The Unintended Consequences Of Medical “Maximalism”

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Health (Photo credit: 401(K) 2013)

The Health Affairs blog questions the American Heart Association’s maximalist approach with the use of statins. The issues sound familiar.

The policy implications of these guidelines are staggering. Estimates show that if these recommendations are fully implemented, close to a third of all Americans will be placed on a statin. But these developments beg the question: Is this the right policy? Is taking a statin the most effective way for the millions of Americans who are at risk of heart disease to reduce their risk?

When appropriately prescribed, evidence substantiates that statins do reduce heart attack risk, but how do they compare to other interventions? We know that lower cholesterol is better, and we know that statins help to reduce heart disease risk, but we also know that the most effective way to reduce heart disease is not necessarily by taking more pills in ever-increasing doses – it’s to engage in lifestyle change. The best way to reduce risk is by losing weight if overweight, quitting smoking if a smoker, exercising if sedentary, and eating a Mediterranean style diet. Over the past few decades, we have gotten less active, we weigh more, and we eat too much unhealthy food. The new guidelines may have the unintended consequence of de-emphasizing the things that we know reduce risk the most in favor of treatments that are less effective.

Lifestyle change is also emphasized in the guidelines, but it can be very difficult to change deeply embedded behaviors, no matter how unhealthy they may be. When people are unable or unwilling to make those changes, frustrated clinicians looking for another solution often turn to medication as the easy answer for their patients. But a blanket prescription that everyone who has heart disease, or who is at risk for it, take a statin may encourage those most at risk to be lulled into a false sense of security. As cholesterol numbers go down, patients may no longer feel at risk, but the truth is a lot more complicated. For individuals who fall into the four benefit groups, then, yes, the drugs will likely lower their risk of a heart attack; but they will still likely have a heart attack at some point in their life. Medications cannot effectively insulate us from the results of our unhealthy choices.

The parallels are not perfect, as exemplified by his emphasis on choice in his closing, but the parallels are close enough to make clear that addiction treatment providers are not alone with our questions about medical maximalism vs. lifestyle changes.

Guidelines like those released last month reinforce how far society and our health care system have swung away from prevention and towards the medical model, which treats disease, but often does an inadequate job of promoting public health. Lifestyle change won’t help everyone. Some may still need to take a statin, even after they change their lifestyle. But for many, making healthier choices is enough. As medical science advances, we will continue to have better drugs, and the tendency of providers might be to expand their use. But the solutions to many of the ills that plague large numbers of Americans—high blood pressure, high cholesterol, diabetes, and the heart disease that they cause—do not lie in taking more and more pills to treat more of our preventable chronic conditions. They lie in motivating the millions of Americans who are currently living an unhealthy lifestyle to make better choices.

While experts in other areas of health may neglect promoting lifestyle changes, I suspect most would acknowledge that, for most people, lifestyle changes are either the preferred way to resolve the chronic health problem, the front line response, or be a prominent feature of every treatment plan. In opiate addiction, the field has swung so far in the maximalist direction that we’ve gotten to the point where we can’t even agree on that.

David Katz addresses the questions this discussion begs:

As far as I’m concerned, the entire debate about statins is part of our societal static. It’s a background noise of cultural misdirection that favors the conflated interests of Big Food and Big Pharma while ignoring the compelling, consistent, signal of what lifestyle as medicine could do for us all.

We could prevent all those heart attacks, and more, without putting statins in the drinking water. We could add years to life, and life to years, and save rather than spend money doing it – if lifestyle were our preferred medicine. The signal has been there for literal decades that minimally 80 percent of all heart disease could be eliminated by lifestyle means readily at our disposal. There is a case that, but for rare anomalies, heart disease as we know it could be virtually eradicated by those same lifestyle means. And the same lifestyle medicine that could do this job would slash our risk for every other bad outcome as well, while enhancing energy, cultivating vitality, and contributing to overall quality of life. And unlike our statins, we could share these benefits with those we love.

But for the most part, we as individuals, and collectively as a culture, seem deaf to this signal. We watch our peers and parents succumb to heart disease, and wring our hands. We fret over the same fate overtaking us. We get prescriptions for drugs we wish we didn’t have to take, worry about serious side effects, suffer through minor ones, grumble about copays, and implicate ourselves in the unmanageable burden of “health” care costs.

via The Unintended Consequences Of The New Statin Guidelines – Health Affairs Blog.

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