In today’s modern world we feel fortunate that modern medicine can offer us “a pill for every ill”. It is true that we have access to powerful medications that can improve the health problems suffered by many people. The trouble is that our most common medical conditions for which we obediently take our “pills” are really only risk factors, markers of a disease process. Medications and procedures can indeed improve these markers but are they really getting to the root cause of our health issues?
Consider these cases in point. High blood pressure is a signal of poorly functioning blood vessels which can lead to a heart attack or stroke. High blood cholesterol is a marker of plaque development in blood vessels, the eventual cause of fatal and non-fatal cardiovascular events. High blood sugar is a warning of fat build-up in muscles and organs, the forerunner of diabetes. Erectile dysfunction is a sign of unhealthy blood vessels throughout the body, not just within the penis. We take medications for these symptoms and our blood tests often improve but what about our health outcomes down the road? People don’t die from risk factors. They die from the disease that the risk factor is predicting. When we go to our doctors for help, our goal is not to improve lab results but to gain back our health.
Reducing risk factors does indeed lower the risk of many diseases, but by how much? Let’s look at the following illustration. As the negative ramifications of high blood cholesterol have become obvious, “statin” drugs are now one of the most frequently prescribed classes of drug in Canada (1). Information from the Package Insert composed by the manufacturer, Pfizer, for Lipitor, a statin known generically as atorvastatin, states the following;
“LIPITOR significantly reduced the rate of coronary events [either fatal coronary heart disease (46 events in the placebo group vs 40 events in the LIPITOR group) or nonfatal MI (108 events in the placebo group vs 60 events in the LIPITOR group)] with an absolute risk reduction of 1.1% and a relative risk reduction of 36% (based on incidences of 1.9% for LIPITOR vs 3.0% for placebo), p=0.0005 (see Figure 1)]. This risk reduction yields a Number Needed to Treat of 311 patients per year. The risk reduction was consistent regardless of age, smoking status, obesity or presence of renal dysfunction. The effect of LIPITOR was seen regardless of baseline LDL levels. Due to the small number of events, results for women were inconclusive.”
From this we can glean an abundance of information. During the period of drug testing, 40 people treated with Lipitor died of coronary heart disease and 60 suffered a non-fatal heart attack while, in the placebo group (those who did not take Lipitor), 46 people died of coronary heart disease and 108 people experienced a non-fatal heart attack. Hence, 100 people taking Lipitor and 154 people not taking Lipitor had some form of coronary heart event.
Pfizer states that the absolute risk reduction of taking Lipitor is 1.1% (3% minus 1.9%)
Drug companies like to restate this as relative risk reduction because the result looks much more significant. Relative risk compares the change in risk between the treated group and the non-treated group with the risk for the non-treated group.
Relative risk reduction of taking Lipitor is 1.1 divided by 3 = 0.36 or, expressed as a percentage, 36%.
But what does this actually mean?
Pfizer states that the incidence of coronary events for those taking Lipitor was 1.9% so we can calculate that the number of people taking Lipitor in the study was 5264 (1.9% of 5264 is 100). For the placebo, incidence of coronary events was 3% so the number of people taking placebo in the study was about 5133 (3% of 5133 is 154).
Out of the 5133 people in the study who took the placebo, 154 of them had a coronary heart event, but 100 people out of the total of 5264 people who took Lipitor also had an event. Putting this into an easier to understand perspective;
30 people out of 1000 taking the placebo (not taking Lipitor) had a coronary event
19 people out of 1000 taking Lipitor had a coronary event
Therefore 11 people out of 1000 benefited from taking Lipitor.
One more important bit of information is the “Number Needed To Treat” which was 311. This means that 311 people would need to be taking Lipitor before one patient would benefit from the treatment (2).
To sum up: Benefit for only eleven people out of a thousand is very small while the number of people needed to treat before seeing any benefit is very large. It makes one wonder if this difference is enough to subject millions of people to a drug that can cause severe liver damage and increased diabetes risk to mention only two of the many possible adverse side effects that can be caused by Lipitor. Most people are woefully unaware that the actual chance of benefit from taking Lipitor is only 1.1%.
Erectile dysfunction is another increasingly common situation. When proper erection of the penis does not occur naturally, there are medications available to make it happen. Unfortunately, though they may produce an erection, they do nothing for the underlying problem – clogged and crippled arteries. Stiffened arteries cannot relax and open normally to allow the necessary extra blood to flow in and firm up the penis. Erectile dysfunction is actually a “canary in a coal mine”, providing an early warning of problems in all arteries. Why? Because arteries in the penis are very narrow, only about half the diameter of those supplying the heart with blood, so atherosclerotic build-up in the penis will exert its damaging effects much sooner. In fact, a man with erectile dysfunction should be considered a cardiac patient until proven otherwise (3,4,5).
Surgery is no more advantageous. Millions of coronary angioplasties are performed every year. A coronary angioplasty is a surgical procedure that enlarges partially blocked blood vessels supplying the heart. The vessel is inflated by a tiny balloon and a wire mesh stent is left behind to prop the artery open. Emergency angioplasty and stenting during or immediately after a heart attack can save life and prevent extensive heart damage.
However, angioplasty does not prolong life or even prevent heart attacks in stable patients,
the type of patients that are on the receiving end of most of these procedures (8).
Coronary bypass surgery is performed in more extensively blocked blood vessels. This is a more invasive procedure where a vein from the leg or chest is sewn to the ends of the blocked artery before and after the blockage to allow blood to flow around the plaque.
Only 2% to 3% of patients who undergo coronary bypass surgery gain any benefit (9).
Lifestyle changes are startlingly superior. The INTERHEART study which followed over 30,000 people illustrated that changing diet and lifestyle could prevent at least 90% of all heart disease risk (10).
In fact, lifestyle changes can actually reverse atherosclerosis, something that medications have not been able to accomplish with any significance. This stunning outcome was first elucidated in experiments performed by Dr. Dean Ornish. His experimental group followed a low-fat, vegetarian diet that excluded all meat, poultry and fish and minimized vegetable oils. This group also exercised for about half an hour a day, performed stress management exercises and did not smoke. There was a control group that received the standard care that doctors prescribed – a diet centered on “lean” meat, poultry, and fish, along with various medications and advice not to smoke. After a year, the control group patients showed worsening of the blockages in their coronary arteries while 82% of the experimental group showed measurable reversal of their coronary artery blockages (11). The reversal continued over a further five year follow-up (13). Later studies corroborated these results (12,13,14).
A whole food plant-based diet has been shown to produce a 60% absolute risk reduction for major cardiovascular events after only four years.
99.4% of patients who stayed with the healthy diet avoided major cardiovascular events including death from heart attack (14).
These results occur whether the participants are healthy or ill. And all this benefit with only positive side effects. As Dean Ornish himself says, “I don’t understand why asking people to eat a well-balanced vegetarian diet is considered drastic, while it is medically conservative to cut people open and put them on cholesterol lowering drugs for the rest of their lives.”
The number of physicians practicing “lifestyle medicine” is slowly increasing but nowhere near fast enough to stem the ravages of these burgeoning diseases of affluence. Lifestyle medicine is about both preventing and treating chronic disease and, in the vast majority of situations, diet and lifestyle improvements treat chronic diseases more effectively and less expensively than drugs and surgery. A good illustration of this is found in the EPIC study which followed more than 23,000 people, analyzing their adherence to four simple behaviours. The results were eye-opening.
In those who followed four healthy behaviours
Exercising 3.5 hours a week
Eating a healthy diet of vegetables, beans, fruits, whole grains, nuts, seeds and limited meat
Maintaining a healthy weight (BMI of less than 30)
93% of diabetes, 81% of heart attacks, 50% of strokes and 36% of all cancers were prevented (6).
Lifestyle changes reduce more than just risk factors. They target fundamental biological mechanisms such as gene expression, inflammation, body chemistry and metabolism and even our microbiome, factors integral to the development as well as the prevention and reversal of outright devastating disease (7).
At the very least, patients facing treatment should be completely informed about all the choices available to them. Now that we understand the power of diet and lifestyle choices, this wisdom should be passed on to patients as an integral part of the treatment process. Sadly, it is all too often ignored. Doctors have been hampered in the past by a lack of nutritional knowledge beginning all the way back to their years in medical school which traditionally included only meagre information on nutrition. Today, though the knowledge is out there, many doctors do not include it in treatment choice discussions, believing that it is a waste of time. In their estimation most patients are looking for an easy solution and will not be willing to attempt a lifestyle upgrade, let alone make it a lifelong commitment. This lack of faith is in direct contrast to the truth. Studies on implementing a plant-based diet see a high percentage of participants willing to make the necessary substantial lifestyle transition and maintain it for many years. Subjects themselves observe that the lifestyle change gave them control over their own disease (13,14). Is it right though for doctors to assume that their patients would prefer to take a drug of questionable benefit for the rest of their life or undergo serious and invasive open heart surgery rather than improve their lifestyle? I think not. Most people would prefer to hear the whole story and choose their own path to better health.
1 Hennessy, D.A., Tanuseputro, P., Tuna, M., Bennet, C. et al. Statistic Canada Health Reports.
Population health impact of statin treatment in Canada. January 20, 2016.
2 Barratt, A., Wyer, P.C., Hatala, R., McGinn, T. et al. Tips for learners of evidence-based medicine: 1. Relative risk reduction, absolute risk reduction and number needed to treat. CMAJ. 2004 Aug 17; 171(4): 353–358.
3 Meldrum, D.R., Gambone, J.C., Morris, M.A. et al. The link between erectile and cardiovascular health: The canary in the coal mine. Am. J. Cardiol. 2011 108(4):599 – 606.
4 Dong, J.Y., Zhang, Y.H., Qin, L.Q. Erectile dysfunction and risk of cardiovascular disease: Meta-analysis of prospective cohort studies. J. Am. Coll. Cardiol. 2011 58(13):1378 – 1385.
5 Schwartz, B.G., Kloner, R.A. How to save a life during a clinic visit for erectile dysfunction by modifying cardiovascular risk factors. Int. J. Impot. Res. 2009 21(6):327 – 335.
6 Ford, E.S., Bergmann, M.M., Kröger, J., Schienkiewitz, A., Weikert, C., Boeing, H. Healthy living
is the best revenge: findings from the European Prospective Investigation Into
Cancer and Nutrition-Potsdam study. Arch Intern Med. 2009; 169(15):1355-1362.
7 Hyman, M.A., Ornish, D., Roizen, M. Lifestyle Medicine: Treating the Causes of Disease. Altern Ther Health Med. 2009; 15(6):12-14.
8 Boden, W.E., O’Rourke, R.A., Teo, K.K., et al. COURAGE Trial Investigators. Impact of optimal
medical therapy with or without percutaneous coronary intervention on long-term
cardiovascular end points in patients with stable coronary artery disease (from the
COURAGE Trial). Am J Cardiol. 2009; 104(1):1-4.
9 Morrison, D.A., Sacks, J. Balancing benefit against risk in the choice of therapy for coronary
artery disease. Lesson from prospective, randomized, clinical trials of percutaneous
coronary intervention and coronary artery bypass graft surgery. Minerva
Cardioangiol. 2003; 51(5):585-597.
10 Yusuf, S., Hawken, S., Ounpuu, S., et al. INTERHEART Study Investigators. Effect of potentially
modifi able risk factors associated with myocardial infarction in 52 countries (the
INTERHEART study): case-control study. Lancet. 2004; 364(9438):937-952
11 Ornish, D., Brown, S.E., Scherwitz, L.W., Billings, J.H., et al. Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial. Lancet. 1990 Jul 21; 336(8708):129-33.
12 Esselstyn, C.B., Ellis, S.G., Medendorp, S.V., Crowe, T.D. A strategy to arrest and reverse coronary artery disease: a 5-year longitudinal study of a single physician’s practice. J Fam Pract. 1995 Dec; 41(6):560-8.
13 Ornish, D., Scherwitz, L.W., Billings, J.H., Brown, S.E., Gould, K.L. et al. Intensive lifestyle changes for reversal of coronary heart disease. JAMA. 1998 Dec 16; 280(23):2001-7.
14 Esselstyn Jr, C.B., Gendy, G., Doyle, J. et al. A way to reverse CAD? Jour Fam Pract July 2014; 63(7).
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