So, here’s another secret.
Most people think, well, actually FEEL, in binary terms. They like to believe they are discriminating and careful in choosing among options, and that naturally they choose the BEST. No one says, “I’m in the mood for pasta, let’s go to the third-best Italian restaurant in town.” Or “I’d love a cheeseburger, let’s go to a joint ranked #9 on Yelp.”
They think, “Maggiano’s!” Or “Five Guys!” Period.
If it’s a favorite choice, the mind goes straight to it, dragged by the gut or the lizard brain. There’s no competition for the top spot, unless the choice is unavailable.
After the fact, the brain rationalizes the decision: top choice among XYZ for the quality of ABC, the atmosphere of DEF, etc. But the actual process goes something like “chili cheeseburger?” —> TOMMY’S!
Medical folk tend to think in 3s.
Bad vs. Better vs. Best. And as we’ll see, your options more than just triple.
Case in point: serum cholesterol
Specifically, LDL cholesterol (aka LDL-C) and apolipoprotein B (aka Apo B).
Crash course in lipidology: serum cholesterol is what makes up the plaques that spackle the inside of our arteries over time, leading to narrowing and eventually heart attacks and strokes. Unpleasant and complex things happen to those gunky thickenings that cause the final clot and full blockage, but basically if your circulating cholesterol is low enough, there’s less raw material to make the spackle.
The target for the general population used to be an LDL-C less than 130, but for several years that target has been less than 100. Most people walk around with an LDL-C around 130-150, unless they’re deliberately working to lower their numbers.
But 100 isn’t the only number on doctors’ minds.
If you are at increased risk of clogging — if you’ve already HAD a heart attack or stroke, or are a hypertensive diabetic — that target drops to less than 70.
And if you’ve had the fortune of having a SECOND clogging event and surviving it, your cardiologists may talk about driving that puppy down to 35 or less.
Some medical cutting-edge folk, like Dr. Peter Attia, even talk about aiming at that level for the general population, starting in the teens or early 20s. Drive the circulating cholesterol down to fetal levels early in life, and atherosclerotic plaque formation and 2 of the top 4 causes of death in American could disappear.
Bad (over 100), Better (under 70), Very Best (under 35).
Similar cutoffs exist for blood pressure, body weight, blood glucose and A1c, and vitamin levels. Level A is average, and a disease in the making. Level B is much better, but some folks will still develop problems. Level C is unequivocally awesome, now we’re talking.
So, why not always aim for awesome?
You probably already know the answer.
Awesomeness comes at a cost.
In the LDL/Apo B example above, dropping the cholesterol numbers to fetal levels likely demands high doses of potent statins or even medications like the PCSK9 injectables.
Lowering blood pressure to astronaut selection criteria levels would likely require losing enough weight to be considered skinny, doing an hour or more of cardio daily, and taking blood pressure medications.
This is not a promotional for Pharma Putting Drugs In The Water. It’s a description of a fundamental facet of reality: there’s what happens conventionally which is the state of affairs just looking around you, and there’s the hoo-boy that can happen if you bust the curve. But busting, just like it sounds, requires a significant expenditure of energy and resources.
And even when energy and resources are plentiful, there’s this thing called the U-shaped curve.
The U-shaped what now?
Basically, a graphical representation of the point of diminishing returns.
You drive a no bueno number down, and the risk of badness drops — to a point. Keep driving the number below a certain level, and the risk of badness goes up again.
High blood pressure = upped risk of stroke. Lower blood pressure = reduced risk of stroke. Too low a blood pressure = upped odds of getting dizzy, fainting, and cracking your skull or breaking a hip.
If we’re talking medications, maybe you can’t tolerate the doses needed to get you to awesome, or they’d cost too much. If we’re talking extreme weight loss, maybe you lose too much muscle to do a physical job, or your skin sags like wet towels, or fatty toxins get released too quickly, triggering an autoimmune condition.
For each individual, the sweet spot where the benefits outweigh the tolerable risks of doing something vs. doing nothing more will be different. Where you set the slider may not be where I’d set mine.
But the point is that the decision involves a slider, and a range of possibilities balancing risk and benefit. Not just Tommy’s Burgers or nothing.