From a speech by Dr. John McDougall to a group of MDs. These are Dr. Flora's notes...
Why is diet and lifestyle medicine so unpopular?
The main problem is its low profit. If we could change the profitability of lifestyle 'medicine', it would change overnight. But there is also the excuse that it takes some patient 'compliance'/effort. But, of course, that's taught to us, isn't it?
We are taught that patients aren't very smart, right? And, they're not going to do this. That's what I was taught when I was in medical school.. that patients were barely smart enough to sign the check at the end of the office visit and take our drugs. They're stupid and disinterested, and that's part of the education that goes on still today.
I believe that patients are very willing, if we give them half a chance, to make these changes. I see it every day in my practice, and they are very grateful. It's not high-tech.
I had an experience one time. I read an article by Dr. Pannish about how to cure rheumatoid arthritis in the Annals of Internal Medicine. I was doing a radio show at that time and I wanted him as a guest on my radio show. So I tracked him down at the University of Florida in Gainesville. Originally, that's where I looked for him, but he wasn't there anymore - he was at a big university of the East Coast and had become the Department of Internal Medicine head.
I called him up to invite him to be a guest, "Oh, Dr. Pannish, I'm so excited to talk to you. here you are, a man who's really stood up and said you can cure rheumatoid arthritis with diet."
And he said "Wait a minute, I don't want to talk about that."
I said, "What do you mean?"
"I don't do that anymore," he said.
"Well, what do you do?" I asked him.
He said, "I'm at this big university. Real doctors don't talk about diet and disease."
"So, what do real doctors talk about?"
"Well, you know, things like genetics and viruses and biochemistry and things like that. You see, it's not sexy. The person you saw at the front desk can teach you about diet and lifestyle. You don't have to be a doctor or a dietitian. I mean, anyone can teach you. It's not really sexy, is it? So, it's not very popular. And then, when you give patient control, then you as a doctor lose control and this is an ego-centered business, isn't it?"
Yeah, it is an ego-centered business. That's why we have operating theaters.
Then Dr. McDougall showed a pie chart of chronic illnesses.
"OK, let's get down to the treatment of disease. I'd give us medical doctors a report card. I'd give us an A for treating acute illnesses and I'd give us, at best, a D- for treating chronic illnesses. So, we've made great contributions in terms of people's health in several areas such as sanitation... Antibiotics, of course, are really wonderful; trauma care, and immunizations. They have made a huge difference in the welfare of people throughout the world. But, these are acute illnesses that we are dealing with primarily.
When it comes to chronic illness, seven of the leading causes of death are due to chronic illness. They are the diseases you see up there like heart disease, cancer, strokes, lung disease, diabetes, liver disease and atherosclerosis. And it represents 3/4ths of the health care dollars spent in this country - chronic diseases. The treatment of chronic illness with drugs, with medication, can't possibly work. Just the fact that it's called chronic, and continues to be called chronic, is an admission of failure.
Americans are sick, they're sicker than ever, and most Americans over the age of 55 have at least one risk factor for diseases. For example, 1/3rd have elevated cholesterol, most are inactive, 1/3rd have high blood pressure, 30% are obese, more than 65% are overweight, and 10% are diabetic. I mean, those are the facts and we treat those patients primarily with drugs. What we treat, of course, is not the patient or the disease, but we treat the risk factors, the signs and symptoms of the disease."
He introduced us to a term called 'disease mongering.' A monger is a derogatory term for a dealer, like a used-car dealer. Dr. Ray Moynihan defines disease mongering:
"It's the selling of sickness that widens the boundaries of illness and grows the market for those who sell and deliver treatments. It's exemplified most explicitly by the many pharmaceutical industry funded disease-awareness campaigns. Disease mongering turns healthy people into patients."
The most common way in which we disease monger is to treat risk factors and not diseases. In fact, it's not just risk factors we are treating anymore - it's risk factors for risk factors: pre hypertension, pre-diabetes, pre-osteoporosis (osteopenia), etc.
So that's what we treat as risk factors: symptoms. I've been in practice for 40 years and I've never seen a patient die of high cholesterol! I've never seen a patient die of high blood pressure and I have never seen a patient die of high blood sugar, ever. These people who have these risk factors die of real diseases, don't they? I mean, they really are sick.
Unfortunately, we don't treat the underlying sickness that kills them, and we see tragedies in people's lives. 1.2 million people have heart attacks every year. 700,000 have strokes.
What would happen if instead of dealing with the risk factors, which we treat very effectively with drugs, we instead dealt with the underlying diseases? We might have to do something drastic, like change people's diets! Or, make them exercise! Or, cause them to quit smoking! But the problem is, how do we charge for that? How do you make a living doing that?
OK, lifestyle is what it's all about, correcting the cause through a change in lifestyle. Most of you understand that it's a plant-based diet, it's modern exercise and it's clean habits that work. Let me give you an example of disease mongering just so you all get up to speed on this and see how it works:
Treatment of hypertension. The end points for treating high blood pressure, how do we succeed? Do blood pressure lowering medications lower blood pressure. Definitely, no question about it. In fact, when you read the scientific studies on high blood pressure, what do you find?
Yes, Drug A lowers blood pressure as well as Drug B.
Do they reduce the risk of dying of heart disease? No.
Do they reduce the risk of stroke? A little bit.
Do they have side effects and complications? A LOT!
We are taught by the provocatively dressed drug representatives and by the drug companies that high blood pressure medicine is very effective, it cuts the risk of stroke in half. And you think that there's a practitioner who thinks, "I would be foolish if I didn't treat my patients with high blood pressure pills," because they cut the risk of stroke nearly in half... Well, if you look at scientific research, this is what you find:
The risk of stroke for 5 years: People who have mild hypertension between 90 and 110 mm of mercury, if you don't treat them they have 15 chances of having a stroke out of every 1,000 people untreated. But, if you treat them, their risk is now 9 chances out of every 1,000 patients. So, what do we have here? We have a risk reduction over five years. That's 15 minus 9, which is 6, divided by 15 we have a relative risk reduction of 40%. That's a relative risk reduction, but that's not the way we should look at things, is it?
The risk of stroke for five years, in terms of absolute reduction is six strokes per 1,000 people. That's one less stroke per year by treating 1,000 people with medication. It looks a little bit different now. So what we do is talk in terms of relative and absolute risk reduction which means no sense at all. It makes a profitable sense but no sense in the terms of the welfare of our patients.
Disease mongering expands the definition of sickness. When Walter Kempner was taking care of high blood pressure patients, his blood pressure patients came in with blood pressures of 200/140. He got 60% of them down to normal blood pressures. When I started in medicine, it was called mild high blood pressure when it was 160/100. Soon, it became 140/90. Then there was a report, the first came out about 18 years ago, but another one came out a couple of years ago that said that if your blood pressure was 120/80 or greater, that you had twice the risk of dying of heart disease. It made national headlines. I'm sure the PR people, the spin doctors, at the drug stores. It made national headlines.
I'm sure the PR spin doctors, at the drug companies made sure that everybody learned about that. Now that is true, if your blood pressure is elevated, it is an indication that you have higher risk of having diseases associated with a western diet. It's a sign that says you're sick. But does treating signs necessarily solve the problem? Well, the drug companies think we should do that even though the results of those treatments don't show those benefits. So we have doctors out there treating people with blood pressures of 120/80 or higher or maybe 110/70 or higher. Remember, that's pre-hypertension. So, you expand the market greatly by expanding the definition of sickness.
Now, this is the guideline that I use and the one I would encourage you to use, from the British literature. It's the most current guideline on treating high blood pressure. And that is why I don't feel uncomfortable at all taking patients off blood pressure lowering medications. That is why I don't feel uncomfortable having my patients blood pressures at 140/90 or 150/95 without medication, because of the British guidelines, which have looked carefully at the scientific literature and have made some profound statements that should dictate our practice.
In these guidelines, there are summary points that all people with high blood pressure, borderline or high normal blood pressure should be advised on lifestyle modifications.
Now how many doctors do you think do that? I mean do you think a patient goes ionto a doctor's office and when the blood pressure is detected, the first thing the doctor does is say, "You're going to take a 10-week diet and lifestyle course before I put you on drugs."
You think that ever happens? Or do you think maybe, more likely what happens is, when the patient comes into the doctor's office, the first reading of elevated blood pressure dictates a life-long treatment for high blood pressure. Do you think that's possible? I think so.
Then they go on and say that you should initiate drug therapy if there is a sustained, as in not 15 minutes, but months, 160 systolic and 100 or greater diastolic. That's what the British guidelines say. Now, if you feel uncomfortable about not initiating high blood pressure therapy, for what you know is less than mild hypertension, or if you feel uncomfortable about taking people off high blood pressure medication, just use the British guidelines. It's the most current recommendations out there, and I believe much less biased because I believe the British literature is much less influenced than the U.S. literature.
More on disease mongering. Here's another way to do it. You exaggerate the goals of treatment. The goal, I can't think of a patient who has come in with anything but the goal of making the blood pressure normal with drugs. 110-78 or less, that's the goal.
Well, using medication, reaching that goal results in more death and disability, more heart attacks. What happens is when the diastolic is high and you treat, say it's 120 , the blood pressure, the risk of heart attacks and death decreases until you hit a level of about 95 mm of mercury in diastolic. Certainly, no lower than 85 mm of mercury. Then, the risk of death increases. It's called the "J" or "U" phenomenon of mortality. It's been written about for over 30 years. It makes a lot of sense, doesn't it?
Here you have a patient whose blood vessel system is all clogged up, it's full of sludge from what they ate, their arteries are in spasm.
The heart and the body perceive these problems: "We are not delivering the nutrients to the tissues because of all this peripheral resistance. So, what do we need to do?"
The body says to itself. "Well, we need to increase the pressure in the system," so the pressure goes up. So, what do we do as agents of medical care, agents of the pharmaceutical industry? We poison the system at various levels. We poison the heart with beta blockers, we poison the arteries with calcium channel blockers, we poison the kidneys with diuretics. And the blood pressure comes down, as expected.
But what happens to all that effort the body is making to deliver nutrients to the tissues? What happens is, that effort is stopped.
The consequence is you decrease pressure to the tissues and the patient dies. But, at least he died with a normal blood pressure, right?
Peace and Love Be With You,
Dr. Flora van Orden III
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