Overdosed America (36 page)

When corporate partners fund the flow of information, the message is likely to accentuate treatment strategies that are in their interest and downplay those that are not. For example,
fewer than one-third of the diabetics
in the United States get adequate exercise. Simply by
walking two or more hours each week
, diabetics can lower their death rate by 39 percent. How does this compare with the highly touted benefit of cholesterol-lowering statin therapy? Treating 250 diabetic patients in the Heart Protection Study with a statin drug for one year prevented one death. In contrast, inactive diabetics can get four times more benefit simply by walking for at least two hours weekly, preventing four deaths among 250 formerly inactive diabetics each year.

Similarly, the 13 percent reduction in death rate among those treated with a statin in the Heart Protection Study is greatly overshadowed by the benefit of moderate weight loss. A study done in Sweden treated
overweight and sedentary diabetic and prediabetic men
with a diet and exercise program for five years. The men in the program who sustained at least a 5 lb. weight loss over the five years of the study had an 83 percent lower death rate than the men who did not lose weight—almost five times more benefit than treatment with a statin. Given the clarity of research about the impact of lifestyle on diabetes, one would expect a special effort by doctors to counsel their diabetic patients about the benefits of exercise and diet. However, according to an article published in the
Journal of the American Medical Association
,
only half of diabetic patients were counseled
about exercise at their last physical exam.

Another study showed that a 12-week intensive
weight-loss program for diabetics
decreased their expenditures on prescription drugs and diabetic supplies by two-thirds; and at one year the expenditures were still only half of what they had been at the beginning of the study. In a more effective and efficient health care system, these savings could be reinvested in health promotion campaigns that help people adopt healthier lifestyles, improve the quality of their lives, stem the diabetes epidemic, and at the same time reduce deaths from heart disease, stroke, and cancer. This is the kind of strategy that most Americans probably expect from major nonprofit institutions ostensibly dedicated to improving Americans’ health. But when drug companies are funding the “educational” effort, nonprofit organizations can be used to direct doctors and patients toward their drugs.

The bottom line is that type 2 diabetes is primarily a disease of lifestyle. When doctors and the public are encouraged to pursue drug therapies over changes in health habits, patients miss the opportunity to benefit from the most effective interventions—exercise, diet, and not smoking. Ideal care combines both approaches, with the emphasis proportional to the potential benefit.

Social anxiety disorder used to be a rare disease—that is, before public relations firms went into action representing the makers of the new antidepressants. Today, according to an
advertisement for Zoloft
, this “medical condition affects over 16 million Americans.” “Sufferers” feel anxious about meeting new people, talking to their bosses, speaking before large crowds, or drawing attention to themselves. (Most of us can think of times when we have experienced these unpleasant feelings.) Pfizer’s website for Zoloft promises that these symptoms can be treated with drug therapy. According to the
Pfizer website
, depression is an even more common disorder, affecting 20 million Americans each year. Published studies show that treatment with the new SSRI (selective seratonin reuptake inhibitor) antidepressants provides significant benefit to people suffering from both of these conditions.

An exquisitely designed study (sponsored—to give credit where credit is due—by Pfizer, the manufacturer of Zoloft)
randomized people suffering from social anxiety
disorder into four groups: two of the groups were treated with Zoloft for 24 weeks and two with a placebo. In turn, one of the groups treated with Zoloft received “exposure therapy” consisting of eight 15-minute sessions with a primary care doctor to talk about their symptoms. These patients also received “homework” to do between sessions to help them learn how to identify and break through their social habits and fears. Similarly, one of the groups treated with the placebo received exposure therapy, and the other group no counseling. The patients’ symptoms were then monitored for 52 weeks—the first 24 weeks while undergoing therapy, and then for 28 weeks after the therapy had been completed.

During the first 24 weeks of the study, the patients in all four groups showed significant improvement, but an unexpected finding emerged when the drug was no longer being taken. The patients who had received “exposure” training without Zoloft continued to improve significantly, while the people who had received Zoloft (with or without counseling) showed slight worsening of their symptoms after the drug was stopped. The most likely explanation is that the people whose symptoms were relieved by drug treatment were less motivated to learn how to change the dysfunctional patterns of reaction and interaction that had given rise to their symptoms in the first place. On the other hand, the patients not given medication were probably more motivated to learn how to make these changes, and proved that it could be done successfully. The discomfort of social anxiety is real, but approaching these symptoms as a fundamentally biomedical disorder and treating dysfunctional social skills or habits with a drug makes about as much sense (for all but the most severe cases) as “treating” a splinter with a narcotic painkiller instead of removing it.

A similar picture emerges in the treatment of depression. In a study published in the journal
Psychosomatic Medicine,
patients suffering from major depression
were randomly assigned to one of three groups: a group to receive Zoloft, a group to receive three exercise sessions a week, and a group to receive both Zoloft and exercise for four months. Depression in all three groups was significantly improved after four months of treatment. Six months after the completion of treatment, however, the results were quite different. Depression had recurred in only 8 percent of the people in the exercise-only group. In contrast to this lasting benefit, relapse occurred in 38 percent of the people treated with Zoloft alone and 31 percent of the people treated with both Zoloft and exercise.

This pattern mirrors the study of social anxiety: short-term treatment with an antidepressant medication relieves symptoms but appears to decrease the likelihood of patients making the positive life changes necessary to prevent symptoms from recurring. These randomized controlled studies suggest that at least some depression could be called an “exercise-deficiency disease,” and some social anxiety disorder could be thought of not as a medical disease but as the consequence of dysfunctional patterns of social interaction shown to be amenable to significant improvement by eight 15-minute sessions of counseling with a family doctor.

To see these “diseases” through this evidence-based lens would turn American medicine on its head. The drug companies have a great deal at stake in persuading doctors and the public to limit their view of social anxiety disorder and depression to the biomedical model of disease. They provide persuasive “scientific” explanations for mental health symptoms, while deflecting consideration of the evidence that, in many cases, lifestyle changes and short-term counseling offer more enduring benefit. Not coincidentally, their approach is also the best way to sell more drugs. Though successful in the short term, these biomedical interventions undermine the natural motivation provided by patients’ symptoms to make the real and lasting changes that would lead to sustained improvement in the quality of their lives.

While medical science works toward finding cures for cancer with occasional but all too limited success, we already know a lot about how to prevent cancer. We know, for example, that from 1965 to 1998, lung cancer quadrupled in women, overtaking breast cancer as the number one cancer killer in women in 1986. Smoking not only is responsible for
87 percent of lung cancers
but also increases the risk of cancer of the mouth, throat, esophagus, and bladder.

A review of all the studies that looked at the relationship between cancer and exercise showed that the risk of developing some of the most common cancers is significantly reduced by exercise. For example,
routine exercise
is associated with a 40 to 50 percent reduction in the risk of developing cancer of the colon and with a 30 to 40 percent reduction in the risk of breast cancer. It is also possible that exercise reduces the risk of prostate cancer.

Diet plays a role
in about 30 percent of the cancers that occur in developed countries, according to a review of international cancer rates published in
The Lancet
in 2002. Age-adjusted rates of the four most common cancers (lung, breast, prostate, and colon) are all much higher in the developed countries, and increase when diets change or people move from less to more developed countries.

Another study compared the diet of 2000 people who developed colon cancer with a control group of the same number. Eating a
“Western diet”
—associated with a higher body mass index and a greater intake of calories and dietary cholesterol—was twice as common among those diagnosed with colon cancer, and the association was strongest among people diagnosed at a younger age.

Consistent with these findings, the patients in the
Lyon Diet Heart Study
who developed less heart disease on a Mediterranean diet (high in vegetables and fruits, whole grains, and vegetable oil, and low in red meat) also developed 61 percent fewer new cancers compared with the people who ate the “prudent Western-style heart diet” (meaning lower in total and saturated fats than the normal diet).

A study conducted in Canada found that being obese
(compared with having a normal body weight) increased the overall risk of developing cancer by 34 percent, with much larger risks for certain cancers: 95 percent for cancer of the ovary, 93 percent for cancer of the colon, 66 percent for breast cancer in postmenopausal women, and 61 percent for leukemia. The researchers calculated that obesity was responsible for 7.7 percent of all cancers in Canada. Given that
twice as many Americans are obese as Canadians
(31 percent versus 15 percent, in 2003), obesity may be responsible for about 15 percent of cancer in the United States.

Finding medical cures for this terrible disease is desperately important, but we can’t forget that the very best cure is prevention. (The U.S. Preventive Services Task Force recommendations for cancer screening are widely recognized as the best available resource. These can be accessed through the
Agency for Healthcare Research and Quality
.)

The biomedical-commercial approach to health fragments medical care into seemingly separate and unrelated diseases—each with its own cause and its own cure. This distracts people (including health professionals) from the fact that many diseases share the same cause, and that cause is often rooted in lifestyle choices such as poor diet, smoking, and lack of exercise; environmental factors; or economic status. The telling characteristic of the biomedical-commercial approach to health is that regardless of the primary source of disease, the biomedical-commercial approach offers (“pushes” is perhaps a better word) commercially advantageous solutions.

The obesity epidemic in the United States is a perfect example. As awareness of this serious problem grows, attention is becoming focused not on its cause, but on medical treatments to mitigate its consequences. These interventions include preventing heart disease (with statin drugs), mitigating the complications of diabetes (with drugs to control blood sugar, statins to protect the heart, and ACE inhibitors to protect the kidneys), treating strokes after they occur (with an expensive new treatment that actually helps fewer than one out of 25 stroke victims), and relieving the pain of osteoarthritis (with expensive new arthritis drugs). There are also medical treatments for obesity itself: surgery (now even in children) and new medications in the pipeline that are sure to be instant blockbusters.

The real cause of obesity is embarrassingly simple: Americans consume more calories than they need to maintain a healthy body weight. According to the U.S. Department of Agriculture, the average American consumed 500 calories more per day in 2000 than in 1970. Much of this increase is explained by the doubling in the amount of food eaten outside the home from the mid-1970s to the mid-1990s, by which time restaurant and takeout food accounted for one-third of total energy consumption. Restaurants offer high-calorie foods and increased portion sizes to attract customers. Marketing of fast food and high-calorie snacks to children continues to become ever more sophisticated, creating an unhealthy appetite for calorie-rich foods.

Americans’ increase in sugar consumption tells an interesting story. The USDA recommends that the average diet include no more than 10 teaspoons of sugar each day. In the 1950s,
Americans’ average daily intake of sugar
and other sweeteners was 23 teaspoons. By 2000 this had increased to 32 teaspoons of sweeteners per day, providing an additional 135 calories. (Just one 20-ounce bottle of soda, for example, contains about 16 teaspoons of sugar.) Without any other changes in diet or exercise, a person taking in an extra 135 calories per day gains more than 1 pound each month (3500 extra calories lead to 1 pound of weight gain). The result is perfectly predictable: the percentage of obese adults doubled between the early 1970s and 2000, and during the same period, the percentage of
obese children and adolescents increased by a factor of almost four
.

Dr. Julie L. Gerberding, director of the Centers for Disease Control and Prevention, told the
Washington Post
in March 2004 that by 2005 the number of
deaths in the United States caused by obesity and physical inactivity
was projected to reach 500,000—more deaths than are caused by smoking, and almost the same number of deaths caused by cancer. Genetic predisposition and just plain bad luck play a role in most diseases, including those contributed to by obesity, but the greatest determinants of health are the habits, choices, demands, and environment of daily life. Obesity is primarily a social disease—the result of aggressive marketing of high-calorie foods and our physically inactive culture—in much the same way that tuberculosis was largely a social disease of the nineteenth century, the result of overcrowding and the uncontrolled ravages of the industrial revolution. Clearly, the outlook for Americans’ health is not good when one of the key risk factors for most chronic diseases is increasing at an epidemic pace and little is being done to get at the heart of the problem.