Thursday, April 17, 2014

A Moment To Pause and Reflect

This past Monday, I had the honor of being present for the signing of the bill that will license naturopathic doctors in the state of Maryland. It has been a long, hard road in pursuit of this goal, but the moment has finally arrived, and in March of 2016, God willing, I will be among the first few NDs to be licensed in the newest licensed state, and this has given me pause for thought.

As a naturopathic doctor actively involved in lobbying efforts on behalf of my profession, I've come to value the following motto, originally said by Robert Baden-Powell, the founder of the Boy Scouts: "Leave this world a little better than when you found it." More than any other motto, I think this captures the spirit of naturopathic doctors' legislative efforts. Be they attempting to gain licensure to better serve their patients, gain insurance reimbursement so they can provide services to a broader portion of the population, or work on public health efforts, the naturopathic doctors I know and have worked with are committed to leaving their campground cleaner than when they found it.

That the battle would be hard was to be expected. Any time a new profession seeks licensure, there is inevitable opposition, and of course it was the same in Maryland as anywhere else. Additionally, while many medical doctors in the state supported the licensure of naturopathic doctors, the organizations who claim to represent them are often staunchly conservative in their position. Such organizations count on the ignorance of consumers, doctors, and legislators to make their positions hold sway; those who have actually become educated through talking with or working with naturopathic doctors often give up their opposition. In the end, the NDs were simply telling the truth and looking to be better able to serve the people of Maryland, and legislators knew this. A bill was ultimately passed, and while it isn't perfect, it's a first step on the path.

It will be almost two years until the first licenses are issued to naturopathic doctors, and probably many more years until naturopathic doctors are able to bill insurance here in Maryland, major efforts are under way. There are plans to start a school of naturopathic medicine here in Maryland, and some of the more forward thinking medical institutions in the area are looking to bring naturopathic doctors into the fold. Additionally, the upcoming licensure means that there are likely to be many more NDs coming to the state soon, which means that a lot more Marylanders will start being a lot healthier. This campground is already starting to look a lot nicer.

Thursday, April 10, 2014

Antibacterial Soaps May Have Unintended Effects

Most of us know about the so-called 'superbug' MRSA, or methcillin-resistant Staphylococcus aureus, and the health problems it causes. Our history of overusing antibiotic drugs has resulted in strains of bacteria that have adapted defenses against those same antibiotics, leaving us in quite a quandary.

There have also been concerns that antibacterial soap may contribute to antibiotic resistance. The conventional line of thinking has been that, like antibiotic drugs, antibacterial soap kill off most bacteria, leaving only a few resistant strains behind, which then multiply and spread. However, a new study has shown something completely unexpected: Some antibacterial soaps may actually promote bacterial colonization.

Triclosan is a common ingredient in antibacterial soap, and is the main one responsible for killing bacteria. It's so common, in fact, that it has begun showing up in the human body and human secretions. In a study published yesterday, researchers found that triclosan is present in the nasal secretions of healthy adults, but that, against expectations, the presence of triclosan in the nasal passages is associated with an increased incidence of Staph aureus colonization, not a decreased incidence.

One might reasonably expect that presence of triclosan in the nasal secretions might help keep out bacteria through antibacterial action, but such is not the case. Instead, the triclosan was present only at nonlethal levels, which, rather than killing the bacteria, simply stressed them and caused them to react. What was their reaction, you ask? Their reaction was to attempt to adhere to local proteins within the nasal passages, forming what bacteriologists call a "biofilm." When bacteria form a biofilm, they're hunkering down for good. The findings of the study show that rather than keeping us squeaky clean, antibacterial soaps actually encourage bacteria to take up residence on our bodies.

It's an old adage that cleanliness is next to godliness. While I won't argue with that, antibacterial cleanliness may be a lot closer to unwanted Staph aureus than any deities. When washing, it's the mechanical action of scrubbing and a mild detergent effect that we need most, not "bacteria fighting power." So go for natural soaps, or at least conventional soaps without added antibacterial agents.

Thursday, April 3, 2014

A Listening Assignment

I've written extensively about smoking in the past, and so I'm returning to the topic again today. However, instead of composing a long argument about the evils of tobacco for you to read, I'm offering a listening assignment.

Freakonomics Radio is a program on NPR that looks into the economics of various phenomena, such as the costs and benefits of learning foreign languages, problematic trends in the Japanese housing market, and 'reasons not to be ugly'. In the wake of the 50th anniversary of the US Surgeon General's report on smoking, they've tackled smoking this week. They investigate efforts to cut smoking in both the US and abroad, and take a good hard look at what has worked and what hasn't.

So tonight, perhaps while you're cooking a simple fish recipe or my favorite Spanish rice, tune in and take a listen.

Freakonomics: How to Make People Quit Smoking

Thursday, March 27, 2014

Belief in Medical Conspiracy Theories Is More Common Than You Think

When most of us think of conspiracy theories, we think of aliens, JFK, the CIA, and other nefarious government agents acting in secret, but a surprising number of conspiracy theories involve modern medicine. Few of us think of these as conspiracies per se, because they are typically presented a conflict between science and pseudoscience. Nonetheless, the list of said conspiracies includes many that may be familiar to readers, such as:
  • The FDA is suppressing important information about natural cures for cancer.
  • Medical doctors still want to vaccinate children despite knowing that vaccines cause autism.
  • Health officials know that cell phones cause cancer, but aren't doing anything because powerful companies won't let them.
  • Public water fluoridation is a way for companies to dump hazardous chemicals into public water.
These theories are derided day in and day out in some online sources, but despite the amount of time spent combatting them, little is understood about why people believe them. The result is that they are addressed as nonsense at best and very dangerous ideas at worst. It's my contention that this approach is failing to change opinions, and in fact is galvanizing opposition. A change is needed.

As a naturopathic doctor, I can understand why the fight against conspiracies can be so vehement. Science simply doesn't support these theories, there's evidence to back up this position, and there are the real-world consequences of some of these conspiracy beliefs. At the same time, the aggressive stance against these ideas is not productive. It creates an adversarial relationship between patient and physician or citizen and government, and that itself has negative effects. It is far more important, I believe, to understand the opinions and why people hold them, so as better to address the concerns. People who subscribe to these theories are not fools, they are attempting to grapple with major problems and make sense of them, and should be addressed as having legitimate concerns.

Enter into this discussion a letter to the editor that was published in the Journal of the America Medical Association Internal Medicine. The two authors, from the University of Chicago's Department of Political Science, found that, in a population of 1351 adults, nearly half subscribed to one so-called 'medical conspiracy theory' or another, and a full 18% subscribed to three or more. This is a surprisingly large number. They also correlated these beliefs with other behaviors and found that those who believed the highest number of conspiracy theories were also much more likely to shop at farm stand, buy organic foods and use herbal medicines. These we might view as health-promoting behaviors. On the contrary, however, they were also less likely to get flu shots, use sunscreen, or get an annual checkup.

What is interesting is the author's conclusion that those who believe the theories were not necessarily less health-conscious, a position they reinforced in an interview with NPR. Conspiracy theorists, they argued, were grappling with all of the same health problems as everyone else, but using different sources for health information. Rather than trusting conventional sources for medical information, these individuals were more likely to listen to friends and family in questions about healthcare, along with 'celebrity doctors' such as Dr. Andrew Weil and Dr. Mehmet Oz. It's not that these individuals were unconcerned with health; it's that they were pursuing alternate sources, which they held to be more reliable.

Now, as you might expect, I'm going to bring this back to naturopathic medicine. The United States needs to make healthcare a priority for all of its citizens. I've often argued that NDs offer an additional route into the healthcare system for those who are mistrustful of the conventional medical system or otherwise feel alienated by it. This includes racial and ethnic minorities, as well as those who, for their own reasons, are mistrustful of the system. These findings suggest that this group, who are actively seeking healthcare answers but less involved in the conventional healthcare system, is far larger than could have been anticipated. If this research is correct, those who would be classified as 'high conspiracists', because they believe in 3 or more of these medical conspiracy theories, constitute 18% of the US population, or just over 57 million people. This is a very large number. The US needs to actively engage these people, recognize the fact that they want a different way to address healthcare, and consider that they may be more willing to work with an ND as a primary health care provider.

We've made major steps towards expanding healthcare to all Americans, but we're not there yet. Health insurance coverage isn't the end of the story. We also need to sell the system, and actively engage populations who have not been involved in healthcare in the past. For some, the barrier has been strictly economic, and the conventional system will meet their needs entirely. For others, there's a different barrier in place, and it's personal, cultural and maybe religious. This population needs service as well, and providing healthcare options is an important step towards reaching them.

Thursday, March 20, 2014

Vaccines and the Return of Preventable Illness

The New York City Department of Health recently issued a warning that there was an active measles outbreak in Upper Manhattan and the Bronx, and urged citizens to get measles vaccines if they were unvaccinated. If this had taken place several decades ago, it might not be out of the ordinary - occasional increases in infectious disease rates would happen and public health officials would renew their calls to parents to make sure their children were vaccinated. But in 2014, a decade after measles was declared eliminated in the US, an outbreak and the subsequent call for vaccination is out of place.

Measles has seen a surge in recent years, so much so that in 2013 there were 175 cases of measles, as compared to 60 cases in previous years. Figures don't exist for 2014 yet, but this outbreak in New York City is troubling. The measles vaccine became available in 1963, and the last great peak in measles incidence was in 1990. Prior to the vaccination becoming available, nearly every child in America caught measles, with several hundred dying from the illness every year and several thousand suffering severe symptoms, such as seizures and nervous system damage. Now, about 90% of Americans are vaccinated against measles.

So what then of this recent outbreak? Well, the suspicion has naturally fallen on increasing resistance to vaccination by those who are concerned about the potential dangers. The debate about a connection between vaccination and autism has been discussed to such a great extent elsewhere that I'm not going to venture into it here. Instead, I'm going to address the reasons people are concerned about vaccines, and the way we should approach these concerns. Regular readers of this blog will remember my past posts about vaccination (1, 2), so my opinion here should come as no surprise.

To kick it off, let me propose something. Let's stop using the term 'anti-vaxxer'. In dealing with parents that have concerns about vaccines, confrontational positions only serve to perpetuate the problem. As healthcare professionals, we know that vaccines are important and that failure to vaccinate has very serious personal and public health consequences. However, patients still have concerns. Firing these patients or labeling them as problematic only pushes these people out of the healthcare system and into a potentially dangerous situation. Compassion and concern are important with these patients, perhaps even more so than many other cases, and it's though compassion that we can keep them in our practices at least, and hopefully convince them of the importance of vaccination.

I also want to address the reason that people are concerned, because there's legitimate concern here. Put simply, people want to protect their children, and mandatory shots that make children scream and cry touch on that intrinsic desire. Unfortunately, vaccines have been a victim of their own success in this regard. In 2014, there is no imminent threat to speak of - these illnesses have largely been eradicated, and while American parents 50 years ago would gladly vaccinate their children to avoid measles, nowadays, their likelihood of a screaming child is higher than their likelihood of one with measles. Likewise, there's no apparent benefit either - as with all preventive medicine, if a vaccine works perfectly, absolutely nothing happens. As a result, they're a hard sell.

Even so, sell we must. For a treatment used nearly universally in America, vaccines have a massively strong safety record. And, unlike some conventional treatments, vaccines have proven remarkably successful as well. Despite major efforts in heart disease, cancer, diabetes, arthritis, and any number of other illnesses, none of these have been declared eliminated, while diphtheria, polio and smallpox (and until recently, measles) are considered illnesses of bygone era.

The recent outbreak, then, is not a call to arms to fight the 'anti-vaxxers' - it's an opportunity to welcome them back into our practices and again reach out to communicate with them, and at least to keep them under medical supervision.

Thursday, March 13, 2014

Uses For Bacteria Abound

Bacteria are everywhere, especially on our bodies. It's an oft-repeated fact that there are more bacterial cells in our intestines than there are human cells in the rest of our body, but it doesn't end there by any means. The mouth, sinuses, and skin are also covered with bacteria, and there are even a few brave souls that live in the human stomach.

This is pretty much a discovery of the past two decades, and it's radically different than the prior belief that bacteria are something we only occasionally encounter, and when we do encounter them, we get sick. Rather, bacteria are something we live with every moment, and their role in the normal functioning of the body is probably enormous, though this is something we are only now coming to understand. In fact, the study of the human microbiome is just over 10 years old - the term was coined in 2001 by biologist Joshua Lederberg to describe the sum total of the bacteria that coexist with human hosts. The Human Microbiome Project, meant to mirror the Human Genome Project, was founded in 2008, making this a serious investigation for only about six years. In that time, however, thousands of symbiotic bacteria have been identified.

Of course, as this research is being done by Americans, it hasn't simply stopped at observing and cataloguing the range of bacteria present. Instead, we've begun to look at practical applications for bacteria. Some have suggested deliberately infecting children with Helicobacter pylori to prevent development of allergies in childhood, and then selectively killing off the bacteria later in life to prevent ulcers in adulthood. Others have proposed using Oxalobacter formigenes to prevent stone formation in patients who have recurrent kidney stones. Others have begun developing mouthwashes that selectively kill Streptococcus mutans to prevent dental cavities. As soon as we discover something, we immediately start fiddling with it. We're Americans, and we can't help it.

As an ND, I take the perspective that selectively killing some bacteria isn't as likely to be helpful as promoting other bacteria, with the intention that they arrive at a balance between multiple bacteria. This has long been my approach to digestive health, and it's been a pet theory of mine that something similar would prove true about oral health as well. Rather than kill the 'bad' bacteria, why not promote the 'good' bacteria? I haven't developed an oral probiotic mouthwash, but perhaps I should have, because I recently read that probiotic mouthwashes are indeed being explored as an approach to halitosis (bad breath). It turns out that some are taking my approach and looking to promote the use of 'good' bacteria to promote oral health, rather than just killing the 'bad' bacteria. 

Perhaps I missed the boat on probiotic mouthwashes, but the future is teeming with possible applications for probiotic bacteria. Will nasal bacteria be used to fight chronic sinus infections? Will they be used to break down harmful substances in the digestive system? Will they perhaps even be used in wound-healing to prevent infection by pathogenic bacteria? This field is still brand new and we're learning about it very rapidly, so I wouldn't cross any of these off the list. Stay tuned.

Thursday, March 6, 2014

We Can Do Better Than This (And Maybe We Are)

Just a few weeks ago, a study was released that demonstrated something shocking. Truly shocking. Of course, we know that overweight and obesity are problems in modern America, and we're beginning to realize exactly how large a problem it is. But one thing we may not fully realize is just how much a poor lifestyle contributes to it.

We know that poor dietary choices and low levels of exercise contribute to obesity, but for consumers, the question is, "What does a poor diet really look like?" and "How much exercise is too little?" Well, we now have a number for how much exercise is too little.

Researchers at the University of Alabama have found that, on average, an obese American man gets 3.6 hours of vigorous exercise. Per year. An average obese American woman gets less. 1 hour per year. Without even addressing dietary choices, this pinpoints low physical activity as a major contributor to obesity.

Some readers have questioned the ability of the researchers to accurately measure exercise levels this low, but even taking margin of error into account, the research clearly shows that obese Americans are getting shockingly low levels of exercise. It's really no wonder that obesity results with activity levels this low.

Is it any wonder, then, that we're seeing the growth of drastic weight loss therapies, such as bariatric surgery, near-starvation diets, and more? Adult Americans have developed dietary and exercise habits that are nearly impossible to break, and have no other option other than drastic solutions. The guideline of 30 minutes of exercise five times a week is well-accepted as a threshold for adults looking to maintain weight and reduce risk of disease, but for obese Americans, this is not nearly enough.

However, at the same time as this shocking result was published, more encouraging news also hit the newspapers. Obesity rates in children dropped a stunning 43% over the past decade. Obese children are many times more likely to be obese adults, and this decline was seen as a massive reversal of a decades-long trend in obesity. In 2012, 8% of 3-5 year olds were obese, as opposed to 14% in 2004, and while this is a dramatic drop, 8% obesity prevalence is still a high percentage, and we'll need to see further drops in the future.

The point is that, despite decades of terrible health habits, including smoking, low levels of exercise, and poor diet, Americans may be starting to change their ways, and are teaching those habits to their children. Here's hoping.