Sure, it is absolutely true that better lifestyle and diet has a huge effect. However it is absolutely certain that the vast majority of people who are told to improve their lifestyle and diet, won't.
The result is doctors giving advice that they know won't be followed. And thereby transferring potential fault from the doctor to the patient, with no improvement in actual outcomes. "I told the patient to lose weight and maintain that with a controlled diet." And yet, most people when told to diet, won't. Most people who start a diet won't complete it. And most people who lose weight on a diet, have the weight back within 5 years. Where each "most" actually is "the overwhelming majority". And the likelihood of the advice resulting in sustained weight loss probably being somewhere around a fraction of a percent.
What, then, is the value of the doctor giving this lecture?
(Disclaimer. I have lost 20 of the pounds I gained during COVID, and am making zero progress on the remaining 30. A few months ago I successfully started a good exercise routine. Given my history, I would expect to only follow it for a few years before falling off the wagon. I believe that this poor compliance puts me well above average. But do you know what I do reliably? Take my prescribed medicine!)
You've communicated that by ignoring or dismissing the question of whether better outcomes are possible through other means than demanding that everyone follow doctors' orders and blaming them if they don't.
"Who cares if better outcomes are possible, so long as blame is in the right place"? Is that how we want to approach this?
In 2015, https://pubmed.ncbi.nlm.nih.gov/26551272/ showed that medicating all of the way to normal works out better than medicating down to stage 1 hypertension, then insisting on diet and exercise. And yet my request in 2018 to be medicated down to normal blood pressure was refused, because the professional guidelines followed by the experts was to only medicate down to stage 1 hypertension, then get the patient to engage with diet and exercise. The expert standard of care was literally the opposite of what research had shown that they should do.
I agree that experts should not be accountable for my laziness. But can you agree that experts should be accountable for following standard of care guidelines that are in direct conflict with medical research? And (as in my case) refusing the patient's request to be treated in a way that is consistent with what medical research says is optimal?
My advice would be to "shop around" for doctors, establish a relationship where you demonstrate openness to what they say, try not to step on their toes unnecessarily, but also provide your own data and arguments. Some of the most "life-changing" interventions in terms of my own healthcare have been due to my own initiative and stubbornness, but I have doctors who humor me and respect my inputs. Credentials/vibes help here I think: in my case "the PhD student from the brand name school across the street who shows up with plots and regressions" is probably a soft signal that indicates that I mean business.
Thanks for posting this. While I would generally advise a healthy dose of skepticism for any individual study, this one was very large and seems to be both well designed and executed. While there was a (statistically) significant increase in side effects with more intensive treatments, only about 1% more patients had adverse effects versus the standard treatment group, which seems like a very reasonable risk given the improved outcomes.
I've been trying to get my blood pressure under control recently and was thinking getting down to 12x/8x was good enough, but this has me rethinking that.
not for me. My cholesterol was hovering in the high 200's, then finally hit 300 and I completely freaked out, radically changed my diet, and lost 22 pounds (from 180 to 158).
What did my high cholesterol do ? It did absolutely nothing. ticked down to like, 280.
So I'm on the statins. my total cholesterol went from high 200's to about 150 in a month and was impacting my liver function. so we reduced the statins to a very low dose (5mg three times a week, crazy low). My total cholesterol hovers around 200 now. My cardiologist tells me that the conventional wisdom of "diet and exercise" is almost entirely disproven to have any meaningful effect on lipids these days (though i havent researched deeply).
I would be immensely skeptical of this unless he was talking about something much more narrow, like how there's a fraction of people who have really unfortunate genetics and can only improve their blood lipids with medication.
We have mountains of data showing that diet can massively improve lipids, and the combination of diet and exercise are our largest levers for reducing the risk of heart disease for most people. (There are always some fraction of people who can do everything right but have outlier genetics that require medication anyway, just as some people have outlier genetics and can smoke a pack a day their whole lives and reach their 90s.)
I'd check out the Barbell Medicine podcast for anything related to the intersection of lifestyle and health. They're extremely evidence based with a preference for measurable improvements in outcomes over hypothetical mechanisms.
Relevant to this thread are their episodes on testing and screening, hypertension / high blood pressure, cholesterol, fiber, and the new PREVENT heart disease risk calculator.
I'd also check out the episodes on diabetes, Alzheimer's, fatty liver disease, and health priorities.
I am one of those unfortunate genetic people, sadly, and have had high cholesterol numbers since my early 20s. Most of my older grandparents passed from heart disease. Now in my 40s, have a decent diet, and my numbers are < 100 for LDL. Current (and previous) PCPs have indicated to me that diet will have little effect for me, and that I will likely be on statins for most of my life. Experiments with stopping the statins have shot my LDL numbers through the roof.
The good news is that it's a pretty low dose with decently high effect.
They are unlikely to get lipid levels down low enough to reach soft plaque regression levels. You need to get sustained levels below 50 to 70 depending on genetics, Lp(a), etc.
If you've lived a healthy life in general and don't have genetically bad Lp(a) this advice is probably enough for you staying that way. If you've spent a significant portion of it with bad lipids for whatever reason, you almost certainly need to go on a combo therapy to get to regression levels.
These effects were first demonstrated in 1953. And has been confirmed over and over again since.
So don't discount the value of diet and exercise just because losing weight didn't fix your cholesterol.
still doesnt explain what my cardiologist was talking about, though. he's not the first dr. to tell me that "diet isn't really going to help you much". one dr. said, "if you went totally vegan, maybe it would have a slight effect". so no I didnt go totally vegan.
i think the idea is diet/exercise can make a 20 point dent in your total cholesterol but in practice, not much more than that, if you have total cholesterol over 250 kind of thing.
i don't know how to source that but I recall a few 20 points lower diets making the news over the years
No doctor wants their patient to have a stroke. But they also only get to meet patients where they are.
Some statins have significant side effect in some patients.
We have many "new" statins that the overwhelming majority of people have no side effects on. Exceedingly small amounts of people have issues with things like rosuvastatin and pitavastatin, and for people that do, repatha and other pcsk9 inhibitors often work fine.
> no downside to a better diet and frequent hard exercise (assuming proper technique). So it usually makes sense to at least try lifestyle modification as the initial therapy.
There is a downside to delaying treatment, and particularly so when they are far out of range, or have spent an extended amount of time out of range.
Accepted medical guidelines not long ago said to bring blood pressure from the dangerous range, to elevated, then encourage patients to engage in diet and exercise. Research such as https://pubmed.ncbi.nlm.nih.gov/26551272/ demonstrated that it is better to medicate all of the way to the normal range.
I personally had specialist in blood pressure follow the old advice around 2018. I asked for further medication, and he refused to give it. In so doing, he was following accepted practice, per professional guidelines. This left me with elevated blood pressure for several years. This despite the fact that when I was personally physically fit (when my blood pressure problems were discovered, I still had my crossfit bod), that did not help my blood pressure.
Guidelines are continuing to evolve. Even today, guidelines about how far down to take blood pressure are somewhat vague in the USA. Many countries stick to the older, higher, targets in who even gets medicated in the first place.
It wasn't until about 2 years ago that I encountered a doctor who was willing to medicate me all of the way into the normal range. Given the 2015 research, I'm very happy about this. But it is far from a guarantee that a random person on HN with high blood pressure will encounter a doctor who is willing to do the same.
That's why I believe that this is not a strawman position. I'd be curious to hear your case explaining why you wrongly assumed that it was.
It's more accurate to say that certain statins have significant side effects in certain patients. Atorvastatin made me dizzy. But I switched to Pravachol and that went away. I switched again to Rosuvastatin and it stayed away.
Not all statins are the same.
How many doctors recommend things like paleo diet, intermittent fasting and so on? Not many, I think - most simply focus on calories, combined with the advice that is either extremely generalized ("avoid sugar") or outright counterproductive ("eat 5 - 6 meals a day"). And then they wonder why people can't follow their diet.
Here I described my own experiences: https://ketoview.wordpress.com/2025/11/09/low-fodmap-keto-di...
