The next big thing in medicine .... behavior change

Modern medicine has been spoiled by some raging successes.  The development of antibiotics and vaccinations have saved millions, perhaps billions, from death and disability from infectious disease.  Similarly, in certain types of cancer (.... although importantly, not all), the use of chemotherapeutic drugs have been life saving.  Some surgical techniques, like removing a ruptured and infected appendix, can be life saving.

Unfortunately, it has also skewed our perspective about how medicine is supposed to work: Person has disease X, we give them intervention Y, and presto, they are back to normal.

However, that model does not accurately reflect the way the human body works.  Most human disability in the United States are related to chronic conditions, and most of those chronic conditions are related to behaviors that cause those chronic conditions.  One important insight to realize is that most disease is therefore related to choices.

I'll use myself as a personal example.  When I was in my 20s, I was in very good shape- I competed in Ironman Triathlons,  and did so with a frame comparable to an NFL safety or linebacker, which was unusual for a triathlete.  In fact, they offer a seperate class for men over 200 lbs, the "Clydesdale" class, in recognition that triathlons are a small man's sport.

As I entered my 30s, I started to make a series of reasonable decisions - prioritizing my PhD, my med school training, my personal relationships, making a national name for myself - that all had as unintended consequence of de-prioritizing my own health.  I didn't get enough sleep, I wasn't working out as much, and while I was generally a healthy eater, I was eating portions more appropriate for a competing triathlete, not a physician seeing patients all day.

And I got fat.

Unfortunately, I didn't have people in my life tell me I was fat routinely, so I didn't really feel the consequences of being fat.  Yes, I had to buy a new wardrobe, but that came on slowly, so it wasn't really that expensive.  I was doing well enough socially, so that didn't have consequences.  I had a high enough baseline level of fitness that I wasn't winded in every day activities, and almost all buildings have elevators these days.

I started having some minor health issues- my cholesterol went up, but a Lipitor helped that.  My blood sugars were not diabetic levels, but they were over 100, so the process of metabolic syndrome was starting.  I had a bunch of aches and pains, but I just wrote them off as in inevitable consequence of aging.

Three big factors contributed to me starting to view the world in a different way, which I think will ultimately add 10-20 years of quality to my life.

1. Sleep.  I was working on an academic project related to testosterone, and started reading the medical literature on how profoundly sleep helps testosterone levels.  Basically, all of your anabolic (healing) hormones are at their lowest when you go to sleep, and increase as you sleep.  I decided that sleep was going to be my #1 health priority, and within weeks noticed that I was less irritable, felt stronger, and many of my aches and pains went away.

2. Friends.  I shared a hallway with some wonderful endocrinologists, and I was talking to one about my concerns about my increasing blood sugars, especially with a strong family history of diabetes.  She told me (and I am paraphrasing- this is what I heard): "You are clearly on a trajectory to become diabetic, so either you focus on diet and exercise like you are a diabetic now and prevent the disease, or wait until you've started having real consequences to make a change."

3. Guatemala.  I was visiting some friends in Antigua, and I realized that someone my size simply couldn't live in Guatemala.  The average man in Guatemala is 5' 2", and I am 6'2-1/2" and even having lost some weight before the trip, weighed about 250 at the time.  The infrastructure of the country- bus seats, beds, toilets, clothing, portion sizes- were not built for someone my size.  

     I remember walking by a heavily guarded bank, and they had the burliest, scariest looking dude they could find guarding the bank with an assault rifle ... he was probably 5'6" and 165 lbs.
     What I realized from that trip was that even allowing for variation in size by country, I was lumbering around at a body size that simply was not how we were supposed to evolve, and was not sustainable.

So, I started prioritizing my own health.  Sleeping better, eating healthier, eating smaller portions, simplifying my life, removing tangential stressors, and exercising more.  Moved to Redmond, Washington, where the degree of difficulty to live healthy is easier.  And I feel healthier than I have in at least a decade.

...... But, I often think about an alternate universe where I didn't make these behavior changes.  Where I still didn't get enough sleep, ate a bit too much, took on extra complexity.  What would the health consequences be?

This is where the unintended consequences of good health care would probably lead to me having WORSE health.   My lipid panel would probably continue to deteriorate, but hey, I can just take a bigger dose of Lipitor.  That nagging Achilles of mine would first give me another excuse not to run, and then would slowly deteriorate and become more debilitating (..... a topic for another time, but Achilles tendinopathy is often the first musculoskeletal manifestation of metabolic syndrome).  I'd probably slowly enter into the diabetic category, and start taking metformin.  And because I don't have a huge incentive to make any changes, because there is always a medication I can substitute for an appropriate behavior change, I would continue the long slow progression to declining health.  This would not be despite good health care, but in large part BECAUSE I have access to good health care.

On another tangent .... when I was in my mid-20s and working on my PhD, I hit a dating dry spell. I was lamenting this with my housemate Stew, and was concerned that perhaps my dry spell was because I was acting too desperate.  He very wisely pointed out to me "No, Gary, just the opposite.  You're not desperate enough.  You're too comfortable- you're enjoying your work, going to the gym, talking to me, and so you simply aren't treating meeting someone like enough of a priority."  It was a brilliant insight- because I had enough other positive aspects to my life, I was not desperate enough to make a real change.

I think the same phenomenon is true of health care.  Behavior change is for the vast majority of patients, including me, the intervention that will make the most significant long term impact on their health.  The challenge is feeling desperate enough to make those changes.

For example, cortisone injections for lateral epicondylopathy ("tennis elbow"), have been shown repeatedly to make patients feel better at the time of the shot, but make people feel worse when followed for the years that follow.  Part of this is likely related to degradation of tissue from the cortisone, but at least part of the effect is likely because patients don't make the needed biomechanical alterations that caused the injury in the first place, and end up reinjuring themselves.

In future posts, I hope to discuss specific tactics on inducing positive change, but I think the first step is the recognition that change the most powerful pill in our medicine cabinet.