The doctor made me not do it

Posted on October 10, 2009 by Heather Mac Donald

We need to induce doctors to practice preventive, not just reactive, care!  is a favored nostrum in the current health care debate.  I’ve yet to hear an example of what this means.  Prevention lies overwhelmingly within the realm of individual behavior, but our modern reflex of transferring agency from favored victim groups—in this case, millions of artery-clogged, waddling Americans—onto less-favored entities guarantees that we see the problems of Fat America as the failure of doctors to practice the right kind of medicine.  Perhaps more doctors could counsel their patients to exercise and avoid over-eating, but my guess is that if they stay silent on these topics, it is from hard-won experience regarding the futility of such suggestions.   As for other types of “preventive medicine,” it has been said repeatedly that doctors run too many diagnostic tests out of pecuniary motives (or, alternatively, as lawsuit protection), but such tests presumably have some preventive uses.  Where medicine truly has preventive power, as in inoculations against polio and other once epidemic diseases, it has been marvelously effective.

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9 Responses to The doctor made me not do it

  1. Joseph Marshall says:
    October 10, 2009 at 1:47 pm

    It strikes me that one of the important reasons for so many more diagnostic tests is the aging of the population. Early detection of disease is one of the few areas where genuinely preventive care is actually possible. I am Type 2 diabetic. Because my GP expected me to become so, given my age, weight, and diet, he ran glucose level tests far earlier than overt symptoms would warrant.

    By doing so, he caught me at the cusp where “insulin resistance” turns into Type 2. This fortunate early detection, now several years in the past, kept me from having to medicate or use daily finger sticks. Mere reduction of products using white flour, white sugar, and total elimination of fruit juice, was sufficient to keep my glucose levels well with the safety zone.

  2. Polichinello says:
    October 10, 2009 at 6:08 pm

    Perhaps more doctors could counsel their patients to exercise and avoid over-eating, but my guess is that if they stay silent on these topics, it is from hard-won experience regarding the futility of such suggestions.

    Ah, but the doctors can’t slap taxes and restriction on no-no foods. The government can, and with Obamacare they can do so with the justification that they’re controlling costs. That’s why government-run health care for all means, in essence, your body is nationalized.

  3. hanmeng says:
    October 11, 2009 at 1:56 pm

    Or perhaps patients could take responsibility for their own health.

  4. Pingback: Matthew Yglesias » What Is Preventive Medicine?

  5. Karl Smith says:
    October 13, 2009 at 1:45 pm

    perhaps more doctors could counsel their patients to exercise and avoid over-eating, but my guess is that if they stay silent on these topics, it is from hard-won experience regarding the futility of such suggestions.

    The problem is that these suggestions, if followed would likely have a very small effect on fatness.

    Exercise as a treatment shows little promise. Meta-analysis shows an average loss of 1 KG and that is in a non-placebo controlled trial. Since clearly you can’t effectively placebo exercise. It should be noted though that weight loss placebos typically show better results than 1 KG.

    Calorie-restriction can be effective but it shows little promise over the long term, for what should be, but unfortunately are not, obvious reasons.

    Clearly long term calorie consumption is no more voluntary than long term breathing. Indeed, the two must perfectly balance in weight neutral person. The instinct to eat and the instinct to breathe are carefully controlled. I don’t think squirrels and bears get fat for the winter because they loose their self-control. The instinct is hardwired.

    Obesity is no more the result of over-eating than asthma is the result of under-breathing. Both are influenced by environmental as well as genetic factors but they are not under direct control by the individual. Just as the asthmatic must carefully avoid triggers, so must the obese.

    The problem is, we are not exactly sure what all the trigger are. We have some idea that living a traditional pre-industrial lifestyle will prevent both but given that most people are not going to do that we have to figure out what exactly it is about modern life that is triggering the asthma attacks and the over-eating.

    In the mean time the most effective treatment for both conditions is medication. Unfortunately the killer drug for obesity, fen-phen, was banned.

  6. Kevembuangga says:
    October 13, 2009 at 5:25 pm


    Karl Smith    :
    The problem is, we are not exactly sure what all the trigger are. We have some idea that living a traditional pre-industrial lifestyle will prevent both but given that most people are not going to do that we have to figure out what exactly it is about modern life that is triggering the asthma attacks and the over-eating.

    We have more than “some idea”, we know perfectly well some triggers.
    It’s mostly a matter of obfuscation by the med/pharm industry.

    In the mean time the most effective treatment for both conditions is medication. Unfortunately the killer drug for obesity, fen-phen, was banned.

    No, the most effective treatment for overweight is this, done it myself, lost 4kg in 2 months, no fuss.

  7. Ivan Karamazov says:
    October 14, 2009 at 10:01 am

    Wow. A whole lot of diet misinformation, a bit in the original post, and a lot in the comments so far. That might be excusable, if Gary Taubes had not yet written “Good Calories, Bad Calories”. But he has, so no excuses anymore. You all need to go read it, and educate yourselves. You won’t regret it, and it may save some of your lives. If the Nation understood and applied the lessons of that book, the obesity epidemic would soon be over, and the total cost of Health Care would plummet. That is not an overstatement.

  8. Karl Smith says:
    October 14, 2009 at 11:53 am

    Kevembuangga

    Not sure exactly what you were getting at with that link. I think Guyenet backs up my thesis that “we do not know for sure what the triggers are” even for heart attacks and heart attacks and obesity are not the same thing.

    I don’t doubt that margarine and other trans fats were a big part of the heart attack boom in the US, but how much?

    Second, I think Seth Robert’s stuff is under clinical trial now. We will see what the results say. I admit that I am fascinated by his anecdotal evidence but at this point it is only anecdotal.

    Ivan
    I think we have all read Taubes. I have conversed with Taubes briefly. He makes a lot of good points and is the most eloquent proponent of the idea that getting fat causes over-eating not the other way around. However, Taubes is a bit more wedded to the insulin hypothesis than is warranted – in my opinion.

    Something important is going on with Leptin and Ghrelin as well and Taubes ignores these completely if I remember.

    The best answer remains: WE DON’T KNOW

  9. Ivan Karamazov says:
    October 14, 2009 at 2:53 pm

    @Karl Smith
    You’re just flat out wrong. But, whatever. You’re the one who has to live with the consequences of your misunderstandings, so it’s all good..

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