Doctors should pay more attention to the moral of the Goldilocks story: Not Too Much, Not Too Little–Just Right! To refresh your memory, Goldilocks snuck into a house in the forest. She found it to be unoccupied at that moment, but she found bowls of porridge left cooling on the table. One bowl of porridge was too hot, one was too cold and one was just right. She also tried sitting in the chairs. One was too hard, one was too soft and one was just right. Ditto for the beds. If doctors paid closer attention to this story they might be less likely to overmedicate their patients.
Finding the Sweet Spot:
Getting the dose of medicines right can be challenging. These days there is a tendency to treat a number of risk factors aggressively.
A generation or two ago, doctors were trained to aim for the sweet spot in a treatment program. They often adopted the concept of moderation in all things, including drug therapy. The tendency to overmedicate was constrained by the idea of “just right.”
When my mother was being treated for hypertension 30 years ago, she started complaining of dizziness. Her young primary care physician referred her to an older internist.
The “expert” advised her not to overmedicate. Instead of going along with three or four antihypertensive medicines in an attempt to get her blood pressure down to 120/80, he advised her to back off a bit. He feared that dizziness might lead to a fall.
The new regimen made her feel much better. She lived to 92 and died from a hospital mistake, not a heart attack or stroke or any other complication of hypertension. You can read her story in our book, Top Screwups.
Has Modern Medicine Forgotten Goldilocks?
Modern medicine may have forgotten the message of Goldilocks. In many cases doctors seem to think that if a little medicine is good then a lot is probably better.
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This philosophy has been applied to blood sugar, salt consumption, cholesterol and blood pressure. In every case, medical organizations suggest that the lower the better for such risk factors.
Changing BP Guidelines:
Take blood pressure, for example. Research has established unequivocally that moderate to severe hypertension increases the risk for strokes, heart attacks, kidney damage and dementia. Decades ago, doctors were told that if a patient had blood pressure readings of 160/95, they should be treated aggressively. That threshold dropped to 140/90 two decades ago. More recently, it was lowered again to 130/80.
To achieve such a level, many people need multiple blood pressure-lowering medications. If these work too well and lower blood pressure too much, patients may experience symptoms such as dizziness, fainting, blurred vision, mental confusion, tiredness and nausea.
A devastating complication of high-dose antihypertensive medications, especially for older people, is the increased risk of falls (JAMA Internal Medicine, April, 2014). A broken hip can lead to disability or even death. The moral: in an attempt to meet the current guidelines a doctor might overmedicate and leave a patient worse off.
The Confusion Over ACCORD:
Blood sugar is another example of the Goldilocks principle at work. The ACCORD clinical trial enrolled 10,251 people with type 2 diabetes. Such patients are a bit like the canaries in coal mines. That’s because they are at high risk for cardiovascular complications. Drug treatment should be especially helpful for such individuals. If they benefit, then less susceptible patients should also benefit.
The results of the ACCORD investigation were somewhat counterintuitive. Lowering blood sugar aggressively “increased mortality” (Diabetes Care, June, 2014). That’s not to say that blood sugar should be high. Rather it should be more in the sweet spot—neither too high nor too low.
The Low-Salt Challenge:
Salt is another good example of the fallacy of trying to lower a risk factor excessively. Dr. Franz Messerli is one of the world’s foremost experts on hypertension. He has warned that a very low-salt diet can have unintended negative consequences with increases in stress hormones. He cautions this “…may be associated with increased cardiovascular disease events and mortality” (American Journal of Medicine, April, 2017).
Dr. Messerli advises his colleagues that the Goldilocks message holds here as well:
“Clearly, with sodium restriction, as is true more often than not in medicine, one size does not fit all.”
Mark Twain is purported to have said:
“It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so.”
We wish more health professionals would be a little more cautious when it comes to prescribing. If they overmedicate ,there can be undesirable consequences.
Joe Graedon is a pharmacologist who has dedicated his career to making drug information understandable to consumers. His best-selling book, The People’s Pharmacy, was published in 1976 and led to a syndicated newspaper column, syndicated public radio show and web site. In 2006, Long Island University awarded him an honorary doctorate as “one of the country's leading drug experts for the consumer.” Read Joe's Full Bio.
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Tinetti M et al, "Antihypertensive medications and serious fall injuries in a nationally representative sample of older adults." JAMA Internal Medicine, April 2014. doi:10.1001/jamainternmed.2013.14764
Margolis KL et al, "Outcomes of combined cardiovascular risk factor management strategies in type 2 diabetes: the ACCORD randomized trial." Diabetes Care, June 2014. DOI: 10.2337/dc13-2334
Messerli FH et al, "Salt, tomato soup, and the hypocrisy of the American Heart Association." American Journal of Medicine, April 2017. DOI: 10.2337/dc13-2334
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