[Ed note: if you’re new to Doc Gumshoe, this is our break from investment chatter: He’s our favorite medical writer and he shares his contrarian and thoughtful commentaries with us every now and again. Any opinions and assertions are his own.]
It all starts with an unassailable truth: the healthier you are to start with, the better your odds of fighting off a whole range of illnesses, from Addison’s Disease to Zollinger-Ellison syndrome. The essentials of staying healthy are not deeply mysterious, and if I listed them here, you would likely emit a groan and move on to something more interesting. But another truth, unfortunately also unassailable, is that for most of history, the emphasis in mainstream medicine has been not on keeping people healthy, but on treating sickness. People go to the doctor, not when they want advice on how to stay healthy, but when they are sick. The first medical question the doctor wants an answer to is, “what’s your principal complaint?” If you don’t have a principal complaint, why are you here?
Yes, there have always been wise doctors who stressed staying healthy, and recently health maintenance has been increasingly emphasized by all manner of medical bodies – government, academic, professional organizations, and voluntary groups. Take high blood pressure – hypertension – as an example.
The JNC7 Catechism
The Joint National Committee on Prevention, Detection, Evaluation, and treatment of High Blood Pressure (widely known as the JNC) has, in its past several treatment recommendations, emphasized “Life Style Modifications” as the treatment for persons having what they now term “prehypertension.” Here’s how they classified blood pressure in their latest recommendations:
[The Seventh Report of the Joint National Committee on Prevention, Detection Evaluation, and Treatment of High Blookd Pressure. JAMA 2003;289:256-71]
And here’s how they say prehypertension needs to be treated:
“Prehypertension is not a disease category. Rather, it is a designation chosen to identify individuals at high risk of developing hypertension, so that both patients and clinicians are alerted to this risk and encouraged to intervene and prevent or delay the disease from developing. Individuals who are prehypertensive are not candidates for drug therapy based on their level of BP and should be firmly and unambiguously advised to practice lifestyle modification in order to reduce their risk of developing hypertension in the future (see Lifestyle Modifications).”
This is what they say about Lifestyle Modifications:
“Adoption of healthy lifestyles by all persons is critical for the prevention of high BP and is an indispensable part of the management of those with hypertension. … BP is also benefited by an adoption of the Dietary Approaches to Stop Hypertension (DASH) eating plan, which is a diet rich in fruits, vegetables, and lowfat dairy products with a reduced content of dietary cholesterol as well as saturated and total fat. … Dietary sodium should be reduced to no more than 100 mmol per day (2.4 g of sodium). Everyone who is able should engage in regular aerobic physical activity such as brisk walking at least 30 minutes per day most days of the week. Alcohol intake should be limited to no more than 1 oz (30 mL) of ethanol, the equivalent of two drinks per day in most men, and no more than 0.5 oz of ethanol (one drink) per day in women and lighter weight persons. … For overall cardiovascular risk reduction, patients should be strongly counseled to quit smoking.”
What Happens in the So-Called “Real World”
So here’s what happens, at least quite a lot of the time: our patient walks into the doctor’s office, and his blood pressure is 135 over 85. (I made our patient a man, because men are more likely to have high blood pressure than women.) The doctor tells him, without a whole lot of conviction, that he has “prehypertension,” and that he needs to do some lifestyle modification. (I should note here that the concept of “prehypertension” has not had a lot of take-up in the clinical community; most docs have a reasonably good notion of which of their patients are at higher risk for developing established hypertension and which ones can continue in the “prehypertension” range without progressing to the real thing.)
Our patient already knows what’s coming: more exercise, less yummy food, less booze, no sm