For most of the 20th century, we doctors had a clearly defined job and it was an enviable one. As medical technology flourished, we got to apply elegant new solutions to age-old problems. Many of the deadly diseases of centuries past, caused by bacteria and microbes, were vanquished. Polio? Wiped out by Salk and Sabin. Tuberculosis? Controlled or eradicated by new anti-tubercular drugs. Pneumonia, Sepsis, Meningitis? Laid low by ever-improved generations of antibiotics. Doctors and the medical science they carried in their bags were able to wipe out the fear of deadly diseases that came, unbidden, in the night.
But the major diseases of our past bear little resemblance to the major diseases of the 21st century. Suddenly, doctors find themselves confronted with a model of illness for which they are poorly trained and which they are ill-equipped to handle. Most of our modern chronic disease does not strike unfairly and for no reason. Rather, it is related to the way we live in today’s world and the life behaviors that are promoted by our modern society. This is a profound change and one that penetrates deeply into the fabric of our health. As such, it is not eradicated by a single pill, potion or prescription.
Nevertheless, medicine keeps looking for that magic. In this week’s New England Journal of Medicine, a study called JUPITER made headlines. Sponsored by Brigham and Women’s Hospital, JUPITER tested the efficacy of treating “apparently healthy” persons with a cholesterol lowering statin drug. There was just one important thing about these “healthy” subjects. They all had an elevated blood test for C Reactive Protein. Elevated CRP reflects inflammation in the body and is known to be a predictor of future cardiovascular events. Sure enough, when treated with the drug, test subjects had a significantly lower incidence of heart attack, stroke and death from cardiovascular causes. In fact, the effect was so strong that the study was stopped after less than two years in order to give those on placebo a chance to take the medication. Does this mean that people who are not yet ill, but who are at risk, should take drugs?
In its editorial on the JUPITER study (titled, “Expanding the Orbit of Primary Prevention”) the New England Journal of Medicine makes just a single mention of “sensible diet, maintaining an ideal body weight, exercising regularly, and not smoking.” The commentary then immediately jumps to a discussion of drugs for the primary prevention of cardiovascular disease. This expands the orbit alright, but in one direction only- the pharmacological one. This is not surprising. Pulling a magical drug out of the hat falls within medicine’s comfort zone.
But not so fast. We doctors are inundated by an unprecedented epidemic of lifestyle-linked disease. In fact, the JUPITER study proves that even a large fraction of our supposedly “healthy” population may not be so healthy after all. CRP is a relatively new marker for possible future cardiovascular incidents. What other red flags are out there that have yet to be discovered? We know, for example, that millions of Americans are pre-diabetic. There is undoubtedly a large subpopulation who have completely normal lab tests yet are already developing the early stages of the disease. We simply don’t have good enough markers to detect this yet. Once we can identify all these soon-to-be-sick, we will be faced with a major question. What is the best way to head off their date with disease destiny?
I would make the case that drug treatment should not be our first choice. Increasingly, we see that treating a single part of the interlocking web of modern disease (diabetes, vascular disease, hypertension, cholesterol, obesity) causes another part to founder. For all of our medicines, the epidemic is getting worse. Kidney disease on the rise. Childhood indications of cardiovascular disease on the rise. Diabetes skyrocketing. Overweight and obesity predicted to reach 75% of adults by 2014. In addition, drugs we use can impact one little area of the larger problem but ignore or worsen others. A good example of this phenomenon was the recent demise of Avandia (rosiglitazone), a drug that seemed to do wonders for blood sugar, but also turned out to cause a worrisome heart attack risk. Similarly, subjects who were assigned to the statin drug in JUPITER had a higher incidence of diabetes than those on placebo. Drugs have unintended consequences. Weight loss, dietary change and exercise are risk free and improve all of the offshoots of modern disease while aggravating none. So, do we really want to treat large portions of the population who are not yet ill…but may be soon…with drugs?
Sometimes, there comes a moment when a paradigm shift is in order. Our country has recently been consumed with the idea of political change. Perhaps we should ask whether we’ve reached a similar moment medically. To achieve this shift, we would need to move our focus from an emphasis on drug treatment to a commitment to changes in our culture and our behaviors. That means believing that lifestyle modification is of deep value, that it works and that it should be aggressively promoted.
For doctors, this shift would ask them to buy into tough messages about how to eat and how to reduce weight permanently. Such advocacy would change the role of doctors significantly, but our current reality suggests that their role needs to change if they are to be effective in treating the diseases they see most commonly. That said, doctors cannot make this enormous change alone. Shifting the paradigm to prevention means getting support from companies so that they incentivize employees to take care of themselves, from government agencies willing to enact policies that pay for prevention and tamp down the influence of food manufacturers, from schools that are willing to go to the mat to feed kids properly, teach prevention and provide physical activity, and from a populace that is ready and willing to accept the message that permanent, healthy life behaviors are not only possible but essential.
We are rapidly approaching the time to choose our fate. A world of preventive medicines or a world that profoundly embraces health. I hope we have the wisdom to choose the latter.