[btilly]

I have an objection to the "better lifestyle and diet" approach.

Sure, it is absolutely true that better lifestyle and diet has a huge effect. However it is absolutely certain that the vast majority of people who are told to improve their lifestyle and diet, won't.

The result is doctors giving advice that they know won't be followed. And thereby transferring potential fault from the doctor to the patient, with no improvement in actual outcomes. "I told the patient to lose weight and maintain that with a controlled diet." And yet, most people when told to diet, won't. Most people who start a diet won't complete it. And most people who lose weight on a diet, have the weight back within 5 years. Where each "most" actually is "the overwhelming majority". And the likelihood of the advice resulting in sustained weight loss probably being somewhere around a fraction of a percent.

What, then, is the value of the doctor giving this lecture?

(Disclaimer. I have lost 20 of the pounds I gained during COVID, and am making zero progress on the remaining 30. A few months ago I successfully started a good exercise routine. Given my history, I would expect to only follow it for a few years before falling off the wagon. I believe that this poor compliance puts me well above average. But do you know what I do reliably? Take my prescribed medicine!)

[a1studmuffin]

Your health is ultimately your own responsibility - it's your body. You have free will, and your appetite for risk is yours alone. You can choose to ignore expert advice and refuse to wear a seatbelt, skip your rehabilitation exercises, invest all-in on crypto, or smoke cigarettes. None of this responsibility should fall on the expert if they communicated the risks clearly.

[getnormality]

What you're communicating here, perhaps unintentionally, is that what matters is not results, but blame. If the doctor said what to do but the patient didn't do it, all that matters is the patient is to blame.

You've communicated that by ignoring or dismissing the question of whether better outcomes are possible through other means than demanding that everyone follow doctors' orders and blaming them if they don't.

"Who cares if better outcomes are possible, so long as blame is in the right place"? Is that how we want to approach this?

[recursive]

It's hard to help someone that doesn't want to be helped.

[getnormality]

Struggling to change is different from not wanting to change. People seem to have trouble with basic distinctions like this when they're heavy into moralizing failure to change.

[wjnc]

Profound point. My mother struggled with alcoholism and ultimately succumbed to that disease. In philosophy of mind they use “akrasia” and “akratic thinking” for acting against ones better judgement. It helped me somewhat getting to understand what my mother was going through at that time.

She wanted to change, tried a many multiple of times and it failed. Fault, guilt, blame are useless concepts to use on the Other. And only in moderation should they be applied to the Self. There deep disconnects between what we think, know and do.

[Terr_]

I find it helps to explicitly abandon the expectation that each person has a unitary and consistent will.

Bob the gambler wants to quit and wants to wager, sometimes sequentially and sometimes simultaneously.

The question isn't whether the whole Bob "means it", but which version of Bob we want to ally-with to war against the other, and what conditions or limitations we put on that assistance.

[joannanewsom]

Reading this thread it seems like you're the only one moralizing and looking down on people. I don't see anyone here shaming people for their choices. But somehow you seem to have read the worst interpretation of every reply.

[Retric]

Drugs expand what helping yourself means to the point where people will actually do so.

Statins, GLP-1 antagonists, etc isn’t magic, but it changes people’s behavior and bodies in such as way as to diminish the importance of willpower. Thus, it’s not that people are lacking instead our medicine is simply to primitive to help with a wide range of issues.

[DennisP]

Not that hard in this case. Just give them a pill.

[jaggederest]

Or, as we're becoming aware with GLP-1 drugs, an injection. (For now!). It's better to help people behave better with drugs than moral condemnation. Almost infinitely better, as it turns out, regarding a lot of problematic behavior regarded as "untreatable" previously.

[gropo]

Why not both?

[UltraSane]

The old adage "You can lead a horse to water but you can't make it drink" applies here.

[vacuity]

It may not be the case for statins specifically, but my main concern is side effects. If there was a panacea, I would support giving it to everyone, but lifestyle changes are usually more available, if not easier.

[EasyMark]

Yeah this prickles my hackles too. It took a fairly high dosage of zepbound and many months for me to get to a normal set of eating habits after a couple of decades of bad, but a prediabetes scare surprise on my labs pushed me into the program, but I would not have done it by "white knuckling". I needed some medication to help me along. All these people just saying "calories in and calories out" "just start exercising dude" are making a complex issue into a "simple solution" that almost never works because change takes time; a lot of time that many people don't feel on a deep level that they have to apply to it. So, they just give up after a couple of weeks of "grit" and "will-power". Isn't it like maybe 1-3% succeed over time, while the rest fail when trying to lose significant weight or other health issues that could be resolved with habit only?

[calenti]

To me the terms mix and it helps to separate the things that are externally manageable from the things that are not. The physical is complex but straightforward - the body biochemistry operates on material in, biochemistry mix, expenditure out. The brain is physical - neurons, pathways, etc. The mind, OTOH, is a virtual little candle isolated in a prison of meat and bone trying to understand how to interact with the world around it. External forces can alter the body and brain, but only the mind can change the mind. And does, in ways that are very difficult to control because the sole operator is part of the mechanism. People who try to change on their own and can't aren't failing or weak, it's just really f-ing hard.

[btilly]

If my health is my responsibility, then shouldn't the treatment that I receive be to the standard that I request?

In 2015, https://pubmed.ncbi.nlm.nih.gov/26551272/ showed that medicating all of the way to normal works out better than medicating down to stage 1 hypertension, then insisting on diet and exercise. And yet my request in 2018 to be medicated down to normal blood pressure was refused, because the professional guidelines followed by the experts was to only medicate down to stage 1 hypertension, then get the patient to engage with diet and exercise. The expert standard of care was literally the opposite of what research had shown that they should do.

I agree that experts should not be accountable for my laziness. But can you agree that experts should be accountable for following standard of care guidelines that are in direct conflict with medical research? And (as in my case) refusing the patient's request to be treated in a way that is consistent with what medical research says is optimal?

[mrlongroots]

Maybe 80-90% of people should take doctors at face value, but it is easy and only getting easier to at least access the knowledge to better advocate for your own healthcare (thanks to LLMs), with better outcomes. Of course, this requires doctors that respect your ability to provide useful inputs, which in your case did not happen.

My advice would be to "shop around" for doctors, establish a relationship where you demonstrate openness to what they say, try not to step on their toes unnecessarily, but also provide your own data and arguments. Some of the most "life-changing" interventions in terms of my own healthcare have been due to my own initiative and stubbornness, but I have doctors who humor me and respect my inputs. Credentials/vibes help here I think: in my case "the PhD student from the brand name school across the street who shows up with plots and regressions" is probably a soft signal that indicates that I mean business.

[ac29]

> In 2015, https://pubmed.ncbi.nlm.nih.gov/26551272/ showed that medicating all of the way to normal works out better than medicating down to stage 1 hypertension

Thanks for posting this. While I would generally advise a healthy dose of skepticism for any individual study, this one was very large and seems to be both well designed and executed. While there was a (statistically) significant increase in side effects with more intensive treatments, only about 1% more patients had adverse effects versus the standard treatment group, which seems like a very reasonable risk given the improved outcomes.

I've been trying to get my blood pressure under control recently and was thinking getting down to 12x/8x was good enough, but this has me rethinking that.

[gropo]

You should have bought some illegal street diet and exercise or cholesterol meds or whatever.

[kelseyfrog]

What if you have an intrinsically lower ability to perform temporal discounting?

[nradov]

Is that really something intrinsic and fixed or can you improve it over time with deliberate effort?

[kelseyfrog]

Open to evidence either way. I haven't seen people improve it even with what seems to be terrible negative consequences associated with poor temporal discounting ability, but I'd love to read differing perspectives.

[btilly]

Research on heritability have found that the amount of temporal discounting we do is moderately heritable. With twin studies ranging from 30-60% of our natural variability explained by genes.

This strongly suggests that genetics definitely slips a thumb on the scale, but ultimately we are able to also impact our personal behavior.

More importantly, research such as https://pubmed.ncbi.nlm.nih.gov/31270766/ shows that there are techniques (such as mindfulness practices) that have been demonstrated to improve our abilities in practice. I have personally seen these have an impact.

Of course if you have a condition such as severe ADHD, you might not be able to reach the same level as is possible for someone with good genetics. But you still have the ability to move the needle. If you have a condition such as traumatic brain injury, even your ability to move the needle may be lacking.

But most of us should be able to make a positive change.

[Filligree]

> This strongly suggests that genetics definitely slips a thumb on the scale, but ultimately we are able to also impact our personal behavior.

If it's 30-60% heritable, that leaves 70-40% to split between personal decisions and environment. It does not guarantee that personal decisions matter much at all...

[zzzeek]

> Sure, it is absolutely true that better lifestyle and diet has a huge effect.

not for me. My cholesterol was hovering in the high 200's, then finally hit 300 and I completely freaked out, radically changed my diet, and lost 22 pounds (from 180 to 158).

What did my high cholesterol do ? It did absolutely nothing. ticked down to like, 280.

So I'm on the statins. my total cholesterol went from high 200's to about 150 in a month and was impacting my liver function. so we reduced the statins to a very low dose (5mg three times a week, crazy low). My total cholesterol hovers around 200 now. My cardiologist tells me that the conventional wisdom of "diet and exercise" is almost entirely disproven to have any meaningful effect on lipids these days (though i havent researched deeply).

[sn9]

> My cardiologist tells me that the conventional wisdom of "diet and exercise" is almost entirely disproven to have any meaningful effect on lipids these days (though i havent researched deeply).

I would be immensely skeptical of this unless he was talking about something much more narrow, like how there's a fraction of people who have really unfortunate genetics and can only improve their blood lipids with medication.

We have mountains of data showing that diet can massively improve lipids, and the combination of diet and exercise are our largest levers for reducing the risk of heart disease for most people. (There are always some fraction of people who can do everything right but have outlier genetics that require medication anyway, just as some people have outlier genetics and can smoke a pack a day their whole lives and reach their 90s.)

I'd check out the Barbell Medicine podcast for anything related to the intersection of lifestyle and health. They're extremely evidence based with a preference for measurable improvements in outcomes over hypothetical mechanisms.

Relevant to this thread are their episodes on testing and screening, hypertension / high blood pressure, cholesterol, fiber, and the new PREVENT heart disease risk calculator.

I'd also check out the episodes on diabetes, Alzheimer's, fatty liver disease, and health priorities.

[agiacalone]

> I would be immensely skeptical of this unless he was talking about something much more narrow, like how there's a fraction of people who have really unfortunate genetics and can only improve their blood lipids with medication.

I am one of those unfortunate genetic people, sadly, and have had high cholesterol numbers since my early 20s. Most of my older grandparents passed from heart disease. Now in my 40s, have a decent diet, and my numbers are < 100 for LDL. Current (and previous) PCPs have indicated to me that diet will have little effect for me, and that I will likely be on statins for most of my life. Experiments with stopping the statins have shot my LDL numbers through the roof.

The good news is that it's a pretty low dose with decently high effect.

[zzzeek]

both of my parents have low cholesterol, my mom's cholesterol is naturally under 200, my dad is on statins but the highest he ever got was about 230. they are in their 80s. Nobody on any side of my family (for which I have about 25 first cousins) has ever had any heart disease of any kind, no bypass surgeries, no heart attacks, nothing.

I'm familiar with the genetically high cholesterol thing and when you look at that you see parents/grandparents having heart attacks in their 40's. nothing like any of that in my family.

anyway yes im on the statins and probably need to boost my dose a little more to be below 200.

[cthalupa]

Diet and exercise are hugely important to health in general, and can make a significant impact on lipids.

They are unlikely to get lipid levels down low enough to reach soft plaque regression levels. You need to get sustained levels below 50 to 70 depending on genetics, Lp(a), etc.

If you've lived a healthy life in general and don't have genetically bad Lp(a) this advice is probably enough for you staying that way. If you've spent a significant portion of it with bad lipids for whatever reason, you almost certainly need to go on a combo therapy to get to regression levels.

[btilly]

Your anecdotal report that diet and exercise did not have a huge effect on your cholesterol does not discount the mountain of evidence that we have showing that diet and exercise has a huge effect on health and lifespan.

These effects were first demonstrated in 1953. And has been confirmed over and over again since.

So don't discount the value of diet and exercise just because losing weight didn't fix your cholesterol.

[zzzeek]

yeah I read all that and it's why i did "diet" (already exercised) first.

still doesnt explain what my cardiologist was talking about, though. he's not the first dr. to tell me that "diet isn't really going to help you much". one dr. said, "if you went totally vegan, maybe it would have a slight effect". so no I didnt go totally vegan.

i think the idea is diet/exercise can make a 20 point dent in your total cholesterol but in practice, not much more than that, if you have total cholesterol over 250 kind of thing.

[bluGill]

i think diet an exercise can get you 20 points lower but you needed 150 or so and no diet claims that.

i don't know how to source that but I recall a few 20 points lower diets making the news over the years

[Spooky23]

I think people use it as cudgel to blame people and as a crutch to avoid action. And we ignore the psychological and other factors that make improving lifestyle and eating better difficult.

No doctor wants their patient to have a stroke. But they also only get to meet patients where they are.

[nradov]

You're arguing against a strawman. The reality is that most doctors will tell the patient their options and let them pick. While statins have some significant side effects in many patients, there is no downside to a better diet and frequent hard exercise (assuming proper technique). So it usually makes sense to at least try lifestyle modification as the initial therapy. And if that doesn't work for whatever reason then prescribe the drugs.

[cthalupa]

> While statins have some significant side effects in many patients

Some statins have significant side effect in some patients.

We have many "new" statins that the overwhelming majority of people have no side effects on. Exceedingly small amounts of people have issues with things like rosuvastatin and pitavastatin, and for people that do, repatha and other pcsk9 inhibitors often work fine.

> no downside to a better diet and frequent hard exercise (assuming proper technique). So it usually makes sense to at least try lifestyle modification as the initial therapy.

There is a downside to delaying treatment, and particularly so when they are far out of range, or have spent an extended amount of time out of range.

[btilly]

Are you sure that this is a strawman?

Accepted medical guidelines not long ago said to bring blood pressure from the dangerous range, to elevated, then encourage patients to engage in diet and exercise. Research such as https://pubmed.ncbi.nlm.nih.gov/26551272/ demonstrated that it is better to medicate all of the way to the normal range.

I personally had specialist in blood pressure follow the old advice around 2018. I asked for further medication, and he refused to give it. In so doing, he was following accepted practice, per professional guidelines. This left me with elevated blood pressure for several years. This despite the fact that when I was personally physically fit (when my blood pressure problems were discovered, I still had my crossfit bod), that did not help my blood pressure.

Guidelines are continuing to evolve. Even today, guidelines about how far down to take blood pressure are somewhat vague in the USA. Many countries stick to the older, higher, targets in who even gets medicated in the first place.

It wasn't until about 2 years ago that I encountered a doctor who was willing to medicate me all of the way into the normal range. Given the 2015 research, I'm very happy about this. But it is far from a guarantee that a random person on HN with high blood pressure will encounter a doctor who is willing to do the same.

That's why I believe that this is not a strawman position. I'd be curious to hear your case explaining why you wrongly assumed that it was.

[nradov]

Yes, I'm sure you were arguing against a strawman. The majority of doctors will tell patients about the available options which are generally safe, and allow them to pick. And they don't usually blame patients. Your personal experience might have been different but it was atypical and just an anecdote.

[btilly]

First, if I'm basing it on things that actually happened, then by definition it cannot be a strawman argument. And your insisting otherwise is just plain rude.

Second, you are just giving your opinion about doctors. You are not providing evidence. In fact what you claim about doctors is just straight up wrong.

I already gave you a link to a 2015 study that demonstrates what the standard of care was at that point. Here is https://www.aafp.org/pubs/afp/issues/2018/0115/p72.html demonstrating that in 2018, the year I had my interaction, the standards were shifting. With not all major medical organizations endorsing bringing blood pressure down to what the 2015 study said they should.

In fact if you look at the actual AAFP guidance, see https://www.aafp.org/pubs/afp/issues/2018/0315/p413.pdf. Read to the last page and look for "Follow up". This matches my experience. I was brought to stage 1 hypertension, then "nonpharmological interventions" were recommended. Namely diet and exercise.

And now it is apparent that you were dead wrong. My doctor in 2018 was not some rogue jerk. My doctor was exactly following the recommended standard of care put forth in that year by a major medical association.

While the USA has evolved their standards further, that 2018 standard in the USA is still common in many other countries.

But look on the bright side. You just were given the opportunity to learn something.

[CalChris]

> While statins have some significant side effects in many patients

It's more accurate to say that certain statins have significant side effects in certain patients. Atorvastatin made me dizzy. But I switched to Pravachol and that went away. I switched again to Rosuvastatin and it stayed away.

Not all statins are the same.

[aldarion]

That is because dietary advice they give is actually bad. It mostly boils down to "limit calories while eating standard western diet" but that is impossible to follow long-term as SWD and similar (e.g. food pyramid) diets are nutrient-deficient.

How many doctors recommend things like paleo diet, intermittent fasting and so on? Not many, I think - most simply focus on calories, combined with the advice that is either extremely generalized ("avoid sugar") or outright counterproductive ("eat 5 - 6 meals a day"). And then they wonder why people can't follow their diet.

Here I described my own experiences: https://ketoview.wordpress.com/2025/11/09/low-fodmap-keto-di...

[GrzegorzWidla]

Nobody recommends western diet. It’s standard practice to recommend DASH or Mediterranean one.

[gropo]

Sure it's absolutely true (I stopped reading there.)