Medicine works best when it restores the body to balance. The ideal procedure, elixir, or pill allows the human body to function as it’s “meant to.” Imbalance is not a perfect framework for illustrating disease, but it is useful. And given the importance of balance to health, we physicians should help our patients find it through lifestyle, no matter our specialty.
There are countless ways for imbalance to occur, and therefore disease to set in. Sadly, for many conditions we still lack the tools to reverse an imbalance (e.g., muscular dystrophy). Yet we now have more tools, for more ailments, than ever. Further, scientific breakthroughs continue to unlock the potential for managing previously untreatable conditions.
Balance restoration varies in form depending on the condition. Psychiatry may have been the branch of medicine that introduced this concept to the lay public by describing major depression as a “chemical imbalance.” To put this in more technical terms: say your brain is low in serotonin, a chemical that plays key roles in mood, desire, sleep, and feelings of reward. This deficiency will make you feel anxious, depressed, and unable to sleep. Well, a pill that increases your level of serotonin might provide relief.
Now apply that concept to, say, biliary tract diseases: If stones are forming in a patient’s gallbladder, this indicates 1) the tissue bag has become a potential source of serious illness, and 2) it has less utility for bile storage. In general, the best approach is to remove the source of the stones via cholecystectomy (gallbladder surgery).
Other examples are found in the realm of infectious disease. Antibiotics, in a sense, work by removing excess foreign bacteria, thereby restoring the microbiome to a healthy balance.
Likewise, when treating nutritional deficiency, of, say, vitamin B12, a supplement can be considered a re-balancing measure.
My subspecialty, allergy and immunology, is rife with balance restoration opportunities. Allergists recommend antihistamines for conditions where excess histamine is produced: namely, in allergic reactions and mast cell-related diseases. We also have a growing array of biologic therapies that target specific cytokines when they become overactive and cause disease.
Preventing physiologic imbalances from occurring is a cornerstone of medicine. We counsel children to say no to smoking, and adult smokers to quit before tobacco causes irreversible damage. We vaccinate to prevent severe infection — the uncontrolled spread of dangerous bugs. We encourage activities that promote mental well-being, because neurotransmitter imbalances, like serotonin deficiency, are to some extent preventable by lifestyle. Finally, we talk to patients about nutrition, exercise, and weight.
So, we have arrived at what I believe are two of the medical profession’s central aims: to prevent imbalance from occurring, and to restore balance to health where possible.
If only it were so easily done! Some imbalances are just too thorny. To make it even more complex, each person’s baseline varies, in ways both large and small, from others’. Notice that all examples above involve interventions that would create, rather than reverse, imbalance in someone else. For a patient who’s not depressed, an SSRI, which increases serotonin molecules by blocking their breakdown, could paradoxically make them likelier to self-harm — and cause depressed mood and sexual dysfunction. Taking out a healthy person’s gallbladder would probably cause digestive problems, not fix them. Overuse of antibiotics wipes out healthy bacteria, ironically paving the way for dangerous ones to invade. Vitamin overdoses can be just as dangerous as vitamin deficiencies. And in someone for whom a cytokine signal is active at normal levels, blocking it will only weaken the immune system. Unnecessary interventions bring unnecessary risks.
Ideally, the goal of healing should be to restore an individual’s body to an appropriate homeostasis. The challenge is determining where their optimal balance lies. An educated guess might be the most we can hope for, at least at the start. For instance, a (tiny) minority of people can be healthy despite only sleeping five hours a night. But this does not mean most people will have optimal health on less than seven hours’ sleep nightly, nor that anyone can thrive on three hours of sleep. Similarly, it’s quite possible that some individuals are suited to body shapes and sizes that would be problematic for the health of others. This again doesn’t negate the strong correlation between poor health outcomes and high body mass indices (nor, for that matter, very low BMIs). Numerous well-designed studies have demonstrated the association between obesity and poorer health, even when removing confounders. If health is to be sought, then there are range limits for body habitus as for hours of sleep.
Often balance can be restored without medical intervention, through targeted effort by the patient. Lifestyle counseling — providing information on avoiding harmful substances and getting adequate sleep, as well as on physical activity and nutrition — should be the domain of every physician regardless of specialty. I say that because of how varied the diseases occurring downstream of an unbalanced body are. Let’s take obesity as an example: excess fat can directly interrupt bodily functions, as in non-alcoholic fatty liver, now among the most common causes of chronic liver disease in the U.S. Even more common are the indirect imbalances brought on by obesity, including cardiovascular, hormonal, and immunologic consequences. Finally, we must also consider the added risks of obesity, including greater likelihood of surgical complications. Encouraging healthy living is therefore a responsibility of all health care leaders.
Let us be open-minded rather than expect every patient to match a rigid set of numbers. But let’s also remember the evidence that supports measuring health to begin with. While lifestyle conversations will look different in the offices of a neurosurgeon, cardiologist, ophthalmologist, and allergist/immunologist, their combined efforts carry a far greater chance of success than if the entire burden falls on one. Nor should sub-specialists pass the buck, expecting these conversations to be the sole purview of the primary care physician (or even more unfairly, the ED). We owe it to our patients to share our knowledge about seeking a healthy balance in daily life.
How do you encourage healthy living in your patients? Share your strategies in the comments below!
Basil Kahwash, MD is a board-certified allergist/immunologist and assistant professor of medicine at Vanderbilt University in Nashville, Tennessee. He was a 2020-2021 Doximity Clinical Case Fellow. Find him on Instagram @bazzlemd and Twitter @basilmd0.
Illustration by Diana Connolly