Maximo Agustin Schiavone: ‘The Lower the Better’ Is Not a Physiological Principle

Maximo Agustin Schiavone, Head of Clinical Research – Bariatric and Metabolic Surgery Department at Hospital Universitario Austral, shared a post on LinkedIn:

“How medicine turned a useful heuristic into a biological distortion

Modern medicine became very good at moving numbers.

Sometimes too good.

Good enough, in fact, to start confusing downward movement with biological truth.

That is the deeper problem with the culture of ‘the lower the better.’ It sounds disciplined. It sounds rigorous. It sounds like medicine at its most precise.

If a variable is associated with risk, the instinct feels almost automatic: push it down.

Lower blood pressure. Lower glucose. Lower inflammatory markers. Lower LDL-C. Lower albuminuria. Lower weight.

The attraction is obvious. It gives direction. It simplifies decisions. It travels well into guidelines, performance metrics, dashboards, and treatment algorithms. It converts complexity into movement. It makes medicine feel measurable.

But once generalized beyond its evidentiary and physiological context, ‘the lower the better’ stops being a heuristic and starts behaving like a worldview. And that is where the distortion begins.

This is not an argument against prevention. It is not an argument against treating risk factors.

And it is certainly not an argument against the fact that, in some settings, lowering a variable clearly improves outcomes. The problem is not lowering itself.

The problem is what medicine quietly started doing with that success: it took a strategy that works in some domains and promoted it into a general grammar of care.

That promotion rests on assumptions that are rarely stated and even less often examined.

It assumes that association is enough to define therapeutic direction. It assumes that more reduction is naturally closer to benefit.

And it assumes that moving a number is broadly equivalent to correcting the biology that produced it.

Those assumptions may be valid in some settings.

They are not laws of physiology.

Because physiology does not work as an endless downward auction.

Biological systems are not organized around infinite minimization. They are organized around regulated ranges, feedback loops, thresholds, compensatory responses, trade-offs, timing, and context.

A variable may act as driver, signal, adaptation, consequence, or some unstable combination of all four depending on the disease stage, the therapeutic mechanism, the patient’s reserve, and the architecture of the system in which that variable is embedded.

That is not a semantic distinction. It is the distinction.

Because biomarkers are not just numbers.

They are expressions of system behavior. Once medicine forgets that, it becomes very easy to confuse movement in the metric with movement in the disease.

And once that confusion becomes normalized, a variable no longer has to be understood biologically in order to be pursued therapeutically. It only has to move in the expected direction.

This is one of the most common epistemic shortcuts in modern clinical thinking: a variable tracks harm, so it becomes a target; the target acquires a direction, and the direction acquires moral weight.

At that point, ‘lower’ is no longer just a therapeutic option. It becomes a virtue.

And that is usually the moment physiology starts losing the argument.

Any serious critique of this culture has to acknowledge the strongest counterexample openly. There are settings in which lower is not merely a slogan but a genuinely evidence-based strategy.

LDL-C in secondary prevention is the clearest case. In high-risk atherosclerotic populations, intensive LDL lowering through causal mechanisms translates into fewer cardiovascular events. That matters. It should be said clearly.

But the lesson from LDL is not that biology always wants ‘lower’ in the abstract.

The lesson is much narrower and much more demanding: in some contexts, through some mechanisms, in some populations, lowering a causal exposure improves outcomes.

That is a scientific conclusion. It is not a universal philosophy of medicine.

And the distinction matters, because medicine has also seen the other side of the story.

It has seen situations in which pushing a variable more aggressively in the supposedly right direction did not yield better overall care, and at times exposed the limits of number-centered thinking.

That is the uncomfortable part. It forces medicine to admit something it does not like admitting: improving a number does not necessarily mean improving the organism.

A target can be reached while the biology remains poorly understood.

A surrogate can improve while system function remains only partially restored. The number can become cleaner while the interpretation becomes shallower.

That is why mechanism matters more than the slogan.

The organism does not only ‘see’ the final value. It also experiences the path that produced it. A reduction achieved by interrupting a disease-driving process is not physiologically equivalent to a reduction achieved by merely forcing a metric downward.

One may represent true restoration of function. The other may represent little more than cosmetic success over a surrogate.

Medicine often flattens that difference because directional clarity is operationally seductive. Biology does not.

Context makes the problem even harder to ignore. The same numerical move can mean very different things depending on disease stage, frailty, physiological reserve, comorbidity burden, treatment burden, and competing risks.

A variable that behaves as a modifiable driver in one setting may function primarily as a marker, a compensation, or a downstream consequence in another.

A target that is useful in one population may be neutral in another, and actively unhelpful in another still.

This is why universal slogans age badly in medicine. They erase the one thing biology never stops demanding: context.

And yet the culture survives, in part, because it is not just clinically convenient. It is managerially elegant.

‘The lower the better’ simplifies communication. It aligns with protocol-driven care. It makes intensification legible. It translates messy physiology into operational direction.

It works well in systems that need measurable outputs and scalable narratives of improvement.

But managerial elegance is not physiological truth.

A variable can become easier to track at exactly the moment its biological meaning becomes harder to interpret.

A dashboard can look cleaner while the underlying pathophysiology remains superficially understood. The number improves.

The case feels better organized. The organism may not be any better served.

That is why this is more than a complaint about oversimplification. At its worst, the culture of  ‘the lower the better’ is anti-physiological.

It trains medicine to think about the body as a collection of separate metrics waiting to be pushed in the preferred direction, rather than as a regulated system whose measurable variables emerge from relationships, constraints, compensations, and trade-offs.

A more biologically literate medicine would begin elsewhere. Before celebrating downward movement in any variable, it would ask what role that variable is actually playing inside the system.

Is it causal, compensatory, consequential, or mixed? Does changing it improve outcomes that matter to patients, or merely the surrogate?

Does benefit depend on mechanism, timing, phenotype, or disease stage? Are we restoring function, or just improving metric appearance?

Those are not softer questions.

They are harder ones.

And they are harder precisely because they demand that medicine do what it too often avoids doing: think physiologically before it celebrates numerically.

That, ultimately, is the point. The issue was never that lowering is always wrong. The issue is that medicine too often behaves as if downward movement of a variable were, by itself, evidence of therapeutic truth.

It is not.

Sometimes lower is better. Sometimes lower is irrelevant. Sometimes lower is harmful.

And sometimes lower only reveals that we have stopped asking what the variable was doing inside the organism in the first place.

‘The lower the better’ is not a physiological principle. It is a heuristic: useful in some domains, valid under some conditions, and deeply misleading the moment it is promoted to doctrine.

The real question is no longer whether we can move numbers in the preferred direction.

It is whether we still know how to interpret them biologically.”

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