Tuesday, June 05, 2012

I Know What's Good For You

In medicine, we have certain beliefs, and these beliefs guide what treatments we prescribe and, more generally, how we tell people they should live their lives.  Sometimes, we're right-- and I say that mostly because people do live longer and healthier lives then they used to.  The average lifespan is longer than it was 50 years ago, so I think medicine is likely doing some things right.  And while some of the things that we prescribe or recommend are guided by evidence-based studies, some are not, or some of the studies are flawed, equivocal, or just plain wrong.  One can't study every detail of lifestyle, diet, sleep, medication response, chemical exposure, or whatever else there is that might alter healthfulness in a controlled and accurate way, though to read some of the stuff out there, one would think you could. 

We don't know a lot-- this is true for all of medicine, not just psychiatry, but it's true for psychiatry too.  Sometimes we think we do, and we proclaim truths that might just not be. 

So I'm going to refer you to a number of sites to see what you think.

Over on KevinMD, Edwin Leap writes about "When self-evident truth in medicine is systematically ignored."  Dr. Leap writes:

And yet, medicine is filled with situations in which “self-evident truth” is systematically ignored, and those who believe in it intentionally and often viciously marginalized.
For example, after years of being told that physicians weren’t giving enough treatment for pain, and after years of clinicians saying, “yes we are, and too many people are addicted and abusing the system,” the data from CDC says that far too many are dying from prescription narcotics, far too many infants being born addicted, and far too many people, young and old, are using analgesics and other drugs not prescribed for them.  To which many of us say, “duh!”

Today's New York Times "most emailed list" includes  articles which question our assumptions or assert new truths :

1) Gary Taubes writes in "Salt, We Misjudged You," :

While, back then, the evidence merely failed to demonstrate that salt was harmful, the evidence from studies published over the past two years actually suggests that restricting how much salt we eat can increase our likelihood of dying prematurely. Put simply, the possibility has been raised that if we were to eat as little salt as the U.S.D.A. and the C.D.C. recommend, we’d be harming rather than helping ourselves.
WHY have we been told that salt is so deadly? Well, the advice has always sounded reasonable. It has what nutritionists like to call “biological plausibility.”

I add as an addendum that I think I missed the lecture in medical school where salt was the "Public Enemy No. 1."   I somehow got through physiology and pathology believing that if a person has normal kidney function and doesn't suffer from congestive heart failure or have problems with fluid retention, that excess salt gets excreted and isn't associated with shortening your life.  (The issue of CHF was a big one though, for those who had it, a bowl of soup could land them in the ICU).  So Gary Taubes is the same guy who wrote a NYTimes Magazine article 10 years ago that gave credibility to the Atkins diet and challenged our beliefs that pasta and carbohydrates and a low-fat diet are good for you in What If It's All Been a Big Fat Lie?

I think we all have beliefs about what it's healthy to eat, but we don't have real answers and I imagine that the answer is more related to individual biology then anything we've come to entertain as a society with our food pyramids. We'll have to see if New Yorkers live longer when they can't get super-sized soft drinks.

2) Jane Brody writes in Slathering on Sunscreen, Early and Often, about the necessity of teaching children to put on sunscreen like we teach them to fasten their seat belts.  She gives statistics for early sun exposure and the increased risk of skin cancers.  It's all said as a given, and maybe she's right, but commenters wrote in asserting that sunscreens cause skin cancer, that the chemicals in them are toxic, that the evidence is lacking, that sunscreen blocks the light rays needed for Vitamin D production and all the problems associated with low Vitamin D levels, and there were examples of populations that spend more time in the sun but have lower rates of skin cancer.  No answers from me, but I'm not as certain as Jane Brody that the evidence is there to suggest that sunscreening everyone will lead to longer, happier, or healthier lives, and I'm not sure it won't either.  I, for one, don't like the smell. 

3) Exercise is good for you, right?  I actually do believe that.  But Gina Kolata writes in For Some, Exercise May Increase Heart Risk that 10% of people got worse, after exercise, on at least one measure (meaning a lab value or their blood pressure) related to heart disease.

The problem with studies of exercise and health, researchers point out, is that while they often measure things like blood pressure or insulin levels, they do not follow people long enough to see if improvements translate into fewer heart attacks or longer lives. Instead, researchers infer that such changes lead to better outcomes — something that may or may not be true.

4) Finally, in The Trouble With Doctor Knows Best, Peter Kahn writes:

Against the gravitational pull of doctor-knows-best culture, research studies that fail to confirm current practice often have surprisingly little effect on our behavior. Guidelines written by academic types only impact the fringes of our practices. And despite the apparent move toward evidence-based medicine and comparative effectiveness research, most of us still feel that our own experiences and insights are the most relevant factors in medical decision-making. 

What's the take home message?  Question everything, and know that there is a lot we don't know.  We live in a society where we're constantly told what's good for us and what's not, where doctors can be insistent about what's best for patients, where people can be judgmental and self-righteous about the lifestyles they choose to follow.  Now if you'll please pass the butter and salt for my popcorn, and yes, I'd like a beer with that. 


Jane said...

I've read that too about sunscreen (that it's not healthy to wear it all the time). And I believe that. I read somewhere, wish I had a link, that Australians were being told to NOT wear sunscreen some of the time during the day. There was a rise in vitamin D deficiencies, because the government was trying to promote sunscreen to decrease skin cancer rates. People wore sunscreen all the time, and doctors ended up treating more vitamin D deficiencies. I really think I got a D deficiency last year because of that. I think the recommendation that I read was that people should get direct sun exposure three times a week at least for 15 minutes a day or longer.

In this heat, I gotta put it on a lot. I've already gotten some nasty sunburns. And that wasn't from going to the beach. That was just from walking around town.

SteveBMD said...

I just got done reading this article about the new DSM-5 "addiction" diagnoses (it actually supports the DSM!) in the NY Times:


Addiction, IMHO, provides another example of "self-evident truth" in medicine. We can argue till we're blue in the face about what constitutes an "addiction," but if you've ever worked with, or lived with, an addict, all the hallmarks are there. You don't need any fancy brain scans or detailed questionnaires, you just see it.

The anti-DSM crowd worry (perhaps correctly) about the risks of overdiagnosis, or the potential cost to our health care system. But if we just use common sense, something tells me we'll be just fine.

Anonymous said...

I think that people frequently fail to factor "moderation" into lifestyle equations. Everyone wants to wear sunscreen ALL the time, or NEVER eat carbs, or exercise EVERY single day. People like the all-or-nothing advice because it's easy to follow. Moderation, on the other hand, takes a certain level of self-control and wisdom.

What I've learned from some of the oldest, healthiest people I know is that they do not tend to live on the extreme end of anything. They don't do the "right" thing 100% of the time, but that seems to work in their favor. Life isn't meant to be flawless.

Sideways Shrink said...

I don't tell my patients what to do--at least not about anything important--unless it has to do with getting them to follow up on a life and death medical test result they have received despite their anxeity.
But I have begun to think that besides the advances in medicine and nutrition, the reason those elderly people report moderate lifestyles as important is because they have the genetics to live that long life and because the grace of old age lends itself to moderation and so they report their current habits as historically true. My suspicion is that besides lucky genetics, no virus,no accident, no war, no birth bed fever happened to them. So now at 90 they report that moderation is the key to their long life.
I'm just saying....

Jane said...

Regarding things like self evident truth, it made me think of all the attention that bullying has been getting. We are now, as a society, starting to hammer it home that bullying takes many different forms. It's not just a little boy waving his fist at another little boy. Girls and women bully maliciously through verbal assaults, social ostracism, and gossip. There is also cyber bullying, teachers who bully students, workplace bullying by insane bosses with ego trips, etc. But then...I feel like people already knew this. It's just getting more attention now.

I guess that would apply to medicine too. I'm sure doctors knew for years that addiction can come in many forms. It doesn't have to be a hard drug (or a drug at all) for something to be addictive. They're just saying it with a stronger voice now with the DSM?

Though this concerns me, because marijuana is considered addictive. That is not because it is physiologically addictive. It is psychologically addictive. Does that mean psych meds are addictive? I've read that they are not considered addictive, because you only get physiologically addicted. No one gets psychologically addicted. But if marijuana gets considered addictive without the physiological component, then why can't antidepressants be considered addictive without the psychological aspect?

Liz said...

ahh!!! no sunscreen? salt is okay? i feel like i'm in the twilight zone.

seriously, though-- thanks for the reminder that "common knowledge" can sometimes just be common misconceptions!

jesse said...

@Sideways: Amen, amen. While I do believe (with the Greeks) that moderation is best, many of those ninety year olds were anything but moderate in their twenties.

Simple Citizen said...


Reducing salt intake could kill you faster
Positive affirmations cause depression.
Home births could be better than hospital births for most people.
Chocolate lowers your BMI.
Diet soda doesn't cause cancer, diabetes, or heart disease.
Prozac is a Placebo.
Foster-kids are actually under treated.

These are all posts I've written on my blog.
The number of things we do that defy all the evidence is INSANE. It's like asking why breech babies need to be delivered by C-Section. (the evidence isn't there)
As physicians we do what rings true to us either because of research or social norms. Neither is a trump card.

Oh yeah - there's also good ole CYA medicine - can't forget that.

Anonymous said...

my favorite quote ever is "Don't believe everything you think"

Dinah said...

I think we like to believe that we have some control over our mortality, and that if we live life perfectly enough, it will all go well (and for a long time). When it works that way, we say: See, if you play by the rules, you get to live a long time.
Seems to me that there are people with healthy lifestyles who follow all the rules and still die young.
And some big rule-breakers who live long.
Genetics, in part, I imagine. Luck seems to have a huge role.

And the sunscreen issue: Jane Brody looks at one end point: skin cancer. There are other ways to die, and we don't know if sunscreen hastens death from other illnesses or alters vitamin D levels, or if there is another mechanism involved.

I'm left with the idea that to some extent you're left to do what feels right for you and hope for the best.

Sarebear said...

Yup. With symptoms starting in my 20's, and diagnosed at 34, my arthritis is due to bad genes, they said. They said they just do NOT see arthritis this severe in someone that age, no matter how heavy you are. They were rather surprised at how severe my arthritis was/is. They told me losing weight wouldn't help it. (Although I've lost 9 pounds recently woohoo!)

And of course there's all sorts of genetic unpleasantness that crops up for people.

It's a bit jarring to realize that you were destined for a prognosis of, as they put it, "increasing pain, decreasing function and MORE PARTS WILL GO" (emphasis theirs) since the cells that formed you first met.

It just IS. No matter what, it just IS. I've mostly accepted that, but there's still a small amount of sad wistfulness for what if it hadn't been in my genes . . . and for all I know, I'll always have that. I am pretty much at peace with it, though.

We'll see how long that lasts the next time a replacement surgery is needed, though!

Sarebear said...

Is labeling me "Permanently Disabled/Incapacitated" what's good for me? I don't think so.

I was applying for food assistance and that's how the state benefits system has me listed.

It was a punch in the gut. I've seen disabled before, in the SS papers, but those three words, together?

I never, ever wanted that to be a label someone or some entity applied to me.

I hope that I can become not only more functional, but LIVE and enjoy life as much as I can with my physical prognoses and limitations/pain.

Who the heck are they, God?

Permanent, my ***. Pardon my French.

Trébuchet said...

Addictions are way overdone. My PCP told me I was addicted to MILK. I do drink a lot of whole milk; love it, maybe overdo it. He told me to mix it up with soda. (I don't drink soda).

Okay, I could understand telling me to mix it up if I were drinking vodka tonics, but now he's just making stuff up. I, like most people (I hope), simply ignore these "addictions" and continue living their lives the way the want.

I def. went through a wild stage when I was 19 and 20, and in today's culture, would have easily been labeled an alcoholic. But, shocker of shocks, I don't drink alcohol now (no tolerance, heh); the annual egg nog or white russian (for the milk of course) at best. I was never 'addicted' to alcohol; I just drank a lot, then I never did again.

And outside of substance use, people aren't addicted to tanning; they like the look (don't KNOW why), and associate tanning with relaxation and beauty. Happens to not be the best thing for you, but I hardly imagine even the worst cases of tanning are that big of a deal. LET them cook! If every habit wasn't labelled 'addictive', maybe people would enjoy their damned selves and wouldn't need prozac.