Whole Living Guide > Examination

One-Size Fits All Medicine?
By Russell Wild . Illustration by J.B. Lowe

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.

Water
THE PUBLIC RX:
Drink eight glasses of water a day.

THE OVERSIMPLIFICATION: “It’s highly important that we all stay well hydrated, but the actual amount of water a person needs depends on size, temperature, and level of physical activity,” says Samantha Heller, MS, RD, senior clinical nutritionist at NYU Medical Center in New York City. “Some people might do fine with only four 8-ounce glasses of water, others may need considerably more than eight.” She also points out that people who eat lots of foods high in water content, foods such as lettuce, tomatoes, and pears, will not need to drink as much as people who live on peanut butter and beef jerky.

YOUR PERSONAL RX: Try to drink at least a 1/2 ounce of water or water-like fluid (juice, skim milk) for each pound of body weight. So if you weigh, say, 150 pounds, that would equate to (.5 x 150) 75 ounces of fluid a day, or around nine 8-ounce glasses. If you eat lots of high water content foods, that might be reduced to perhaps seven glasses. If you are exercising heavily, or if it’s an especially hot day, drink more.

The American College of Sports Medicine recommends that people drink at least two 8-ounce glasses of fluid two hours before exercise, and to continue drinking small amounts at regular intervals throughout exercise. Heller cautions that sugary drinks like soda, caffeinated drinks like coffee, and alcoholic beverages should not be counted toward your total, as they can all dehydrate rather than hydrate you.


Caffeine
THE PUBLIC RX: Two or three cups of coffee a day…anything less is downright un-American.

THE OVERSIMPLIFICATION: “Caffeine is not only addictive, but it presents many potential problems, including insomnia, adding to anxiety and stress, and possibly exacerbating conditions like high blood pressure and heart disease. How much caffeine? Hard to say. We are all sensitive to different degrees,” says Hyla Cass, MD, assistant clinical professor of psychiatry at the UCLA School of Medicine and co-author of Natural Highs (Avery Penguin Putnam, 2002). Certain people, such as those with heart problems, or pregnant women, should unequivocally swear off caffeine. One study in the New England Journal of Medicine concluded that as little as 100 mg of coffee a day (one cup of coffee) may increase the risk of early miscarriage.

YOUR PERSONAL RX: If you’re a caffeine junkie, know that swearing off coffee isn’t going to be easy. You may at first suffer withdrawal symptoms such as headache and fatigue. Most people will get some symptoms, but not everyone does. Bear with it. Know that after a few days, you’ll be free of the addition, and you’ll feel better for it. “After your body adjusts, you’ll actually start to feel more alert,” says Dr. Cass. If you can’t give up caffeine, consider switching from coffee to tea, preferably green tea. Green tea has roughly half as much caffeine as coffee, and you’ll at least be getting a healthy dose of antioxidants, which help ward off disease.

Sun exposure
THE PUBLIC RX: The American Academy of Dermatology recommends sunscreen with an SPF of at least 15 at all times. It’s also a good idea to get checked over by a doctor at least once a year for any signs of early skin cancer.

THE OVERSIMPLIFICATION: Although anyone can get skin cancer, some people are much more susceptible than others. The most susceptible of all: “people with fair skin, people with lots of freckles or moles, and those with a family history of skin cancer,” says Ted Daly, MD, a dermatologist in private practice in Garden City, New York, and director of pediatric dermatology at Nassau University Medical Center in East Meadow.

YOUR PERSONAL RX: If you fit into any of the groups mentioned above, you should be extra cautious about getting too much sun. Whenever outdoors, wear a shirt, a brimmed hat, choose a sunscreen with an SPF of 30 or greater, and see a dermatologist at least once a year for a thorough once-over. If you don’t fit into any of those groups, you still need to exercise some caution. Even the darkest complexioned people, although much less susceptible to skin cancer, are not immune, says Dr. Daly. “Among black people the most common site for melanoma (the most dangerous kind of skin cancer) is under the nail beds. They should check there regularly for any abnormalities.”


Alcohol consumption
THE PUBLIC RX: One glass of beer, wine, or whiskey a day if you’re a woman; two if you’re a man. That’s the limit. Anything under that limit is probably good for you and especially your heart. Anything more than that, and you risk a number of health problems, such as cirrhosis of the liver. You might also, like many before you, lose your career and marriage, or crash your car.

THE OVERSIMPLIFICATION: “Different people have different tolerance levels for alcohol. And even the same person will react differently to alcohol at different times,” says psychologist Michael Nuccitelli, PhD, executive director of SLS Health, a behavioral health care facility in Brewster, New York. Such things as body weight, genetics, whether you’re a regular drinker or not, and the amount of food in your stomach, he explains, will all have a bearing on how your mind and body deal with booze.

YOUR PERSONAL RX: Use the “one or two glasses a day” as a rough rule, “but err toward caution,” says Nuccitelli. “Be especially cautious if you seem to have a genetic predisposition to alcoholism. Look at the drinking habits of your parents, siblings, and grandparents.” Be extra cautious, too, if you are drinking to drown your sorrows. “A very high rate of alcoholics suffer from anxiety and depression,” says Nuccitelli.


Fluoride
THE PUBLIC RX: The optimal amount of fluoride for healthy teeth is attainable by drinking fluoridated water. The optimal level of fluoridation recommended by the US Public Health Service is .7 parts per million in warmer climates, and 1.2 parts per million in cooler climates. (Officials assume that people in Florida and Arizona drink more water than people in Montana and Maine.) In communities without fluoridated water, children from six months to 16 years should receive fluoride supplements.

THE OVERSIMPLIFICATION: “Proponents of fluoridation only see the good in fluoride, but it can also be potentially dangerous. The problem is that people drink vastly different amounts of water, and among individuals there is a wide range of sensitivity to fluoride,” says J. William Hirzy, PhD, a scientist with the US Environmental Protection Agency, and senior vice president of the union that represents EPA professionals. The union has taken an official stand against fluoridation. Some doctors have taken a similar stand.

“There are people getting multiple times the fluoride that others are getting, way more than the amount widely considered optimal,” says Kenneth Rudolph, MD, a general internist in Scranton, Pennsylvania. “We know that high doses of fluoride can cause brittleness in bones and other problems. The only question is ‘how much fluoride?’ I don’t believe that has been fully answered.”

YOUR PERSONAL RX: All experts agree that too much fluoride can cause dental fluorosis, a speckling of the teeth. Experts also agree that children under six months should not be getting fluoride at all. Beyond that, the vast majority of health officials believe that mild overdosing is no big worry. Unfortunately, there is no firm consensus. Roughly two-thirds of America’s water supplies are fluoridated. If you’re unsure about your water supply, you can find out on the Centers for Disease Control Web site http://apps.nccd.cdc.gov/MWF/Index.asp. If you are concerned that your family may be ingesting too much, discuss it with your doctor. Certain water filtration systems can remove fluoride.