The 'natural' meme

It happens at least once a week: a patient who equates natural with beneficial. 

Several months ago she came in with contusions suffered when she slipped and fell on some ice in her driveway. Her blood pressure was elevated at 162/100, and looking back at her chart, her blood pressures had been slowly creeping up over a decade. At her last annual preventive visit it had been 142/90 when she arrived and 140/88 at the conclusion of the visit. We had discussed the linear relationship of cardiovascular disease (heart attack, stroke, kidney failure) to blood pressure and she had agreed to have her blood pressure checked at work every 2 weeks for two months. 

She was here today to review these interval blood pressures. In general, she was healthy. Her life style was certainly beyond reproach: she had never smoked, rarely drank, and then only wine, was a vegetarian, had a well organized exercise program with more than five hours of aerobic exercise plus two strength training sessions weekly, taught a yoga class, got 8 hours of sleep nightly, used her seat belt conscientiously, used sun screen appropriately, did not use a cell phone while driving, and had had a stable long term monogamous relationship with her husband for two decades.

Her recorded blood pressures were all elevated: 156/94, 152/98, 160/68, and 150/100. Her most recent lab showed normal kidney function, an excellent lipid profile (consistent with her exemplary BMI, diet and exercise patterns), and a clear urine. Her EKG was normal. Her family history was positive for stroke in two of four grandparents, one on each side, striking in their mid 60s. One had died and the other had suffered serious permanent deficits. She had moderate but asymptomatic hypertension, without evidence of having incurred damage, and was at risk for stroke and coronary artery disease. She was an excellent candidate for risk reduction with medication.

After explaining my concerns that her elevated BP put her at substantial lifetime risk for disabling or fatal stroke and heart attack, and mentioning that she undoubtedly understood the impact this could have because she had seen it in her family, I suggested we start her on chlorthalidone, a generic once daily diuretic that has been shown to be effective at lowering BP as a single agent, has an excellent safety record (though serum potassium has to be monitored and occasionally replaced), and reduces risk of cardiovascular events. If we could normalize her BP we could also normalize her risk.

She adamantly refused to consider taking any medications for her BP. 

“You know me. I’m a wicked health nut and I take care of myself. I can’t stand the thought of taking medications. Who knows what kinds of unexpected problems they can cause. I just never feel right when I take medication.”

But wait, I said - to myself. Her medication list, verified by my nurse before I entered the room today, consisted of valerian, melatonin, coenzyme Q10, acetyl L-carnitine, grape seed extract, reacted chromium, lipoic acid, primrose oil, hawthorne leaf flower and high potency resveratrol. I pointed this out to her as gently as I could: “Looking at this list of medications, you seem to tolerate medicines pretty well.”

“But doctor, they’re different,” she said with no hesitation.

“How are they different?” I asked.

“Those aren’t drugs,” she said. “They’re natural.”

I pointed out that, unlike the chlorthalidone I was suggesting for her elevated blood pressure, the products she was taking were not subjected to careful testing for side effects, long term safety, purity, or drug interactions, and that the risk was likely to be much higher than the risk from the chlorthalidone. She was unmoved. She was not going to take a prescription medication. 

“Don’t you have something natural you can prescribe?” she asked.

I told her I was not aware of any natural substances that were demonstrated to be both as safe and effective as chlorthalidone in this setting. 

“Well, I only take natural things. When it’s natural, I know it’s safe.”

I asked her how she felt about smallpox and leprosy, both of which are clearly natural. 

Her reply: “That’s different.”

She left without a prescription, and I sat and wondered if it would be possible to market a non-prescription ‘herbal chlorthalidone extract’ to be sold in health food stores in a dark green bottle with flowers and butterflies on the label.

 



 

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