Bad medicine: health promotionBMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e2755 (Published 17 April 2012) Cite this as: BMJ 2012;344:e2755
- Des Spence, general practitioner, Glasgow
Research is flawed and open to the bias of the authors because people don’t invest time and energy to prove themselves wrong. So if research conclusions don’t make intuitive sense, it is prudent to question the validity of the research. So it is with the conclusions of research into health promotion, because I don’t believe that educating (that is, lecturing) patients to change lifestyle works. It is simply not how people operate. Patients are aware of risks but wantonly choose to ignore our advice. But governments ignore this: health promotion in England costs £3.7bn (€4.5bn; $5.9bn) a year.1 The coalition government is promoting the slogan “every contact counts.”2 We are to weigh in and nag about diet and smoking in every health contact because “brief interventions” work. Indeed, outreach health missionaries are storming door to door with so called health promotion propaganda, sticking the foot in whether people want it or not.⇑
But health promotion is hardly new, being the stock and trade of doctors since Hippocrates. This expensive initiative is just another in a long line of central governmental programmes to promote health dating back decades. What is the evidence for health coaches, brief intervention, motivation training, and the so called cycle of change? Isn’t this all really just well intentioned but oversimplistic, mechanistic nonsense?
In the landmark study in general practice for individualised health promotion led by nurses, the absolute benefits were tiny: reductions in cholesterol of 0.1 mmol/L and in blood pressure of 3-7 mm Hg (with the strong possibility that these benefits were artefacts).3 There is certainly no mortality data. As for other outcomes on smoking, exercise, alcohol, and diet, any results are confounded by the dark art that is the self reported questionnaire. It is only human to tell people what they want to hear, especially those in authority. This is not cynicism but realism—for example, in pregnancy, self reported smoking by mothers underestimated true prevalence by 25%.4 We should be sceptical of all evidence based on self reporting, however pseudoscientifically it may be dressed up.
The hard facts are contradictory: weight has increased,5 activity declined, fast food chains expanded, and alcoholic liver diseases increased,6 despite decades of health promotion. Smoking rates have fallen, but perhaps it is little wonder as the dangers of smoking are crystal clear, smoking may cost a smoker £3000 a year, and smoking has been banned in public and private spaces. Health promotion is the weakest of all medicine. Worse, health promotion has been a smokescreen allowing successive governments to abdicate responsibility for tackling the vested interests of food and drink corporations and wealth inequalities. Now that is truly bad medicine.
Cite this as: BMJ 2012;344:e2755