Doctors are often appalled by their patients’ unhealthy habits, as much for aesthetic as for health reasons. They are also irritated by the refractory nature of those habits and the failure of patients to do anything about them even when repeatedly advised to do so. Such repetition serves a purpose, however. Doctors may not be able to cure their patients, but they can at least make them feel guilty. To do so relieves the doctor’s feelings.
Now that Type II diabetes – that used to be called maturity-onset in the days before children began to get it – has reached epidemic proportions, the scope for medical lifestyle badgering has increased enormously. But does it do any good?
The results of a very prolonged trial in America have just been published in the New England Journal of Medicine. More than 5000 fat Type II diabetics aged between 45 and 75 were randomly allocated to normal treatment and standard advice, on the one hand, and (sinister phrase) “intensive lifestyle intervention” on the other. The investigators ended the trial after most patients had participated in it for about ten years. Something called “futility analysis” revealed that prolongation of the trial was unlikely to produce positive results.
“Intensive lifestyle intervention” consisted of weekly individual counselling sessions for six months, more infrequently thereafter, a diet of 1200 – 1800 kilocalories per day, moderate exercise for about three hours a week, and “meal replacement products” (“Darling, your meal replacement product is on the table”). Control patients received their medication as per usual and only casual advice about how to live.
The patients were followed up to see whether a) they lost weight under the intensive regime and had better diabetic control, and b) whether, if so, it translated into lower death rates from cardiovascular disease, fewer non-fatal heart attacks and strokes, and less hospitalization for angina.
The intensively intervened patients did indeed lose more weight, especially at the beginning of the intervention (they lost 8.5 percent of their body weight instead of only 0.7 percent), and their diabetic control was better. So far so good.
Unfortunately, when it came to the matter of death, heart attack, stroke and angina, there was no difference between the groups: 403 of the intensively intervened group had experienced one of the above, while 418 of the control group had. The difference was so small that it could easily have arisen by chance.
There was some consolation for believers in intervention, however. The intervened group felt better, had less sleep apnoea, and needed to use less insulin and other medications than the control group. Indeed, the fact that they used less medicine was one reason suggested for the failure of the intervened group to do better.
To me this seemed a bit like clutching at straws. The Journal’s editorial that accompanied the article concluded:
The investigators have shown that attention to activity and diet can safely reduce the burden of diabetes and have reaffirmed the importance of lifestyle approaches as one of the foundations of modern diabetes care…
Evidence, like beauty, is obviously in the eye of the beholder.
The extremely modest benefit of the “intensive lifestyle intervention” was bought at considerable cost that neither the investigators nor the editorial mentioned. For example, the extensively intervened group spent something like three months of their waking lives doing moderate exercise that they would not otherwise have done. Perhaps they really enjoyed it, in which case fine; but what if they did not? What if they would have preferred to do something else?
I am reminded of the spirit of the father who said to the mother, “Find out what the children are doing and tell them to stop it.”