More than a few commenters recently noted something disturbing in my writing. They said my words are increasingly taking a blame-the-patient tone. That bothers me. Of all people, I know about making imperfect health choices.
These comments got me thinking about striking the right balance in writing about health, say, between apathy and defeatism, (oh well, here is the script, it is hopeless), and overzealous boot camp instructor, (you are lazy and weak, 100 more pushups, then to CrossFit.)
It gets even trickier with atrial fibrillation–a malady that affects people in many different ways, but is so clearly lifestyle-related. We know more than we used to about AF, but we still donâ€™t know essential things.
We know the brain and heart are connected; so itâ€™s clear that when the brain is unsettled the heart may be as well. But what is the connection? How does personality type, frowny faces and stress management skills connect to arrhythmia triggers? Something has to trigger those focal impulses. A colleague once wrote to me that he felt neural imbalances were more important than inflammation as a cause of AF. Ok, but the neural ganglia around the heart are connected to the brain.
Then there are the genetics of AFâ€”tall, northern Euro, Type Aâ€™s. Sure there are strong genetic ties, but actionable gene information is far off in the future. African-Americans, for instance, have much lower rates of AF despite having a higher prevalence of risk factors, such as diabetes and high blood pressure. Why is that? I wonder—are the genes that predispose to AF inherited along with those that make one think Ironman triathlons are a good thing? (Grin, athletes, grin.)
And of course there is the lifestyle component. Obesity, high blood pressure and sleep disorders stretch and scar the atria, but not every patient with lifestyle-related diseases gets AF. Why not?
Alcohol intake associates with AF in a linear way, but not all who drink get AF. Remember, alcohol also affects the brain, which is connected to the heart.
Finally, we know inflammation plays a role in AF, but inflammation is essential for life. Why do some pneumonias and recoveries from surgery induce AF, and others do not? How much inflammation is too much?
See. We donâ€™t know essential things. I could go on.
The other reason I harp on lifestyle factors is that AF treatments are so lousy. Itâ€™s hardly hyperbole to say that AF gets most dangerous when doctors get involved. What is a side effect of a rhythm-control drug? Answer: Sudden death. And, tell me, how is making 60 burns in the left atrium, done to isolate areas that may or may not be driving AF, a good therapy?
The point is that it sucks to have AF. But it also sucks to take AF treatment. So, if AF were unnecessary, this would be a good thing.
If you look at population maps and overlay wealth and rates of obesity, you see clearly that AF is a disease of riches. The more we have as a society, in convenience, in expectations, in longevity, the more AF we can expect. Maybe such wealth distorts the view of what is â€œnormal.â€
Here, I will close with a note from Joe, one of my many fine commenters.
At the risk of attracting ire, Iâ€™ll point out that most of us (myself included) are very bad at objectively evaluating our own situation. We look around the office and say â€œIâ€™m not working too hardâ€ when all of us are burning the candle at both ends. We look around the restaurant and say, â€œsee, my diet isnâ€™t so badâ€ when all of us have 1300 calories on our plates. We look around the gym and say, â€œsee, Iâ€™m not that out of shapeâ€ when weâ€™re really seeing a typical cross-section of our obese society.
Modern life has eliminated most of the limiting mechanisms that slowed us down as our bodies evolved. We work and play well into the night, we have constant access to abundant food, we typically move via machine instead of under our own power, and we enjoy a longevity of life that is unprecedented. All of this seems â€˜normalâ€™ to us, but itâ€™s all very abnormal over the arc of human history.
Simply put, our bodies arenâ€™t designed to handle all of this. Our version of â€˜normalâ€™ is quite unusual.
I know that small minority of AF patients exists. I strongly suspect that more than a small minority think they are in the small minority.
Ladies and gentleman, I pledge to stay mindful of tone going forward. Human disease, especially AF, does not fall into discrete boxes.
Yet there is no denying that how we live, the choices we make, affect our health. And that great harm has been done because modern medicine too often ignores this fact.