Coming Out Against the Healthy Lifestyle
OK, the title is click bait.
I am a great believer in the healthy lifestyle. If Americans lived healthier lives, we would all be in a better place. There would be less obesity, diabetes, and heart disease. We would probably be treating fewer patients for depression, cancer, and addictions. It is his talk about these points, about which everyone agrees, that tempt many to ignore RFK Jr.’s bizarre and dangerous ideas.
What I am actually coming out against is the cult of the healthy lifestyle. This cult worships diet and exercise as panaceas. Cult members believe that there is no disease that a greater dedication to wellness, and fewer seed oils and nightshades, and more adaptogens and nootropics cannot prevent or cure. Those devoted to the God of the healthy lifestyle seem convinced that healthful living will guarantee a future that is happy, satisfying, and whole, living in bliss with a partner who is not just a soulmate, but also radiantly beautiful and transcendently charismatic.
It is rare that a post on twitter or substack about a patient’s illness or a doctor’s use of well-proven medicines is not met with comments about how the patient could have avoided his ills had he just lived better. Commenters also question how the doctor can sleep at night being such a pharma stooge.
This attitude, is self-satisfied, ill-informed, insensitive, and short-lived.
MP is a 50-year-old woman with hypertension and diabetes. She is obese with a BMI of 32. She is on losartan/hydrochlorothiazide, atorvastatin, and metformin. Her A1C is 8.5 and we discuss that it is probably time to start a GLP1-RA.
Are you crazy, say those who worship at the altar of the healthy lifestyle. If her BMI was 23, she would be on no medications! Do you really think that adding one more drug will make a difference?
A little more history.
MP is a single mother of 2. Her 72-year-old father also lives with her, he is disabled after working in the NW Indiana steel mills for 30 years. She lives in the Englewood neighborhood on the South Side of Chicago. They live on her salary and her father’s pension and disability. She commutes 60-90 minutes each way to her job at O’Hare. The commute, and her care giving needs, leave her no time to exercise. She can’t afford to live near her job and can’t afford to take a job near where she lives. Even if she had time to exercise, her neighborhood does not lend itself to a 30-minute brisk walk outside.
She tries to eat well and prepare healthy meals but, given her schedule, she often buys prepared food that she can just reheat. She does occasionally buy Oreos. She knows they are bad for her, but they taste so good and they make a nice treat after everyone goes to bed.
AP comes in for help with his alcohol use. We discuss naltrexone, acamprosate, and disulfiram. He opts to start both acamprosate and disulfiram.
Oh boy, says the cultist, now we are medicalizing addictions. What about some good old-fashioned willpower? At least refer the guy to AA.
AP watched his father die of cirrhosis. AP has had multiple stays in rehab and too many periods of sobriety followed by relapse to count. He has a wife and two small children whom he is desperate to do right by. This visit comes after his most recent fall off the wagon. He had gone months without a drink and then woke up in an emergency room. His last memory? Walking by the bar in which he was later found unconscious.
TT is a 30-year-old woman. She is Native American, born in New Mexico where her family has lived since “the beginning of time.” She recently moved to Chicago with her husband and two small children. She is obese, with a BMI of 35. She says that, historically, nobody in her family was overweight until her grandmother became heavy in later life. Now, her mother, aunts, uncles and siblings are all obese. Her diet is reasonable. She doesn’t much exercise, she works a desk job and cares for her children.
Many of my patients suffer from diseases that were written into their genomes. Their current illnesses are caused by genes perfectly suited to a past world of scarcity, not our present world of unimaginable plenty. Other people are tripped up by a food supply filled with cheap food, processed to be a perfectly addicting blend of salt, fat, and sugar. Many of my patients live in neighborhoods not designed to encourage exercise and work in jobs that demand physical inactivity and devour time that could be spent in healthful pursuits. Then there are financial stressors and community violence that disrupt sleep and further predispose my patients to weight gain.
Make no mistake, we would all be better off if we lived healthy lives. I spend every day counseling my patients on a healthy diet, exercise, smoking cessation, and abstinence from alcohol. Personally, a healthy lifestyle is practically a hobby of mine. I eat almost no processed food.1 I am pathologically addicted to exercise — swimming, running, stair-climbing, rowing, biking.
I am not preaching hopelessness, lowering expectations, or dismissing free will. It is repellant to me when people don’t take responsibility for things within their control. However, it is the height of cruel indifference to ignore realities and demand people achieve the unachievable.
I sometimes worry about the cultists. How will they deal with the cognitive dissonance that awaits them when their luck runs out, as it inevitably will, and they fall ill. As Redd Foxx famously said, “Health nuts are going to feel stupid someday, lying in hospitals dying of nothing.”
Thanks for reading my rant. I feel better. Now, I am going out for a run.
“Almost no processed food” because the quality of my life would be poorer without the occasional pork sausage.
Photo Credit: Geert Pieters
Ok, as a subscriber from the beginning, I love Sensible Medicine. It’s one of my three favorite Substacks, the others being Racket News (Taibbi & Kirn) and of course, Vinay’s Observations. But I really have to push back on you here, Adam.
I live in West Virginia. Moved there from northern California 25 years ago. I used to work in a largely government subsidized health clinic before I switched specialties. I grocery shop weekly myself, in a very working class WV grocery store and every week for years I’ve see what the people Adam described buy and feed their families and themselves.
When you have a box of Kellogg’s Something Cereal for $7, frozen Chicken Tenders for $15, the big bag of Doritos for $8.99, Soda for $5.99, 4 hamburger buns cost $5.00 and you believe vegetables are carrots, corn and potatoes,that’s a problem. These are typical ingredients of the shopping carts I see. These foods are government subsidized, too. I see the SNAP cards used.
I don’t buy that stuff, nor was I raised in my blue collar family to eat that way. My mother clipped coupons, didn’t buy convenience foods. My mother worked full time but she still cooked, and we kids learned to as well. Lots of times we cooked ahead of time and prepped meals to eat later in the week, or we refroze our leftovers. We made it work with the time we had when we had it. Healthier meal prep and avoiding eating crap can be done if you are poor.
Why do so many doctors and white collar workers automatically believe the working class can’t feed themselves in a healthier manner?
How about our system start addressing the root cause of America’s chronic disease epidemic? Why is it always the excuse- oh that poor worker, she can’t afford nutritious food or fix it. So it’s ok if she and her kids are morbidly obese, the doctor can help with their diabetes and hypertension.
I think it’s a cop out on the part of medicine to neglect teaching our kids and their parents that a pill or shot is not the way to make things better.
The widespread belief that workers are helpless due to circumstances creates more dependency on the medical system and doesn’t treat workers as part of their own health care team, which is empowering.
This is my hope for MAHA. Teach and influence those who lack knowledge, right the nutrition ship, and don’t teach that medicine is the basis for improved health.
This seems a bit like a strawman. I don’t think there are many people who sincerely believe no harm will come to them if they eat well, sleep well, exercise, and so on. Perhaps you’re more exposed to the extremes of opinions because your job requires you to be very active online, but I have yet to meet anyone who has the mindset you’ve described in your essay. I think the point of RFK is to focus on the large, low hanging fruit that impacts everyone’s lives instead of pouring billions into the next drug with marginal improvements in EF for heart failure. Last point in my mini rant: I really hope there’s an essay coming soon where you point out the specific things you disagree with RFK on, that would be more interesting and helpful!