The prescription nobody writes you

Your knee aches on the stairs again. The doctor has 10 minutes. You leave with a prescription for anti-inflammatories. By Thursday the ache has faded.

Problem solved, right?

Maybe. It's the quick fix, often the one we want. But a pill can quiet a symptom while the cause carries on. Some send the bill years later.

For many of the slow problems of midlife, a habit works as well as the pill, sometimes better, and it also works on the cause.

This matters more as prescriptions pile up. Last month a BMJ study of 2.3 million adults over 66 in Ontario looked at how often a second drug gets prescribed to treat side effects of the first. It's called a prescribing cascade.

Want your numbers first? The Bloodwork Cheat Sheet has the markers to ask for and six scripts for your doctor on p.21.

Anti-inflammatories do take the edge off arthritis pain. In a Lancet review of 76 trials and more than 58,000 people, the strongest, like diclofenac, eased knee and hip pain enough to notice.

Acetaminophen (paracetamol) didn't. In a BMJ review, it did only slightly better than a dummy pill for arthritis pain. The authors judged the difference too small to matter to patients.

The cost shows up somewhere else. Pooled trials in The Lancet found about 3 extra people in every 1,000 on high-dose anti-inflammatories like diclofenac for a year had a heart attack, stroke or vascular death. One of those 3 died.

Every anti-inflammatory studied roughly doubled the risk of heart failure. Serious stomach problems, like bleeds, rose about 2 to 4 times.

That's the catch we're rarely told about. And when you're in pain, it's hard to stop and ask whether it's worth it.

Exercise eases the pain by a similar amount. A Cochrane review of 44 trials found exercise cut knee arthritis pain by about a quarter. The authors called that comparable with anti-inflammatories.

Weight loss adds to it. For each pound (or half-kilo) lost, your knee carries about 4 pounds (or 2 kilos) less with every step (Arthritis & Rheumatism). And in the IDEA trial in JAMA, people who dropped about 11% of their weight through diet and exercise had about a fifth less pain than those who only exercised.

What's on your plate matters beyond the scale. In 2 long-running US studies of more than 6,000 people, those who ate the most fiber had about 30% to 60% lower odds of painful knee arthritis than those who ate the least (Annals of the Rheumatic Diseases). People who ate closest to a Mediterranean diet, with oily fish, olive oil, vegetables and beans, were less likely to see their knee pain get worse over 4 years (Clinical Nutrition).

Fish shows up again in rheumatoid arthritis. People who ate it at least twice a week had milder disease than those who rarely did (Arthritis Care & Research). These studies followed what people already ate, so they show a link rather than proof, but it's the same way of eating that helps your heart.

Both help the knee. But moving more, eating well and losing a little weight also help your heart, blood sugar and mood. The pill can strain your heart and stomach.

Same pattern, four more problems.

We're not against pills. For an infection, a heart attack, severe depression or pain that stops you moving, they're often exactly right. It's the slow problems, built over years, where a pill can settle the symptom while the cause keeps building, only to rear its ugly head later.

Offered a long-term prescription for one of these, or already on one? We'd ask three questions:

Please don't stop a medicine on your own. Some need tapering. A few, like acid reflux medicines, can bring symptoms back worse if you stop suddenly (J Clin Med).

Start the habit alongside it instead. Give it 12 weeks. Notice how your joint, mood or sleep feels. Then take your weight, blood pressure and fasting glucose to the review.

One honest caveat. Most of these comparisons come from separate trials of drugs and of exercise, rarely head to head. And a habit only helps while you keep it up. That's partly why the pill is the default. It's easier to stick with.

Asked well, these could make your next 10 minutes with the doctor the most useful of your year.

Have you ever been offered a pill when you wanted to try something else first? Hit reply and tell us what happened. We read every one.

Next up: what sits between the habit and the prescription. Supplements. Most don't do much, and we'll show you the 4 with evidence worth paying for.

Until Wednesday.

Longevity Daily / The Building Decades

P.S. Know someone who's just been handed a new prescription? Forward this so they've got the three questions ready.