Rethinking Aging: Growing Old and Living Well in an Overtreated Society Review

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Rethinking Aging: Growing Old and Living Well in an Overtreated Society ReviewAuthor Hadler, professor of medicine at the University of North Carolina, is one of a number of 'medical minimalists' that believe far too much care is provided - often making the patient's condition worse. Hadler focuses on older Americans and contends that too often health care provided aging Americans serves to profit the provider rather than b enefit the patient. His aim in 'Rethinking Aging' is to warn and arm readers to promote informed decision-making.
Health-adverse behaviors and cardiovascular risk factors account for about 20-25% of the hazard of dying before age 85, but one has to push the limits to pay this price. The biggest hazards to living from age 60 to 85, according to Hadler, relate to socioeconomic status, having a job you hate, loneliness, and lack of control over one's life. People with a higher education or higher-level job live longer, healthier lives, per Hadler, and he shows data to support that conclusion.
Information about weight loss programs/diets constantly bombard Americans. A Canadian study on 1,000 persons aged 25 and older in 1994-95 that were studied for several years found that, adjusting for age, sex, smoking habits, and physical activity, those underweight were nearly 2X as likely to die before those with a normal body-mass-index (BMI); those moderately overweight were also less likely to die. Only the morbidly obese were negatively affected by excess weight. An Australian study found similar results, and also pinpointed sedentary lifestyle as a more important factor. Hadler contends the discrepancies of these two studies vs. most other findings are due to inadequate adjustments for other risk factors. If you want to lose weight, says Hadler, it doesn't matter what you eat, just eat about 10% less.
Type-II diabetes (adult-onset), exercise, diet, and cholesterol-lowering programs are dissed in 'Rethinking Aging' because they all deal with low changes in low absolute probabilities of death (hyped by reporting changes in relative probability), failing to improve death odds (while admittedly improving various physiological measures), side effects in some instances, and the financial biases of many of the 'experts' involved. Hadler also is more conservative regarding the treatment of most hypertension for similar reasons - except when associated with serious underlying problems such as kidney disease.
Age-adjusted coronary artery disease mortality rates have decreased over 30% in our lifetimes. Stenting, angioplasty, and CABG, however, are not credited by Hadler. He contends they are no better than pills in terms of longevity, incidence of heart attacks, and likelihood of chest pain. (Hadler makes an exception for a tiny subset of patients with a particular blockage that do benefit form CABG.) Aspirin (low-dose) is best during/after a heart attack, but not as an ongoing treatment. Plavix, statins, and blood pressure medications are mostly not supported by evidence. CABG is not subject to FDA licensing, stents (devices) only need be proven safe in the sort-term and don't need to demonstrate efficacy for FDA approval. Hadler explains the popularity of all these treatments on providers telling patients that they are different from those in the trials, and/or rushing to complete a procedure within the optimal time-frame - even if it is not needed at all. (That logic seems a bit goofy.)
Hadler also takes on screening for breast, colon, and prostate cancer, which has not been shown to decrease all-cause mortality but does increase radiation exposure, surgeries, and worry. On lower back pain - the rate of surgery increased 8-fold between 1979-1992 - Medicare should stop payying for this until there is unequivocal demonstration of benefit to some subset in a randomized trial.
Hadler goes further than other medical minimalists, and I'm hesitant to accept his recommendations without further study. Other sources, for example, contend that while stents are no better than medication for STABLE angina, they are clearly the best for sudden blockage. As for blood-thinners, others report Plavix is more effective in some patients than others, with genetic background and/or other medications being possible complicating factors. Further, Hadler claims surgical cardiac interventions are no more effective than pills, yet also basically says the pills aren't worth much either. Hadler also contends there is no epidemic of obesity, nor any upsurge - that blatantly contradicts CDC reports. I would suggest NOT taking Hadler's advice at face value. Hadler is a rheumatologist, and possibly 'prescribing' beyond his competency.
On the other hand, Hadler's conclusions are endorsed by highly regarded Drs. Steffie Woolhandler and David Himmelstein in a NEJM review - 5/8/2008. So read carefully, and seek additional opinions. Even if Hadler is only half right, this book reinforces the viewpoint that there is enormous excess utilization in American health care.Rethinking Aging: Growing Old and Living Well in an Overtreated Society Overview

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