Book Review

Living Healthier and Longer: What Works, What Doesn't

N Engl J Med 2008; 359:2852-2853December 25, 2008

Article

Living Healthier and Longer: What Works, What Doesn't
By Carl E. Bartecchi and Robert W. Schrier. 224 pp. Pueblo, CO, MFTP Publications, 2008. Available for download, free of charge, at www.healthierlongerlife.org.

As Paul S. Frame observed at a meeting of the U.S. Preventive Services Task Force in the early 1990s, “An ounce of prevention is a ton of work.” This observation remains true today, and Carl Bartecchi and Robert Schrier have done much of the heavy lifting necessary to make an important contribution to the field of preventive health. Their book is designed as a resource for clinicians and the educated lay public to use as an authoritative resource on reducing the risk of premature death and disease caused by unhealthy behaviors and promoting health. It is available for patients and their doctors to download at no cost from the Web site www.healthierlongerlife.org, and free bound copies have already been sent to 60,000 households in Pueblo, Colorado. Funding for the production and shipping of the book was provided by foundations, hospitals, the local newspaper, and the Pueblo City–County Health Department, and the authors donated the text. The creation and distribution of the book represent an interesting, community-wide experiment in information sharing and patient empowerment; Bartecchi and Schrier plan to evaluate the effect of the project on the residents of Pueblo.

Schrier will be well known to readers of the Journal as the author of many articles; he also served as the chair of the department of medicine at the University of Colorado School of Medicine for many years. Bartecchi is a prominent Colorado internist whose many years of clinical practice are evident in the practical observations and recommendations that appear throughout the book. The tone of the book is set in the foreword by former Colorado Governor Richard Lamm, who reminds the reader that of the 30 years of added life expectancy Americans have enjoyed since 1900, only 5 years were added by advances in clinical medicine. Most of the gains in life expectancy were the result of public health interventions such as improvements in water quality, sanitation, and food safety and in the development of a broad array of vaccines. The book addresses the more complex and challenging task of changing human behavior, in the areas of primary prevention (e.g., refraining from tobacco use, exercising regularly, eating a healthy diet, practicing safe sex, moderating intake of alcohol, avoiding substance abuse, and using seat belts) and secondary prevention (e.g., adhering to recommended schedules for mammography, blood pressure screening, and colonoscopy).

Two developments of the past decade are reason for optimism about the outcome of the project. First, a number of published studies have shown that having patients share in decision making about their health care improves patients' adherence to prevention guidelines, increases their satisfaction with the outcome of clinical treatment, or both. Second, the dramatic growth of resources on the Internet has made information on health and disease available to patients as never before. But the Internet has been a mixed blessing, as many patients are confused by the contradictory advice retrieved when they enter a search term on Google or Yahoo. Authoritative sources are critically important, and this book is an important addition to Web sites such as the one sponsored by the U.S. Preventive Services Task Force (www.ahrq.gov/clinic/uspstfix.htm). The other problem with the information on the Internet is access: there is no comparable alternative for those who find themselves on the wrong side of the Internet divide because of lack of education, a language barrier, or lack of access to a computer. This portion of the U.S. population is often at greatest risk for the unhealthy behaviors that contribute to the large burden of preventable premature death and disease, and they require outreach measures that go beyond the scope of this useful new resource.

The beauty of having such a resource available online is that changes can be made as new data become available. And there are some minor changes that should be made now to make the current version clearer. For example, a pie chart in the introduction shows the leading causes of death without adjustment for age; translating these causes of death into lost quality-adjusted life-years (QALY) would make the case for prevention even more powerful. The authors also recommend a few interventions, such as breast self-examination for women 20 years of age and older, that appear to reflect personal opinions rather than evidence-based decisions. But these and other minor issues do not detract from what is an otherwise excellent contribution to the goal of improved preventive health care.

The authors conclude with a persuasive argument for eschewing alternative and complementary medicines whose efficacy has not been demonstrated in clinical trials, and they make strong policy recommendations to bring herbal remedies and dietary supplements under the scrutiny of the Food and Drug Administration and to define these remedies as drugs, not as nutritional supplements, as they are now defined in the Dietary Supplement Health and Education Act. Perhaps by educating the patients who will use this new resource, the authors will succeed in generating the social will to counter the powerful lobbying of the alternative and complementary medicine industry.

Robert S. Lawrence, M.D.
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21208
rlawrenc@jhsph.edu