Up and running: An underutilized prescription in primary care

General practitioners (GPs) are observing more and more patients with complaints related to modern lifestyle. The consequences of a sedentary lifestyle and high caloric intake have only just begun to emerge, and the incidence of newly diagnosed type II diabetes is rising steeply. Despite progress being made in managing many diseases such as cardiovascular diseases (CVD), modern medicine has failed to stand up to the challenges of contemporary civilization. The reason for this is partly due to the fact that these problems are only to a certain degree medical problems; they are, rather, complications of our way of life and should be dealt with accordingly. The use of pills to solve every complaint is an oversimplified solution to a complex problem and the cost of medicine is rising in most Western countries.

Medical management of an obese patient with reflux esophagitis, hypertension, type II diabetes, osteoarthritis, gout and sleep apnea syndrome will lead to the prescription of many pills. This patient might need 2–3 drugs to treat hypertension, a pill for the reflux disease, at least one type of pill for high blood glucose, another pill to treat the symptoms of osteoarthritis, and one to prevent attacks of gout. Often this kind of treatment ends up in a multifaceted polypharmacia with unforeseen side effects and drug interactions.

The prevalence of obesity has risen considerably over recent decades and the health risks of obesity are well known, i.e. diabetes, hypertension, stroke, depression, and gallbladder diseases just to mention a few. Furthermore, the health benefits of weight loss among overweight patients have been convincingly confirmed in large studies with lower all-cause, CVD, and cancer mortality, and reduction in diabetes and hypertension [1,2]. The fundamental issue in the battle against the obesity epidemic is, not surprisingly, prevention. Although many studies have shown an important effect on preventing type II diabetes, the long-term results seem to diminish to some extent with time though the effects of a lifestyle intervention can persist as long as 10 years after the intervention [3]. The types of treatment that GPs can offer their obese patients are diet therapy, exercise, behavior modification, and in the worst cases surgery. Many drugs have been tested in this battle: sibutramine, orlistat, phentermine, and many more. The results of these trials have been disappointing to say the least, and it is unlikely that the obesity epidemic can be solved with pills. However, GPs can help patients to lose weight with counseling sessions, and the most important method is combining diet with increase in physical activity (PA) [4]. To be as effective as possible, GPs need specific training in how to promote PA and lifestyle changes [5,6].

Another example of how modern medicine is trying to cope with medical problems is the use of SSRI antidepressants. Despite studies showing positive results only among one-third of patients treated, doctors continue to prescribe these drugs in increasing numbers [7]. The prescription of medicine for depression is almost twice as high in Iceland compared with Norway, and it is an unlikely conclusion that this only reflects a higher prevalence of depression among Icelandic patients [8]. This is more likely to be explained by different prescription habits among doctors. Is it a reasonable goal to try to defeat depression or periodic unhappiness with pills?

According to the Icelandic Directorate of Health 69% of Icelandic men and 81% of Icelandic women received at least one drug prescription over a one-year period during 2010. The ratio of people receiving at least three prescriptions per year was 54% and the proportion obtaining five or more prescriptions was 41%. Hence, in Iceland at least, doctors are very “efficient” in prescribing drugs to their patients. The number of older people is increasing and it is reasonable to assume that this will lead to an even higher proportion of the population using more drugs.

The challenge of modern medicine is obviously to change this and to support the aim that when people get older they will be as healthy as possible, hopefully with fewer pills than this age group is using today. Drugs are without doubt needed in many cases and studies have repeatedly shown fairly convincing results when it comes to secondary prevention of CVD. However, the need to prevent risk factors for CVD and type II diabetes from emerging is compelling. This should primarily be done through a comprehensive approach involving the public, governments, health authorities, and health care providers. GPs can play a key role in enforcing these “cultural” changes.

With its positive effects on physical and mental health and very few, if any, side effects, and cost-effectiveness without comparison, a prescription for physical activity (PA) to people of all ages should be among the first and most commonly utilized prescriptions given by GPs and other primary care providers.