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Editor's Choice

Pills are not the answer to unhealthy lifestyles

BMJ 2018; 362 doi: (Published 12 July 2018) Cite this as: BMJ 2018;362:k3046

Re: Pills are not the answer to unhealthy lifestyles

Pills are not the answer to unhealthy lifestyles but maybe nutrition and physical exercise advises aren't either (sort of victim blaming [1] "I eat a lot and too few vegetables and I move too little"), and privatizing the solution to an individual level being a public health issue that maybe needs a communitarian approach [2]).

Social determinants of health must lead our understanding of social inequalities BEFORE applying a patient-centered approach [3]. There is no use (or worst, there is a misuse of) shared-decision making if we (physicians, nutritionists, nurses...) support our speech or address issues like obesity, type 2 diabetes mellitus, hypertension... on the calories-in calories-out basis. Even if this view was objectively true (at describing cause and effect), we see day after day a non-random distribution of this health problems. Athina Raftopoulou (her thesis is coming. Maybe at the end of 2018 we could take a look on it) analysed the geographic determinants of individual obesity risk in Spain [4]:
-"[...] controlling not only for the individual effects and those of the immediate environment but also for the broader setting to which individuals and their immediate environment belong"; she found that "[...] attributes from all three levels of analysis have an effect on individual weight status and obesity. Lack of green spaces and criminality taken as proxies of the social environment positively affect individual and women's BMI and obesity, respectively". Asymmetric incidence of obesity driven by sex and socioeconomical status are not new topics (or should not be to us).

Michael Marmot said in 2005 [5] that:
-"[...] If the remedies of the social causes of health should be social, what should we do? I am now up to my ears in a new Commission on Social Determinants of Health [3]". Their team and he "[...] are trying to take a social approach to reducing inequalities in health between and within countries". It is (in my point of view) less unfair in this way indifferent of the option applied at the end (pill or other treatment).

Saibal Mitra [6] wrote:
-"[...] We need to consider new ways of effecting lifestyle change. A possible solution is to exploit the fact that poor lifestyle choices cost society a lot of money. This is an additional problem that can, however, be used to finance interventions that promote lifestyle changes. E.g. one can consider implementing a free of charge healthy food ration system"

Why? Well because Nicole Darmon and Adam Drewnowski studied whether social class predicts diet quality [7] (Table 1, Table 2, and Figure 1 are of special interest for me). Interesting findings:
-"[...] it is possible to purchase an energy-dense diet for a relatively high cost, while economic constraints will necessarily increase energy density. In other words, the more affluent groups have a choice of high-energy-density or low-energy-density diets, whereas for low-SES groups, the ability to adopt a healthier diet may have less to do with motivation than with economic means. Recent studies from both the United Kingdom (194) and the United States (195) have shown that providing vouchers for purchasing fruit and vegetables was a simple and effective way of increasing fruit and vegetables intakes in low-income women, whereas dietary advice alone had no great effect (194)."

Let me repeat their statement: dietary advice alone had no great effect (maybe hard to read for a nutritionist. I had my doubts too in my second year bachelor's degree about it). I repeat my initial statement: pills are not the answer to unhealthy lifestyles, but maybe nutrition isn't either (alone or / and without a perspective of social determinants of health).

I don't know what is the answer to unhealthy lifestyles. But I am sure we can do better managing our actions in this uncertainty. We can't prescribe money yet [8] but we can (and must) recognize patterns of injustice in the lifestyle of the communities (not only just focusing on the individuals in an isolated way). For example, sociocultural and socioeconomic influences on Type 2 Diabetes Mellitus risk in African-American and Latino-American children and adolescents [9], gender inequalities [10], and asking ourselves if the problem is obesity or difficulties in making ends meet [11].

Maybe there is no (simple and reductionist) answer at the end. But we must watch very carefully how we look for it.

[2]: Ataguba JE, Mooney G. A communitarian approach to public health. Health Care Anal. 2011 Jun;19(2):154-64
[3]: Lang T. Ignoring social factors in clinical decision rules: a contribution to health inequalities? Eur J Public Health. 2005 Oct;15(5):441
[4]: Raftopoulou A. Geographic determinants of individual obesity risk in Spain: A multilevel approach. Econ Hum Biol. 2017 Feb;24:185-193
[5]: Marmot M. Historical perspective: the social determinants of disease--some blossoms. Epidemiol Perspect Innov. 2005 Jun 2;2:4
[7]: Darmon N, Drewnowski A. Does social class predict diet quality? Am J Clin Nutr. 2008 May;87(5):1107-17
[9]: Rebecca E. Hasson, Tanja C. Adam, Jay Pearson, Jaimie N. Davis, Donna Spruijt-Metz, and Michael I. Goran, “Sociocultural and Socioeconomic Influences on Type 2 Diabetes Risk in Overweight/Obese African-American and Latino-American Children and Adolescents,” Journal of Obesity, vol. 2013, Article ID 512914, 9 pages, 2013
[10]: Sandín-Vázquez, María & Espelt, Albert & Escolar Pujolar, Antonio & Arriola, Larraitz & Larrañaga, Isabel. (2011). Desigualdades de género y diabetes mellitus tipo 2: La importancia de la diferencia. Avances en Diabetología. 27. 78–87.
[11]: Escolar Pujolar A. [Social determinants vs. lifestyle in type 2 diabetes mellitus in Andalusia (Spain): difficulty in making ends meet or obesity?]. Gac Sanit. 2009 Sep-Oct;23(5):427-32

Competing interests: No competing interests

15 July 2018
Marc Casañas Escarré
Baixada Sant Miquel nº2 (Spain). Catalonia, Tarragona (El Vendrell)