Thursday, March 29, 2012

Is It Really Allergy Season Again?

Last year, I wrote a comprehensive blog entry about allergies in response to a friend's inquiries. If you're suffering from allergies this year, I suggest you click this link to get back to that article - it's extensive and discusses a variety of natural approaches to allergy treatment. This year, I'm going to discuss two more factors in treating seasonal allergies, one is a treatment and the other is a clinical pearl.

In my many years of working in natural health, not only in clinical practice, but in my time at a health food store, I have often heard patients say that they consume local honey during the allergy season in order to prevent the allergic symptoms. In theory, it would seem to make sense – consuming small amounts of allergen desensitizes the immune system to the offending allergen, so that the body doesn’t react as strongly. This is, after all, roughly how allergy shots are believed to work.

But what does the research say? In our modern world, we like to see the hard data and don’t necessarily believe everything we hear, no matter how plausible it may seem.

I was able to find only two articles on the topic of honey consumption to reduce allergic symptoms. The first, conducted in 2002, allotted 36 participants to receive either a local, unfiltered honey, a mass-produced commercial honey, or a honey-flavored corn syrup placebo – participants consumed one tablespoon per day, and reported their symptoms to researchers. The results were poor, and researchers concluded that local honey provided essentially no benefit. However, the study had significant limitations, and I’m not sure we can take this result as completely valid. A third of participants dropped out of the study because they didn’t like the taste of the honey, reducing the study’s size to only 23 participants. A group that small is very unlikely to produce statistically significant results, not to mention the fact that small groups may not represent the larger population. The study design, with three arms, each receiving a different type of ‘honey’, was ingenious, and it would be great to see this repeated using a larger group. (Interestingly, the drop out rate was highest in the corn-syrup placebo group, and lowest in the local honey group – perhaps because local honey tastes better?)

The second study assessed the ability of honey to reduce allergic symptoms among participants who suffered birch pollen allergies. This study also featured three arms – one consuming honey with birch pollen added, one consuming regular honey, and a control group using their usual allergy medication. The results here were stronger – the group was still fairly small at 50 participants, but the drop out rate was much lower. Researchers found that participants consuming honey had lower total allergic symptoms, more asymptomatic days, fewer severe days and less antihistamine use, indicating a significant benefit to honey consumption. No significant differences were found between the group consuming normal honey and honey with birch pollen, however, which makes us question the exact mechanism behind honey’s effect on seasonal allergies. Here’s the caveat – the honey-consuming participants started consuming the honey in November in order to reduce their springtime allergies, so if you’ve not yet started your honey consumption, you may have to wait until next year to try this out.

Taken together, these studies present a mixed view of honey and seasonal allergies. Honey has a number of additional benefits, and few would fault you for consuming local honey, but the science is mixed. Hopefully we’ll see more studies on this topic in the future.

So here’s part two – the clinical pearl.

Just a few days ago, a patient came to me asking about allergy prevention. I conducted an intake, as per my usual, and as it seemed she was suffering from seasonal allergies, as she did every year, I made recommendations along the lines of what I wrote about last year. This week, I heard back from her, and found out that she hadn’t gotten any relief from the supplement I’d recommended – in fact, she had gotten significantly worse!

Far from her sniffling, sneezing and watery eyes, a day or two after I saw her, she’d developed pain and some really thick mucus discharge – unable to reach me, she’d gone to her family doctor on short notice. It turns out that she’d developed a sinus infection in the day or two after I saw her. She’s on antibiotics now, and we’ll see how she fares. The important lesson is this – complementary therapies are extremely effective, but only for those conditions for which they are indicated! Always make sure you make a proper diagnosis before proceeding on to treatment. I was a bit unlucky because she’d not fully developed the sinus infection when I saw her, but the incident underlined for me the importance of not missing the diagnosis!

That’s all for this week, allergy sufferers. Here’s hoping you find some relief!

Monday, March 26, 2012

A Kefta Recipe

Made all over the Middle East and called by a variety of names, kefta are lightly spiced, aromatic lamb meat balls, and are a guaranteed hit with any audience (even the most lamb-resistant). Traditionally, kefta are grilled, but as many of us apartment-dwellers don't have access to grills, the following recipe has been adapted for an oven.

2 lbs ground lamb
1 medium onion, chopped
3-4 tbsp flat-leaf parsley
3-4 tbsp cilantro
1/4 tsp cumin
1/4 tsp coriander
1/4 tsp ginger
1/4 tsp cinnamon
1/2 tsp salt
1/4 tsp pepper
1/4 tsp dried red chili powder (I use chipotle, but cayenne is also acceptable)

Combine all ingredients except the lamb in a food processor and puree. The result should be very green and relatively thick.

Combine the vegetable and spice mixture with the lamb in a large bowl. I find that in order to get a consistent mixture, you need to mix by hand, which of course gets your hands very, very lamb-y. When you've mixed them fully, roll them into small meatballs about the size of a walnut. Evenly space them on a cookie sheet or in a baking dish.

Place in preheated oven and cook at 400 for 20-25 minutes, until meatballs attain a pleasant firmness. Finish under the broiler for about 5 minutes, or until the meatballs are lightly browned.

Though not a traditional topping for kefta, I find that they go very well with muhammara. The contrast of the sweet meat and light spices with the tang of the pomegranate is a guaranteed crowd-pleaser.

Thursday, March 22, 2012

Three Things You Didn’t Know About Menopause

I spend a significant amount of time every week reading medical research abstracts. Most of what you come across while doing that is fairly typical, especially if you’re a naturopathic physician concerned with diet and exercise – study after study will show that regular exercise, not smoking, and a healthy diet prevents a large number of diseases and symptoms. Of course, each study examines a slightly different aspect of a healthy lifestyle, with one looking at omega-3 fats, another at fiber, and a third at moderate physical exercise, but in total, they more or less reinforce each other.

Occasionally, however, you come across really unexpected information, the sort of stuff that makes you stand up and say, ‘What?!’ Today’s column is devoted to three such articles relating to menopause.

The first is about night sweats. In a study of 867 women conducted over 11.5 years, it was discovered that women who had both hot flashes and night sweats had a 30% lower risk of all-cause mortality than women who did not have this combination of symptoms. Women who had hot flashes alone did not have this benefit. Adding further interest to the finding is the fact that women who had night sweats but not hot flashes had a similar protective benefit, though in this case it extended only to cardiovascular disease and coronary heart disease. The researchers controlled rigorously for a variety of risk factors, including hormonal therapy, further strengthening the finding.

The main question to ask ourselves with this study is – why could this possibly be happening? The causes of vasomotor symptoms associated with menopause are poorly understood, so we can really only speculate as to why night sweats apparently provide a protective benefit. I’ll be on the lookout for more info on this.

The second is about hot flashes. A team of Greek researchers found that women with increased subclinical atherosclerosis suffered from more severe hot flashes. You lay people are probably wondering what this means – here’s a brief explanation: researchers measured the amount of plaque in the carotid arteries of 110 women via ultrasound, and discovered that those women who suffered more severe hot flashes also had thicker deposits of plaque in their artery walls. Carotid artery plaque is routinely used as marker for atherosclerosis throughout the body. The increases in plaque were minor, and the study population was somewhat small, but the findings were statistically significant, and appeared to correlate to the severity of the symptoms – the women were classified as having no symptoms, minor symptoms, or moderate to severe symptoms, and it was clear that progressively severe symptoms were correlated to progressively severe plaquing.

Here again, because menopausal symptoms are so poorly understood, we can only guess at why atherosclerosis might play a role in their prevalence. What’s interesting though, is that hot flashes may help to alert clinicians to cardiovascular risk in the future.

Finally, severity of menopausal symptoms may be largely influenced by the time of year in which you were born. I’ll admit that this research left me astounded. A group of Italian researchers found that menopausal symptoms are significantly more severe in women born during the spring and summer, as opposed to women born the fall. Not only was this finding statistically significant, but the effect was also remarkably strong – the women born in the spring and summer had symptom scores that were more than twice as high as their counterparts born in the fall. This applied more strongly to symptoms of anxiety and depression, but also quite strongly to somatic symptoms as well.

Despite reading a lot of research, this really counts as one of the most surprising studies I’ve seen. I was tempted initially to dismiss the findings, but this study was done on quite a large group of women – over 2500 – and once you get groups that large, the chance of having fluke results diminishes. The clinical significance of this result has yet to be borne out, but for the time being, this is a fascinating result to read about.

Monday, March 19, 2012

Red Meat And Premature Mortality

Next week I'll be posting a recipe for kefta, a traditional lamb meatball from the Near East. It's a true specialty of the house, and a guaranteed crowd-pleaser. This week, however, I'm posting about the recent debate around red meat, to brace your enthusiasm for next week's recipe a bit.

Last week, an article was published in the Archives of Internal Medicine, a prestigious journal if ever there was one, which presented data showing a link between red meat consumption and an increased risk of premature death from all causes, especially, but not exclusively cardiac disease and cancer. The study followed over 120,000 men and women for more than 25 years, and while it was strictly an observational study, when you get this many people together for this long a period of time, you get pretty sound data.

The article was a hit in the media last week, with just about every main news source reporting on it. I myself read the reports published by both the New York Times and the Guardian. It's caused a bit of a furor, and people are weighing in about it left and right, many of which are apologies for the meat-eaters of the world.

While these authors say that perhaps the effect isn't as strong as it seems once you fiddle with the numbers and make it look like a smaller problem than it is, or that it's not the meat that's at fault, it's the way the meat is grown, I think apologies aren't helping anything - let's not sugar-coat this one, folks. Occasional red meat is fine - more than fine, in fact, it can be transcendent when served well - but the daily consumption of meat, the almost unconscious consumption of meat, is not. Given that the researchers found such significant benefits simply by substituting poultry, fish, or vegetarian sources of protein, we need to be strongly emphasizing that people eat significantly less red meat.

Just some food for thought on your Monday.

(And contrary to what the National Pork Board says, pork is a red meat, the same as veal, beef or lamb.)

Thursday, March 15, 2012

Who Uses CAM and Why?

Recently, I wrote a blog post about the safe and appropriate use of homeopathy following the publishing of an English translation of a health technology assessment (HTA) written for the Swiss government’s Complementary Medicine Evaluation Program. I recently received a copy of the book myself and have subsequently dived in. All in all, it’s a fascinating document, as it provides an assessment of complementary and alternative medicine (CAM) as a whole, and not just homeopathy. This assessment includes discussion of appropriate usage, clinical and preclinical (in vitro) studies, the limitations of randomized control trials in assessing a complex medical system, and cost-effectiveness. Not merely a review of homeopathy’s clinical effectiveness, this is an assessment of how all types of complementary therapy operate, and their place in healthcare.

Today, I’m relating some information on complementary medicine’s demographics. People have a lot of opinions regarding who uses complementary medicine, but few of them actually cite studies or hard evidence about on the topic. It’s a fairly important topic, as it helps us to understand the place of CAM in the broader healthcare system, but it also helps NDs and other professionals, as it gives them information on the blind spots in their own practices. I was refreshed to learn that there is actual research in the literature about who uses complementary medicine as well as why they seek it out. In their report, the researchers referenced 52 studies on CAM usage.

Although I’ve argued in the past that NDs and other CAM providers need to reach out to minority communities, and I believe that NDs also need to reach out to male patients (because men utilize healthcare much less frequently than women), the information the researchers culled from studies indicates that users are by in large women between the ages of 30 and 50, who are more highly educated and in higher income brackets than non-users. So much for trying to buck stereotypes, right?

Although this information shouldn’t come as a surprise to anyone who’s worked in a ND or acupuncturist’s office, I will say that while on the one hand it gives us some information about which audiences might be the most receptive to our message regarding natural health alternatives, on the other hand, it also shows us who we’re not reaching, and to whom we need to be directing our efforts. I think it’s also important to mention that 9 of the 52 studies did not find significant differences between users and non-users, although some of these equivocal studies were too small to provide adequate information. In my own experience as a naturopathic student rotating through a drop-in clinic for homeless youth, I can say that sometimes naturopathic doctors’ status as ‘outsiders’ can serve to make us more accessible to some marginalized groups. There may be a typical CAM user, but that doesn’t mean they’re the only ones.

Additionally, it’s worth mentioning that the countries producing the studies may be affecting the demographics of those who use complementary therapies. I have noted in particular that the studies we conducted entirely in Westernized countries (US, Europe, Canada, Australia), and that CAM usage patterns may be remarkably different in, for example, India or China.

The authors went on to discuss reasons why patients sought out CAM providers. The clear winner in this category was, unsurprisingly, a dissatisfaction with conventional medicine. The authors did not go on to discuss the details of the dissatisfaction, perhaps because of lack of detail in the studies they were working from, but even so, NDs and acupuncturists are more than familiar with these complaints.

The next most common reasons given for seeking out CAM providers were: specific use of CAM for particular indications (e.g. food sensitivity elimination for IBS); a good doctor-patient relationship; a good experience with CAM (self of others); and a desire to avoid side effects from conventional medicine. These speak to the pragmatic appeal of complementary therapies to patients. There was no mention of a rejection of conventional medicine, but rather a desire to attain specific benefits – a strong doctor-patient relationship, a positive experience similar to a family member’s, or a low incidence of side effects.

I think this pragmatic approach is mirrored by the fact that, in the studies that examined the topic, about 66% of patients using CAM therapies were also using conventional therapies. The remaining third of patients were a bit harder to parse out – these users either used CAM in place of conventional medicine, used it when conventional medicine had proved ineffective, or used it and did not require conventional medicine. The authors stressed that there were not enough studies to make any conclusions regarding the place of CAM as regards conventional medicine, but I think that most NDs and acupuncturists recognize the importance of cooperation with other medical professionals in treatment.

Stay tuned, readers, for more information gleaned from this fascinating report. 

Monday, March 12, 2012

It's The Prices, Stupid

Next week we'll be back to talking about recipes and pictures and all that, but this Monday, I'm posting yet another brief piece on the cost of healthcare. Many of you may remember that a few months ago, I wrote a blog post arguing that the lack of transparency in healthcare pricing was a major contributor to the current healthcare crisis - consumers can't shop around or access information on pricing, which means that we're unable to make smart purchases, as we can in other industries. In many ways, this has become a pet issue for me - in my practice, I make sure that I cut my patients a fair deal and am honest and up front about pricing, and in my blogging I write regularly on the topic.

Last week saw a great article in the Washington Post's Business section which detailed a major source of the rise in healthcare costs - the pricing of the procedures themselves. I've posted charts in the past about why Americans pay more for pharmaceuticals than our Canadian neighbors, but it turns out that we pay more for procedures across the board, in some cases double what is paid by our peer nations. Click here to link to the article, but let me warn you that some of the numbers are shocking. Were the US leading the world in healthcare performance, that would be one thing, but our performance is average at best - our infant mortality rates are poor for an industrialized nation, life expectancy is similarly low, and our obesity rates are rising dramatically (click that last link to see the most disturbing animation of CDC data you'll ever see). We're not getting a sufficient bang for our buck, and while the Health Care Reform bill will be a step in the right direction, it's not nearly enough.

Thursday, March 8, 2012

Green Tea and Flu Prevention

As regular readers of this blog will know, I’m a big fan of Camellia sinensis, the tea leaf. Sometimes I hardly know where to start in singing its praises, but today I’m keeping things limited to a fairly small area of green tea’s activity. Few people think of flu prevention when they think of green tea, but several studies in Japan have looked into that exact problem.

A few years ago, some researchers did some in vitro studies on green tea and influenza virus, and found that green tea inhibits the ability of influenza virus to replicate within cells. The mode of action is the following – the catechins found in green tea prevent the influenza virus from fusing with human cells in the first place, thus preventing the virus from being able to replicate. The exact mechanism isn’t fully understood, but it’s believed that his happens through a combination of membrane protein changes, as well as altering the properties of the viral membrane itself (1, 2). As a side note, these catechins are also responsible for the antioxidant properties of green tea.

This is all well and good if you’re a Madin-Darby canine kidney cell swimming in a sea of supraphysiologic concentrations of green tea catechins, but if you’re a living breathing human, you’re probably more interested in clinical results. What can green tea do to help you?

In 2006, a group of Japanese researchers found that elderly residents of a nursing home were less likely to catch the flu if they gargled daily with a catechin and theanine solution during the peak flu season. While the idea of gargling with green tea may seem unusual to us, these researchers were drawing on the previous research, which had shown that green tea catechins inhibited the flu virus by direct contact – the research was done to see if the in vitro results translated into clinical results by preventing the flu virus from infecting cells right in the mouth and throat. Though the means of delivery seems odd, these same results ought to translate to a similar effect garnered from the act of drinking green tea.

A further study showed that drinking green tea does indeed seem to prevent the flu. The results of a survey done on schoolchildren showed that those who drank at least one cup of green tea per day were 40% less likely to get the seasonal flu. On the one hand, this was only a survey, and not a clinical trial, so we can’t necessarily draw major conclusions from it, but on the other hand, the survey group was fairly large – about 2000 schoolchildren – which makes us take this result more seriously. Were the survey done on a smaller number of children, we could easily chalk the results up to chance, and the problems inherent counting on accurate self-reporting by children. However, because of the large group size, these problems become less likely to affect results, and so we can draw a reasonably reliable conclusion that drinking green tea does prevent flu infection.

Finally, a randomized control trial (the highest level of medical evidence) showed that healthcare workers who consumed a daily capsule of green tea catechins and theanine were significantly less likely to catch the flu compared to those consuming a placebo. What differentiates this study from the previous studies is not only the high level of evidence seen in the study, but also the mechanism. The prior studies showed that green tea prevents flu, but probably because of direct inhibition of the flu virus in the throat and mouth – when you’re taking a capsule, that’s not a factor in how it works. Rather, this study implies that the green tea nutrients help prevent the flu after they’ve been absorbed into the blood. We can only speculate as to how this happens – it may be that the catechins continue to inhibit viruses in the same way we saw in Petri dishes, it may be that they boost the immune system in some way. Either way, this study shows that green tea not only prevents the flu by stopping the flu virus in the mouth, but also that the body somehow uses the nutrients in green tea to fight the flu.

Taken together, it’s clear that green tea helps prevent the seasonal flu. We see that in both the lab, and in clinical settings. Interestingly, we see that green tea does this by two modes of action: the direct inhibition of flu virus in the mouth and throat, and also by supplying the body with nutrients it uses to conduct its own fight against the flu. Fortunately for all of us, there is a convenient, user-friendly way to apply both methods of prevention – just boil up some water, brew up some tea, and enjoy!

Tuesday, March 6, 2012

Another Graphic, Part Two

As promised, here's part two of yesterday's graphic. This chart is almost certain to be more controversial than yesterday's, and I'd disagree with a few of the points below, but am posting this today in the hopes of engendering conversation. While it's true that malpractice itself isn't bankrupting the system, the fear of litigation has encouraged defensive medicine - over-ordering labs and imaging studies, over-diagnosing, and over-prescribing; there's even an acronym doctors use for it: CYA (cover your donkey). Likewise, obesity is indeed a major health problem, and while obesity's effect on diabetes isn't exclusively driving the country to the brink of catastrophe, obesity's effects on cardiovascular disease, rheumatoid arthritis, osteoarthritis (and subsequent joint replacements), and cancer is a major driver of healthcare costs. Finally, the statements 'Providers charge more because they can' and 'Our doctors are overpaid' encourage folks to blame doctors for a system in which doctors get the short end of the stick just as often as patients - the truth is that doctors charge more because it's difficult to anticipate how much insurance will pay out, and while some doctors make healthy livings, many doctors, especially the all-important general practitioners, are going out of business.

So why put this chart up if I'm only going to bash it? The point is this - while we all complain about healthcare costs, few of us understand how the money works, and this lack of transparency prevents us from being smart consumers or having any ability to solve the problem. I may disagree with some of the points the chart authors are making, but I think it's important that we consumers learn more about how the healthcare system works, have our ideas about how it works challenged, and talk more with each other about how to fix it. While the so-called Obamacare bill will offer some fixes, it won't solve the problem entirely, and we're likely to need more work in the future. So share this chart, share yesterday's, and start talking - let's see what we can come up with.

Why Your Stitches Cost $1,500 - Part Two
Via: Medical Billing And Coding

Monday, March 5, 2012

Another Monday, Another Graphic

Few people understand how the money works in healthcare, including many doctors. This is a crying shame, as it means that we have little ability to use our good judgment when accessing medical services - while we can shop around for a good deal on a car or house, few of us know how to shop around for medical services. I blogged about this problem a few months ago, and, soon thereafter, as if by magic, I came across this chart - made by the same folks who made this and this. Hope you folks enjoy it, and check back in tomorrow for part two.

  Why Your Stitches Cost $1,500 - Part One
Via: Medical Billing And Coding

Thursday, March 1, 2012

Thoughts On Radical Weight-Loss Solutions

If you’re like most Americans who made a New Year’s resolution to lose weight, you may have given up on it already. I don’t think statistics exist regarding how many people make this sort of New Year’s resolution, and how long they stick with it, but suffice it to say that if these resolutions were widely successful, we wouldn’t be bombarded each January with advertisements trying to capitalize on the desire to lose weight.

I’ve blogged in the past about weight loss, about the importance of diet, exercise, support, and about following tried and true approaches to weight loss. I still stand by these recommendations, for though they require work, they also produce results. In my experience, it’s the support that is the absolutely crucial element of losing weight the old-fashioned way – having someone to go walking or jogging with, to eat with, or to periodic provide support as you make your way to your goal weight.

One of the core tenets of naturopathic medicine is that it’s best to start with low-force methods as much as possible. In practice, this generally means that we start with diet and exercise and work our way up from there, through supplements and herbs and then, if necessary, on towards medications and surgery. A healthy diet and regular exercise forms the basis for health and prevents nearly all chronic diseases, so not only do they help patients lose weight, but they also help prevent heart disease, cancer, diabetes, and many other chronic health problems.

However, naturopathic physicians are nothing if not practical, and we recognize that sometimes it’s necessary to intervene more drastically. For example, a person with a blood pressure of 140/85 can probably be helped strictly through diet, exercise, and perhaps some herbal therapies, but a person with a blood pressure of 210/100 needs much more drastic intervention, probably including multiple medications. Likewise, a person needing to lose 20-30 pounds can probably do it with diet, exercise, and support, but what about someone needing to lose 50 pounds? 90 pounds? More? In these circumstances, NDs recognize the need for more aggressive interventions. By no means does the need to intervene more strongly obviate the need to educate the patient about eating well and exercising, but it does necessitate our finding another solution that works more strongly and more quickly.

So why bring this up? I read an article recently about the Diet Tube, a weight-loss protocol developed in Italy that involves the insertion of a nasogastric tube in an otherwise healthy, ambulatory, but overweight patient. Sounds intense, right? The tube, and the pump to which it is attached, supplies the stomach with small amounts of a protein-rich fluid that triggers feelings of satiety, but without supplying significant amounts of calories. The article was decrying the modern obsession with easy weight-loss schemes that didn’t involve work from the patient – also on the list were gastric bands and gastric bypasses. While on the one hand, these weight loss programs could be considered the ‘easy way out’ for some folks, on the other, these programs provide some patients with their only real hope of attaining a healthy weight, and reaping the benefits thereof.

Naturopathic physicians cannot place gastric bands, nor can they place a Diet Tube (which I’m also fairly sure is not FDA-approved here in the US) but they can certainly help guide you in your efforts to lose weight as part of a team of providers. The whole point of integrative medicine is that no one health discipline has all the answers, and that these therapies need to work together. An ND can help educate you about diet and exercise, not only as a primary intervention for weight loss, but also as an aspect of weight loss concurrent with gastric bands or other weight loss programs. Additionally, they can help you work through the process of deciding whether the procedure is right for you, when to make the decision, what to try first, etc, not to mention monitoring your health as you lose the weight. Weight loss is a challenging prospect – never go it alone. The world is full of people and providers that are happy to help you on your way.