Let's Take the Blame out of Lifestyle Medicine
I would like to start this blog with a concept that I struggled with as a preventive and family physician- how do we find the cause without casting blame?
If I find a pathogen like a bacteria that has caused an infection, I consider it responsible and treat it accordingly. In medicine we say “name it, blame it, and tame it!” But what do we do when we learn that lifestyle choices are what ails us? How do we find the cause without casting blame?
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A majority of chronic diseases (e.g. diabetes, heart disease, dementia, and hypertension) can be reversed, improved or prevented through lifestyle medicine. I am humbled by the complexity and simplicity of this truth.
The issue is that many people interpret this truth as blame. The internal dialogue is: "well I brought this on myself."
This is not my belief, nor it is my intent. It is not productive and simply not true in many cases. Sometimes I feel like pulling a Good Will Hunting and telling patients "its not your fault, its not your fault, its not your fault." Although we use diagnoses sometimes like labels in medicine, they are not judgements of your character. You are not your disease. You are not your thoughts. You are not your emotions. You are not your desires. You are a person; you are dynamic.
Lifestyle as medicine should be approached the same way any other therapy is approached. For instance, Metformin has been proven to decrease symptoms and mortality in individuals with diabetes. Yet, the formation of diabetes is multifactorial and it clearly isn't rooted in a metformin deficiency. Similarly, high cholesterol isn’t a statin deficiency.
The point I am trying to make is that the treatment is not necessarily tied to the cause. I know a doctor who prescribes cooked greens, 6 times a day, to complex cardiac patients who have severe heart disease. He wants to bathe their blood vessels in antioxidants and support endothelial function. Does this mean that if someone gets heart disease it’s their fault because they didn't eat spinach 6 times a day? Although this may seem obvious, I find it incredibly important in my work.
A mentor once told me, “Things that matter the most should never be at the mercy of things that matter the least.” He was talking about the ever growing time constraints, paperwork, and red tape that can distract a physician from listening to a patient and understanding the story that is told by the signs and symptoms of illness. Blame is a distraction in the work of preventing and turning the clock back on disease.
Before I continue to get carried away, let me take a minute to thank everyone for all the questions and responses last week. I am so humbled by the enormous response from my Ask Me Anything on Reddit. I have sifted through many of the unanswered questions and wanted to make a few additional points.
Now for a few more questions
Note: Several questions were related to complex medical conditions which do not always have easy cures or easy solutions. I hope that my answers did not come across as trivializing the hardships that many of you might be facing. If so I want to take responsibility and apologize. I am sorry for my lack of ability to express my heart and passion through the written word, but I truly hope you are able to get answers and support. If I could sum up what I have learned through my years of training into a sentence it would be this: Healing requires meaning and meaning provides the fuel for action and empowerment.
“I notice in one of your answers you mention that hookah is just as bad as cigarettes. Out of curiosity, What is your opinion on marijuana's effects on longevity?”
I will say habitual recreational marijuana smoking has significant risks and should not be regarded as a recommended activity by doctors in this country. This is different than therapeutic use of marijuana especially for things like pain. I thought about addressing this question head on, especially at a time where easy solutions to pain and addiction remain elusive. According to the CDC, “Every day, 44 people in the U.S. die from overdose of prescription painkillers, and many more become addicted.” I was ready to start discussing THC, cannabidiol (CBD), and cannabinoids in general, but Sanjay Gupta, MD has done an incredible job reporting please see the CNN series called Weed. He did an incredible job tackling this issue also see his AMA on the subject.
“I've been suffering with Crohn's disease for 8 years now, ended up having a resection and ending up with a permanent colostomy at 25. I worry if I have kids that they would end up with it and its almost putting me off because I could not bare to see my kids go through what I have. Do you have any personal views on prevention or treatments?”
Crohn’s can be very severe and unrelenting. It leaves many individuals, friends, family and medical professionals feeling frustrated and defeated. When you have a difficult course and the disease and treatment have a huge impact on your quality of life, it can be overwhelming and scary to think of your loved ones suffering too.
Some people with Crohn’s suffer a significantly more severe course of disease. That said, approximately 10 to 20 percent of patients experience a prolonged remission after initial presentation with Crohn's disease. Predictors of a more severe course include age less than 40, the presence of perianal or rectal disease, smoking, low education level, and initial requirement for glucocorticoids (Peppercorn et al, 2014). We also know that there is likely genetic susceptibility. “Approximately 10 to 25 percent of individuals with IBD have a first degree relative with either Crohn disease or ulcerative colitis” (Peppercorn et al, 2015). “In humans, alterations in 160 distinct single genes confer a modest effect by themselves; it is likely that the aggregate effect at several loci contributes to the IBD phenotype.” (Snapper et al, 2013)
My hope is that every patient of mine increases their chances to be in the 10 to 20 percent of patients who experience prolonged remission. What we need to ask is what makes those individuals different? Although much of Crohn's disease isn't completely understood, some individuals experience benefits from lifestyle change ranging from decreased flares to feeling back to normal. Not only can stopping smoking decrease flares, but decreasing intra-abdominal fat, eating more fiber especially from fruit, and getting more exercise can all play huge roles. Additionally, one should try to remove foods that can increase risk for inflammation, suggested culprits include animal fats, refined sugars, milk protein, and the high intake of omega-6 fatty acids. Obviously results will vary and we cannot reverse surgical changes. But, I am optimistic that much can be done that currently is not always done for many Crohn’s sufferers.
I hope you do not perceive this as an attempt to undermine the importance of traditional therapies. I am not so arrogant to think that lifestyle treatment alone is valid and worth exploring. And yet I am not so naïve as to think that I am the only one who can see the deficiencies and problems of an approach which takes these lifestyle factors for granted.
So I will leave you again with the question, how do we find the cause without casting blame? Let’s start with the data, translate the meaning into effective stories and build healing relationships. Let us fuel action and empowerment within ourselves, our households and our communities. I will take responsibility, but you are not to blame.
Peppercorn M, et al. Definition, epidemiology, and risk factors in inflammatory bowel disease. 2015. Up-To-Date Literature Review. http://www.uptodate.com/contents/definition-epidemiology-and-risk-factors-in-inflammatory-bowel-disease?source=see_link, accessed 05/2015
Snapper SB, et al. Genetic Factors in Inflammatory Bowel Disease. 2013. Up-To-Date Literature Review. http://www.uptodate.com/contents/genetic-factors-in-inflammatory-bowel-disease?source=see_link. Accessed 05/2015
Peppercorn M, et al. Clinical manifestations, diagnosis and prognosis of Crohn disease in adults. 2014 Up-To-Date Literature Review. http://www.uptodate.com/contents/clinical-manifestations-diagnosis-and-prognosis-of-crohn-disease-in-adults?source=see_link. Accessed 05/2015