consent discussion that allows prospective diners to understand the risk that they will be infantilized, made dependent, and may well receive unnecessary and injurious diagnostic and therapeutic interventions as a consequence of that grilled cheese and soup”—particularly, I would add, if you’re feeding your patients grilled cheese, having already chalked up your first such “unnecessary and injurious” act!

So, if you don’t have any symptoms or issues, should you even have an annual check-up? That was the subject of my last video, Is It Worth Getting Annual Health Check-Ups?.

Should All Children Have Their Cholesterol Checked, too? Watch the video to find out!

Check out this video to Find Out If Your Doctor Takes Drug Company Money.

I sometimes stumble across these peripheral issues and fall down various rabbit holes. For example, I’ve got a whole series of videos on various diagnostic tests such as mammograms. I don’t want to get too far away from nutrition, but whenever I learn something new and interesting—particularly if there are conflicts of interest trying to muddy the waters—I feel compelled to try to share to help set the record straight.

In health,

Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live presentations:

Dr. Gundry’s The Plant Paradox Is Wrong

A book purported to expose “hidden dangers” in healthy foods doesn’t even pass the whiff test.

I started getting emails about The Plant Paradox, a book purporting to expose “the hidden dangers in ‘healthy’ foods that cause disease and weight gain”—foods like beans, whole grains, and tomatoes. Hidden dangers? The author’s talking about lectins in a rehashing of the discredited Blood Type Diet from decades ago. I reviewed it a while ago in my video Blood Type Diet Debunked, but it just keeps coming back. The Plant Paradox was written by an MD, but if you’ve seen my medical school videos including Physicians May Be Missing Their Most Important Tool, you’ll know that is effectively an anti-credential when it comes to writing diet books, basically advertising to the world that they’ve likely received little or no formal training in nutrition. Dr. Atkins was, after all, a cardiologist. Even when we give the benefit of the doubt, the problem is it doesn’t even seem to pass the sniff test, as I discuss in my video Dr. Gundry’s The Plant Paradox Is Wrong.

If lectins are bad, then beans would be the worst, so bean counters would presumably find that bean eaters cut their lives short. But, the exact opposite may be true, with legumes—beans, split peas, chickpeas, and lentils—found to be perhaps “the most important dietary predictor of survival in older people” in countries around the world. As Dan Buettner pointed out in his Blue Zones work, lectin-packed foods are the “cornerstones” of the diets of all the healthiest, longest-lived populations on the planet. Plant-based diets in general and legumes, the most lectin-lush of foods, in particular are a common thread among longevity Blue Zones around the world, as you can see at 1:30 in my video.

If lectins are bad, then whole-grain consumers should be riddled with disease when in fact “whole grain intake is associated with a reduced risk of coronary heart disease,” the number one killer of men and women, “cardiovascular disease, and total cancer, and mortality from all causes” put together. This means that people who eat whole grains tend to live longer and suffer from fewer “respiratory diseases, infectious diseases, diabetes, and all non-cardiovascular, non-cancer causes” to boot. And, this is not only the case in population studies. As I showed in my video Can Oatmeal Help Fatty Liver Disease?, you can randomize people into whole grain interventions and prove cause-and-effect benefits. It’s the same with tomatoes. When you randomize women to a cup and a half of tomato juice or water every day, all that nightshade tomato lectin “reduces systemic inflammation” or has waist-slimming effects, reducing cholesterol as well as inflammatory mediators.

So, when people told me about The Plant Paradox, I thought to myself: Let me guess. He sells a line of lectin-blocking supplements. And, what do you know? His Lectin Shield capsules “assist your body in the fight against lectins” for only $79.95 a month. That’s only about a thousand dollars a year—a bargain for “pleasant bathroom visits.” Then, of course, there are ten other supplements for sale, so for only $8,000 or $9,000 a year, you can lick those lectins. Let’s not forget his skincare line. “Firm + Sculpt” for an extra $120 a month, which is all so much more affordable when you subscribe to his VIP club.

Look, people ask me all the time to comment on a new blog, book, or YouTube video, and I remind them that a hundred thousand peer-reviewed scientific papers on nutrition are published in the medical literature every year and we can barely keep up with those. But because people continually emailed me about this book, I decided I’d give it a chance.  He tells us to “forget everything you thought you knew was true.” (Diet books love saying that.) Okay. Ready? Chapter 1, citation 1: “Eating shellfish and egg yolks dramatically reduces total cholesterol.” What?! Egg yolks reduce cholesterol? What is this citation? I’ve linked the paper he cites on shellfish consumption so you can see it for yourself. By now, you know how these studies go. How do you show a food decreases cholesterol? Remove so much meat, cheese, and eggs that, overall, saturated fat falls—in this case, about 50 percent, as you can see at 4:15 in my video. If you cut saturated fat in half, of course cholesterol levels are going to drop. So, the researchers got a drop in cholesterol after removing meat, cheese, and egg yolks, yet that’s the paper he uses to support his statement that “egg yolks dramatically reduce[d] cholesterol.” That’s unbelievable! That’s the opposite of the truth. As you can see at 4:36 in my video, the truth is if you add egg yolks to people’s diets, their cholesterol goes up. How dare he say otherwise? What’s more, it’s not like he’s spewing some harmless foolishness, like saying the Earth is flat. Heart disease is the number one killer of men and women. His claims could actually hurt people.

So much for my giving him the benefit of the doubt.

This is an unusual article for me. I normally try to stay out of the so-called diet wars and just stick to bringing you the latest science. Roughly 100,000 papers are published on nutrition in the peer-reviewed medical literature every year, and we have a hard enough time keeping up with them, but let me know what you think: Would you like me to allocate time to more of these types of reactive discussions?

You’ll note I never really addressed Dr. Gundry’s thesis about lectins, but I do exactly that in these two videos: How to Avoid Lectin Poisoning and Are Lectins in Food Good or Bad for You?.


Here are links to the videos I alluded to in this article, if you want to learn more:

What else can tomatoes do? See Inhibiting Platelet Activation with Tomato Seeds.

One of the key reasons whole grains may be so beneficial is their effect on our good bacteria. Check out Gut Microbiome: Strike It Rich with Whole Grains and Microbiome: We Are What They Eat to learn more.

In health,

Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live presentations:

Kidney Toxins Created by Meat Consumption

As I discuss in my video How to Treat Heart Failure and Kidney Failure with Diet, one way a diet rich in animal-sourced foods like meat, eggs, and cheese may contribute to heart disease, stroke, and death is through the production of an atherosclerosis-inducing substance called TMAO. With the help of certain gut bacteria, the choline and carnitine found concentrated in animal products can get converted into TMAO. But, wait a second. I thought atherosclerosis, or hardening of the arteries, was about the buildup of cholesterol. Is that not the case?

“Cholesterol is still king,” but TMAO appears to accelerate the process. It seems that TMAO appears to increase the ability of inflammatory cells within the atherosclerotic plaque in the artery walls to bind to bad LDL cholesterol, “which makes the cells more prone to gobble up cholesterol.” So TMAO is just “another piece to the puzzle of how cholesterol causes heart disease.”

What’s more, TMAO doesn’t just appear to worsen atherosclerosis, contributing to strokes and heart attacks. It also contributes to heart and kidney failure. If you look at diabetics after a heart attack, a really high-risk group, nearly all who started out with the most TMAO in their bloodstream went on to develop heart failure within 2,000 days, or about five years. In comparison, only about 20 percent of those starting out with medium TMAO levels in the blood went into heart failure and none at all in the low TMAO group, as you can see at 1:21 in my video.

So, those with heart failure have higher levels of TMAO than controls, and those with worse heart failure have higher levels than those with lesser stage heart disease. If you follow people with heart failure over time, within six years, half of those who started out with the highest TMAO levels were dead. This finding has since been replicated in two other independent populations of heart failure patients.

The question is, why? It’s probably unlikely to just be additional atherosclerosis, since that takes years. For most who die of heart failure, their heart muscle just conks out or there’s a fatal heart rhythm. Maybe TMAO has toxic effects beyond just the accelerated buildup of cholesterol.

What about kidney failure? People with chronic kidney disease are at a particularly “increased risk for the development of cardiovascular disease,” thought to be because of a diverse array of uremic toxins. These are toxins that would normally be filtered out by the kidneys into the urine but may build up in the bloodstream as kidney function declines. When we think of uremic toxins, we usually think of the toxic byproducts of protein putrefying in our gut, which is why specially formulated plant-based diets have been used for decades to treat chronic kidney failure. Indeed, those who eat vegetarian diets form less than half of these uremic toxins.

Those aren’t the only uremic toxins, though. TMAO, which, as we’ve discussed, comes from the breakdown of choline and carnitine found mostly in meat and eggs, may be increasing heart disease risk in kidney patients as well. How? “The cardiovascular implication of TMAO seems to be due to the downregulation of reverse cholesterol transport,” meaning it subverts our own body’s attempts at pulling cholesterol out of our arteries.

And, indeed, the worse our kidney function gets, the higher our TMAO levels rise, and those elevated levels correlate with the amount of plaque clogging up their arteries in their heart. But once the kidney is working again with a transplant, your TMAO levels can drop right back down. So, TMAO was thought to be a kind of biomarker for declining kidney function—until a paper was published from the Framingham Heart Study, which found that “elevated choline and TMAO levels among individuals with normal renal [kidney] function predicted increased risk for incident development of CKD,” chronic kidney disease. This suggests that TMAO is both a biomarker and itself a kidney toxin.

Indeed, when you follow kidney patients over time and assess their freedom from death, those with higher TMAO, even controlling for kidney function, lived significantly shorter lives, as you can see at 4:44 in my video. This indicates this is a diet-induced mechanism for progressive kidney scarring and dysfunction, “strongly implying the need to focus preventive efforts on dietary modulation,” but what might that look like? Well, maybe we should reduce “dietary sources of TMAO generation, such as some species of deep-sea fish, eggs, and meat.”

It also depends on what kind of gut bacteria you have. You can feed a vegan a steak, and they still don’t really make any TMAO because they haven’t been fostering the carnitine-eating bacteria. Researchers are hoping, though, that one day, they’ll find a way to replicate “the effects of the vegetarian diet…by selective prebiotic, probiotic, or pharmacologic therapies.”


For more on this revolutionary TMAO story, see:

For more on kidney failure, see Preventing Kidney Failure Through Diet and Treating Kidney Failure Through Diet.

In health,

Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live presentations: