Medicine is Unnecessarily Complicated
In medical school, the 2nd-year curriculum was/is structured around organ systems – cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, endocrine, etc. – with each unit taught by the respective specialist physicians. I remember well the subject-by-subject advancement through each unit, with the pathophysiology being coordinated with the supporting pathology and pharmacology relevant to the topic at hand. For example, we would spend several days on a topic like Hypertension (elevated blood pressure), learning a plethora of details relevant to that diagnosis, then hard-stop and move on to the next topic, e.g. Ischemic Heart Disease. Each “disease” was treated as an island, or a silo, effectively a unique disease process that had its own risk factors and unique treatments.
Fast forward to 8-9 years ago when I finally recognized that our modern convention of labeling diseases was misleading. Working in the hospital setting, I recognized a pattern among the majority of my patients carrying largely the same diagnoses, to the point almost of being able to “rubber stamp” charts with a cluster of diagnoses from among the following:
- Type 2 diabetes
- Dyslipidemia (abnormal lipids)
- Obstructive Sleep Apnea
- Fatty Liver
- Coronary Artery Disease (CAD)
- Peripheral Arterial Disease (PAD)
- Stroke (cerebrovascular disease)
- Erectile Dysfunction
Why is it that nearly every patient with diabetes and obesity also has hypertension? And fatty liver . . . and dyslipidemia. And why does every patient with heart disease, stroke, or erectile dysfunction also have hypertension?
Do these patients really have 10+ different diseases? Of course not.
A Unifying Disease Process
The reason for the grouping of these conditions is that all of these diagnoses are driven by the same disease process – Insulin Resistance. We are so fixated on each individual medical problem existing on its own as a separate entity that we struggle to see that they’re just different symptoms of the same metabolic disease.
In fact, the diagnosis of Metabolic Syndrome is, by definition, a combination of these conditions – elevated blood pressure, elevated fasting glucose, abdominal obesity, and abnormal lipids. As of 2014, the incidence of Metabolic Syndrome was 32.3% (and increasing) among adults in the United States. Thus, nearly 1/3 of US adults have at least 3 of these conditions. Why, then, would we think that each one is a different disease process?!?
The common thread among these conditions is that they are all driven by Insulin Resistance, and addressing the Insulin Resistance results in improvement in all of these manifestations. Occam’s Razor states that the simpler explanation is likely the correct one – also stated as “Entities are not to be multiplied beyond necessity.” Thus, if one disease process explains the presence of multiple conditions in the same individual, then that is far more likely than if there were multiple different disease processes all occurring simultaneously. This principle is cited endlessly in medicine, but seems to be ignored in this most obvious example of metabolic disease.
In medicine, we compile lists of multiple conditions considered “risk factors” for other conditions. For example, the risk factors for CAD include: tobacco exposure, physical inactivity, increased body weight (overfat), hypertension, dyslipidemia, diabetes, metabolic syndrome, cerebrovascular disease, peripheral arterial disease, and an unmodifiable risk factor of family history. Does that list sound familiar? Many of these so-called risk factors are really just different symptoms of the same disease.
Basically, when you find a couple of these conditions in an individual, you’re likely to find a couple of the other conditions, as well – because they’re really just different manifestations of the same disease process.