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One-Size Fits All Medicine? 

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POP QUIZ: What’s the best shoe size?
A)6 ½ B)10 C)15 D)It depends… are we talking about Kobe Bryant or Dr. Ruth?
Obviously, the best answer—the only answer—is D. It depends.

What is glaringly obvious in the world of footwear isn’t always so obvious in the world of medicine. Standard recommendations for everything from drug dosage and cholesterol levels to water intake and alcohol consumption are often made with the “average” person in mind. But is “average” Kobe Bryant or Dr. Ruth? Calista Flockhart or Oprah? Your 18-year-old nephew or your 85-year-old great-aunt? Medical guidelines can be helpful. They allow us, and allow our doctors, to easily remember certain numbers. Cholesterol level of 190 is good. Cholesterol level of 210 is bad. Drinking two glasses of wine a day is okay. Drinking three is not okay. These kinds of guidelines are so simple and easy.

But they’re often too simple. Too easy. In this article, we take a look at some common prescriptions for public health, and why they might, in many cases, be gross oversimplifications. Then we’ll ask the experts how you should, with the help of your physician, create your own personal, customized, more appropriate health guidelines.

Prescription medications
THE PUBLIC RX: Follow your doctor’s instructions or the dosage amounts on the side of the package.

THE OVERSIMPLIFICATION: “Drug companies like to foster a one-size-fits-all regimen because it makes their products more marketable. Doctors like drug doses that are easy to remember and quick to prescribe. But a one-size-fits-all approach to drugs is a problem—a problem that goes against basic medical science and a problem that's potentially serious when women take man-size doses,” says University of California, San Diego professor Jay S. Cohen, MD, author of Over Dose (Jeremy P. Tarcher/Putnam, 2001). A 105-pound woman taking the same dosage as a 200-pound man will obviously be getting much more drug for her body weight. This can lead to much higher blood levels of a drug, causing a higher risk of side effects, says Dr. Cohen. The 1997 withdrawal from the market of Seldane, an antihistamine, occurred because of heart problems that primarily struck women.

Race and ethnicity can also affect the optimal dosage of a medication. The majority of Americans are Caucasian, and most drug-trial participants are Caucasian. “But a small difference in a few genes can affect the body's reaction to drugs,” says Dr. Cohen. Studies, for example, show that four times as much of the popular ulcer drug Prilosec accumulates in the blood of some Asian Americans as it does in Caucasians.

And age is yet another important factor to consider. As you grow older, your metabolism changes. The liver and kidneys may work more slowly. Body composition changes. “Often, the proper dosages for an elderly person might be half of what they would be for a younger person. But with many top-selling drugs, the elderly are prescribed the very same strong doses as young healthy adults,” says Dr. Cohen.

YOUR PERSONAL RX: If you are anything other than a 35-year-old Caucasian male, you should thoroughly discuss matters of gender, age, and race with your doctor before walking off with a new prescription. Together, the two of you should review the “clinical pharmacology” and “special populations” sections of the drug package insert or the Physician’s Desk Reference (PDR).

Also, recognize that the amount of medicine you need can often be reduced—and sometimes eliminated—through lifestyle changes. Weight loss, exercise, and salt reduction can lower high blood pressure. Eating less saturated fat and more fruits and vegetables can lower cholesterol. Arthritis pain can be alleviated by warm-water soaks, stretching, and the application of ice. Make sure you discuss lifestyle changes and home remedies with your doctor.

Cholesterol
THE PUBLIC RX: If your total cholesterol is less than 200 mg/dL and your HDL is 35 mg/dL or higher, and you have no other risk factors for heart disease, then you’re OK. If your total cholesterol is above 200, and especially if it’s above 240, you are likely at increased risk of heart disease, and you are urged to bring your cholesterol down either by changes to your diet, or medication, or both.

THE OVERSIMPLIFICATION: “We should be treating patients, not numbers. It is simply wrong for any doctor to say, ‘OK, I see a cholesterol level of 243, so we’re going to put you on this drug,’” says Stephen Sinatra, MD, a cardiologist with the Eastern Connecticut Health Network and author of Lower Your Blood Pressure in 8 Weeks (Ballantine, 2003). In recent years, says Dr. Sinatra, medical science has shown that other substances in the blood, such as the amino acid homosysteine, may be even more closely linked to your risk of heart disease than is cholesterol. “By looking at a complete picture of a person, with a thorough blood analysis, and an examination of lifestyle, only then can we determine a person’s risk of heart disease,” says Dr. Sinatra.

YOUR PERSONAL RX: Don’t allow a physician to put you on a cholesterol-lowering medication (all of which have certain side effects) or suggest radical lifestyle changes without first getting a complete physical. Ask, too, for your doctor to review with you natural means for bringing high cholesterol levels down to earth. Often, changes in diet can do as much or more than pills. Most important, says Dr. Sinatra: Cut way down on saturated fats (found in meat and dairy products). Eliminate the consumption of trans fats (found in many snack foods). And up your intake of good-for-the-heart foods such as fish, soy products, and garlic.

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